Laura Graham

All Publications

• Variations in Current Practice and Protocols of Intraoperative Multimodal Analgesia: A Cross-Sectional Study Within a Six-Hospital US Health Care System. Anesthesia and analgesia Graham, L. A., Illarmo, S. S., Wren, S. M., Odden, M. C., Mudumbai, S. C. 2024

  Abstract

  Multimodal analgesia (MMA) aims to reduce surgery-related opioid needs by adding nonopioid pain medications in postoperative pain management. In light of the opioid epidemic, MMA use has increased rapidly over the past decade. We hypothesize that the rapid adoption of MMA has resulted in variation in practice. This cross-sectional study aimed to determine how MMA practices have changed over the past 6 years and whether there is variation in use by patient, provider, and facility characteristics.Our study population includes all patients undergoing surgery with general anesthesia at 1 of 6 geographically similar hospitals in the United States between January 1, 2017 and December 31, 2022. Intraoperative pain medications were obtained from the hospital's perioperative information management system. MMA was defined as an opioid plus at least 2 other nonopