Arden M. Morris, MD, MPH is Professor of Surgery and Vice-Chair for Research in the Stanford Department of Surgery. She is Director of the S-SPIRE Center, a health services research collaborative to study patient-centered care, clinical optimization, and health care economics. In her own work, Dr. Morris uses quantitative and qualitative research methods to focus on quality of and equity in cancer care. She serves as vice-chair of the Commission on Cancer’s National Accreditation Program for Rectal Cancer Quality Committee, American Society of Colon and Rectal Surgeons’ representative to the American Joint Commission on Cancer, and Chair of the ACS Cancer Surgery Standards Program Implementation and Integration Committee.

Clinical Focus

  • Colon and Rectal Surgery

Academic Appointments

Administrative Appointments

  • Director, S-SPIRE Center, Department of Surgery, Stanford University School of Medicine (2016 - Present)
  • Professor, Department of Surgery, Division of General Surgery Stanford University School of Medicine (2016 - Present)
  • Vice Chair, Clinical Research, Department of Surgery, Stanford University School of Medicine (2016 - Present)

Honors & Awards

  • Top Doctor, Hour Detroit Magazine Top Doctor (2015)
  • Visiting Scholar, Russell Sage Foundation, New York, NY (2014-2015)
  • Outstanding Clinician Award, University of Michigan Medical School (2014)

Professional Education

  • Fellowship: University of Minnesota General Surgery Residency (2003) MN
  • Medical Education: Rush Medical College Office of the Registrar (1993) IL
  • Board Certification: American Board of Colon and Rectal Surgery, Colon and Rectal Surgery (2006)
  • Board Certification: American Board of Surgery, General Surgery (2003)
  • Residency: Oregon Health and Science University (2000) OR

Clinical Trials

  • A Study of TransCon TLR7/8 Agonist With or Without Pembrolizumab in Patients With Advanced or Metastatic Solid Tumors Not Recruiting

    TransCon TLR7/8 Agonist is an investigational drug being developed for treatment of locally advanced or metastatic solid tumors. This Phase 1/2 study will evaluate TransCon TLR7/8 Agonist as monotherapy or in combination with pembrolizumab in dose escalation and dose expansion. Participants will receive intratumoral (IT) injection of TransCon TLR7/8 Agonist every cycle. The primary objectives are to evaluate safety and tolerability, and define the Maximum Tolerated Dose (MTD) and Recommended Phase 2 Dose (RP2D) of TransCon TLR7/8 Agonist alone or in combination with pembrolizumab.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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  • Efficacy and Safety of LifeSeal™ Kit for Colorectal Staple Line Sealing Not Recruiting

    LifeSeal™ Kit, surgical sealant designed for staple-line reinforcement that is applied over the anastomotic line to prevent bowel content leakage until full physiological function is restored. RATIONALE : Postoperative anastomotic leakage is one of the most devastating and feared complications in colorectal surgery. The risk of postoperative anastomotic leakage varies widely depending on the level of anastomosis while the risk is higher in low anastomosis. In order to best demonstrate the benefits of LifeSeal™ in providing staple line reinforcement and helping to reduce leaks, the study includes high risk anastomoses, defined as colorectal and coloanal anastomoses performed within 10 cm from the anal verge. STUDY DESIGN: This study is designed as a prospective, multi-center, multinational randomized, single-blind, double armed study PRIMARY OBJECTIVE: The primary objective of this study is to assess the efficacy and safety of LifeSeal™ Kit as measured by the change in overall anastomotic leak rates in subjects undergoing low anterior resection with an anastomosis below 10 cm from the anal verge, over the first 17 weeks after surgery. SECONDARY OBJECTIVES: The secondary objective of this study is to assess the incidence of post-operative leaks and additional benefits that could be related to the use of LifeSeal™ Kit such as reducing the severity and improving the outcome of a leak once it has occurred. In addition, the study will allow for collection and analysis of additional safety data and usability assessment of the device, medical resource utilization, and health related quality of life measures.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.

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2023-24 Courses

All Publications

  • Statistical Methods to Examine Racial and Ethnic Disparities in the Surgical Literature: A Review and Recommendations for Improvement. Annals of surgery Harris, A. H., Eddington, H., Shah, V. B., Shwartz, M., Gurewich, D., Rosen, A. K., Quinteros, B., Wilcher, B., Nieser, K. J., Jones, G., Wu, J. T., Morris, A. M. 2024


    We characterized the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022.Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature has never been systematically reviewed.We searched for 2021-2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of three methodological criteria: 1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH); 2) accounting for clustering of patients within hospitals or other subunits ("providers") and; 3) distinguishing within- and between-provider effects.We identified 224 papers describing racial and/or ethnic differences. Of the 38 single institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of overall disparities were driven by within versus between provider effects.Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and therefore may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies.

    View details for DOI 10.1097/SLA.0000000000006440

    View details for PubMedID 38979600

  • Hospital Presumptive Eligibility Emergency Medicaid Programs: An Opportunity for Continuous Insurance Coverage? Medical care Knowlton, L. M., Arnow, K., Trickey, A. W., Tran, L. D., Harris, A. H., Morris, A. M., Wagner, T. H. 2024


    Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment.To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment.This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services.The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017.We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not.HPE emergency Medicaid approval at the time of hospitalization.The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval.Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enrollin Medicaid (aOR 0.77, P<0.001). Surgical intervention (aOR 1.10, P<0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P<0.001).California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency.

    View details for DOI 10.1097/MLR.0000000000002026

    View details for PubMedID 38986116

  • Correction: Standardization of Colon Resection for Cancer: An Overview of the American College of Surgeons Commission on Cancer Standard 5.6. Annals of surgical oncology Thomas, K. K., Francescatti, A. B., Vreeland, T. J., Teshome, M. K., Morris, A. M., Hunt, K. K., Katz, M. H., Villano, A. M. 2024

    View details for DOI 10.1245/s10434-024-15331-8

    View details for PubMedID 38662097

  • Impact of a coaching program on resident perceptions of communication confidence and feedback quality. BMC medical education Gold, C. A., Jensen, R., Sasnal, M., Day, H. S., Miller-Kuhlmann, R. K., Blankenburg, R. L., Rassbach, C. E., Morris, A. M., Korndorffer, J. R., Nassar, A. K. 2024; 24 (1): 435


    While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback.The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis.The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas.These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

    View details for DOI 10.1186/s12909-024-05383-5

    View details for PubMedID 38649901

    View details for PubMedCentralID PMC11036561

  • Automated and Personalized Outreach to Level the Playing Field for Colorectal Cancer Screening. JAMA network open Pohl, A. L., Morris, A. M. 2024; 7 (4): e245260

    View details for DOI 10.1001/jamanetworkopen.2024.5260

    View details for PubMedID 38625705

  • 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

  • The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation. Surgery Kapadia, M. R., Senatore, P. J., Messick, C., Hull, T. L., Shaffer, V. O., Morris, A. M., Dietz, D. W., Wexner, S. D., Wick, E. C. 2024


    Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation.An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data.A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel.Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.

    View details for DOI 10.1016/j.surg.2023.12.005

    View details for PubMedID 38267342

  • A Qualitative Study of Emergency Medicaid Programs From the Perspective of Hospital Stakeholders. The Journal of surgical research Boncompagni, A. C., Handley, T. J., Sasnal, M., Morris, A. M., Knowlton, L. M. 2023; 295: 530-539


    Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-d emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-d HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow and (2) facilitators and barriers to HPE approval to understand process improvement opportunities.We conducted semi-structured interviews between September-December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement.Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics.This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates.

    View details for DOI 10.1016/j.jss.2023.11.038

    View details for PubMedID 38086253

  • Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA network open Welch, J. M., Gomez, G. I., Chatterjee, M., Shapiro, L. M., Morris, A. M., Gardner, M. J., Sox-Harris, A. H., Baker, L., Koltsov, J. C., Castillo, T., Giori, N., Salyapongse, A., Kamal, R. N. 2023; 6 (12): e2347834


    Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

    View details for DOI 10.1001/jamanetworkopen.2023.47834

    View details for PubMedID 38100104

  • Disparities in Preoperative Goals of Care Documentation in Veterans. JAMA network open Wu, A., Giannitrapani, K. F., Garcia, A., Bozkurt, S., Boothroyd, D., Adams, A. S., Kim, K. M., Zhang, S., McCaa, M. D., Morris, A. M., Shreve, S., Lorenz, K. A. 2023; 6 (12): e2348235


    Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans.This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022.Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression.In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001).In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

    View details for DOI 10.1001/jamanetworkopen.2023.48235

    View details for PubMedID 38113045

    View details for PubMedCentralID PMC10731481

  • Transforming the Future of Surgeon-Scientists. Annals of surgery Ladner, D. P., Goldstein, A. M., Billiar, T. R., Cameron, A. M., Carpizo, D. R., Chu, D. I., Coopersmith, C. M., DeMatteo, R. P., Feng, S. H., Gallagher, K. A., Gillanders, W. E., Lal, B. K., Lipshutz, G. S., Liu, A., Maier, R. V., Mittendorf, E. A., Morris, A. M., Sicklick, J. K., Velazquez, O. C., Whitson, B. A., Wilke, L. G., Yoon, S. S., Zeiger, M. A., Farmer, D. L., Hwang, E. S. 2023


    To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists.Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice.An American Surgical Association (ASA) Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A SWOT analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies.Taskforce recommendations: (1) SURGEONS: Growth mindset: identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set: align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair: mentor - mentee matching / regular meetings / accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (e.g., RVU equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee: enthusiastic / eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (e.g., T- / P-grants), leveraging of institutional resources, negotiation of formalized / formulaic funds flow investment from AMC towards science, philanthropy; (4) STRUCTURAL / STRATEGIC SUPPORT: Structural: grants administrative support, biostats / bioinformatics support, clinical trial and research support, regulatory support, shared departmental lab space / equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention / recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses / mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (e.g., endowed chairs), promotion friendly towards surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator (ESI) status, surgeon representation on study section, focused award strategies for professional societies/foundations.Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists towards advancements of science.

    View details for DOI 10.1097/SLA.0000000000006148

    View details for PubMedID 37916404

  • ASO Visual Abstract: Standardization of Colon Resection for Cancer-An Overview of the American College of Surgeons Commission on Cancer Standard 5.6. Annals of surgical oncology Thomas, K. K., Francescatti, A. B., Vreeland, T. J., Teshome, M. K., Morris, A. M., Hunt, K. K., Katz, M. H., Villano, A. M. 2023

    View details for DOI 10.1245/s10434-023-14492-2

    View details for PubMedID 37914924

  • Standardization of Colon Resection for Cancer: An Overview of the American College of Surgeons Commission on Cancer Standard 5.6. Annals of surgical oncology Thomas, K. K., Francescatti, A. B., Vreeland, T. J., Teshome, M. K., Morris, A. M., Hunt, K. K., Katz, M. H., Villano, A. M. 2023


    The purpose of this editorial is to review the American College of Surgeons Commission on Cancer Standard 5.6, which pertains to curative intent colon resections performed for cancer. We first provide a broad overview of the Operative Standard, followed by the underlying rationale, technical components, and documentation requirements.

    View details for DOI 10.1245/s10434-023-14414-2

    View details for PubMedID 37880516

    View details for PubMedCentralID 4649108

  • SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening. Journal of pediatric surgery Martin, N. R., Claypool, A. L., Diyaolu, M., Chan, K. S., A'Neals, E., Iyer, K., Stewart, C. C., Egge, M., Bernacki, K., Hallinan, M., Zuo, L., Gupta, U., Naru, N., Scheinker, D., Morris, A. M., Brandeau, M. L., Chao, S. 2023


    Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse.CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021).Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention).Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger.Level II.Study of Diagnostic Test.

    View details for DOI 10.1016/j.jpedsurg.2023.10.025

    View details for PubMedID 37953157

  • Do Hospital-Based Emergency Medicaid Programs Benefit Trauma Centers? A Mixed-Methods Analysis. The journal of trauma and acute care surgery Knowlton, L. M., Logan, D. S., Arnow, K., Hendricks, W. D., Gibson, A. B., Tran, L. D., Wagner, T. H., Morris, A. M. 2023


    INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization which can offset patient costs of care, increase access to post-discharge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement, as well as characterize incentives for HPE participation among hospitals and TCs. We hypothesized there would be financial, operational, and mission-based incentives.METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (HCAI) (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semi-structured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8).RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE 77 (21%) of which are TCs. As of early 2015, 100% of trauma centers had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II trauma centers. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue (b = 6.74, p < 0.001) and decreased uncompensated care costs (b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included: reduction of hospital bad debt, improved patient satisfaction and community benefit in access to care.CONCLUSION: HPE programs are a promising pathway not only for long-term insurance coverage for trauma patients, but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program.LEVEL OF EVIDENCE: Economic/decision study, Level II.

    View details for DOI 10.1097/TA.0000000000004162

    View details for PubMedID 37828656

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer. Journal of the American College of Surgeons Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482


    High-deductible health plans (HDHPs) have been shown to delay timing of breast and colon cancer screening, although the relationship to the timing of cancer surgery is unknown. The objective of this study was to characterize timing of surgery for breast and colon cancer patients undergoing cancer operations following routine screening.Data from the IBM MarketScan Commercial Claims Database from 2007 to 2016 were queried to identify patients who underwent screening mammogram and/or colonoscopy. The calendar quarters of screening and surgery were analyzed with ordinal logistic regression. The time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function.Among 32,562,751 patients who had screening mammograms, 0.7% underwent breast cancer surgery within the following year. Among 9,325,238 patients who had screening colonoscopies, 0.9% were followed by colon cancer surgery within a year. The odds of screening (OR 1.146 for mammogram, 1.272 for colonoscopy; p < 0.001) and surgery (OR 1.120 for breast surgery, 1.219 for colon surgery; p < 0.001) increased each quarter for HDHPs compared to low-deductible health plans. Enrollment in an HDHP was not associated with a difference in TTS. Screening in Q3 or Q4 was associated with shorter TTS compared to screening in Q1 (hazard ratio 1.061 and 1.046, respectively; p < 0.001).HDHPs were associated with delays in screening and surgery. However, HDHPs were not associated with delays in TTS. Interventions to improve cancer care outcomes in the HDHP population should concentrate on reducing barriers to timely screening.

    View details for DOI 10.1097/XCS.0000000000000737

    View details for PubMedID 38085770

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482
  • Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. Journal of pain and symptom management Giannitrapani, K. F., Sasnal, M., McCaa, M., Wu, A., Morris, A. M., Connell, N. B., Aslakson, R. A., Schenker, Y., Shreve, S., Lorenz, K. A. 2023


    CONTEXT: Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively.OBJECTIVES: To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons.METHODS: We conducted semi-structured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8).RESULTS: Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: (1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; (2) establish risk assessment processes to identify patients who may benefit from a PC consult; (3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; (4) provide sufficient resources to allow for an interdisciplinary sharing of care.CONCLUSION: The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

    View details for DOI 10.1016/j.jpainsymman.2023.08.021

    View details for PubMedID 37643653

  • Disparities in the Timing of Preoperative Hemodialysis Among Patients With End-Stage Kidney Disease. JAMA network open Fielding-Singh, V., Vanneman, M. W., Morris, A. M., Chertow, G. M., Lin, E. 2023; 6 (7): e2326326

    View details for DOI 10.1001/jamanetworkopen.2023.26326

    View details for PubMedID 37505500

  • Predicting treatment response for the safe non-operative management of patients with rectal cancer using an MRI-based deep-learning model Selby, H. M., Liu, C., Sheth, V., Napel, S., Wagner, T., Morris, A. M. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Decision Making and Cost in Healthcare: The Patient Perspective. Journal of surgical orthopaedic advances Lindsay, S. E., Alokozai, A., Eppler, S. L., Yao, J., Morris, A., Kamal, R. N. 2023; 32 (1): 23-27


    Unsustainable spending and unsatisfactory outcomes have prompted a reanalysis of healthcare policy towards value. Several strategies have been proposed as part of this effort including cost sharing plans to shift costs to patients and gain-sharing models to shift risk to health systems. The patient perspective is rarely elicited in policy formation despite efforts to increase patient-centered care. We conducted a prospective study of 118 patients presenting to hand clinic to assess patient perspective of who should constrain treatment options (patient, physician, insurance company, hospital) and be responsible for costs in scenarios of clinical equipoise. We found that patients believed that insurance companies and hospitals should not constrain which treatment options are available to a patient and that physicians and patients should together influence the availability of treatment options. Patients were willing to cost share with insurance companies when choosing more expensive treatments or in the setting of non-life-threatening diseases. In addressing rising healthcare costs, patient perspectives can inform policies designed to increase value. Asking patients to cost share when choosing a more expensive treatment option in the setting of clinical equipoise could be a strategy for health systems to increase value. Level of Evidence: III (Journal of Surgical Orthopaedic Advances 32(1):023-027, 2023).

    View details for PubMedID 37185073

  • Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA network open Aslakson, R. A., Rickerson, E., Fahy, B., Waterman, B., Siden, R., Colborn, K., Smith, S., Verano, M., Lira, I., Hollahan, C., Siddiqi, A., Johnson, K., Chandrashekaran, S., Harris, E., Nudotor, R., Baker, J., Heidari, S. N., Poultsides, G., Conca-Cheng, A. M., Cook Chapman, A., Lessios, A. S., Holdsworth, L. M., Gustin, J., Ejaz, A., Pawlik, T., Miller, J., Morris, A. M., Tulsky, J. A., Lorenz, K., Temel, J. S., Smith, T. J., Johnston, F. 2023; 6 (5): e2314660


    Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation.The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI Identifier: NCT03611309.

    View details for DOI 10.1001/jamanetworkopen.2023.14660

    View details for PubMedID 37256623

  • Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors. JAMA network open Ghazal, L. V., Abrahamse, P., Ward, K. C., Morris, A. M., Hawley, S. T., Veenstra, C. M. 2023; 6 (4): e235897


    Importance: Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners.Objective: To understand long-term FT and its association with HRQoL among partners of CRC survivors.Design, Setting, and Participants: This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023.Exposures: Three components of FT, including financial burden, debt, and financial worry.Main Outcomes and Measures: Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL.Results: Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P=.03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P=.03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P=.005), fatigue (-0.33 [0.15]; P=.03), and pain interference (-0.33 [0.14]; P=.02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL.Conclusions and Relevance: This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.

    View details for DOI 10.1001/jamanetworkopen.2023.5897

    View details for PubMedID 37022684

  • 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

  • "Next Gen" Operative Notes - Synoptic Operative Reporting for Cancer Surgery Burns, W. R., Hieken, T. J., Zheng, L., Francescatti, A. B., Teshome, M., Vreeland, T., Morris, A. M., Staudenmayer, K. L., Hunt, K. K., Katz, M. H. SPRINGER. 2023: S77-S78
  • Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations. JAMA network open Kim, K. M., Giannitrapani, K. F., Garcia, A., Boothroyd, D., Wu, A., Van Cleve, R., McCaa, M. D., Yefimova, M., Aslakson, R. A., Morris, A. M., Shreve, S. T., Lorenz, K. A. 2023; 6 (2): e2255407


    Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.

    View details for DOI 10.1001/jamanetworkopen.2022.55407

    View details for PubMedID 36757697

  • Recurrent lower abdominal pain, altered bowel habits and malaise: Conservative or surgical approach to a common disorder. Gastroenterology Morris, A. M., Fider, J. L., Mau, B., Strate, L. L. 2023

    View details for DOI 10.1053/j.gastro.2023.01.011

    View details for PubMedID 36657527

  • "It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period. Journal of pain and symptom management Sasnal, M., Lorenz, K. A., McCaa, M., Wu, A., Morris, A. M., Schenker, Y., Shreve, S. T., Giannitrapani, K. F. 2023


    CONTEXT: Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear.OBJECTIVES: To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period.METHODS: This cross-sectional multiphase qualitative study included 23 semi-structured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review.RESULTS: Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: (1) mutual trust; (2) mutual respect; (3) perceived usefulness; (4) shared clinical objectives; (5) effective communication; and (6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: (1) Being present, available, and responsive; (2) Understanding roles; (3) Establishing communication; (4) Recognizing an intermediary and connecting role of supporting team members; (5) Working as a team; and (6) Building on previous experiences.CONCLUSIONS: The study informs future interventions to improve the quality of care for seriously ill patients by better-involving palliative care in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.

    View details for DOI 10.1016/j.jpainsymman.2022.12.140

    View details for PubMedID 36646332

  • Peer Review in a General Medical Research Journal Before and During the COVID-19 Pandemic. JAMA network open Perlis, R. H., Kendall-Taylor, J., Hart, K., Ganguli, I., Berlin, J. A., Bradley, S. M., Haneuse, S., Inouye, S. K., Jacobs, E. A., Morris, A., Ogedegbe, O., Perencevich, E., Shulman, L. N., Trueger, N. S., Fihn, S. D., Rivara, F. P., Flanagin, A. 2023; 6 (1): e2253296


    Importance: Although peer review is an important component of publication for new research, the viability of this process has been questioned, particularly with the added stressors of the COVID-19 pandemic.Objective: To characterize rates of peer reviewer acceptance of invitations to review manuscripts, reviewer turnaround times, and editor-assessed quality of reviews before and after the start of the COVID-19 pandemic at a large, open-access general medical journal.Design, Setting, and Participants: This retrospective, pre-post cohort study examined all research manuscripts submitted to JAMA Network Open between January 1, 2019, and June 29, 2021, either directly or via transfer from other JAMA Network journals, for which at least 1 peer review of manuscript content was solicited. Measures were compared between the period before the World Health Organization declaration of a COVID-19 pandemic on March 11, 2020 (14.3 months), and the period during the pandemic (15.6 months) among all reviewed manuscripts and between pandemic-period manuscripts that did or did not address COVID-19.Main Outcomes and Measures: For each reviewed manuscript, the number of invitations sent to reviewers, proportions of reviewers accepting invitations, time in days to return reviews, and editor-assessed quality ratings of reviews were determined.Results: In total, the journal sought review for 5013 manuscripts, including 4295 Original Investigations (85.7%) and 718 Research Letters (14.3%); 1860 manuscripts were submitted during the prepandemic period and 3153 during the pandemic period. Comparing the prepandemic with the pandemic period, the mean (SD) number of reviews rated as high quality (very good or excellent) per manuscript increased slightly from 1.3 (0.7) to 1.5 (0.7) (P<.001), and the mean (SD) time for reviewers to return reviews was modestly shorter (from 15.8 [7.6] days to 14.4 [7.0] days; P<.001), a difference that persisted in linear regression models accounting for manuscript type, study design, and whether the manuscript addressed COVID-19.Conclusions and Relevance: In this cohort study, the speed and editor-reported quality of peer reviews in an open-access general medical journal improved modestly during the initial year of the pandemic. Additional study will be necessary to understand how the pandemic has affected reviewer burden and fatigue.

    View details for DOI 10.1001/jamanetworkopen.2022.53296

    View details for PubMedID 36705922

  • 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

  • Life After Rectal Cancer Treatment: Time to Turn to the Experts. Diseases of the colon and rectum Morris, A. M. 2022; 65 (12): 1413-1414

    View details for DOI 10.1097/DCR.0000000000002576

    View details for PubMedID 36382837

  • Association of an Online Home-Based Prehabilitation Program With Outcomes After Colorectal Surgery. JAMA surgery Kimura, C. S., Bidwell, S., Gurland, B., Morris, A., Shelton, A., Kin, C. 2022


    This quality improvement study evaluates the association of an online home-based patient prehabilitation program with colorectal surgery outcomes.

    View details for DOI 10.1001/jamasurg.2022.4485

    View details for PubMedID 36322070

  • 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
  • Predictive Value of Clinical Complete Response after Chemoradiation for Rectal Cancer Liu, C., Boncompagni, A. A., Perrone, K., Agarwal, A., Hur, D. G., Lopez, I., Sheth, V., Morris, A. M. LIPPINCOTT WILLIAMS & WILKINS. 2022: S51-S52
  • 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 dyadic survey study of partner engagement in and patient receipt of guideline-recommended colorectal cancer surveillance. BMC cancer Veenstra, C. M., Ellis, K. R., Abrahamse, P., Ward, K. C., Morris, A. M., Hawley, S. T. 2022; 22 (1): 1060


    BACKGROUND: We investigated whether partner (spouse or intimate partner) engagement in colorectal cancer (CRC) surveillance is associated with patient receipt of surveillance.METHODS: From 2019 to 2020 we surveyed Stage III CRC survivors diagnosed 2014-2018 at an academic cancer center, a community oncology practice and the Georgia SEER registry, and their partners. Partner engagement was measured across 3 domains: Informed about; Involved in; and Aware of patient preferences around surveillance. We evaluated bivariate associations between domains of partner engagement and independent partner variables. Analysis of variance and multivariable logistic regression were used to compare domains of engagement with patient-reported receipt of surveillance.RESULTS: 501 patients responded (51% response rate); 428 had partners. 311 partners responded (73% response rate). Partners were engaged across all domains. Engagement varied by sociodemographics. Greater partner involvement was associated with decreased odds of receipt of composite surveillance (OR 0.67, 95% CI 0.48-0.93) and trended towards significance for decreased odds of receipt of endoscopy (OR 0.60, 95% CI 0.34-1.03) and CEA (OR 0.75, 95% CI 0.55-1.04). Greater partner awareness was associated with increased odds of patients' receipt of endoscopy (OR 2.18, 95% CI 1.15-4.12) and trended towards significance for increased odds of receipt of composite surveillance (OR 1.30, 95% CI 0.91-2.04).CONCLUSION: Partners are engaged (informed, involved, and aware) in CRC surveillance. Future research to develop dyadic interventions that capitalize on the positive aspects of partner engagement may help partners effectively engage in surveillance to improve patient care.

    View details for DOI 10.1186/s12885-022-10131-3

    View details for PubMedID 36229796

  • Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA surgery Graham, L. A., Schoemaker, L., Rose, L., Morris, A., Aouad, M., Wagner, T. H. 2022


    Importance: The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding.Objective: To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders.Design, Setting, and Participants: This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019.Interventions: The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital.Main Outcomes and Measures: Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days.Results: A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P=.01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits.Conclusions and Relevance: Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.

    View details for DOI 10.1001/jamasurg.2022.4978

    View details for PubMedID 36223115

  • 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

  • Misinterpretation of Surgeons' Statements on Cancer Removal-The Adverse Effects of "We Got It All". JAMA oncology Wong, B. O., Clapp, J. T., Morris, A. M. 2022

    View details for DOI 10.1001/jamaoncol.2022.3769

    View details for PubMedID 36107410

  • Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA network open Tewari, P., Sweeney, B. F., Lemos, J. L., Shapiro, L., Gardner, M. J., Morris, A. M., Baker, L. C., Harris, A. S., Kamal, R. N. 2022; 5 (9): e2231911


    Importance: Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.Objective: To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.Evidence Review: A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.Findings: Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.Conclusions and Relevance: In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

    View details for DOI 10.1001/jamanetworkopen.2022.31911

    View details for PubMedID 36112373

  • Patient Perspectives on Recovery and Information Needs After Surgery: A Qualitative Study of Veterans. The Journal of surgical research Sasnal, M., Langston, A. H., Morris, A. M., Harris, A. H., Arya, S. 2022; 279: 765-773


    INTRODUCTION: Little is known about patients' postoperative emotional and social functioning and preferences for recovery settings. This qualitative study explores patients' perspectives on factors influencing postoperative recovery, including the proportion of time recovering at home (home time) and unmet information needs.METHODS: Semistructured interviews were conducted between September and December 2020 with veteran patients aged 65y or older who underwent surgery at a single hospital. A purposeful sampling strategy was used to identify patients with a broad representation of major operations and various amounts of home time. One-hour interviews were audio-recorded, transcribed verbatim, and anonymized for analysis. A rigorous team-based in-depth thematic analysis was performed. Validation techniques to enhance the quality and credibility of the study included triangulation, independent coding, and search for disconfirming evidence.RESULTS: Twelve patients were interviewed (11 [91.7%] males; mean (standard deviation) age, 72.3 [4.8] y). Five factors that influenced the recovery process emerged: (1) professional support services, (2) informal caregiver support, (3) environment for recovery, (4) individual traits, and (5) physical and functional impairments. The analysis also elucidated four unmet information needs regarding recovery: (1) personalized and detailed information, (2) anticipated recovery time, (3) possible complications, and (4) comprehensive information about discharge location options.CONCLUSIONS: The study demonstrated that patients recovering from surgery require wide-ranging levels of support to meet their unique needs and preferences. Patients value easy-to-understand and personalized information about recovery from providers. These findings may be helpful to develop strategies that better support patients in their postoperative recovery and post-acute care transition pathways.

    View details for DOI 10.1016/j.jss.2022.06.050

    View details for PubMedID 35944331

  • 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

  • "They Don't Have to Love Us or Even Like Us, but They Have to See that We Benefit the Patient and Family Dynamic": Palliative Care Teams on Relationships with Surgeons Giannitrapani, K., Sasnal, M., McCaa, M., Morris, A., Lorenz, K. ELSEVIER SCIENCE INC. 2022: 1113
  • Call for Papers on the Effects of War on Health and Health Care Delivery, Access, and Equity. JAMA network open Rivara, F. P., Haneuse, S. J., Morris, A. M., Fihn, S. D. 2022; 5 (5): e2217872

    View details for DOI 10.1001/jamanetworkopen.2022.17872

    View details for PubMedID 35622371

  • Strategies to Improve Perioperative Quality of Care Through Palliative Care Giannitrapani, K., McCaa, M., Sasnal, M., Morris, A., Connell, N., Schenker, Y., Lorenz, K. ELSEVIER SCIENCE INC. 2022: 918-919
  • Integrated single-cell and plasma proteomic modeling to predict surgical site complications, a prospective cohort study Tsai, A. S., Hedou, J., Einhaus, J., Rumer, K., Verdonk, F., Stanley, N., Choisy, B., Ganio, E. A., Bonham, A., Jacobsen, D., Warrington, B., Gao, X., Tingle, M., McAllister, T., Fallahzadeh, R., Feyaerts, D., Stelzer, I., Gaudilliere, D., Ando, K., Shelton, A., Morris, A., Kebebew, E., Aghaeepour, N., Kin, C., Angst, M. S., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2022: 1204-1205
  • A National Study of Surgical Palliative and End-of-Life Facility-Level Measures and Outcomes in the Department of Veterans Affairs Lorenz, K., Aslakson, R., Garcia, A., Boothroyd, D., Morris, A., Arya, S., Giannitrapani, K., Shreve, S. ELSEVIER SCIENCE INC. 2022: 912
  • Technical Standards for Cancer Surgery: Improving Patient Care through Synoptic Operative Reporting. Annals of surgical oncology Hieken, T. J., Burns, W. R., Francescatti, A. B., Morris, A. M., Wong, S. L., Cancer Surgery Standards Program of the American College of Surgeons 2022


    The Operative Standards for Cancer Surgery manuals define critical elements of optimal cancer surgery based on data and expert opinion. These key aspects of commonly performed cancer operations define technical standards that can be used as a quality assurance tool for practicing surgical oncologists and as an educational tool for trainees. This article provides background on these operative standards and their subsequent integration into synoptic operative report templates. With the goal of codifying the most important aspects of surgical oncology care to elevate and harmonize cancer care, the American College of Surgeons Cancer Programs has developed comprehensive synoptic operative reports. Synoptic operative reports are structured so that key data elements are recorded in a standardized format with prespecified terminology. In contrast to the narrative or structured operative reports frequently used by surgeons, these synoptic operative reports improve semantic clarity, provide uniform fields for abstraction, and facilitate passive data collection and real-time analytics while delivering key information for downstream multidisciplinary patient care. In this way, the synoptic operative report is a key component of a comprehensive effort to elevate the quality of cancer care nationally.

    View details for DOI 10.1245/s10434-022-11330-9

    View details for PubMedID 35174447

  • Association Between High-Deductible Health Plans and Hernia Acuity. JAMA surgery Yelorda, K., Rose, L., Bundorf, M. K., Muhammad, H. A., Morris, A. M. 2022


    Importance: About half of people younger than 65 years with private insurance are enrolled in a high-deductible health plan (HDHP). While these plans entail substantially higher out-of-pocket costs for patients with chronic medical conditions who require ongoing care, their effect on patients undergoing surgery who require acute care is poorly understood. It is plausible that higher out-of-pocket costs may lead to delays in care and more complex surgical conditions.Objective: To determine the association between enrollment in HDHPs and presentation with incarcerated or strangulated hernia.Design, Setting, and Participants: This retrospective cohort analysis included privately insured patients aged 18 to 63 years from a large commercial insurance claims database who underwent a ventral or groin hernia operation from January 2016 through June 2019 and classified their coverage as either a traditional health plan or an HDHP per the Internal Revenue Service's definition. Multivariable regression, adjusting for demographic and clinical covariates, was used to examine the association between enrollment in an HDHP and the primary outcome of presentation with an incarcerated or strangulated hernia.Exposures: Traditional health plan vs HDHP.Main Outcomes and Measures: Presence of an incarcerated or strangulated hernia per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes.Results: Among 83 281 patients (71.9% men and 28.1% women; mean [SD] age, 48.7 [10.9] years) who underwent hernia surgery, 27 477 (33.0%) were enrolled in an HDHP and 21 876 (26.2%) had a hernia that was coded as incarcerated or strangulated. The mean annual deductible was considerably higher for those in the HDHP group than their traditional health plan counterparts (unadjusted mean [SD], $3635 [$2094] vs $705 [$737]; adjusted, -$2931; P<.001). Patients in the HDHP group were more likely to present with an incarcerated or strangulated hernia (adjusted odds ratio, 1.07; 95% CI, 1.03-1.11; P<.001).Conclusions and Relevance: In this cohort study, enrollment in an HDHP was associated with higher odds of presenting with an incarcerated or strangulated hernia, which is more likely to require emergency surgery that precludes medical optimization. These data suggest that, among patients with groin and ventral hernias, enrollment in an HDHP may be associated with delays in surgical care that result in complex disease presentation.

    View details for DOI 10.1001/jamasurg.2021.7567

    View details for PubMedID 35152285

  • ASO Visual Abstract: Technical Standards for Cancer Surgery-Improving Patient Care through Synoptic Operative Reporting. Annals of surgical oncology Hieken, T. J., Burns, W. R., Francescatti, A. B., Morris, A. M., Wong, S. L., Cancer Surgery Standards Program of the American College of Surgeons 1800

    View details for DOI 10.1245/s10434-022-11342-5

    View details for PubMedID 35094185

  • Barriers to high-quality rectal cancer care: A qualitative study. American journal of surgery Hendren, S., Kanters, A. E., Morris, A. M., Abdelsattar, Z. M., Berry, R. R., Resnicow, K., Birkmeyer, N. J. 1800


    BACKGROUND: High quality multidisciplinary care improves outcomes for rectal cancer (RC) but is not consistently provided. Our objective was to understand surgeons' barriers to RC care.METHODS: Semi-structured interviews were conducted with 18 surgeons from 10 Michigan hospitals. Reports of hospital performance were shared. Interview transcripts were dual coded; data were reduced into emergent themes; and disagreements were resolved by discussion.RESULTS: Barriers to high quality care included negative attitudes, (resistance to change; not taking responsibility) lack of training/experience, complex care coordination, and financial disincentives. Facilitators included providers' positive attitudes and relationships, training/experience, surgeon leadership (development of protocols), patient-level systems of care (patient navigator), and higher-level support (cancer center reviews quality data). Themes were incorporated into an explanatory framework, with patient, provider, and systems domains.CONCLUSIONS: In this qualitative study of RC surgeons, we identified barriers to and facilitators of high-quality care. The framework developed will facilitate the design of quality improvement interventions.

    View details for DOI 10.1016/j.amjsurg.2022.01.011

    View details for PubMedID 35101275

  • ASO Author Reflections: Surgeons Adding Value-Are Synoptic Operative Reports a Step Forward in Cancer Care? Annals of surgical oncology Hieken, T. J., Morris, A. M., Burns, W. R., Francescatti, A. B., Wong, S. L. 1800

    View details for DOI 10.1245/s10434-021-11299-x

    View details for PubMedID 35015181

  • 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

  • Integrated Single-Cell and Plasma Proteomic Modeling to Predict Surgical Site Complications: A Prospective Cohort Study. Annals of surgery Rumer, K. K., Hedou, J., Tsai, A., Einhaus, J., Verdonk, F., Stanley, N., Choisy, B., Ganio, E., Bonham, A., Jacobsen, D., Warrington, B., Gao, X., Tingle, M., McAllister, T. N., Fallahzadeh, R., Feyaerts, D., Stelzer, I., Gaudilliere, D., Ando, K., Shelton, A., Morris, A., Kebebew, E., Aghaeepour, N., Kin, C., Angst, M. S., Gaudilliere, B. 1800


    OBJECTIVE: The aim of this study was to determine whether single-cell and plasma proteomic elements of the host's immune response to surgery accurately identify patients who develop a surgical site complication (SSC) after major abdominal surgery.SUMMARY BACKGROUND DATA: SSCs may occur in up to 25% of patients undergoing bowel resection, resulting in significant morbidity and economic burden. However, the accurate prediction of SSCs remains clinically challenging. Leveraging high-content proteomic technologies to comprehensively profile patients' immune response to surgery is a promising approach to identify predictive biological factors of SSCs.METHODS: Forty-one patients undergoing non-cancer bowel resection were prospectively enrolled. Blood samples collected before surgery and on postoperative day one (POD1) were analyzed using a combination of single-cell mass cytometry and plasma proteomics. The primary outcome was the occurrence of an SSC, including surgical site infection, anastomotic leak, or wound dehiscence within 30 days of surgery.RESULTS: A multiomic model integrating the single-cell and plasma proteomic data collected on POD1 accurately differentiated patients with (n = 11) and without (n = 30) an SSC [area under the curve (AUC) = 0.86]. Model features included coregulated proinflammatory (eg, IL-6- and MyD88- signaling responses in myeloid cells) and immunosuppressive (eg, JAK/STAT signaling responses in M-MDSCs and Tregs) events preceding an SSC. Importantly, analysis of the immunological data obtained before surgery also yielded a model accurately predicting SSCs (AUC = 0.82).CONCLUSIONS: The multiomic analysis of patients' immune response after surgery and immune state before surgery revealed systemic immune signatures preceding the development of SSCs. Our results suggest that integrating immunological data in perioperative risk assessment paradigms is a plausible strategy to guide individualized clinical care.

    View details for DOI 10.1097/SLA.0000000000005348

    View details for PubMedID 34954754

  • Out-of-Pocket Costs Among Patients With a New Cancer Diagnosis Enrolled in High-Deductible Health Plans vs Traditional Insurance. JAMA network open Fu, S. J., Rose, L., Dawes, A. J., Knowlton, L. M., Ruddy, K. J., Morris, A. M. 1800; 4 (12): e2134282


    Importance: The financial burden of a cancer diagnosis is increasing rapidly with advances in cancer care. Simultaneously, more individuals are enrolling in high-deductible health plans (HDHPs) vs traditional insurance than ever before.Objective: To characterize the out-of-pocket costs (OOPCs) of cancer care for individuals in HDHPs vs traditional insurance plans.Design, Setting, and Participants: This retrospective cohort study used the administrative claims data of a single national insurer in the US for 134 826 patients aged 18 to 63 years with a new diagnosis of breast, colorectal, lung, or other cancer from 2008 to 2018 with 24 months or more of continuous enrollment. Propensity score matching was performed to create comparator groups based on the presence or absence of an incident cancer diagnosis.Exposures: A new cancer diagnosis and enrollment in an HDHP vs a traditional health insurance plan.Main Outcomes and Measures: The primary outcome was OOPCs among individuals with breast, colon, lung, or all other types of cancer combined compared with those with no cancer diagnosis. A triple difference-in-differences analysis was performed to identify incremental OOPCs based on cancer diagnosis and enrollment in HDHPs vs traditional plans.Results: After propensity score matching, 134 826 patients remained in each of the cancer (73 572 women [55%]; median age, 53 years [IQR, 46-58 years]; 110 071 non-Hispanic White individuals [82%]) and noncancer (66 619 women [49%]; median age, 53 years [IQR, 46-59 years]; 105 023 non-Hispanic White individuals [78%]) cohorts. Compared with baseline costs of medical care among individuals without cancer, a breast cancer diagnosis was associated with the highest incremental OOPC ($714.68; 95% CI, $664.91-$764.45), followed by lung ($475.51; 95% CI, $340.16-$610.86), colorectal ($361.41; 95% CI, $294.34-$428.48), and all other types of cancer combined ($90.51; 95% CI, $74.22-$106.79). Based on the triple difference-in-differences analysis, compared with patients without cancer enrolled in HDHPs, those with breast cancer paid $1683.36 in additional yearly OOPCs (95% CI, $1576.66-$1790.07), those with colorectal cancer paid $1420.06 more (95% CI, $1232.31-$1607.80), those with lung cancer paid $467.25 more (95% CI, $130.13-$804.37), and those with other types of cancer paid $550.87 more (95% CI, $514.75-$586.99).Conclusions and Relevance: Patients with cancer and private insurance experienced sharp increases in OOPCs compared with those without cancer, which was amplified among those with HDHPs. These findings illustrate the degree to which HDHPs offer poorer protection than traditional insurance against unexpected health care expenses. Coupled with the increasing cost of cancer care, higher cost sharing in the form of increasing enrollment in HDHPs requires further research on the potential clinical consequences through delayed or foregone care.

    View details for DOI 10.1001/jamanetworkopen.2021.34282

    View details for PubMedID 34935922

  • 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

  • MOTIVATIONS AND BARRIERS TOWARD IMPLEMENTATION OF A RECTAL CANCER SYNOPTIC OPERATIVE REPORT: A PROCESS EVALUATION. Diseases of the colon and rectum Bidwell, S., Poles, G., Shelton, A., Staudenmayer, K., Bereknyei Merrell, S., Morris, A. M. 2021


    BACKGROUND: Use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties.OBJECTIVE: To evaluate the process of implementing a synoptic operative report.DESIGN: Mixed methods process evaluation including surveys and qualitative interviews.SETTINGS: Colorectal Surgery practices across the United States.PATIENTS: Twenty-eight board-certified colorectal surgeons.INTERVENTIONS: Implementation of the synoptic operative report for rectal cancer.MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use.RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range=1-5, standard error (SE)=0.15), mean feasibility was 3.90 (SE=0.15), and acceptability was 3.98 (SE=0.18). Participants indicated substantial administrative and technical support were necessary but not always available for implementation and many were frustrated by the need to change their workflow.LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all U.S. colon and rectal surgeons. Additionally, as the synoptic operative report is implemented more broadly across the U.S., it will be important to consider variations in the process by EMR system.CONCLUSIONS: The synoptic operative report for rectal cancer was generally easy to implement and incorporate into workflow but surgeons remained concerned about additional burden without immediate and tangible value. In spite of recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at

    View details for DOI 10.1097/DCR.0000000000002202

    View details for PubMedID 34711713

  • 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

  • Structural Racism and JAMA Network Open. JAMA network open Rivara, F. P., Bradley, S. M., Catenacci, D. V., Desai, A. N., Ganguli, I., Haneuse, S. J., Inouye, S. K., Jacobs, E. A., Kan, K., Kim, H. S., Morris, A. M., Ogedegbe, O., Perencevich, E. N., Perlis, R. H., Powell, E., Rubenfeld, G. D., Shulman, L. N., Trueger, N. S., Fihn, S. D. 2021; 4 (6): e2120269

    View details for DOI 10.1001/jamanetworkopen.2021.20269

    View details for PubMedID 34115135

  • 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

  • Self-efficacy Toward a Healthcare Career Among Minority High School Students in a Surgical Pipeline Program: A Mixed Methods Study. Journal of surgical education Yelorda, K., Bidwell, S., Fu, S., Miller, M. O., Merrell, S. B., Koshy, S., Morris, A. M. 2021


    OBJECTIVE: While many barriers to healthcare careers exist for URM students, a strong sense of self-efficacy may help mitigate these obstacles. This study explores how URM high school students describe their academic challenges and compares their descriptions across self-efficacy scores.DESIGN: We conducted a convergent mixed methods study of URM high school students. Students completed a validated self-efficacy questionnaire and participated in semi-structured focus group interviews to discuss their approach to academic challenges, goal setting, and achievement. The primary outcome was academic, social, and emotional self-efficacy, measured using the Self-Efficacy Questionnaire for Children. We separated participants into high and low self-efficacy groups based on scores in each domain. Using thematic analysis, we identified and compared common themes associated with academic challenges and goal setting.SETTING: Surgical exposure pipeline program sponsored by Stanford University Department of Surgery PARTICIPANTS: Low-income, high academic achieving URM high school students interested in science, technology, engineering and mathematics, and/or healthcare careers.RESULTS: Thirty-one high school students completed the focus groups and self-efficacy questionnaire. Most students scored in the high self-efficacy group for at least one domain: 65% for academic self-efficacy, 56% for social self-efficacy, and 19% for emotional self-efficacy. Four emergent themes highlighted participants' perspectives toward educational success: fulfillment in academic challenges, focus on future goals, failing forward, and asking for help. Compared to students with low self-efficacy scores, students in the high-scoring self-efficacy groups more often discussed strategies and concrete behaviors such as the importance of seeking support from teachers and peers and learning from failure.CONCLUSIONS: Students in high self-efficacy groups were more comfortable utilizing approaches that helped them succeed academically. Additional efforts are needed to bolster student self-efficacy, particularly in students from URM backgrounds, to increase diversity in medical schools.

    View details for DOI 10.1016/j.jsurg.2021.04.010

    View details for PubMedID 34011476

  • Colorectal Cancer Screening Starting at Age 45 Years-Ensuring Benefits Are Realized by All. JAMA network open Mehta, S. J., Morris, A. M., Kupfer, S. S. 2021; 4 (5): e2112593

    View details for DOI 10.1001/jamanetworkopen.2021.12593

    View details for PubMedID 34003278

  • 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

  • Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala A Qualitative Study ANNALS OF SURGERY Coughran, A. J., Merrell, S., Pineda, C., Sceats, L. A., Yang, G. P., Morris, A. M. 2021; 273 (3): 606–12
  • Partners' engagement in surveillance among survivors of colorectal cancer: A qualitative study. Cancer medicine Veenstra, C. M., Acosta, J., Sharar, R., Hawley, S. T., Morris, A. M. 2021


    OBJECTIVES: Following treatment of Stage III colorectal cancer, guidelines recommend 3-5years of surveillance for recurrence. However, over half of the 1.2million U.S. survivors of colorectal cancer fail to receive guideline-concordant surveillance. In light of growing recognition that members of couples are interdependent and influence each other's health behaviors, we sought to describe, in their own words, the perspectives of spouses/partners on their engagement in patients' surveillance.METHODS: We conducted in-person, semi-structured interviews with 10 survivors of stage III colorectal cancer and their partners, together and separately. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes pertaining to partner engagement. Findings were validated through triangulation between study team members and triangulation between dyadic and individual interviews, and through an extensive search of transcripts for disconfirming evidence.RESULTS: We identified three overarching domains of partner engagement in surveillance. First, psychosocial engagement included promoting patient participation in surveillance, showing care and concern, and attending to partner self-care. Second, information-seeking and dyadic communication focused on gathering information, staying informed about test results, and communicating about surveillance. Third, instrumental engagement referred to any explicit, objective activities such as scheduling appointments, attending appointments, and managing responsibilities at home. Participants shared strategies, examples, and in some cases unmet needs.CONCLUSIONS: This study generated new, clinically meaningful knowledge about the ways in which partners engage in patients' surveillance. Opportunities to leverage partners as informal resources in surveillance include development of dyadic interventions to help partners engage most effectively.

    View details for DOI 10.1002/cam4.3725

    View details for PubMedID 33463029

  • Adjuvant Therapy for Stage II Colon Cancer: ASCO Guideline Update. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Baxter, N. N., Kennedy, E. B., Bergsland, E., Berlin, J., George, T. J., Gill, S., Gold, P. J., Hantel, A., Jones, L., Lieu, C., Mahmoud, N., Morris, A. M., Ruiz-Garcia, E., You, Y. N., Meyerhardt, J. A. 2021: JCO2102538


    To develop recommendations for adjuvant therapy for patients with resected stage II colon cancer.ASCO convened an Expert Panel to conduct a systematic review of relevant studies and develop recommendations for clinical practice.Twenty-one observational studies and six randomized controlled trials met the systematic review inclusion criteria.Adjuvant chemotherapy (ACT) is not routinely recommended for patients with stage II colon cancer who are not in a high-risk subgroup. Patients with T4 tumors are at higher risk of recurrence and should be offered ACT, whereas patients with other high-risk factors, including sampling of fewer than 12 lymph nodes in the surgical specimen, perineural or lymphatic invasion, poorly or undifferentiated tumor grade, intestinal obstruction, tumor perforation, or grade BD3 tumor budding, may be offered ACT. The addition of oxaliplatin to fluoropyrimidine-based ACT is not routinely recommended, but may be offered as a result of shared decision making. Patients with mismatch repair deficiency/microsatellite instability tumors should not be routinely offered ACT; if the combination of mismatch repair deficiency/microsatellite instability and high-risk factors results in a decision to offer ACT, oxaliplatin-containing chemotherapy is recommended. Duration of oxaliplatin-containing chemotherapy is also addressed, with recommendations for 3 or 6 months of treatment with capecitabine and oxaliplatin or fluorouracil, leucovorin, and oxaliplatin, with decision making informed by key evidence of 5-year disease-free survival in each treatment subgroup and the rate of adverse events, including peripheral neuropathy.Additional information is available at

    View details for DOI 10.1200/JCO.21.02538

    View details for PubMedID 34936379

  • 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

  • The Patient Perspective on Patient-Reported Outcome Measures Following Elective Hand Surgery: A Convergent Mixed-Methods Analysis. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Roe, A. K., Morris, A., Kamal, R. N. 2020


    PURPOSE: Patient-reported outcome measures (PROMs) have traditionally been used for research purposes, but are now being used to evaluate outcomes from the patient's perspective and inform ongoing management and quality of care. We used quantitative and qualitative approaches to evaluate the short-version Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Specific Functional Scale (PSFS) with regard to patient preference and measurement of patient goals and their responsiveness after treatment.METHODS: Patients 18 years or older undergoing elective hand surgery received the QuickDASH and PSFS questionnaires before and at 6 weeks after surgery. Two additional questions intended to elicit patients' preferences regarding the QuickDASH and PSFS were included. Responsiveness was measured by change in pre- to postoperative score. We analyzed patients' responses to the 2 additional questions to identify themes in PROM preferences. Results from the quantitative and qualitative analyses were combined into a convergent mixed-methods (eg, quantitative and qualitative) analysis.RESULTS: Thirty-eight patients completed preoperative questionnaires; 25 (66%) completed postoperative questionnaires. Seventeen patients (77%) preferred the PSFS, 3 (14%) had no preference, 2 (9%) preferred the QuickDASH. The average change from pre- to postoperative QuickDASH was -10 (SD, 20), and that of the PSFS was -27 (SD, 26). Ten patients (40%) reported QuickDASH score changes above the minimal clinically importance difference (MCID), 17 patients (68%) reported PSFS score changes above the MCID. Content analysis revealed 4 themes in preference for a PROM: instrument simplicity (ease of instrument understanding and completion), personalized assessment (individualization and relevance), goal directed (having measurable aims or objectives), distinct items (concrete or specific instrument items or functions).CONCLUSIONS: Most patients felt the PSFS better measured their goals because it is a simple, personalized instrument with distinct domains.CLINICAL RELEVANCE: Whereas standardized PROMs may better compare across populations, physicians, or conditions, employing PROMs that address patient-specific goals may better assess aspects of care most important to patients. A combination of these 2 types of PROMs can be used to assess outcomes and inform quality of care.

    View details for DOI 10.1016/j.jhsa.2020.09.008

    View details for PubMedID 33183858

  • A comparison of provider perspectives on cultural competency training: A mixed methods study. American journal of surgery Liu, M. M., Miller, M. O., Merrell, S. B., Bruce, J. S., Kin, C., Morris, A. M. 2020


    BACKGROUND: We aimed to identify differences in training among colorectal cancer physicians and advanced practice providers with high and low cultural competency METHODS: Using explanatory sequential mixed methods, we surveyed providers and dichotomized into high and low cultural competency (CC) groups, conducted qualitative interviews, and analyzed verbatim transcripts using deductive and inductive codes to compared findings across groups using a joint display.RESULTS: Fifty-four of 92 providers (59%) responded; 10 respondents from each group (20/36 invited) completed semi-structured interviews about previous CC trainings. Low CC providers' training included explanations of cultural differences that, in practice, improved awareness and utilization of communication tools, but they also desired decision-making tools and cultural exposure. High CC providers' training included action-oriented toolkits. In practice, they admitted failures, improved communication, and attributed patient behaviors to external factors. High CC providers desired performance evaluations.CONCLUSIONS: Behaviorally-oriented CC training offered a robust foundation for culturally competent care.

    View details for DOI 10.1016/j.amjsurg.2020.11.003

    View details for PubMedID 33220937

  • Outcome Metrics in the Treatment of Carpal Tunnel Syndrome: A Systematic Review. Hand (New York, N.Y.) Mertz, K., Lindsay, S. E., Morris, A., Kamal, R. N. 2020: 1558944720949951


    BACKGROUND: The purpose of this systematic review was to determine the metrics used to assess outcomes after treatment for carpal tunnel syndrome.METHODS: We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of level I and II randomized controlled trials of treatment for carpal tunnel syndrome. We searched the PubMed/MEDLINE electronic database for studies on treatment of carpal tunnel syndrome from January 2008 to January 2018. A total of 105 studies were included in the final analysis. The metrics used to assess outcomes in each studies were collected, compared, and described.RESULTS: Nearly all the studies used a patient-reported outcome measure (PROM) to assess outcomes (94%). The most common PROMs used were the Boston Carpal Tunnel Questionnaire (60%) and the Visual Analog Scale for pain (51%). Electrophysiological testing and physical examination were also commonly used to assess outcomes (50% and 46%, respectively). Cost, sleep, and return to activities of daily living were assessed in a minority of studies (1%, 1%, and 5%, respectively).CONCLUSIONS: Successful treatment of carpal tunnel syndrome is commonly defined based on a PROM, highlighting recent efforts to measure outcomes from the patient's perspective. Other patient-centered metrics such as return to work and sleep quality, however, were rarely reported, whereas objective measures such as nerve conduction studies were prevalent. Further work is needed to determine patients' preferred method of measuring outcomes after treatment for carpal tunnel syndrome to inform goal-directed decision-making and treatment.

    View details for DOI 10.1177/1558944720949951

    View details for PubMedID 33073583

  • A Deep Immune Profiling in Inflammatory Bowel Disease Reveals Disordered Immune Cell Frequencies Before and in Response to Major Abdominal Operations Rumer, K., Stanley, N., Ganio, E., Tsai, E., Kin, C., Shelton, A. A., Morris, A. M., Angst, M., Aghaeepour, N., Gaudilliere, B. ELSEVIER SCIENCE INC. 2020: S50
  • Development and characteristics of a multidisciplinary colorectal cancer clinic. American journal of surgery Vu, J. V., Morris, A. M., Maguire, L. H., De Roo, A. C., Mukkamala, A., Krauss, J. C., Regenbogen, S. E., Hendren, S., Hardiman, K. M. 2020


    BACKGROUND: Multidisciplinary cancer clinics deliver streamlined care and facilitate collaboration between specialties. We described patient volume and specialty service utilization, including surgery, of a multidisciplinary colorectal cancer clinic established at a tertiary care academic institution.METHODS: We conducted a retrospective observational cohort study of adult patients with colorectal adenocarcinoma from 2012 to 2017. We performed a descriptive analysis of patient volume, percentage of rectal cancer patients, and the number of patients who saw and received surgery, chemotherapy, and radiation each year.RESULTS: Over 5 years, 1711 patients were served at the multidisciplinary clinic. Patient volume increased 37%, from n=228 (annualized) to n=312. The percentage of rectal cancer patients increased from 29% in 2013 to 42% in 2017. The highest rate of utilization was for surgery; 792 (46%) patients had surgery at the multidisciplinary clinic institution, and 510 (30%) received chemotherapy there. Out of 635 rectal cancer patients, 114 (18%) received radiation there.CONCLUSIONS: Over the five-year experience of a colorectal cancer-focused multidisciplinary clinic, overall patient volume increased by 37%. Over the study period, 63% of patients seen at the multidisciplinary clinic ultimately received at least one treatment modality at the clinic institution. Overall, the clinic's establishment resulted in the increased referral of complex patients.

    View details for DOI 10.1016/j.amjsurg.2020.08.030

    View details for PubMedID 32943178

  • Gaps in Alcohol Screening and Intervention Practices in Surgical Healthcare: A Qualitative Study. Journal of addiction medicine Fernandez, A. C., Guetterman, T. C., Borsari, B., Mello, M. J., Mellinger, J., Tonnesen, H., Hosanagar, A., Morris, A. M., Blow, F. C. 2020


    OBJECTIVES: Risky alcohol use before surgery is associated with an increased risk of postoperative complications and longer hospital stays. Preoperative alcohol interventions can improve surgical outcomes but are not commonly integrated into routine care. This study sought to better understand patient's and provider's perceptions of alcohol-related surgical health and healthcare practices and illuminate gaps in care and how they could be improved.METHODS: This study used a descriptive qualitative research design. Data were collected between July 2017 and March 2018. One-on-one interviews assessed domains related to knowledge, gaps in alcohol-related screening and intervention, and interest in enhancing alcohol-related care. Key themes emerged from a process of iterative coding and thematic analysis.RESULTS: Participants included elective surgical patients who met alcohol screening criteria (n = 20) and surgical healthcare providers (n = 9). Participants had modest or low awareness of alcohol-related surgical health risks. Basic alcohol screening was a routine part of care, but results were often discounted or overlooked. Providers did not routinely initiate preoperative alcohol education or intervention. Providers viewed improving alcohol-related clinical practices as a low priority. Patients were interested in receiving alcohol interventions before surgery if they were delivered in a nonjudgement style and focused on surgical health optimization.CONCLUSIONS: This study highlights potential gaps in alcohol-related knowledge and care, and found providers place a low priority on alcohol interventions in the perioperative context. Given the high complication rate associated with preoperative alcohol use, these topics are worthy of future research. To be successful strategies to overcome specific barriers to alcohol screening and intervention must address the needs of patients and providers.

    View details for DOI 10.1097/ADM.0000000000000706

    View details for PubMedID 32769774

  • 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

  • IMMUNE PROFILING TO PREDICT RECOVERY OUTCOMES AFTER SURGERY Tsai, E. S., Rumer, K., Wong, K., Warrington, B., Shelton, E., Ganio, E., Verdonk, F., Ando, K., Tingle, M., Folk-Tolbert, M., Shankar, K., Shelton, A., Morris, A., Kirilcuk, N., Gurland, B., Kebebew, E., Kin, C., Angst, M. S., Aghaeepour, N., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2020: 66–67
  • A Multi-Center Randomized Controlled Trial of Perioperative Palliative care in Cancer Surgery (the PERIOP-PC trial) - Barriers and Opportunities for Palliative Care Trials in Surgical Settings Aslakson, R. A., Rickerson, E., Johnston, F., Fahy, B. N., Morris, A., Lorenz, K., Smith, T. J. LIPPINCOTT WILLIAMS & WILKINS. 2020: 759–61
  • Impact of the Affordable Care Act Insurance Marketplaces on Out-of-Pocket Spending Among Surgical Patients. Annals of surgery Liu, C., Maggard-Gibbons, M., Weiser, T. G., Morris, A. M., Tsugawa, Y. 2020


    OBJECTIVE: To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces ("Marketplaces") and financial protection for patients undergoing surgery.BACKGROUND: The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients' healthcare spending remains largely unknown.METHODS: We analyzed a nationally representative sample of adults aged 19-64 who underwent surgery in 2010-2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%-250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%-400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income.RESULTS: Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): -$1169 to -$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: -$1652 to -$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: -8.3 percentage points; 95% CI: -14.9 to -1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients.CONCLUSIONS: The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.

    View details for DOI 10.1097/SLA.0000000000003823

    View details for PubMedID 32221119

  • Dealing with your first complications: Strategies for anticipation, management, communication, and support SEMINARS IN COLON AND RECTAL SURGERY Morris, A. M., Shelton, A. A. 2020; 31 (1)
  • Palliative Care and End-of-Life Outcomes Following High-Risk Surgery. JAMA surgery Yefimova, M., Aslakson, R. A., Yang, L., Garcia, A., Boothroyd, D., Gale, R. C., Giannitrapani, K., Morris, A. M., Johanning, J. M., Shreve, S., Wachterman, M. W., Lorenz, K. A. 2020


    Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.Exposures: Palliative-care consultation within 30 days before or 90 days after surgery.Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P=.007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P=.004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P=.05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

    View details for DOI 10.1001/jamasurg.2019.5083

    View details for PubMedID 31895424

  • Checklist Compliance and Long-term Outcomes. Diseases of the colon and rectum Morris, A. M. 2020; 63 (1): 1–2

    View details for DOI 10.1097/DCR.0000000000001551

    View details for PubMedID 31804263

  • Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study. Diseases of the colon and rectum Bidwell, S. S., Merrell, S. B., Poles, G. n., Morris, A. M. 2020; 63 (2): 190–99


    The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports.The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer.This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews.The study was conducted at US medical centers.Colorectal surgeons were included.After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems.Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured.Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons.The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only.Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en (Traducción-Dr. Adrian E. Ortega).

    View details for DOI 10.1097/DCR.0000000000001518

    View details for PubMedID 31914112

  • A systematic review and meta-analysis of postoperative use of NSAIDs and risk of anastomotic leak. Canadian journal of surgery. Journal canadien de chirurgie Morris, A. M., Temple, L. n., Raval, M. n. 2020; 63 (4): E359–E361

    View details for DOI 10.1503/cjs.021419

    View details for PubMedID 32772524

  • Unmet Emotional Support Needs Among Diverse Patients with Colorectal Cancer. The American surgeon Kapadia, M. R., Veenstra, C. M., Davis, R. E., Hawley, S. T., Morris, A. M. 2020; 86 (6): 695–702


    Social support, which is partly emotional support, is associated with adherence to colorectal cancer (CRC) treatment, quality of life, and survival. We hypothesized that the needs, sources, and availability of emotional support would vary by race and income among CRC patients and sought to quantify the emotional support and the perceived adequacy of support reported by patients.We surveyed CRC patients from Detroit and Georgia Surveillance, Epidemiology and End Results registries about the quantity and quality of emotional support received from different sources. We tested differences using the chi-square test, t-tests, and logistic regression.There were 1909 patients who met inclusion criteria and 1301 (68%) completed surveys. Among respondents, 68% were white, 25% black, and 7% other. Black patients were more likely to be female and younger and reported lower annual income and education. Patients reported high support from several sources. Among those with a spouse/partner (58%), 95% reported high levels of support; however, older, black, female, or lower income patients were less likely to have spouses/partners (P < .001). Patients also endorsed high support from family (88.6%), important others (82.9%), and clinicians (71.3%). Black patients were less likely than white patients to report support that was "just right" (P < .001).Most patients reported high emotional support from at least 1 source. Black patients were most at risk for low support or unmet support needs. Spouse/partner support was important but only available to 58% of respondents. Patients at risk for unmet emotional support needs may benefit from additional support resources.

    View details for DOI 10.1177/0003134820923318

    View details for PubMedID 32683961

  • 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

  • Characteristics of Patients Seeking Second Opinions at a Multidisciplinary Colorectal Cancer Clinic. Diseases of the colon and rectum De Roo, A. C., Morris, A. M., Vu, J. V., Schuman, A. D., Abbott, K. L., Kandagatla, P. n., Hardiman, K. M., Hendren, S. n. 2020


    Patients seeking second opinions are a challenge for the colorectal cancer provider due to complexity, failed therapeutic relationship with another provider, need for reassurance, and desire for exploration of treatment options.To describe the patient and treatment characteristics of patients seeking initial and second opinions in colorectal cancer care at a multidisciplinary colorectal cancer clinic.Retrospective cohort study SETTINGS:: Prospectively collected clinical registry of a multidisciplinary colorectal cancer clinic.Patients with colon or rectal cancer seen from 2012-2017.Data were analyzed for initial vs. second opinion and demographic and clinical characteristics.Of 1711 colorectal cancer patients, 1008 (58.9%) sought an initial opinion, 700 (40.9%) sought a second opinion. As compared to initial opinion patients, second opinion patients were more likely to have Stage IV disease (OR 1.94, 95% CI 1.47-2.58), recurrent disease (OR 1.67, 95% CI 1.13-2.46), and be ages 40-49 (OR 1.47, 95% CI 1.02-2.12). Initial and second opinion cohorts were similar in terms of gender, race, and proportion of colon vs. rectal cancer. Among second opinion patients, 246 (35%) second opinion patients transitioned their care to the multidisciplinary colorectal cancer clinic.We were unable to capture final treatment plan for those patients who did not transfer care to the multidisciplinary colorectal cancer clinic.Patients seeking a second opinion represent a unique subset of colorectal cancer patients. In general, they are younger, and more likely to have Stage IV or recurrent disease than patients seeking an initial opinion. Although transfer of care to a multidisciplinary colorectal cancer clinic after second opinion is lower than for initial consultations, multidisciplinary colorectal cancer clinics provide an important role for patients with complex disease characteristics and treatment needs. See Video Abstract at

    View details for DOI 10.1097/DCR.0000000000001647

    View details for PubMedID 32109918

  • Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study. Diseases of the colon and rectum Kethman, W. C., Harris, A. H., Morris, A. M., Shelton, A., Kirilcuk, N., Kin, C. 2019


    BACKGROUND: Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes.OBJECTIVE: The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection.DESIGN: This is a multicenter, quasiexperimental cohort study using propensity score weighting.SETTINGS: Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.PATIENTS: Adult patients who underwent rectal cancer resection in 2016 were included.MAIN OUTCOME MEASURES: The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated.RESULTS: Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002).LIMITATIONS: This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings.CONCLUSIONS: Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at

    View details for DOI 10.1097/DCR.0000000000001534

    View details for PubMedID 31764247

  • 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

  • Surgical Decision-Making for Rectal Prolapse: One Size Does Not Fit All. Postgraduate medicine Lee, A., Kin, C., Syan, R., Morris, A., Gurland, B. 2019


    Background: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. Methods: 91 consecutive patients ≥18 years old diagnosed with external and/or high grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgement and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. Results: Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p<0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. Conclusions: With multiple options available for treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

    View details for DOI 10.1080/00325481.2019.1669330

    View details for PubMedID 31525304

  • A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC). Journal of palliative medicine Aslakson, R. A., Chandrashekaran, S. V., Rickerson, E., Fahy, B. N., Johnston, F. M., Miller, J. A., Conca-Cheng, A., Wang, S., Morris, A. M., Lorenz, K., Temel, J. S., Smith, T. J. 2019; 22 (S1): 44–57


    Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on (NCT03611309, First received: August 2, 2018).

    View details for DOI 10.1089/jpm.2019.0130

    View details for PubMedID 31486730

  • Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury JOURNAL OF SURGICAL RESEARCH Rosenberg, G. M., Shearer, E. J., Zion, S. R., Mackey, S. C., Morris, A. M., Spain, D. A., Weiser, T. G. 2019; 241: 277–84
  • For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection? ANNALS OF SURGICAL ONCOLOGY Halverson, A. L., Morris, A. M., Cleary, R. K., Chang, G. J. 2019; 26 (8): 2497–2506
  • Duration of Oxaliplatin-Containing Adjuvant Therapy for Stage III Colon Cancer: ASCO Clinical Practice Guideline JOURNAL OF CLINICAL ONCOLOGY Lieu, C., Kennedy, E. B., Bergsland, E., Berlin, J., George, T. J., Gill, S., Gold, P. J., Hantel, A., Jones, L., Mahmoud, N., Meyerhardt, J., Morris, A. M., Ruiz-Garcia, E., You, Y., Baxter, N. 2019; 37 (16): 1436-+
  • 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

  • Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients DISEASES OF THE COLON & RECTUM Sceats, L. A., Morris, A. M., Bundorf, M., Park, K. T., Kin, C. 2019; 62 (5): 586–94
  • Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study. Annals of surgery Coughran, A. J., Merrell, S. B., Pineda, C., Sceats, L. A., Yang, G. P., Morris, A. M. 2019


    OBJECTIVE: To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians.SUMMARY BACKGROUND DATA: STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians.METHODS: Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence.RESULTS: We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM.CONCLUSIONS: While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

    View details for PubMedID 31009390

  • Duration of Oxaliplatin-Containing Adjuvant Therapy for Stage III Colon Cancer: ASCO Clinical Practice Guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Lieu, C., Kennedy, E. B., Bergsland, E., Berlin, J., George, T. J., Gill, S., Gold, P. J., Hantel, A., Jones, L., Mahmoud, N., Meyerhardt, J., Morris, A. M., Ruiz-Garcia, E., You, Y. N., Baxter, N. 2019: JCO1900281


    PURPOSE: To develop recommendations for duration of adjuvant chemotherapy with a fluoropyrimidine and oxaliplatin for patients with completely resected stage III colon cancer based on the results of trials of 3 months compared with 6 months of treatment.METHODS: ASCO convened an Expert Panel and conducted a systematic review of relevant studies. The guideline recommendations were based on the review of evidence by the Expert Panel.RESULTS: Pooled data from the six International Duration Evaluation of Adjuvant Chemotherapy (IDEA) Collaboration randomized controlled trials comprise the evidence base for these guideline recommendations.RECOMMENDATIONS: The recommendations for therapy duration apply to patients with completely resected stage III colon cancer who are being offered adjuvant chemotherapy with oxaliplatin and a fluoropyrimidine. Recommendations are informed by the findings of a recent pooled analysis of clinical trials that compared 6 months versus 3 months of oxaliplatin-based chemotherapy. For patients at a high risk of recurrence (T4 and/or N2), adjuvant chemotherapy should be offered for a duration of 6 months. For patients at a low risk of recurrence (T1, T2, or T3 and N1), either 6 months of adjuvant chemotherapy or a shorter duration of 3 months may be offered on the basis of a potential reduction in adverse events and no significant difference in disease-free survival with the 3-month regimen. In determining duration of therapy, the Expert Panel recommends a shared decision-making approach, taking into account patient characteristics, values and preferences, and other factors and including a discussion of the potential for benefit and risks of harm associated with treatment duration. Additional information is available at .

    View details for PubMedID 30986117

  • Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections JOURNAL OF SURGICAL RESEARCH Kethman, W. C., Shelton, E. A., Kin, C., Morris, A. M., Shelton, A. A. 2019; 236: 340–44
  • Epidemiology, Pathophysiology, and Treatment of Diverticulitis GASTROENTEROLOGY Strate, L. L., Morris, A. M. 2019; 156 (5): 1282-+
  • 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

  • Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology Strate, L. L., Morris, A. M. 2019


    Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications, and guidelines now recommend antibiotics for only specific patients. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require more emergent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.

    View details for PubMedID 30660732

  • Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections. The Journal of surgical research Kethman, W. C., Shelton, E. A., Kin, C., Morris, A. M., Shelton, A. A. 2019; 236: 340–44


    BACKGROUND: Current procedural terminology (CPT) for colon and rectal surgery lacks procedural granularity and misclassification rates are unknown. However, they are used in performance measurement, for example, in surgical site infection (SSI). The objective of this study was to determine whether American College of Surgeons National Surgical Quality Improvement Program (NSQIP) abstraction methods accurately classify types of colorectal operations and, by extension, reported SSI rates.MATERIALS AND METHODS: This was a retrospective study conducted at a single tertiary care center. The colectomy- and proctectomy-targeted NSQIP database from January 2011 to July 2016 was used to perform a semiautomated reclassification (SAR) of all colectomy and proctectomy cases performed by colorectal surgeons. The primary outcome was the difference in perioperative SSI rates by case classification method.RESULTS: Thousand sixty-three patients underwent a colectomy or proctectomy during the study period with a mean age of 55.7 (SD=16.7) years. Use of the NSQIP classification scheme resulted in 849 colectomy and 214 proctectomy cases. Use of the SAR method resulted in 650 colectomy cases and 413 proctectomy cases (P<0.001), a 23.4% reclassification of colectomy cases. The group of cases classified as colectomy by SAR had a lower rate of deep/organ space infections than those classified as colectomy by NSQIP (4.5% versus 7.1%, P=0.034).CONCLUSIONS: These findings highlight the challenges of CPT code-based patient classification and subsequent outcomes analysis. Expanding the CPT system to more accurately represent colorectal operations would allow for more representative reported outcomes, thus enabling benchmarking and quality improvement.

    View details for PubMedID 30694775

  • Patient Decision-Making in Severe Inflammatory Bowel Disease: The Need for Improved Communication of Treatment Options and Preferences. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Lai, C. n., Sceats, L. n., Qiu, W. n., Park, K. T., Morris, A. M., Kin, C. n. 2019


    Patients with inflammatory bowel disease and their physicians must navigate ever-increasing options for treatment. The aim of this study was to elucidate the key drivers of treatment decision-making in inflammatory bowel disease.We conducted qualitative semi-structured in-person interviews of 20 adult patients undergoing treatment for inflammatory bowel disease at an academic medical centre who either recently initiated biologic therapy or underwent an operation or surgical evaluation. Interviews were audio-recorded, transcribed verbatim, iteratively coded, and discussed to consensus by five researchers. We used thematic analysis to explore factors influencing decision-making.Four major themes emerged as key drivers of treatment decision-making: perceived clinical state and disease severity, the patient-physician relationship, knowledge, attitudes, and beliefs about treatment options, and social isolation and stigma. Patients described experiencing a clinical turning point as the impetus for proceeding with a previously undesired treatment such as infusion medication or surgery. Patients reported delays in care or diagnosis, inadequate communication with their physicians, and lack of control over their disease management. Patients often stated that they considered surgery to be the treatment of last resort, which further compounded the complexity of making treatment decisions.Patients described multiple barriers to making informed and collaborative decisions about treatment, especially when considering surgical options. Our study reveals a need for more comprehensive communication between the patient and their physician about the range of medical and surgical treatment options. We recommend a patient-centred approach toward the decision-making process that accounts for patient decision-making preferences, causes of social stress, and clinical status. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/codi.14759

    View details for PubMedID 31295766

  • Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students. JAMA network open Bidwell, S. S., Miller, M. O., Lee, E. W., Yelorda, K. n., Koshy, S. n., Hawn, M. n., Morris, A. M. 2019; 2 (8): e199991

    View details for DOI 10.1001/jamanetworkopen.2019.9991

    View details for PubMedID 31441933

  • 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

  • Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients. Diseases of the colon and rectum Sceats, L. A., Morris, A. M., Bundorf, M. K., Park, K. T., Kin, C. n. 2019


    Sex-based treatment disparities occur in many diseases. Women undergo fewer procedural interventions, and their care is less consistent with guideline-based therapy. There is limited research exploring sex-based differences in ulcerative colitis treatment. We hypothesized that women are less likely to be treated with strategies consistent with long-term disease remission, including surgery and maintenance medications.The aim of this study was to determine if patient sex is associated with choice of treatment strategy for ulcerative colitis.This is a retrospective cohort analysis.Data were gathered from a large commercial insurance claims database (Truven MarketScan) from 2007 to 2015.We identified a cohort of 38,851 patients newly diagnosed with ulcerative colitis, aged 12 to 64 years with at least 1 year of follow-up.The primary outcomes measured were the differences between male and female patients in 1) rates and types of index ulcerative colitis operations, 2) rates and types of ulcerative colitis medication prescriptions, and 3) rates of opioid prescriptions.Men were more likely to undergo surgical treatment for ulcerative colitis (2.94% vs 1.97%, p < 0.001, OR 1.51, p < 0.001). The type of index operation performed did not vary by sex. Men were more likely to undergo treatment with maintenance medications, including biologic (12.4% vs 10.2%, p < 0.001, OR 1.22, p < 0.001), immunomodulatory (16.3% vs 14.9%, p < 0.001, OR 1.08, p = 0.006), and 5-aminosalicylate medications (67.0% vs 63.2%, p < 0.001, OR 1.18, p < 0.001). Women were more likely to undergo treatment with rescue therapies and symptomatic control with corticosteroids (55.5% vs 54.0%, p = 0.002, OR 1.07, p = 0.002) and opioids (50.2% vs 45.9%, p < 0.001, OR 1.17, p < 0.001).Claims data lack clinical characteristics acting as confounders.Men with ulcerative colitis were more likely to undergo treatment consistent with long-term remission or cure, including maintenance medications and definitive surgery. Women were more likely to undergo treatment consistent with short-term symptom management. Further studies to explore underlying mechanisms of sex-related differences in ulcerative colitis treatment strategies and disease trajectories are warranted. See Video Abstract at

    View details for PubMedID 30762599

  • Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury. The Journal of surgical research Rosenberg, G. M., Shearer, E. J., Zion, S. R., Mackey, S. C., Morris, A. M., Spain, D. A., Weiser, T. G. 2019; 241: 277–84


    Monitoring longitudinal patient-reported outcomes after injury is important for comprehensive trauma care. Current methodologies are resource-intensive and struggle to engage patients.Patients ≥18 y old admitted to the trauma service were prospectively enrolled. The following inclusion criteria were used: emergency operation, ICU length of stay ≥2 midnights, or hospital length of stay ≥4 d. Validated and customized questionnaires were administered using a novel internet-based survey platform. Three-month follow-up surveys were administered. Contextual field notes regarding barriers to enrollment/completion of surveys and challenges faced by participants were recorded.Forty-seven patients were eligible; 26 of 47 (55%) enrolled and 19 of 26 (73%) completed initial surveys. The final sample included 14 (74%) men and 5 (26%) women. Primary barriers to enrollment included technological constraints and declined participation. Contextual field notes revealed three major issues: competing hospital tasks, problems with technology, and poor engagement. The average survey completion time was 43 ± 27 min-21% found this too long. Seventy-four percent reported the system "easy to use" and 95% reported they would "very likely" or "definitely" respond to future surveys. However, 10 of 26 (38%) patients completed 3-mo follow-up.Despite a well-rated internet-based survey platform, study participation remained challenging. Lack of email access and technological issues decreased enrollment and the busy hospitalization posed barriers to completion. Despite a thoughtful operational design and implementation plan, the trauma population presented a challenging group to engage. Next steps will focus on optimizing engagement, broadening access to survey reminders, and enhancing integration into clinical workflows.

    View details for PubMedID 31042606

  • For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection? Annals of surgical oncology Halverson, A. L., Morris, A. M., Cleary, R. K., Chang, G. J. 2019


    The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer.A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed.The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection.Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.

    View details for PubMedID 31025228

  • Shared Decision Making in Appendicitis Treatment: Optimized, Standardized, or Usual Communication. JAMA network open Sceats, L. n., Kin, C. n., Morris, A. M. 2019; 2 (6): e194999

    View details for DOI 10.1001/jamanetworkopen.2019.4999

    View details for PubMedID 31173112

  • Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development'' ANNALS OF SURGERY Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2018; 268 (6): E52–E53
  • The Challenges of Providing Feedback to Referring Physicians After Discovering Their Medical Errors JOURNAL OF SURGICAL RESEARCH Dossett, L. A., Kauffmann, R. M., Miller, J., Jagsi, R., Lee, M., Morris, A. M., Quinn, G. P., Dimick, J. B. 2018; 232: 209–16
  • Surgeon Perspectives Regarding Death and Dying JOURNAL OF PALLIATIVE MEDICINE Dillon, B. R., Healy, M. A., Lee, C. W., Reichstein, A. C., Silveira, M. J., Morris, A. M., Suwanabol, P. A. 2019; 22 (2): 132–37
  • Surgeon Perspectives Regarding Death and Dying. Journal of palliative medicine Dillon, B. R., Healy, M. A., Lee, C. W., Reichstein, A. C., Silveira, M. J., Morris, A. M., Suwanabol, P. A. 2018


    BACKGROUND: Surgical patients most commonly receive palliative care services within 24-48 hours of death, and reasons for this delay are poorly understood. Research with nonsurgeons suggests that physician characteristics and beliefs about death and dying may contribute to late referral.OBJECTIVE: To describe surgeon perspectives related to death and dying, and their relationship with delayed referrals to palliative care.DESIGN: Using a previously validated survey instrument supplemented by open-ended questions, deductive content analysis was used to describe surgeon preferences for end-of-life care.SETTINGS: Participants were all current nonretired members of the American Society of Colon and Rectal Surgeons.MAIN OUTCOME MEASURES: Surgeon descriptions of a "good death" and how personal experiences influence care provided.RESULTS: Among 131 survey respondents (response rate 16.5%), 117 (89.3%) completed all or part of the qualitative portion of the survey. Respondents consistently reported their personal preferences for end-of-life care, and four central themes emerged: (1) pain and symptom management, (2) clear decision making, (3) avoidance of medical care, and (4) completion. Surgeons also reflected on both good and bad experiences with patients and family members dying, and how these experiences impact practice.LIMITATIONS: The small sample size inherent to Internet surveys may limit generalizability and contribute to selection bias.CONCLUSION: This study reveals surgeon preferences for end-of-life care, which may inform initiatives aimed at surgeons who may underuse or delay palliative care services. Future studies are needed to better understand how surgeon preferences may directly impact treatment recommendations for their patients.

    View details for PubMedID 30457430

  • 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

  • Common Issues in the Unique Environment of Global Surgical Health Services Research JAMA SURGERY Morris, A. M., Lee, C. 2018; 153 (11): 979–80
  • Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach? ANNALS OF SURGICAL ONCOLOGY Cleary, R. K., Morris, A. M., Chang, G. J., Halverson, A. L. 2018; 25 (12): 3587–95


    Compared with open surgery, minimally invasive surgery for colon cancer has been shown to improve short-term outcomes and yield equivalent long-term oncologic results. It remains to be seen if oncologic outcomes for the minimally invasive approach for rectal cancer are equivalent to traditional open rectal resection.We conducted a systematic review of Medline, SCOPUS, and Cochrane databases. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five key questions comparing minimally invasive and open oncologic outcomes for rectal cancer were specifically analyzed. A meta-analysis was not done due to heterogeneity of studies.Forty-five studies met inclusion criteria, including six randomized controlled trials. The laparoscopic approach to rectal resection was not more likely than the traditional open approach to have clear circumferential and distal margins, a complete total mesorectal excision grade, ≥ 12 lymph nodes in the resected specimen, reduced local recurrence rates, or reduced overall survival rates. Two randomized trials revealed that successful laparoscopic resection was not noninferior to open.Caution should be exercised when choosing surgical options for rectal cancer. Results of randomized trials could not prove that short-term oncologic outcomes of laparoscopic surgery were equivalent to those after open surgery even when performed by surgeons with laparoscopic expertise. However, reported long-term data have not shown a difference in outcomes between laparoscopic and open surgery. Future advances in minimally invasive technology may improve oncologic margins but these will require careful study and scrutiny.

    View details for PubMedID 30187281

  • Life After Surgery: Surgeon Assessments of Quality of Life Among Patients With Familial Adenomatous Polyposis DISEASES OF THE COLON & RECTUM Dossa, F., Morris, A. M., Wilson, A. R., Baxter, N. N. 2018; 61 (10): 1217–22


    Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers.We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis.We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis.Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons.Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch.Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02).This study was limited by the sample size.For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at

    View details for PubMedID 30192330

  • Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Knowlton, L. M., Morris, A. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018; 227 (2): 172–80
  • Lost in translation: Informed consent in the medical mission setting. Surgery Sceats, L. A., Morris, A. M., Narayan, R. R., Mezynski, A., Woo, R. K., Yang, G. P. 2018


    BACKGROUND: Informed consent is a fundamental tenet of ethical care, but even under favorable conditions, patient comprehension of consent conversations may be limited. Little is known about providing informed consent in more uncertain situations such as medical missions. We sought to examine the informed consent process in the medical mission setting.METHODS: We studied informed consent for adult patients undergoing inguinal herniorrhaphy during a medical mission to Guatemala using a convergent mixed-methods design. We audiotaped informed consents during preoperative visits and immediately conducted separate surveys to elicit comprehension of risks. Informed consent conversations and survey responses were translated and transcribed. We used descriptive statistics to examine informed consent content, including information provided by surgeon, the translation of information, and patient comprehension, and used thematic analysis to examine the consent process.RESULTS: Thirteen adult patients (median age 53 years, 69% male) participated. Surgeons conveyed 4 standard risks in 10 out of 13 encounters (77%); all 4 risks were translated to patients in 10 out of 13 encounters (77%). No patient could recall all 4 risks. Qualitative themes regarding the informed consent process included limited physician language skills, verbal domination by physicians and interpreters, and mistranslation of risks. Patients relied on faith and prior or vicarious experiences to qualify surgical risks instead of consent conversations. Many patients restated surgical instructions when asked about risks.CONCLUSION: Despite physicians' attempts to provide informed consent, medical mission patients did not comprehend surgical risks. Our data reveal a critical need to develop more effective methods for communicating surgical risks during medical missions.

    View details for PubMedID 30061041

  • Common Issues in the Unique Environment of Global Surgical Health Services Research. JAMA surgery Morris, A. M., Lee, C. N. 2018

    View details for PubMedID 30046811

  • The Effect of Peer Support on Colorectal Cancer Patients' Adherence to Guideline-Concordant Multidisciplinary Care DISEASES OF THE COLON & RECTUM Kanters, A. E., Morris, A. M., Abrahamse, P. H., Mody, L., Suwanabol, P. A. 2018; 61 (7): 817–23


    Multidisciplinary care is critical for the successful treatment of stage III colorectal cancer, yet receipt of adjuvant chemotherapy remains unacceptably low. Peer support, or exposure to others treated for colorectal cancer, has been proposed as a means to improve patient acceptance of cancer care.The purpose of our study was to evaluate the effect of peer support on the attitudes of patients with colorectal cancer toward chemotherapy and their adherence to it.We conducted a population-based survey of patients with sage III colorectal cancer and compared demographics and adjuvant chemotherapy adherence after patient-reported exposure to peer support.Patients were identified by using Surveillance, Epidemiology, and End Results Program cancer registries and were recruited 3 to 12 months after cancer resection.All patients with stage III colorectal cancer who underwent colorectal resection between 2011 and 2013 and were located in the Detroit and Georgia regions were included.The main outcome measure was adjuvant chemotherapy adherence. Exposure to peer support was an intermediate outcome.Among 1301 patient respondents (68% response rate), 48% reported exposure to peer support. Exposure to peer support was associated with younger age, higher income, and having a spouse or domestic partner. Exposure to peer support was significantly associated with receipt of adjuvant chemotherapy (OR, 2.94; 95% CI, 1.89-4.55). Those exposed to peer support reported positive effects on attitudes toward chemotherapy.This study has limitations inherent to survey research including the potential lack of generalizability and responses that are subject to recall bias. Additionally, the survey results do not allow for determination of the temporal relationship between peer support exposure and receipt of chemotherapy.Our study demonstrates that exposure to peer support is associated with higher adjuvant chemotherapy adherence. These data suggest that facilitated peer support programs could positively influence patient expectations and coping with diagnosis and treatment, thereby affecting the uptake of postoperative chemotherapy. See Video Abstract at

    View details for PubMedID 29771795

    View details for PubMedCentralID PMC5992023

  • Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors ANNALS OF SURGERY Dossett, L. A., Kauffmann, R. M., Lee, J. S., Singh, H., Lee, M., Morris, A. M., Jagsi, R., Quinn, G. P., Dimick, J. B. 2018; 267 (6): 1077–83


    Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors.Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral.We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure.Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships.Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

    View details for DOI 10.1097/SLA.0000000000002427

    View details for Web of Science ID 000434301200021

    View details for PubMedID 28742712

  • Precision Medicine Versus Population Medicine in Colon Cancer: From Prospects of Prevention, Adjuvant Chemotherapy, and Surveillance. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting Hall, M. J., Morris, A. M., Sun, W. 2018: 220–30


    With the advances of technologic revolution that provides new insights into human biology, genetics and cancer, as well as advantages of big data which amasses large amounts of information for us to approach cancer treatment and prevention, we are facing challenges of organically combining data from studies based on general population and information from individual testing and setting out precisional recommendations in cancer diagnosis, prevention, and treatment. We are obligated to accelerate the adaptation of new scientific discoveries into effective treatments and prevention for cancer. In this review, we introduce our opinions on bringing knowledge of precision and population medicine together to guide our clinical practice from the prospects of colorectal cancer prevention, stage III colon cancer adjuvant therapy, and postsurgery surveillance.

    View details for PubMedID 30231337

  • Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals. Journal of the American College of Surgeons Knowlton, L. M., Morris, A. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018


    BACKGROUND: Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability.STUDY DESIGN: We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin.RESULTS: California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n= 4) and nonprofit-owned SNHs (64%, n= 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p<0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively.CONCLUSIONS: The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.

    View details for PubMedID 29680414

  • Characterizing the Role of US Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Suwanabol, P. A., Kanters, A. E., Reichstein, A. C., Wancata, L. M., Dossett, L. A., Rivet, E. B., Silveira, M. J., Morris, A. M. 2018; 55 (4): 1196-+


    The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear.We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients.We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings.A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers.Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.

    View details for PubMedID 29221845

  • Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society JOURNAL OF PALLIATIVE MEDICINE Suwanabol, P. A., Reichstein, A. C., Suzer-Gurtekin, Z., Forman, J., Silveira, M. J., Mody, L., Morris, A. M. 2018: 780–88


    Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care.To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs.This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions.Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons.Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified.Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources.Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias.Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.

    View details for PubMedID 29649396

  • Employment benefits and job retention: evidence among patients with colorectal cancer CANCER MEDICINE Veenstra, C. M., Abrahamse, P., Wagner, T. H., Hawley, S. T., Banerjee, M., Morris, A. M. 2018; 7 (3): 736–45


    A "health shock," that is, a large, unanticipated adverse health event, can have long-term financial implications for patients and their families. Colorectal cancer is the third most commonly diagnosed cancer among men and women and is an example of a specific health shock. We examined whether specific benefits (employer-based health insurance, paid sick leave, extended sick leave, unpaid time off, disability benefits) are associated with job retention after diagnosis and treatment of colorectal cancer. In 2011-14, we surveyed patients with Stage III colorectal cancer from two representative SEER registries. The final sample was 1301 patients (68% survey response rate). For this study, we excluded 735 respondents who were not employed and 20 with unknown employment status. The final analytic sample included 546 respondents. Job retention in the year following diagnosis was assessed, and multivariable logistic regression was used to evaluate associations between job retention and access to specific employment benefits. Employer-based health insurance (OR = 2.97; 95% CI = 1.56-6.01; P = 0.003) and paid sick leave (OR = 2.93; 95% CI = 1.23-6.98; P = 0.015) were significantly associated with job retention, after adjusting for sociodemographic, clinical, geographic, and job characteristics.

    View details for PubMedID 29473344

  • Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development". Annals of surgery Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2017

    View details for PubMedID 29064907

  • Surgery for diverticulitis in the 21(st) century: recent evidence MINERVA GASTROENTEROLOGICA E DIETOLOGICA Morris, A. M., Kin, C. 2017; 63 (2): 158–62
  • The Primary Care Provider (PCP)-Cancer Specialist Relationship: A Systematic Review and Mixed-Methods Meta-Synthesis CA-A CANCER JOURNAL FOR CLINICIANS Dossett, L. A., Hudson, J. N., Morris, A. M., Lee, M. C., Roetzheim, R. G., Fetters, M. D., Quinn, G. P. 2017; 67 (2): 156-169


    Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

    View details for DOI 10.3322/caac.21385

    View details for Web of Science ID 000395701500007

    View details for PubMedCentralID PMC5342924

  • Surgery for diverticulitis in the 21st century: recent evidence. Minerva gastroenterologica e dietologica Morris, A. M., Kin, C. 2017


    Sigmoid diverticulitis is an increasingly common disease in Western countries. As technology has led to increased knowledge about the disease and options for treatment, management strategies have become less certain. In previous years, the rationale for early elective surgery was largely preventive, due to concern that diverticulitis recurrence would result in increased risk of sepsis or the need for a colostomy. New technology has enabled diagnosis, through computed tomography scans, predictive information through clinical and administrative databases, and less invasive treatment options, through laparoscopic techniques. While the new data have mitigated outdated beliefs regarding recurrence prevention strategies, there is little to replace previous guidelines for care. For example, we lack clear guidelines for whether and when to use percutaneous drainage, intra-peritoneal lavage, minimally invasive techniques, and fecal diversion via ostomy. Fortunately, several newly published high impact studies attempt to address these more nuanced questions. In this paper, we review available findings and potential for use of the data from recent surgical randomized controlled trials. It is important to note that controlling sepsis when present remains the most important goal of treatment.

    View details for DOI 10.23736/S1121-421X.17.02389-3

    View details for PubMedID 28240005

  • Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation. Surgery Nikolian, V. C., Kamdar, N. S., Regenbogen, S. E., Morris, A. M., Byrn, J. C., Suwanabol, P. A., Campbell, D. A., Hendren, S. n. 2017


    Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m(2), tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 10(9)/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.

    View details for DOI 10.1016/j.surg.2016.12.033

    View details for PubMedID 28238345

  • Cultural challenges to engaging patients in shared decision making PATIENT EDUCATION AND COUNSELING Hawley, S. T., Morris, A. M. 2017; 100 (1): 18-24


    Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.

    View details for DOI 10.1016/j.pec.2016.07.008

    View details for Web of Science ID 000391224200006

    View details for PubMedCentralID PMC5164843

  • Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the colon & rectum Vogel, J. D., Johnson, E. K., Morris, A. M., Paquette, I. M., Saclarides, T. J., Feingold, D. L., Steele, S. R. 2016; 59 (12): 1117-1133

    View details for PubMedID 27824697

  • The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis. CA: a cancer journal for clinicians Dossett, L. A., Hudson, J. N., Morris, A. M., Lee, M. C., Roetzheim, R. G., Fetters, M. D., Quinn, G. P. 2016


    Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

    View details for DOI 10.3322/caac.21385

    View details for PubMedID 27727446

  • Shared Decision Making for Rectal Cancer Care: A Long Way Forward. Diseases of the colon & rectum Morris, A. M. 2016; 59 (10): 905-906

    View details for DOI 10.1097/DCR.0000000000000663

    View details for PubMedID 27602920

  • Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians PSYCHO-ONCOLOGY Morris, A. M., Doorenbos, A. Z., Haozous, E., Meins, A., Javid, S., Flum, D. R. 2016; 25 (9): 1050-1056


    American Indian/Alaska Native (AI/AN) patients are significantly less likely than non-Hispanic whites to receive guideline-concordant cancer care. Our objective was to examine cancer treatment decision making among AI/AN patients and their providers.From 2011 to 2014, AI/AN cancer patients and their surgeons were identified through a hospital registry in Washington State. Patients were invited to participate in a mailed survey that queried socio-demographics, cultural affiliation, everyday perceived discrimination, and trust in providers. Both patients and surgeons were queried about decision-making quality (collaboration and satisfaction). The primary outcome was association between patient and provider assessments of decision-making quality. The secondary outcome was non-adherence to treatment.Forty-nine patients (62% response rate) and 14 surgeons (37% response rate) returned surveys. Half of patients had not completed high school; 41% were living in poverty. Half of patients reported a strong tribal affiliation and most reported experiencing some form of discrimination. Patients endorsed high trust in surgeons and a high quality decision-making process; and surgeons' rated decision-making quality even more highly than patients did in every domain. Non-adherence to treatment recommendations was common (26%) and was significantly associated with lower patient-reported collaboration and satisfaction with decision making.Given the importance of adherence to cancer treatment for survival, the many non-clinical reasons for non-adherence, and the currently demonstrated association between decision-making quality and adherence, it would be worthwhile to investigate how to increase AI/AN patient satisfaction with decision making and whether improving satisfaction yields improved adherence to the cancer treatment plan. Copyright © 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.

    View details for DOI 10.1002/pon.4191

    View details for Web of Science ID 000385722700006

    View details for PubMedID 27279001

    View details for PubMedCentralID PMC5014590

  • Cancer Journey for American Indians and Alaska Natives in the Pacific Northwest ONCOLOGY NURSING FORUM Haozous, E. A., Doorenbos, A., Alvord, L. A., Flum, D. R., Morris, A. M. 2016; 43 (5): 625-635


    To describe the experiences of American Indian and Alaska Native cancer survivors to improve understanding of the trajectory of cancer treatment. .Qualitative focus group research..Rural and geographically isolated American Indian and Alaska Native communities in the Pacific Northwest..30 American Indian and Alaska Native cancer survivors or caregivers. .The authors analyzed data from two focus groups with cancer survivors by using thematic analysis informed by indigenous methodologies..Based on focus group findings, the authors developed a conceptual model of the cancer experience called Rough Waters. Participants described their cancer experience as a collective journey involving family and friends and requiring resources to offset challenges along the way. Dominant themes were delays, isolation, communication, money, advocacy, spirituality, and family involvement..American Indians and Alaska Natives in the Pacific Northwest have special cultural needs during cancer care. The current study provides examples that can guide patient-provider interactions..Using the metaphor of cancer as a journey, clinicians can begin a dialogue to identify what will impede or assist the cancer journey for their American Indian and Alaska Native patients.

    View details for DOI 10.1188/16.ONF.625-635

    View details for Web of Science ID 000382298000015

    View details for PubMedID 27541555

  • Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure JOURNAL OF SURGICAL RESEARCH Sheetz, K., Hemmila, M. R., Duby, A., Krapohl, G., Morris, A., Campbell, D. A., Hendren, S. 2016; 205 (1): 108-114


    Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates.We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions.A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications.Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.

    View details for DOI 10.1016/j.jss.2016.05.017

    View details for Web of Science ID 000383360300015

    View details for PubMedID 27621006

  • Evaluating disparities in inpatient surgical cancer care among American Indian/Alaska Native patients AMERICAN JOURNAL OF SURGERY Simianu, V. V., Morris, A. M., Varghese, T. K., Porter, M. P., Henderson, J. A., Buchwald, D. S., Flum, D. R., Javid, S. H. 2016; 212 (2): 297-304


    American Indian/Alaska Native (AI/AN) patients with cancer have the lowest survival rates of all racial and ethnic groups, possibly because they are less likely to receive "best practice" surgical care than patients of other races.Prospective cohort study comparing adherence with generic and cancer-specific guidelines on processes of surgical care between AI/AN and non-Hispanic white (NHW) patients in Washington State (2010 to 2014) was conducted.A total of 156 AI/AN and 6,030 NHW patients underwent operations for 10 different cancers, and had similar mean adherence to generic surgical guidelines (91.5% vs 91.9%, P = .57). AI/AN patients with breast cancer less frequently received preoperative diagnostic core needle biopsy (81% vs 94%, P = .004). AI/AN patients also less frequently received care adherent to prostate cancer-specific guidelines (74% vs 92%, P = .001).Although AI/ANs undergoing cancer operations in Washington receive similar overall best practice surgical cancer care to NHW patients, there remain important, modifiable disparities that may contribute to their lower survival.

    View details for DOI 10.1016/j.amjsurg.2015.10.030

    View details for Web of Science ID 000382234300016

    View details for PubMedID 26846176

    View details for PubMedCentralID PMC4939142

  • Cultural challenges to engaging patients in shared decision making. Patient education and counseling Hawley, S. T., Morris, A. M. 2016


    Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.

    View details for DOI 10.1016/j.pec.2016.07.008

    View details for PubMedID 27461943

  • Development of The American Society of Colon and Rectal Surgeons' Rectal Cancer Surgery Checklist DISEASES OF THE COLON & RECTUM Glasgow, S. C., Morris, A. M., Baxter, N. N., Fleshman, J. W., Alavi, K. S., Luchtefeld, M. A., Monson, J. R., Chang, G. J., Temple, L. K. 2016; 59 (7): 601-606


    There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality.The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer.A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed.The study was conducted through meetings and discussion to consensus.Patient data were extracted from an initial literature review.The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases.The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery.The study was limited by its lack of prospective validation.The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.

    View details for DOI 10.1097/DCR.0000000000000606

    View details for PubMedID 27270511

  • Assessing Cultural Competence Among Oncology Surgeons. Journal of oncology practice Doorenbos, A. Z., Morris, A. M., Haozous, E. A., Harris, H., Flum, D. R., Doorenbos, A. Z., Morris, A. M., Haozous, E. A., Harris, H., Flum, D. R. 2016; 12 (1): 61-?


    Racial and ethnic minority groups in the United States have the highest mortality rates for the most common cancers. Various factors, including a perceived lack of culturally congruent care and culturally competent providers, might lead minority patients to decline or delay care. As part of a large multimethod study to understand barriers to care among American Indian and Alaskan native patients with cancer, we examined surgical provider attributes associated with culturally congruent care.Surgical providers from six hospitals in the Puget Sound region of Washington State were invited to participate. Participants completed a 50-item survey that assessed demographic data and incorporated the Cultural Competence Assessment (CCA) and the Marlowe-Crowne Social Desirability Scale.Survey response rate was 51.1% (N = 253). Participants reported treating diverse patient populations; 71% encountered patients from six or more racial and ethnic groups. More than one half of participants (58%) reported completing cultural diversity training, with employer-sponsored training being the most common type reported (48%; 71 of 147). CCA scores ranged from 5.99 to 13.75 of a possible 14 (mean, 10.3; standard deviation, ±1.3), and receipt of diversity training was associated with higher scores than nonreceipt of diversity training (10.56 v 9.82, respectively; P<.001). After controlling for Marlowe-Crowne Social Desirability Scale score and hospital system,participation in diversity training was the variable most significantly associated with CCA score (P<.001).Culturally competent care is an essential but often overlooked component of high-quality health care. Future work should compare training offered by various hospital systems.

    View details for DOI 10.1200/JOP.2015.006932

    View details for PubMedID 26759469

    View details for PubMedCentralID PMC4960461

  • Rational vs. Intuitive Judgment in Surgical Decision Making. Annals of surgery Morris, A. M. 2016; 264 (6): 887–88

    View details for PubMedID 27828817

  • Association of Paid Sick Leave With Job Retention and Financial Burden Among Working Patients With Colorectal Cancer JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Veenstra, C. M., Regenbogen, S. E., Hawley, S. T., Abrahamse, P., Banerjee, M., Morris, A. M. 2015; 314 (24): 2688-2690

    View details for Web of Science ID 000366939800025

    View details for PubMedID 26717032

  • Potential Biases Introduced by Conflating Screening and Diagnostic Testing in Colorectal Cancer Screening Surveillance CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Becker, E. A., Griffith, D. M., West, B. T., Janz, N. K., Resnicow, K., Morris, A. M. 2015; 24 (12): 1850-1854


    Screening and postsymptomatic diagnostic testing are often conflated in cancer screening surveillance research. We examined the error in estimated colorectal cancer screening prevalence due to the conflation of screening and diagnostic testing.Using data from the 2008 National Health Interview Survey, we compared weighted prevalence estimates of the use of all testing (screening and diagnostic) and screening in at-risk adults and calculated the overestimation of screening prevalence across sociodemographic groups.The population screening prevalence was overestimated by 23.3%, and the level of overestimation varied widely across sociodemographic groups (median, 22.6%; mean, 24.8%). The highest levels of overestimation were in non-Hispanic white females (27.4%), adults ages 50-54 years (32.0%), and those with the highest socioeconomic vulnerability [low educational attainment (31.3%), low poverty ratio (32.5%), no usual source of health care (54.4%), and not insured (51.6%); all P < 0.001].When the impetus for testing was not included, colorectal cancer screening prevalence was overestimated, and patterns of overestimation often aligned with social and economic vulnerability. These results are of concern to researchers who use survey data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess cancer screening behaviors, as it is currently not designed to distinguish diagnostic testing from screening.Surveillance research in cancer screening that does not consider the impetus for testing risks measurement error of screening prevalence, impeding progress toward improving population health. Ultimately, to craft relevant screening benchmarks and interventions, we must look beyond "what" and "when" and include "why."

    View details for DOI 10.1158/1055-9965.EPI-15-0359

    View details for Web of Science ID 000366129100006

    View details for PubMedID 26491056

    View details for PubMedCentralID PMC4670579

  • Laparoscopic peritoneal lavage for perforated diverticulitis: in search of evidence LANCET Morris, A. M. 2015; 386 (10000): 1219-1221
  • Putting the Integration Into Integrated Health Care Systems JOURNAL OF CLINICAL ONCOLOGY Morris, A. M. 2015; 33 (8): 821-?

    View details for DOI 10.1200/JCO.2014.59.6015

    View details for Web of Science ID 000356055600006

    View details for PubMedID 25624433

  • MLH1 promotor hypermethylation does not rule out a diagnosis of Lynch syndrome: a case report FAMILIAL CANCER Raymond, V. M., Morris, A. M., Hafez, K. S., Greenson, J. K. 2015; 14 (1): 77-80


    There are approximately 136,830 new colorectal cancer (CRC) cases diagnosed annually in the United States. In an effort to identify those at highest risk for Lynch Syndrome, an inherited CRC predisposition syndrome, several professional guidelines advocate for routine screening of all colorectal adenocarcinomas for features of DNA mismatch repair, microsatellite instability (MSI) and/or absent immunohistochemistry staining. Approximately 12-17 % of CRCs demonstrate MSI with germline mutations in genes involved in DNA mismatch repair, MLH1, MSH2, MSH6, PMS2 and TACSTD1/EPCAM and somatic MLH1 promotor hypermethylation being alternative pathways for the development of microsatellite unstable CRC. It is important to distinguish between these two events as the underlying cause of cancer development as management and implications for the patient and family members vary significantly. We describe a patient with multiple primary cancers, a deleterious germline MSH6 mutation and somatic MLH1 promotor hypermethylation highlighting the importance of incorporating the clinical history with the genetic evaluation.

    View details for DOI 10.1007/s10689-014-9753-0

    View details for Web of Science ID 000351171000010

    View details for PubMedID 25213678

  • A Composite Measure of Personal Financial Burden Among Patients With Stage III Colorectal Cancer MEDICAL CARE Veenstra, C. M., Regenbogen, S. E., Hawley, S. T., Griggs, J. J., Banerjee, M., Kato, I., Ward, K. C., Morris, A. M. 2014; 52 (11): 957-962


    Despite improved survival with chemotherapy for stage III colorectal cancer (CRC), patients may suffer substantial economic hardship during treatment. Methods for quantifying financial burden in CRC patients are lacking.To derive and validate a novel patient-reported measure of personal financial burden during CRC treatment.Within a population-based survey of patients in the Detroit and Georgia Surveillance, Epidemiology and End Results regions diagnosed with stage III CRC between 2011 and 2013, we asked 7 binary questions assessing effects of disease and treatment on personal finances.We used factor analysis to compute a composite measure of financial burden. We used χ tests to evaluate relationships between individual components of financial burden and chemotherapy use with χ analyses. We used Mantel-Haenszel χ trend tests to examine relationships between the composite financial burden metric and chemotherapy use.Among 956 patient surveys (66% response rate), factor analysis of 7 burden items yielded a single-factor solution. Factor loadings of 6 items were >0.4; these were included in the composite score. Internal consistency was high (Cronbach α=0.79). The mean financial burden score among all respondents was 1.72 (range, 0-6). The 812 (85%) who reported chemotherapy use had significantly higher financial burden scores than those who did not (mean burden score 1.88 vs. 0.88, P<0.001).Financial burden is high among CRC patients, particularly those who use adjuvant chemotherapy. We encourage use of our instrument to validate our measure in the identification of patients in need of additional financial support during treatment.

    View details for Web of Science ID 000343930300004

    View details for PubMedID 25304021

    View details for PubMedCentralID PMC4270346

  • The Effect of Care Setting in the Delivery of High-Value Colon Cancer Care CANCER Veenstra, C. M., Epstein, A. J., Liao, K., Morris, A. M., Pollack, C. E., Armstrong, K. A. 2014; 120 (20): 3237-3244


    The effect of care setting on value of colon cancer care is unknown.A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File.Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001).Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.

    View details for DOI 10.1002/cncr.28874

    View details for Web of Science ID 000342908800020

    View details for PubMedID 24954628

    View details for PubMedCentralID PMC4325980

  • The Personal Financial Burden of Complications After Colorectal Cancer Surgery CANCER Regenbogen, S. E., Veenstra, C. M., Hawley, S. T., Banerjee, M., Ward, K. C., Kato, I., Morris, A. M. 2014; 120 (19): 3074-3081


    Patients with colorectal cancer (CRC) may suffer significant economic hardship during treatment. Complications are common after surgery for CRC and may exacerbate the financial burden of CRC even further.Within a population-based survey of patients with stage III CRC, the authors investigated the effects of disease and treatment on personal finances and computed a composite measure of financial burden. Correlations were examined between components of financial burden and patient-reported postoperative complications using chi-square analyses, and Mantel-Haenszel chi-square tend tests were used to evaluate correlations between composite financial burden scores and surgical complications, controlling for patient characteristics and other factors by using multivariable Poisson regression.Among 937 respondents, 224 (24%) reported complications after surgery. Those with complications had significantly higher composite financial burden (P < .001 for trend): they were more likely to spend savings (40% vs 31%; P  = .01), borrow or take loans (18% vs 11%; P = .007), fail to make credit card payments (18% vs 11%; P = .005), reduce spending for food or clothes (38% vs 27%; P = .001), and decrease recreational activities (41% vs 33%; P = .03). They took significantly longer to return to work (P  = .009) and were more likely to experience significant worry about finances (61% vs 52%; P = .01).Complications after surgery for CRC result in significant personal financial consequences as well as morbidity. Financial stress impairs quality of life and may prevent adherence to recommended treatments. Therefore, patients who suffer complications may require not just additional clinical care but also economic support and services.

    View details for DOI 10.1002/cncr.28812

    View details for Web of Science ID 000342630000021

    View details for PubMedID 24889014

  • Expanding the NCCN guidelines for distress management: a model of barriers to the use of coping resources. The Journal of community and supportive oncology Allen, J. O., Zebrack, B., Wittman, D., Hammelef, K., Morris, A. M. 2014; 12 (8): 271-277


    Cancer-related distress impacts quality of care, resource use, and patient outcomes. Patients are increasingly screened for distress, yet many do not receive coping resources and psychosocial support services that may help to reduce their distress. Distress screening must be paired with attention to the different phases of the distress and coping process, with emphasis on barriers and facilitators of cancer patients' use of coping resources. This paper offers a conceptual model illustrating key pathways and modifying factors of distress and use of coping resources among cancer patients, and potential roles for cancer care providers and institutions in facilitating effective coping and distress reduction. Building on a review of relevant empirical and theoretical literature, we developed a conceptual model that integrates concepts from Stress and Coping Theory into the National Comprehensive Cancer Network's guidelines for Distress Management. We found that barriers and facilitating factors that may inhibit receipt of coping resources and services to reduce cancer-related distress include health and cancer beliefs, accessibility and acceptability, the role of caregivers in cancer treatment, coordination of care, and the quality of patient-provider relationships. Herein, we highlight largely modifable factors that can infuence the successful uptake of coping resources and services to reduce distress among cancer patients. We conclude with recommendations for how cancer care providers and systems can better identify and address barriers to the use of distress reduction resources and support services.

    View details for PubMedID 25372363

  • Guideline-Concordant Cancer Care and Survival Among American Indian/Alaskan Native Patients CANCER Javid, S. H., Varghese, T. K., Morris, A. M., Porter, M. P., He, H., Buchwald, D., Flum, D. R. 2014; 120 (14): 2183-2190


    American Indians/Alaskan Natives (AI/ANs) have the worst 5-year cancer survival of all racial/ethnic groups in the United States. Causes for this disparity are unknown. The authors of this report examined the receipt of cancer treatment among AI/AN patients compared with white patients.This was a retrospective cohort study of 338,204 patients who were diagnosed at age ≥65 years with breast, colon, lung, or prostate cancer between 1996 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare database. Nationally accepted guidelines for surgical and adjuvant therapy and surveillance were selected as metrics of optimal, guideline-concordant care. Treatment analyses compared AI/ANs with matched whites.Across cancer types, AI/ANs were less likely to receive optimal cancer treatment and were less likely to undergo surgery (P ≤ .025 for all cancers). Adjuvant therapy rates were significantly lower for AI/AN patients with breast cancer (P < .001) and colon cancer (P = .001). Rates of post-treatment surveillance also were lower among AI/ANs and were statistically significantly lower for AI/AN patients with breast cancer (P = .002) and prostate cancer (P < .001). Nonreceipt of optimal cancer treatment was associated with significantly worse survival across cancer types. Disease-specific survival for those who did not undergo surgery was significantly lower for patients with breast cancer (hazard ratio [HR], 0.62), colon cancer (HR, 0.74), prostate cancer (HR, 0.52), and lung cancer (HR, 0.36). Survival rates also were significantly lower for those patients who did not receive adjuvant therapy for breast cancer (HR, 0.56), colon cancer (HR, 0.59), or prostate cancer (HR, 0.81; all 95% confidence intervals were <1.0).Fewer AI/AN patients than white patients received guideline-concordant cancer treatment across the 4 most common cancers. Efforts to explain these differences are critical to improving cancer care and survival for AI/AN patients.

    View details for DOI 10.1002/cncr.28683

    View details for Web of Science ID 000339010800018

    View details for PubMedID 24711210

    View details for PubMedCentralID PMC4219619

  • Complication Rates of Ostomy Surgery Are High and Vary Significantly Between Hospitals DISEASES OF THE COLON & RECTUM Sheetz, K. H., Waits, S. A., Krell, R. W., Morris, A. M., Englesbe, M. J., Mullard, A., Campbell, D. A., Hendren, S. 2014; 57 (5): 632-637


    Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement.The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement.This was a retrospective cohort study.The study took place within the 34-hospital Michigan Surgical Quality Collaborative.Patients included were those undergoing ostomy creation surgery between 2006 and 2011.We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type).A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals.This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes.Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

    View details for Web of Science ID 000334475100496

    View details for PubMedID 24819104

    View details for PubMedCentralID PMC4197143

  • The quality of surgical dare in safety net hospitals: A systematic review SURGERY Mouch, C. A., Regenbogen, S. E., Revels, S. L., Wong, S. L., Lemak, C. H., Morris, A. M. 2014; 155 (5): 826-838


    The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs.We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article.Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent.Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States.

    View details for DOI 10.1016/j.surg.2013.12.006

    View details for Web of Science ID 000335291100013

    View details for PubMedID 24787109

  • The effect of complications on the patient-surgeon relationship after colorectal cancer surgery SURGERY Regenbogen, S. E., Veenstra, C. M., Hawley, S. T., Hendren, S., Ward, K. C., Kato, I., Morris, A. M. 2014; 155 (5): 841-850


    Trust in physicians is an essential part of therapeutic relationships. Complications are common after colorectal cancer procedures, but little is known of their effect on patient-surgeon relationships. We hypothesized that unexpected complications impair trust and communication between patients and surgeons.We performed a population-based survey of surgically diagnosed stage III colorectal cancer patients in the Surveillance Epidemiology and End Results registries for Georgia and Metropolitan Detroit between August 2011 and October 2012. Using published survey instruments, we queried subjects about trust in and communication with their surgeon. The primary predictor was the occurrence of an operative complication. We examined patient factors associated with trust and communication then compared the relationship between operative complications and patient-reported trust and communication with their surgeons.Among 622 preliminary respondents (54% response rate), 25% experienced postoperative complications. Those with complications were less likely to report high trust (73% vs 81%, P = .04) and high-quality communication (80% vs 95%, P < .001). Complications reduced trust among only 4% of patient-surgeon dyads with high-quality communication, whereas complications diminished patients' trust in 50% with poorer communication (P < .001). After controlling for communication ratings, we found there was no residual effect of complications on trust (P = .96).Most respondents described trust in and communication with their surgeons as high. Complications were common and were associated with lower trust and poorer communication. However, the relationship between complications and trust was modified by communication. Trust remained high, even in the presence of complications, among respondents who reported high levels of patient-centered communication with their surgeons.

    View details for DOI 10.1016/j.surg.2013.12.011

    View details for Web of Science ID 000335291100015

    View details for PubMedID 24787111

    View details for PubMedCentralID PMC4254758

  • Implementation of a hospital-based quality assessment program for rectal cancer. Journal of oncology practice Hendren, S., McKeown, E., Morris, A. M., Wong, S. L., Oerline, M., Poe, L., Campbell, D. A., Birkmeyer, N. J. 2014; 10 (3): e120-9


    Quality improvement programs in Europe have had a markedly beneficial effect on the processes and outcomes of rectal cancer care. The quality of rectal cancer care in the United States is not as well understood, and scalable quality improvement programs have not been developed. The purpose of this article is to describe the implementation of a hospital-based quality assessment program for rectal cancer, targeting both community and academic hospitals.We recruited 10 hospitals from a surgical quality improvement organization. Nurse reviewers were trained to abstract rectal cancer data from hospital medical records, and abstracts were assessed for accuracy. We conducted two surveys to assess the training program and limitations of the data abstraction. We validated data completeness and accuracy by comparing hospital medical record and tumor registry data.Nine of 10 hospitals successfully performed abstractions with ≥ 90% accuracy. Experienced nurse reviewers were challenged by the technical details in operative and pathology reports. Although most variables had less than 10% missing data, outpatient testing information was lacking from some hospitals' inpatient records. This implementation project yielded a final quality assessment program consisting of 20 medical records variables and 11 tumor registry variables.An innovative program linking tumor registry data to quality-improvement data for rectal cancer quality assessment was successfully implemented in 10 hospitals. This data platform and training program can serve as a template for other organizations that are interested in assessing and improving the quality of rectal cancer care.

    View details for DOI 10.1200/JOP.2014.001387

    View details for PubMedID 24839288

    View details for PubMedCentralID PMC4018456

  • Surgery for Diverticulitis in the 21st Century A Systematic Review JAMA SURGERY Regenbogen, S. E., Hardiman, K. M., Hendren, S., Morris, A. M. 2014; 149 (3): 292-302


    Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years.To review and classify the primary data published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis.We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines.We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms.The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.

    View details for DOI 10.1001/jamasurg.2013.5477

    View details for Web of Science ID 000334609400014

    View details for PubMedID 24430164

  • Sigmoid Diverticulitis A Systematic Review JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Morris, A. M., Regenbogen, S. E., Hardiman, K. M., Hendren, S. 2014; 311 (3): 287-297


    Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms.To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines.We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics: pathophysiology, natural history, medical management, and indications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines.Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted.Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.

    View details for DOI 10.1001/jama.2013.282025

    View details for Web of Science ID 000329566400021

    View details for PubMedID 24430321

  • Shared Decision-Making for Cancer Care Among Racial and Ethnic Minorities: A Systematic Review AMERICAN JOURNAL OF PUBLIC HEALTH Mead, E. L., Doorenbos, A. Z., Javid, S. H., Haozous, E. A., Alvord, L. A., Flum, D. R., Morris, A. M. 2013; 103 (12): E15-E29


    To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of "shared decision-making," "cancer," and "minority groups," using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals' preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient-physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders.

    View details for DOI 10.2105/AJPH.2013.301631

    View details for Web of Science ID 000331043200009

    View details for PubMedID 24134353

    View details for PubMedCentralID PMC3828995

  • Funding Sources in Faculty Development: Strategies for Success in Submitting Proposals CLINICS IN COLON AND RECTAL SURGERY Morris, A. M. 2013; 26 (4): 224-227


    Although the capacity for integrated research and potential for translating research findings to the clinical setting have never been stronger, we are paradoxically entering a period of highly constrained funding. It is more important than ever for clinician scientists and young researchers to be strategic in the approach to funding. The purpose of this article is to discuss strategies for a successful approach to appropriate grant funding agencies.

    View details for DOI 10.1055/s-0033-1356721

    View details for Web of Science ID 000209414100006

    View details for PubMedCentralID PMC3835433

  • Analytic morphometric assessment of patients undergoing colectomy for colon cancer JOURNAL OF SURGICAL ONCOLOGY Sabel, M. S., Terjimanian, M., Conlon, A. S., Griffith, K. A., Morris, A. M., Mulholland, M. W., Englesbe, M. J., Holcombe, S., Wang, S. C. 2013; 108 (3): 169-175


    Analytic morphometrics provides objective data that may better stratify risk. We investigated morphometrics and outcome among colon cancer patients.An IRB-approved review identified 302 patients undergoing colectomy who had CT scans. These were processed to measure psoas area (PA), density (PD), subcutaneous fat (SFD), visceral fat (VF), and total body fat (TBF). Correlation with complications, recurrence, and survival were obtained by t-tests and linear regression models after adjusting for age and Charlson index.The best predictor of surgical complications was PD. PMH, Charlson, BMI, and age were not significant when PD was considered. SF area was the single best predictor of a wound infection. While all measures of obesity correlated with outcome, TBF was most predictive. Final multivariate Cox models for survival included age, Charlson score, nodal positivity, and TBF.Analytic morphometric analysis provided objective data that stratified complications and outcome better than age, BMI, or co-morbidities.

    View details for DOI 10.1002/jso.23366

    View details for Web of Science ID 000322318500008

    View details for PubMedID 23846976

  • Racial Disparities in Esophageal Cancer Outcomes ANNALS OF SURGICAL ONCOLOGY Revels, S. L., Morris, A. M., Reddy, R. M., Akateh, C., Wong, S. L. 2013; 20 (4): 1136-1141


    Racial disparities in outcomes have been documented among patients with esophageal cancer. The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality.Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer (squamous cell carcinoma or adenocarcinoma) from 2003-2008. Age, marital status, stage, histology and location were examined as predictors of receipt of surgery and mortality in multivariate analyses.A total of 6,737 patient files (84 % white, 10 % black, 6 % Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26 %, respectively; p < 0.001) and lesions in the midesophagus (58 vs. 38 vs. 26 %, respectively; p < 0.001). Blacks and Hispanics were less likely to undergo esophagectomy (adjusted odds ratio 0.48, 95 % confidence interval (CI) 0.39-0.60 and 0.71, 95 % CI 0.56-0.90]. We noted significant variations in esophagectomy rates among patients with midesophageal cancers; 15 % of blacks underwent esophagectomy compared to 22 % of Hispanics and 29 % of whites (p < 0.001). Black and Hispanic patients had a higher unadjusted risk of mortality (hazard ratio 1.38, 95 % CI 1.25-1.52 and 1.20, 95 % CI 1.05-1.37). However, differences in mortality were no longer significant after adjusting for receipt of surgery.Disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery. To decrease disparities in mortality it will be necessary to understand and target underlying causes of lower surgery rates in nonwhite patients and develop interventions, especially for midesophageal cancers.

    View details for DOI 10.1245/s10434-012-2807-3

    View details for Web of Science ID 000316392600014

    View details for PubMedID 23263780

    View details for PubMedCentralID PMC4547835

  • Preoperative risk factors for postoperative Clostridium difficile infection in colectomy patients AMERICAN JOURNAL OF SURGERY Krapohl, G. L., Morris, A. M., Cai, S., Englesbe, M. J., Aronoff, D. M., Campbell, D. A., Hendren, S. 2013; 205 (3): 343-347


    Wide variation among hospitals in the rate of Clostridium difficile infection (CDI) after surgery was hypothesized to be related to different prophylactic antibiotic practices.Between March 2008 and March 2010, 30-day confirmed postoperative CDI rates were prospectively collected for patients undergoing colectomy surgery at 23 hospitals participating in a collaborative quality improvement program. Preoperative variables significantly associated with CDI (P ≤ .10) in a bivariate analysis were incorporated into a logistic regression model to test for independent associations.Among 4,936 patients, the overall rate of CDI was 1.6% (range by hospital, 0%-9%). After adjusting for patient comorbidities and hospital site, type of preoperative antibiotics used for prophylaxis was not significantly associated with CDI. Emergency surgery, low albumin, and neurologic and renal comorbidities emerged as independent preoperative predictors of CDI.Perioperative antibiotic practices did not prove to be independently associated with CDI after colectomy surgery.

    View details for DOI 10.1016/j.amjsurg.2012.10.028

    View details for Web of Science ID 000315948900043

    View details for PubMedID 23375705

    View details for PubMedCentralID PMC4119815

  • Evaluating Patients Undergoing Colorectal Surgery to Estimate and Minimize Morbidity and Mortality SURGICAL CLINICS OF NORTH AMERICA Hendren, S. K., Morris, A. M. 2013; 93 (1): 1-?


    This review discusses the preoperative evaluation of patients preparing for elective colorectal resection, touching on several specific categories of morbidity, including cardiac, pulmonary, hepatic, renal, and surgical site complications. For each of these, the evidence for practices that optimize patient function and minimize risk is reviewed. Finally, authors discuss how to counsel high-risk surgical patients, including those for whom elective surgery is not recommended.

    View details for DOI 10.1016/j.suc.2012.09.005

    View details for Web of Science ID 000313145800003

    View details for PubMedID 23177062

  • Surgeon-Level Variation in Patients' Appraisals of Their Breast Cancer Treatment Experiences ANNALS OF SURGICAL ONCOLOGY Hawley, S. T., Lillie, S. E., Morris, A., Graff, J. J., Hamilton, A., Katz, S. J. 2013; 20 (1): 7-14


    While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.

    View details for DOI 10.1245/s10434-012-2582-1

    View details for Web of Science ID 000312709400004

    View details for PubMedID 23054105

  • Routine Leak Testing in Colorectal Surgery in the Surgical Care and Outcomes Assessment Program ARCHIVES OF SURGERY Kwon, S., Morris, A., Billingham, R., Frankhouse, J., Horvath, K., Johnson, M., McNevin, S., Simons, A., Symons, R., Steele, S., Thirlby, R., Whiteford, M., Flum, D. R. 2012; 147 (4): 345-351


    To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined.Observational, prospectively designed cohort study.Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP).Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009.Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter.Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals.Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99).Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

    View details for Web of Science ID 000302904600012

    View details for PubMedID 22508778

    View details for PubMedCentralID PMC4209849

  • Identification of Consensus-Based Quality End Points for Colorectal Surgery DISEASES OF THE COLON & RECTUM Manwaring, M. L., Ko, C. Y., Fleshman, J. W., Beck, D. E., Schoetz, D. J., Senagore, A. J., Ricciardi, R., Temple, L. K., Morris, A. M., Delaney, C. P. 2012; 55 (3): 294-301


    Process and outcome measures for quality assessment of colorectal surgical care are poorly defined.The aim of this study was to develop candidate end points for use in surgeon-specific registries designed for case reporting and quality improvement program development.The study design was based on modified Delphi-based development of consensus quality end points.This study was undertaken by the American Society of Colon and Rectal Surgeons Executive Council, Quality Committee, and by the ColoRectal Education System Template Committee, American Board of Colon and Rectal Surgery.No patients were included in this study.Six areas of colorectal surgery were defined by members of the American Society of Colon and Rectal Surgeons' Executive Council and the American Board of Colon and Rectal Surgery to cover areas of importance for colorectal surgeons. These included colectomy, rectal cancer, hemorrhoidectomy, anal fistula and abscess, colonoscopy, and rectal prolapse. Relevant American Society of Colon and Rectal Surgeons' committee members through a series of 4 panel discussions identified important demographic, process, and outcome measures in each of these 6 areas that might be suitable for the American College of Surgeons case log. Panel size was sequentially expanded from 8 members to 28 members to include all active committee members. Panelists contributed additional process and outcome measures for inclusion during each discussion. Modified Delphi methodology was used to generate consensus, and, after each panel discussion, members rated the relative importance of each end point from 1 (least important) to 4 (most important).The mean rating for each process and outcome measure after each round was recorded with the use of standardized definitions for relevant variables.Eighty-nine process and outcome measures were compiled and rated. Mean scores following the final round ranged from a low of 1.3 (anal fistula/abscess, preoperative imaging) to a high of 4.0 (colectomy-anastomotic leak).The limitations of this study involved the use of consensus, small study size, and the fact that no end points were excluded.With the use of modified Delphi methodology, a consensus-derived ranked list of 89 process and outcome measures was developed in 6 key areas of colorectal surgery. These data provide a framework for development of guideline standards for case-reporting program development initiatives for colon and rectal surgery.

    View details for DOI 10.1097/DCR.0b013e318241b11f

    View details for Web of Science ID 000300636200012

    View details for PubMedID 22469796

  • Features Associated with Successful Recruitment of Diverse Patients onto Cancer Clinical Trials: Report from the American College of Surgeons Oncology Group ANNALS OF SURGICAL ONCOLOGY Diehl, K. M., Green, E. M., Weinberg, A., Frederick, W. A., Holmes, D. R., Green, B., Morris, A., Kuerer, H. M., Beltran, R. A., Mendez, J., Gines, V., Ota, D. M., Nelson, H., Newman, L. A. 2011; 18 (13): 3544-3550


    The clinical trials mechanism of standardized treatment and follow-up for cancer patients with similar stages and patterns of disease is the most powerful approach available for evaluating the efficacy of novel therapies, and clinical trial participation should protect against delivery of care variations associated with racial/ethnic identity and/or socioeconomic status. Unfortunately, disparities in clinical trial accrual persist, with African Americans (AA) and Hispanic/Latino Americans (HA) underrepresented in most studies.We evaluated the accrual patterns for 10 clinical trials conducted by the American College of Surgeons Oncology Group (ACOSOG) 1999-2009, and analyzed results by race/ethnicity as well as by study design.Eight of 10 protocols were successful in recruiting AA and/or HA participants; three of four randomized trials were successful. Features that were present among all of the successfully recruiting protocols were: (1) studies designed to recruit patients with regional or advanced-stage disease (2 of 2 protocols); and (2) studies that involved some investigational systemic therapy (3 of 3 protocols).AA and HA cancer patients can be successfully accrued onto randomized clinical trials, but study design affects recruitment patterns. Increased socioeconomic disadvantages observed within minority-ethnicity communities results in barriers to screening and more advanced cancer stage distribution. Improving cancer early detection is critical in the effort to eliminate outcome disparities but existing differences in disease burden results in diminished eligibility for early-stage cancer clinical trials among minority-ethnicity patients.

    View details for DOI 10.1245/s10434-011-1818-9

    View details for Web of Science ID 000297358900005

    View details for PubMedID 21681382

  • Proximity to Disease and Perception of Utility: Physicians' vs Patients' Assessment of Treatment Options for Ulcerative Colitis DISEASES OF THE COLON & RECTUM Brown, L. K., Waljee, A. K., Higgins, P. D., Waljee, J. F., Morris, A. M. 2011; 54 (12): 1529-1536


    Physician values regarding the benefit of continued medical therapy vs colectomy for moderate ulcerative colitis have not been defined. If physicians perceive these states differently than patients, their therapeutic recommendations may not align with patient values.This study aimed to compare physician and patient willingness to trade life years with moderately active ulcerative colitis vs undergoing colectomy.This survey of physicians' and patients' utility values used standardized scenarios for moderately active ulcerative colitis and colectomy.The investigation was conducted at a tertiary academic medical center.Gastroenterologists, colorectal surgeons, and patients with ulcerative colitis who were either living with moderate disease or were postcolectomy completed the survey.Utility values were measured by the use of the time trade-off method.We surveyed 17 physicians, 150 postcolectomy patients, and 69 patients with moderate ulcerative colitis. Utility values for ulcerative colitis and colectomy states were (0.87, 0.95), (0.86, 0.92), and (0.91, 0.91). On average, physicians and postcolectomy patients assessed the utility of life with ulcerative colitis more poorly than the postcolectomy state. Patients with moderately active ulcerative colitis who had not undergone colectomy viewed both health states equally.This study was limited by the physician subject sample size.Patients living with moderate ulcerative colitis value the pre- and postcolectomy states differently than physicians and postcolectomy patients. Recognizing the differences between their own and patients' values may help physicians to better counsel patients preoperatively. In addition, exposure to postcolectomy patients may help those with moderate disease who are weighing the comparative benefits of colectomy.

    View details for DOI 10.1097/DCR.0b013e31823436a8

    View details for Web of Science ID 000296854300010

    View details for PubMedID 22067181

    View details for PubMedCentralID PMC5361885

  • Early Discharge and Hospital Readmission After Colectomy for Cancer DISEASES OF THE COLON & RECTUM Hendren, S., Morris, A. M., Zhang, W., Dimick, J. 2011; 54 (11): 1362-1367


    Early discharge after colectomy has been shown to be feasible in studies from specialty centers, but we hypothesized that benefits of early discharge might be offset by higher risk of readmission in the surgical community as a whole. Minimizing readmissions is a national health policy priority.This study aimed to determine whether hospitals discharging patients early had increased readmission rates.Patients undergoing colectomy surgery for cancer were studied using national Medicare data (MEDPAR database). Multiple logistic regression was performed to determine whether hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) had increased readmission rates. Results were adjusted for patient comorbidity, emergency operation, laparoscopic surgery, demographic factors, and complications. A separate analysis at the patient level was conducted to determine risk factors for readmission.Early discharge rates at US acute care hospitals were investigated.Patients 65 and older undergoing colectomy surgery for cancer (2003-2008, n = 477,461) were included.The main outcome measure was 30-day, all hospital readmission rates.Hospitals with a pattern of early discharge (median length of stay ≤ 5 d) were not found to have a higher risk-adjusted readmission rate than hospitals with the usual median length of stay (16.3% vs 15.7%, P = .077). However, changing the cutoff for "early discharge" to ≤ 4 days revealed an increased risk for readmission among "very early discharge" hospitals (risk-adjusted readmission rate 21.3% vs 15.7%, P < .001). At the patient level, independent risk factors for readmission included older age, male sex, black race, lower socioeconomic status, urgent/emergent surgery, comorbidities, complications, open (vs laparoscopic) surgery, and longer length of stay for the index hospitalization.Limitations of this study included the limitations of the administrative data and elderly population.Hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) do not have a higher risk-adjusted readmission rate than other hospitals. These results support the safety of early discharge programs in the Medicare population.

    View details for DOI 10.1097/DCR.0b013e31822b72d3

    View details for Web of Science ID 000295878800005

    View details for PubMedID 21979179

  • Measuring quality in colorectal surgery BRITISH MEDICAL JOURNAL Morris, A. 2011; 343

    View details for DOI 10.1136/bmj.d4859

    View details for Web of Science ID 000294209500003

    View details for PubMedID 21846715

  • Bowel Preparation for Colectomy and Risk of Clostridium difficile Infection DISEASES OF THE COLON & RECTUM Krapohl, G. L., Phillips, L. R., Campbell, D. A., Hendren, S., Banerjee, M., Metzger, B., Morris, A. M. 2011; 54 (7): 810-817


    Mechanical bowel preparation before colectomy is controversial for several reasons, including a theoretically increased risk of Clostridium difficile infection.The primary aim of this study was to compare the incidence of C difficile infection among patients who underwent mechanical bowel preparation and those who did not. A secondary objective was to assess the association between C difficile infection and the use of oral antibiotics.This was an observational cohort study.The Michigan Surgical Quality Collaborative Colectomy Project (n = 24 hospitals) participates in the American College of Surgeons-National Surgical Quality Improvement Program with additional targeted data specific to patients undergoing colectomies.Included were adult patients (21 years and older) admitted to participating hospitals for elective colectomy between August 2007 and June 2009.The main outcome measure was laboratory detection of a positive C difficile toxin assay or stool culture.Two thousand two hundred sixty-three patients underwent colectomy and fulfilled inclusion criteria. Fifty-four patients developed a C difficile infection, for a hospital median rate of 2.8% (range, 0-14.7%). Use of mechanical bowel preparation was not associated with an increased incidence of C difficile infection (P = .95). Among 1685 patients that received mechanical bowel preparation, 684 (41%) received oral antibiotics. The proportion of patients in whom C difficile infection was diagnosed after the use of preoperative oral antibiotics was smaller than the proportion of patients with C difficile infection who did not receive oral antibiotics (1.6% vs 2.9%, P = .09).The potential exists for underestimation of C difficile infection because of the study's strict data collection criteria and risk of undetected infection after postoperative day 30.In contrast to previous single-center data, this multicenter study showed that the preoperative use of mechanical bowel preparation was not associated with increased risk of C difficile infection after colectomy. Moreover, the addition of oral antibiotics with mechanical bowel preparation did not confer any additional risk of infection.

    View details for DOI 10.1007/DCR.0b013e3182125b55

    View details for Web of Science ID 000291382600008

    View details for PubMedID 21654247

    View details for PubMedCentralID PMC3111940

  • Individual Health Discount Rate in Patients with Ulcerative Colitis INFLAMMATORY BOWEL DISEASES Waljee, A. K., Morris, A. M., Waljee, J. F., Higgins, P. D. 2011; 17 (6): 1328-1332


    In cost-effectiveness analysis, discount rates are used in calculating the value of future costs and benefits. However, standard discount rates may not accurately describe the decision-making of patients with ulcerative colitis (UC). These patients often choose the long-term risks of immunosuppressive therapy over the short-term risks of colectomy, demonstrating very high discount rates for future health. In this study we aimed to measure the discount rate in UC patients and identify variables associated with the discount rate.We surveyed patients with UC and patients who were postcolectomy for UC to measure their valuations of UC and colectomy health states. We used Standard Gamble (SG) and Time-Trade-Off (TTO) methods to assess current and future health state valuations and calculated the discount rate.Participants included 150 subjects with UC and 150 subjects who were postcolectomy for UC. Adjusted discount rates varied widely (0%-100%), with an overall median rate of 55.0% (interquartile range [IQR] 20.6-100), which was significantly higher than the standard rate of 5%. Within the normal range of discount rates, patients' expected discount rate increased by 0.80% for each additional year of age, and female patients had discount rates that averaged ≈ 8% less than their age-matched counterparts and approached statistical significance.The accepted discount rate of 5% grossly underestimates UC patients' preference for long-term over short-term risk. This might explain UC patients' frequent choice of the long-term risks of immunosuppressive medical therapy over the short-term risks of colectomy.

    View details for DOI 10.1002/ibd.21515

    View details for Web of Science ID 000290442400031

    View details for PubMedID 21560195

    View details for PubMedCentralID PMC4813665

  • Perceived and Actual Quality of Life With Ulcerative Colitis: A Comparison of Medically and Surgically Treated Patients AMERICAN JOURNAL OF GASTROENTEROLOGY Waljee, A. K., Higgins, P. D., Waljee, J. F., Tujios, S. R., Saxena, A., Brown, L. K., Chaudhary, M. N., Morris, A. M. 2011; 106 (4): 794-799


    Patients with chronic ulcerative colitis (UC) often refuse colectomy, despite data indicating that it might improve quality of life. We hypothesized that perceived utility values are different for patients living with UC compared with UC patients after total proctocolectomy. Our aims were to compare the perceived utility assigned by UC patients with and without a colectomy to standardized chronic UC and post-colectomy scenarios, and to compare the utility of actual health states among groups.We surveyed patients in a tertiary referral center from three groups, including non-UC, UC patients without colectomy, and UC patients who were post-colectomy. We measured the Time-Trade-Off (TTO) utilities of subjects for standardized scenarios, describing moderate UC and a post-colectomy state. Among all UC patients (with and without colectomy), we measured TTO utility for their own health state.Responses were obtained from 150 patients per group (n=450). The non-UC patients considered UC and colectomy scenarios equally (0.92), which was similar to UC patients without colectomy (0.90 and 0.91). Post-colectomy patients strongly preferred the colectomy scenario to the UC scenario (0.86 vs. 0.92, P<0.001). The median utility of UC patients without colectomy for their actual health state was higher than that of post-colectomy patients (0.96 and 0.92, P<0.05). Patients with more social support were more likely to have undergone colectomy compared with patients with little social support (odds ratio=1.20 per dependent/supporter).Patients living with UC prefer their actual health state to a perceived UC scenario or a post-colectomy scenario. Patients who have undergone colectomy equate the quality of life in their actual state with that in a post-colectomy scenario, and prefer each to a perceived chronic UC state. Given the variety of preferences and the importance of social support, opportunities to interact with UC patients who have previously undergone colectomy could help patients living with UC and their physicians to navigate these complex choices.

    View details for DOI 10.1038/ajg.2011.39

    View details for Web of Science ID 000289232900024

    View details for PubMedID 21364547

    View details for PubMedCentralID PMC4429766

  • Surgical Complications Are Associated With Omission of Chemotherapy for Stage III Colorectal Cancer DISEASES OF THE COLON & RECTUM Hendren, S., Birkmeyer, J. D., Yin, H., Banerjee, M., Sonnenday, C., Morris, A. M. 2010; 53 (12): 1587-1593


    Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer.We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied.We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001).Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

    View details for DOI 10.1007/DCR.0b013e3181f2f202

    View details for Web of Science ID 000284146500001

    View details for PubMedID 21178851

  • Understanding Racial Disparities in Cancer Treatment and Outcomes JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Morris, A. M., Rhoads, K. F., Stain, S. C., Birkmeyer, J. D. 2010; 211 (1): 105-113
  • Canadian Association of General Surgeons and the American College of Surgeons DISEASES OF THE COLON & RECTUM Morris, A., Bailey, R., Woolfson, K. 2010; 53 (6): 953-955

    View details for DOI 10.1007/DCR.0b013e3181d86b27

    View details for Web of Science ID 000278101300018

    View details for PubMedID 20485012

  • Health Care Reform and Comparative Effectiveness Implications for Surgeons ARCHIVES OF SURGERY Urbach, D. R., Morris, A. M. 2010; 145 (2): 120-122

    View details for Web of Science ID 000274468900001

    View details for PubMedID 20157076

  • Hospital Factors and Racial Disparities in Mortality After Surgery for Breast and Colon Cancer JOURNAL OF CLINICAL ONCOLOGY Breslin, T. M., Morris, A. M., Gu, N., Wong, S. L., Finlayson, E. V., Banerjee, M., Birkmeyer, J. D. 2009; 27 (24): 3945-3950


    Black patients have worse prognoses than whites with breast or colorectal cancer. Mechanisms underlying such disparities have not been fully explored. We examined the role of hospital factors in racial differences in late mortality after surgery for breast or colon cancer.Patients undergoing surgery after new diagnosis of breast or colon cancer were identified using the Surveillance Epidemiology and End Results-Medicare linked database (1995 to 2005). The main outcome measure was mortality at 5 years. Proportional hazards models were used to assess relationships between race and late mortality, accounting for patient factors, socioeconomic measures, and hospital factors. Fixed and random effects models were used to account for quality differences across hospitals.Black patients, compared with white patients, had lower 5-year overall survival rates after surgery for breast (62.1% v 70.4%, respectively; P < .001) and colon cancer (41.3% v 45.4%, respectively; P < .001). After controlling for age, comorbidity, and stage, black race remained an independent predictor of mortality for breast (adjusted hazard ratio [HR] = 1.25; 95% CI, 1.16 to 1.34) and colon cancer (adjusted HR = 1.13; 95% CI, 1.07 to 1.19). After risk adjustment, hospital factors explained 36% and 54% of the excess mortality for black patients with breast cancer and colon cancer, respectively. Hospitals with large minority populations had higher late mortality rates independent of race.Hospital factors, including quality, are important mediators of the association between race and mortality for breast and colon cancer. Hospital-level quality improvement should be a major component of efforts to reduce disparities in cancer outcomes.

    View details for DOI 10.1200/JCO.2008.20.8546

    View details for Web of Science ID 000269064300013

    View details for PubMedID 19470926

    View details for PubMedCentralID PMC2734396

  • Racial Clustering and Access to Colorectal Surgeons, Gastroenterologists, and Radiation Oncologists by African Americans and Asian Americans in the United States A County-Level Data Analysis ARCHIVES OF SURGERY Hayanga, A. J., Waljee, A. K., Kaiser, H. E., Chang, D. C., Morris, A. M. 2009; 144 (6): 532-535


    Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level.A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists.All counties in the United States.Prevalence rate of African Americans and Asian Americans within a county.Rate of colorectal surgeons, gastroenterologists, and radiation oncologists.Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13).Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

    View details for Web of Science ID 000267011300009

    View details for PubMedID 19528386

  • Socioeconomic status and surgical mortality in the elderly MEDICAL CARE Birkmeyer, N. J., Gu, N., Baser, O., Morris, A. M., Birkmeyer, J. D. 2008; 46 (9): 893-899


    Although racial disparities in the quality of surgical care are well described, the impact of socioeconomic status on operative mortality is relatively unexplored.We used Medicare data to identify all patients undergoing 1 of 6 common, high risk surgical procedures between 1999 and 2003. We constructed a summary measure of socioeconomic status for each US ZIP code using data from the 2000 US Census linked to the patient's ZIP code of residence. We assessed the effects of socioeconomic status on operative mortality rates while controlling for other patient characteristics and then examined the extent to which disparities in operative mortality could be attributed to differences in hospital factors.Socioeconomic status was a significant predictor of operative mortality for all 6 procedures in crude analyses and in those adjusted for patient characteristics. Comparing the lowest quintile of socioeconomic status to the highest, the adjusted odds ratios (OR) and 95% confidence intervals (CI) ranged from OR = 1.17; 95% CI: 1.10-1.25 for colectomy to OR = 1.39; 95% CI: 1.18-1.65 for gastrectomy. After further adjustment for hospital factors, the odds ratio associated with socioeconomic status for coronary artery bypass (OR = 1.14; 95% CI: 1.09-1.19), aortic valve replacement (OR = 1.13; 95% CI: 1.04-1.23), and mitral valve replacement (OR = 1.11; 95% CI: 1.00-1.23) were diminished, and those for lung resection (OR = 0.93; 95% CI: 0.81-1.07), colectomy (OR = 1.04; 95% CI: 0.98-1.12), and gastrectomy (OR = 1.11; 95% CI: 0.90-1.38) were reduced and also were no longer statistically significant. Within hospitals, there were only small differences in adjusted operative mortality by patient socioeconomic status.Patients with lower socioeconomic status have higher rates of adjusted operative mortality than patients with higher socioeconomic status across a wide range of surgical procedures. These disparities in surgical outcomes are largely attributable to differences between the hospitals where patients of higher and lower socioeconomic status tend to receive surgical treatment.

    View details for Web of Science ID 000258945400002

    View details for PubMedID 18725842

  • Does surgeon case volume influence nonfatal adverse outcomes after rectal cancer resection? JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Billingsley, K. G., Morris, A. M., Green, P., Dominitz, J. A., Matthews, B., Dobie, S. A., Barlow, W., Baldwin, L. 2008; 206 (6): 1167-1177


    The aim of this study was to assess the relationship between surgeon and hospital volume and major postoperative complications after rectal cancer surgery, and to define other surgeon and hospital characteristics that may explain observed volume-complication relationships.This was a retrospective cohort design using data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry program for individuals with stage I to III rectal cancer diagnosed between 1992 and 1999 and treated with resection. The patients' Surveillance, Epidemiology, and End Results data were linked with Medicare claims data from 1991 to 2000. The primary outcomes were 30-day postoperative procedural interventions (PPI) to treat surgical complications, such as reoperation. The association between surgeon volume and PPI was examined using logistic regression modeling with adjustment for covariates.The odds of a rectal cancer patient requiring a PPI is notably less if the operation is performed by one of a small subset of very high volume surgeons (unadjusted odds ratio 0.53; 95% CI 0.31 to 0.92). Board certification in colorectal surgery did not alter the relationship between surgeon volume and PPI, although surgeon age did, with mid-career surgeons having the lowest rates of PPI, regardless of practice volume. When adjusted for surgeon age, surgeon volume is no longer a marked predictor of complications (adjusted odds ratio 0.57; 95% CI 0.30 to 1.09).Overall, rectal cancer operations are safe, with a low frequency of severe complications. A subset of very high volume rectal surgeons performs these operations with fewer complications that require procedural intervention or reoperation. Surgeon age, as an indicator of experience, also contributes modestly to outcomes. These data do not justify regionalizing rectal cancer care based on safety concerns.

    View details for DOI 10.1016/j.jamcollsurg.2007.12.042

    View details for PubMedID 18501815

  • Residual treatment disparities after oncology referral for rectal cancer JOURNAL OF THE NATIONAL CANCER INSTITUTE Morris, A. M., Billingsley, K. G., Hayanga, A. J., Matthews, B., Baldwin, L., Birkmeyer, J. D. 2008; 100 (10): 738-744


    Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

    View details for DOI 10.1093/jnci/djn145

    View details for Web of Science ID 000256172400011

    View details for PubMedID 18477800

    View details for PubMedCentralID PMC2766763

  • Hospital lymph node examination rates and survival after resection for colon cancer JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wong, S. L., Ji, H., Hollenbeck, B. K., Morris, A. M., Baser, O., Birkmeyer, J. D. 2007; 298 (18): 2149-2154


    Several studies suggest improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer. The National Quality Forum and other organizations recently endorsed a 12-node minimum as a measure of hospital quality.To assess whether hospitals that examine more lymph nodes after resection for colon cancer have superior late survival rates.Retrospective cohort study, using the national Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1995-2005), of US patients undergoing colectomy for nonmetastatic colon cancer (n = 30 625). Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into 4 evenly sized groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.Hospitals' lymph node examination rates in association with cancer staging, use of adjuvant chemotherapy (indicated for patients with node-positive disease), and 5-year survival rate.Hospitals with the highest proportions of patients with examination of 12 or more lymph nodes tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery (adjusted hazard ratio, highest vs lowest hospital quartile, 0.95; 95% confidence interval, 0.88-1.03). Although the 4 hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors and had very similar overall unadjusted rates of adjuvant chemotherapy (26% vs 25%, highest vs lowest hospital quartile).The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.

    View details for Web of Science ID 000250869800020

    View details for PubMedID 18000198

  • Racial variation in colorectal polyp and tumor location JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Thornton, J. G., Morris, A. M., Thornton, J. D., Flowers, C. R., McCashland, T. M. 2007; 99 (7): 723-728


    The incidence and mortality from colorectal cancer among whites have decreased, but they have remained unchanged among African Americans. To explain this disparity, we used the multicenter endoscopy database of the Clinical Outcomes Research Initiative to compare the prevalence of proximal polyps and tumors among asymptomatic African Americans and whites undergoing routine screening colonoscopy.African Americans and whites undergoing colonoscopy between January 1, 2002 and September 30, 2003 were considered for analysis.There were 145,175 index colonoscopy reports on unique patients. After applying exclusion criteria, 46,726 patients remained for analysis. Adjusting for age, gender, American Society of Anesthesiologists level, bowel preparation and endoscopic setting, African Americans were less likely to have polyps [adjusted odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.70-0.84]. However, the odds of having proximal polyps was higher in African Americans (OR = 1.30; 95% CI: 1.11-1.52) compared to whites. In regards to tumors, African Americans were more likely to have tumors (OR = 1.78; 95% CI: 1.14-2.77) and more likely to have proximal tumors than whites (OR = 4.37; 95% CI: 1.16-16.42).After adjusting for confounders, African Americans undergoing screening colonoscopy in multiple practice settings had higher odds of proximal polyps and tumors than whites, suggesting current colorectal cancer screening recommendations in African Americans should be expanded.

    View details for Web of Science ID 000248108300003

    View details for PubMedID 17668638

    View details for PubMedCentralID PMC2574351

  • Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery - Understanding the volume-outcome relationship ARCHIVES OF SURGERY Billingsley, K. G., Morris, A. M., Dominitz, J. A., Matthews, B., Dobie, S., Barlow, W., Wright, G. E., Baldwin, L. 2007; 142 (1): 23-31


    Although numerous studies have demonstrated an association between surgical volume and improved outcome in cancer surgery, the specific structures and mechanisms of care that are associated with volume and lead to improved outcomes remain poorly defined. We hypothesize that there are modifiable surgeon and hospital characteristics that explain observed volume-outcome relationships.Retrospective cohort study.Surveillance, Epidemiology, and End Results cancer registry areas.Patients aged 66 years and older, diagnosed and surgically treated for stage I, II, or III colon cancer between 1992 and 1996 (n = 22 672).Thirty-day postoperative mortality and 30-day postoperative procedural interventions, including reoperation and image-guided percutaneous procedures.Surgeon volume, but not hospital volume, is a significant predictor of postoperative procedural intervention (adjusted odds ratio for very high-volume surgeons vs low-volume surgeons, 0.79; 95% confidence interval, 0.64-0.98). In the unadjusted analyses, high hospital volume (odds ratio, 0.67; 95% confidence interval, 0.56-0.81) and very high hospital volume (odds ratio, 0.65; 95% confidence interval, 0.54-0.79) is associated with lower postoperative mortality. Postoperative procedural intervention is not a significant mediator of the relationship between hospital volume and mortality. A single variable-the presence of sophisticated clinical services-was the most important explanatory variable underlying the relationship between hospital volume and mortality.Very high surgeon volume is associated with a reduction in surgical complications. However, the association between increasing hospital volume and postoperative mortality appears to derive mainly from a full spectrum of clinical services that may facilitate the prompt recognition and treatment of complications.

    View details for PubMedID 17224497

  • Reoperation as a quality indicator in colorectal surgery - A population-based analysis ANNALS OF SURGERY Morris, A. M., Baldivin, L., Matthews, B., Dominitz, J. A., Barlow, W. E., Dobie, S. A., Billingsley, K. G. 2007; 245 (1): 73-79


    To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay.Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored.Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database.sociodemographics, tumor characteristics, comorbidity, and acuity.postoperative procedural intervention.Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures.A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5-3.6), obstruction (RR = 1.6; 95% CI = 1.4-1.8), and emergent admission (RR = 1.3; 95% CI = 1.1-1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1-2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1-2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3-3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4-1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1-2.3).Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.

    View details for DOI 10.1097/01.sla.0000231797.37743.9f

    View details for Web of Science ID 000243314300012

    View details for PubMedID 17197968

    View details for PubMedCentralID PMC1867944

  • Medicare policy and colorectal cancer screening - Will changing access change outcomes? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Morris, A. M. 2006; 296 (23): 2855-2856

    View details for Web of Science ID 000242826400029

    View details for PubMedID 17179464

  • Racial disparities in late survival after rectal cancer surgery JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Morris, A. M., Wei, Y., Birkmeyer, N. J., Birkmeyer, J. D. 2006; 203 (6): 787-794


    African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear.Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality.African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20).Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients.

    View details for DOI 10.1016/j.jamcollsurg.2006.08.005

    View details for Web of Science ID 000242567300001

    View details for PubMedID 17116545

  • Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis GUT Waljee, A., Waljee, J., Morris, A. M., Higgins, P. D. 2006; 55 (11): 1575-1580


    Increased infertility in women has been reported after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis but reported infertility rates vary substantially.(1) To perform a systematic review and meta-analysis of the relative risk of infertility post-IPAA compared with medical management; (2) to estimate the rate of infertility post-IPAA; and (3) to identify modifiable risk factors which contribute to infertility.Medline, EMBASE, Current Contents, meeting abstracts, and bibliographies were searched independently by two investigators. The titles and abstracts of 189 potentially relevant studies were reviewed; eight met the criteria and all data were extracted independently. Consensus was achieved on each data point, and fixed effects meta-analyses, a funnel plot, and sensitivity analyses were performed.The initial meta-analysis of eight studies had significant heterogeneity (p = 0.004) due to one study with very high preoperative infertility (38%). When this study was omitted, the relative risk of infertility after IPAA was 3.17 (2.41-4.18), with non-significant heterogeneity. The weighted average infertility rate in medically treated ulcerative colitis was 15% for all seven studies, and the weighted average infertility rate was 48% after IPAA (50% if all eight studies are included). We were unable to identify any procedural factors that consistently affected the risk of infertility.IPAA increases the risk of infertility in women with ulcerative colitis by approximately threefold. Infertility, defined as achieving pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis. This provides a basis for counselling patients considering colectomy with IPAA. Further studies of modifiable risk factors are needed.

    View details for DOI 10.1136/gut.2005.090316

    View details for Web of Science ID 000241363600013

    View details for PubMedID 16772310

    View details for PubMedCentralID PMC1860095

  • Race and surgical mortality in the United States ANNALS OF SURGERY Lucas, F. L., Stukel, T. A., Morris, A. M., Siewers, A. E., Birkmeyer, J. D. 2006; 243 (2): 281-286


    This study describes racial differences in postoperative mortality following 8 cardiovascular and cancer procedures and assesses possible explanations for these differences.Although racial disparities in the use of surgical procedures are well established, relationships between race and operative mortality have not been assessed systematically.We used national Medicare data to identify all patients undergoing one of 8 cardiovascular and cancer procedures between 1994 and 1999. We used multiple logistic regression to assess differences in operative mortality (death within 30 days or before discharge) between black patients and white patients, controlling for patient characteristics. Adding hospital indicators to these models, we then assessed the extent to which racial differences in operative mortality could be accounted for by the hospital in which patients were cared for.Black patients had higher crude mortality rates than white patients for 7 of the 8 operations, including coronary artery bypass, aortic valve replacement, abdominal aortic aneurysm repair, carotid endarterectomy, radical cystectomy, pancreatic resection, and esophagectomy. Among these 7 procedures, odds ratios of mortality (black versus white) ranged from 1.23 (95% confidence interval, 1.18-1.29) for CABG to 1.61 (95% confidence interval, 1.28-2.03) for esophagectomy. Adjusting for patient characteristics had modest or no effect on odds ratios of mortality by race. However, there remained few clinically or statistically significant differences in mortality by race after we accounted for hospital. Hospitals that treated a large proportion of black patients had higher mortality rates for all 8 procedures, for white as well as black patients.Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.

    View details for DOI 10.1097/01.sla.0000197560.92456.32

    View details for Web of Science ID 000234912700019

    View details for PubMedID 16432363

    View details for PubMedCentralID PMC1448914

  • Patient-centered outcomes after therapy for colorectal cancer SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA Morris, A. M. 2006; 15 (1): 195-?


    In practical terms, clinicians can use the results of patient-centered outcome instruments to track patients' functional status and quality-of-life changes through treatment. Noting formalized results might help clinicians better communicate with patients at critical times during treatment, especially with regard to patient expectations.Although numerous clinical variables of uncertain value are regularly followed, validated functional and quality-of-life results have been put to use only rarely in the clinical setting. Clinicians' ability to interpret and apply quality-of-life results will surely improve with practice, and likely would be well worth the contribution to our patients' well-being.

    View details for DOI 10.1016/j.soc.2005.09.005

    View details for Web of Science ID 000241757800014

    View details for PubMedID 16389158

  • Misdiagnosis of appendicitis and the use of diagnostic imaging JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Flum, D. R., McClure, T. D., Morris, A., KOEPSELL, T. 2005; 201 (6): 933-939


    CT and ultrasound (US) are increasingly recommended to establish the diagnosis of appendicitis, but population-based rates of misdiagnosis (negative appendectomy [NA]) have not improved over time. The objective of this study was to determine the relationship between CT/US and NA in common practice.Using data from the Group Health Cooperative on all patients undergoing appendectomy between 1980 and 1999, a longitudinal study was conducted to determine the frequency of NA over time and a case-control, medical record-based study of a subset of patients from the 1990s was conducted to determine the accuracy of CT/US.Of 4,058 patients undergoing appendectomy (mean age 31 +/- 18.6 [SD] years, 49.6% women), 631 (15.5%) had an NA. The overall incidence of NA remained stable over time at 1.5/10,000 patient-years, as did the age and gender adjusted rate (incident rate ratio 0.95, 95% CI 0.97, 1.01). In 1999, nearly 40% of patients had either CT or US. The aggregate sensitivity of these tests was only 74.2% (95% CI 65.7, 83.7), with a positive predictive value of 95.1% (95% CI 91.5, 96.8). CT scans were 88.3% sensitive, with 97.2% positive predictive value (95% CI 92.9, 100). Ultrasounds were 69.5% sensitive, with a positive predictive value of 94.1% (95% CI 89.6, 96.4). More than one in five tests obtained in patients with NA were positive for appendicitis (21.7% for CT and 20.8% for US).The rate of NA was unchanged over time despite the introduction and use of CT/US, and this appeared to be related to the inconsistent performance characteristics of the tests. This study cautions against overreliance on CT/US in diagnosing appendicitis and emphasizes the need for test benchmarking in routine practice before establishing protocols for presumed appendicitis.

    View details for DOI 10.1016/j.jamcollsurg.2005.04.039

    View details for Web of Science ID 000233737300015

    View details for PubMedID 16310698

  • Lymph node evaluation in colorectal cancer patients: A population-based study JNCI-JOURNAL OF THE NATIONAL CANCER INSTITUTE Baxter, N. N., Virnig, D. J., Rothenberger, D. A., Morris, A. M., Jessurun, J., Virnig, B. A. 2005; 97 (3): 219-225


    Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation.For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided.Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location.In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.

    View details for DOI 10.1093/jnci/dji020

    View details for Web of Science ID 000226748200013

    View details for PubMedID 15687365

  • Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: A population-based analysis INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Baxter, N. N., Morris, A. M., Rothenberger, D. A., Tepper, J. E. 2005; 61 (2): 426-431


    To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown.The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection.In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS.Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.

    View details for DOI 10.1016/j.ijrobp.2004.06.259

    View details for Web of Science ID 000226700200016

    View details for PubMedID 15667963

  • Adjuvant radiation for rectal cancer: Do we measure up to the standard of care? An epidemiologic analysis of trends over 25 years in the United States DISEASES OF THE COLON & RECTUM Baxter, N. N., Rothenberger, D. A., Morris, A. M., Bullard, K. M. 2005; 48 (1): 9-15


    In the United States, adjuvant radiation therapy is currently recommended for most patients with rectal cancer. We conducted this population-based study to evaluate the rate of radiation therapy and the factors affecting its delivery.We used the Surveillance Epidemiology and End Results database to assess treatment of patients with nonmetastatic rectal cancer diagnosed over a 25-year period (1976 through 2000). We evaluated the rate of radiation therapy use and its timing (preoperative vs. postoperative) and the influence of factors such as tumor stage and grade; patient gender and race; and geographic location.In this 25-year period, 45,627 patients met our selection criteria. The rate of radiation therapy use increased dramatically over time: from 17 percent of advanced-stage patients in 1976 to 65 percent in 2000 (P < 0.0001). Until 1996, the increase was due almost entirely to postoperative radiation therapy. Since 1996, the rate of preoperative radiation therapy use has increased (P < 0.0001) and the rate of postoperative radiation therapy use has begun to decline. We found, after controlling for the year of diagnosis, that female patients, African Americans, older patients, and patients with low-grade lesions were less likely to undergo radiation therapy (P < 0.0001). Geographic location was also an important predictor of radiation therapy use.The use of radiation therapy for patients with rectal cancer has dramatically increased over the 25-year period studied, with a recent shift to the use of preoperative radiation therapy; however, in 2000, over 30 percent of patients with advanced-stage nonmetastatic rectal cancer did not undergo radiation therapy. Given the variation in radiation therapy use that we found to be due to demographic factors, access to adjuvant radiation therapy can be improved.

    View details for DOI 10.1007/s10350-004-0792-8

    View details for Web of Science ID 000226058500002

    View details for PubMedID 15690651

  • Complications of chronic pelvic radiation injury JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Krabbenhoft, D. M., Hoang, C. D., Morris, A., Hunter, D. W., Payne, W. D., Dunn, D. L., Bullard, K. M. 2004; 198 (6): 1022-1023
  • Racial disparities in rectal cancer treatment - A population-based analysis ARCHIVES OF SURGERY Morris, A. M., Billingsley, K. G., Baxter, N. N., Baldwin, L. M. 2004; 139 (2): 151-155


    We hypothesized that there are significant racial disparities in delivery of care to rectal cancer patients. We examined differential surgical and radiation treatment for these patients and determined whether blacks were less likely than whites to undergo sphincter-sparing procedures, which are associated with a higher quality of life than sphincter-ablating procedures.Cross-sectional cohort study.The Surveillance Epidemiology and End Results database provided population-based data for rectal cancer patients who were diagnosed between 1988 and 1999, were older than 35 years, and had no prior colorectal or other pelvic cancer.Using logistic regression, we compared receipt and type of surgical therapy and radiation therapy, controlling for age, sex, year, geography, stage, and anatomic location.Among 52 864 patients, 3851 were black and 44 010 were white. Blacks were younger than whites and had more advanced disease (P<.001). Among patients who underwent operation, rates of sphincter-ablating procedure were 37% for whites and 43% for blacks (adjusted odds ratio [AOR], 1.42; 95% confidence interval [CI], 1.23-1.65). Moreover, 53% of whites and 56% of blacks received no radiation therapy for stage II to III disease (AOR, 1.30; 95% CI, 1.15-1.47).Blacks with rectal cancer were diagnosed at a younger age and more advanced disease stage than whites, implying a need for more aggressive screening. After adjusting for stage and other covariates, surgical and radiation treatment also differed along racial lines. Our data suggest that treatment disparities may contribute to differences in outcome among racial/ethnic groups with rectal cancer, and they highlight the need for improving access to state-of-the-art surgical care for minority patients with rectal cancer.

    View details for Web of Science ID 000188791000007

    View details for PubMedID 14769572

  • Acute transanal evisceration of the small bowel - Report of a case and review of the literature DISEASES OF THE COLON & RECTUM Morris, A. M., Setty, S. P., Standage, B. A., Hansen, P. D. 2003; 46 (9): 1280-1283


    We report a patient who presented with rectal rupture and transanal evisceration, a rare entity with only 52 cases previously described in the world literature. Our case is the first to implicate sheer stress on the anterior rectum caused by postoperative adhesions as the major etiologic contributing feature. Moreover, this case is the third reported with chronic constipation without rectal prolapse as an additional preexisting contributory condition. A summary of the medical literature including etiology, treatment, and outcomes is presented.

    View details for DOI 10.1097/01.DCR.0000084368.32164.88

    View details for Web of Science ID 000185384700018

    View details for PubMedID 12972975

  • Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses MEDICAL CARE Morris, A. M., Flowers, C. R., Morris, K. T., Schmidt, W. A., Pommier, R. F., Vetto, J. T. 2003; 41 (8): 962-971


    Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy.To compare cost-effectiveness of TTS and traditional methods.The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions.In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost.The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model.

    View details for Web of Science ID 000184477700009

    View details for PubMedID 12886175

  • Clostridium difficile colitis - An increasingly aggressive iatrogenic disease? ARCHIVES OF SURGERY Morris, A. M., Jobe, B. A., Stoney, M., Sheppard, B. C., Deveney, C. W., Deveney, K. E. 2002; 137 (10): 1096-1100


    The diagnosis of Clostridium difficile colitis is increasing in frequency, with worsening patient outcomes.Retrospective cohort study.University hospital.One hundred fifty-seven patients diagnosed with C difficile colitis between 1994-2000.Resolution of disease, operative intervention, and death.Compared with our previous 10-year experience, overall cases of C difficile colitis have risen by more than 30%, and immunocompromised patients comprise a larger proportion of those affected. One third of patients were receiving posttransplantation medication, chemotherapy, or had human immunodeficiency virus. Of these, 2 (4%) of 51 required surgical intervention and 10 (20%) of 51 died. An additional 18.5% of patients had diabetes, renal failure, or both. Of these, 2 (7%) of 30 required surgery and 4 (13%) of 30 died. Only 9.5% of patients had prophylactic perioperative antibiotics as a sole risk factor; 2 (13%) of 15 required surgery and 3 (20%) of 15 died. The overall mortality rate was 15.3%, increased from 3.5% in our previous series. Neither need for surgery nor mortality differed among these patient groups.The frequency of C difficile colitis remains high and seems to be associated with increasing mortality. Among patients with positive C difficile toxin assay results, immunocompromise and delayed diagnosis no longer seem to be associated with higher risk for death. All patients taking antibiotics are at risk and require early recognition and aggressive medical intervention.

    View details for Web of Science ID 000178493300002

    View details for PubMedID 12361411

  • Has misdiagnosis of appendicitis decreased over time? A population-based analysis JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Flum, D. R., Morris, A., KOEPSELL, T., Dellinger, E. P. 2001; 286 (14): 1748-1753


    Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery.To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy.Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998.Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix.Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P =.005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P =.17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001).Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.

    View details for Web of Science ID 000171466800025

    View details for PubMedID 11594900

  • Usefulness of the triple test score for palpable breast masses ARCHIVES OF SURGERY Morris, K. T., Pommier, R. F., Morris, A., Schmidt, W. A., Beagle, G., Alexander, P. W., Toth-Fejel, S., Schmidt, J., Vetto, J. T. 2001; 136 (9): 1008-1012


    The triple test score (TTS) is useful and accurate for evaluating palpable breast masses.Diagnostic test study.University hospital multidisciplinary breast clinic.Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000.Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up.The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255).All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign.The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.

    View details for Web of Science ID 000170895600008

    View details for PubMedID 11529822

  • Induction of anti-mammary cancer immunity by engaging the OX-40 receptor in vivo BREAST CANCER RESEARCH AND TREATMENT Morris, A., Vetto, J. T., Ramstad, T., Funatake, C. J., Choolun, E., Entwisle, C., Weinberg, A. D. 2001; 67 (1): 71-80


    The OX-40 receptor (OX-40R) is a member of the tumor necrosis factor receptor (TNF-R) superfamily that is expressed on activated CD4+ T cells. The OX-40R is a costimulatory molecule that induces CD4+ T cell activation when engaged by its ligand (OX-40 L; found on antigen presenting cells). In human and murine tumors, we have shown upregulation of the OX-40R on CD4+ T cells from tumor-infiltrating lymphocytes (TIL) and tumor-draining lymph node cells (TDLNC) but not on systemic CD4+ T cells, such as peripheral blood lymphocytes (PBL) or splenocytes. In order to examine potentially heightened anti-tumor immunity through enhanced costimulation when engaging OX-40R in vivo, we inoculated mice with a murine mammary cancer cell line (SM1) and then treated with a soluble form of the OX-40 L. Mice injected with a lethal inoculum of SM1 cells were given two intraperitoneal injections (days 3 and 7 post-inoculation) of 100 microg soluble OX-40 L. Seven of 28 treated mice survived the lethal tumor inoculum, as compared to one of 28 control mice, demonstrating a significant survival benefit with treatment (p = 0.0136, log rank analysis). Mice that did not develop tumor by day 90 were rechallenged; all remained tumor-free. Mice were also injected with a second mammary tumor line (4T1) and treated with OX-40L:Ig with similar therapeutic results. Activation of OX-40R+ CD4+ T cells during mammary cancer priming stimulated an antitumor immune response resulting in enhanced survival and protective anti-tumor immunity. These results should have practical applications for treatment modalities for patients with breast cancer.

    View details for PubMedID 11518468

  • Engagement of the OX-40 receptor in vivo enhances antitumor immunity JOURNAL OF IMMUNOLOGY Weinberg, A. D., Rivera, M. M., Prell, R., Morris, A., Ramstad, T., Vetto, J. T., Urba, W. J., Alvord, G., Bunce, C., Shields, J. 2000; 164 (4): 2160-2169


    The OX-40 receptor (OX-40R), a member of the TNFR family, is primarily expressed on activated CD4+ T lymphocytes. Engagement of the OX-40R, with either OX-40 ligand (OX-40L) or an Ab agonist, delivers a strong costimulatory signal to effector T cells. OX-40R+ T cells isolated from inflammatory lesions in the CNS of animals with experimental autoimmune encephalomyelitis are the cells that respond to autoantigen (myelin basic protein) in vivo. We identified OX-40R+ T cells within primary tumors and tumor-invaded lymph nodes of patients with cancer and hypothesized that they are the tumor-Ag-specific T cells. Therefore, we investigated whether engagement of the OX-40R in vivo during tumor priming would enhance a tumor-specific T cell response. Injection of OX-40L:Ig or anti-OX-40R in vivo during tumor priming resulted in a significant improvement in the percentage of tumor-free survivors (20-55%) in four different murine tumors derived from four separate tissues. This anti-OX-40R effect was dose dependent and accentuated tumor-specific T cell memory. The data suggest that engagement of the OX-40R in vivo augments tumor-specific priming by stimulating/expanding the natural repertoire of the host's tumor-specific CD4+ T cells. The identification of OX-40R+ T cells clustered around human tumor cells in vivo suggests that engagement of the OX-40R may be a practical approach for expanding tumor-reactive T cells and thereby a method to improve tumor immunotherapy in patients with cancer.

    View details for Web of Science ID 000085296600067

    View details for PubMedID 10657670

  • Accurate evaluation of palpable breast masses by the triple test score ARCHIVES OF SURGERY Morris, A., Pommier, R. F., Schmidt, W. A., Shih, R. L., Alexander, P. W., Vetto, J. T. 1998; 133 (9): 930-933


    We previously reported that the triple test (physical examination, mammography, and fine needle aspiration) for palpable breast masses yields 100% diagnostic accuracy when all 3 components are concordant (all benign or all malignant). However, 40% of cases are nonconcordant and require open biopsy.To evaluate our experience with the triple test to develop a method to further limit the need for surgical biopsy.Diagnostic test study.University hospital multidisciplinary breast clinic.Two hundred fifty-nine patients with 261 palpable breast masses studied between 1991 and 1997.The triple test was prospectively applied to each breast mass. Each component of the triple test was assigned 1, 2, or 3 points for a benign, suspicious, or malignant result, respectively, yielding a total triple test score (TTS).The TTS was correlated with subsequent histopathologic examination results.Eighty-eight masses had a TTS of more than 6 points; all had malignant histopathologic characteristics. One hundred fifty-two masses had a TTS of 4 points or lower; all were benign. In both groups, diagnostic accuracy and predictive value were 100%, with P<.001. Twenty-one masses had a TTS of 5 points; of these, 13 (62%) were benign and 8 (38%) were malignant.The TTS reliably guides evaluation and treatment of palpable breast masses. Masses that score 6 points or higher are malignant and should undergo definitive therapy; masses that score 4 points or lower are benign and may be clinically followed up. Only those masses that score 5 points (8% of our database) require open biopsy.

    View details for PubMedID 9749842

  • Presence of the T-cell activation marker OX-40 on tumor infiltrating lymphocytes and draining lymph node cells from patients with melanoma and head and neck cancers AMERICAN JOURNAL OF SURGERY Vetto, J. T., Lum, S., Morris, A., Sicotte, M., Davis, J., Lemon, M., Weinberg, A. 1997; 174 (3): 258-265


    The OX-40 antigen is a cell surface glycoprotein in the tumor necrosis factor receptor family that is expressed primarily on activated CD4+ T cells. Selective target organ expression of the OX-40 receptor on autoantigen specific T cells has been found in autoimmune disease. In order to evaluate whether OX-40 is expressed on T cells from patients with nodal-draining carcinomas, OX-40 expression was assessed in tumor infiltrating lymphocytes (TILs), draining lymph node cells (DLNCs), and/or peripheral blood lymphocytes (PBLs) of 13 patients with head and neck squamous cell carcinomas and 9 patients with melanomas.Cell phenotype was determined by fluorescence cell analysis using a monoclonal antibody to human OX-40, and CD4+ T cell lymphokine production was determined by reverse transcriptase-polymerase chain reaction (RT-PCR).Expression of the OX-40 receptor was found in as many as 31% of the TILs and as many as 28% of the DLNCs tested. Conversely, no OX-40 expression was found in PBLs. In addition, CD4+ T cells isolated from DLNCs (but not from TILs or PBLs) secreted a Th1 pattern of cytokines (IL-2, gamma interferon). Co-culture of autologous CD4+ TILs with an MHC class II+ melanoma cell line transfected with OX-40 ligand cDNA resulted in T cell proliferation and in vitro tumor regression.These findings suggest that OX-40+ CD4+ T cells isolated from tumors and their adjacent draining nodes may represent a tumor-specific population of activated T cells capable of mediating tumor reactivity. These cells may play an exploitable role in future trials of immunotherapy.

    View details for PubMedID 9324133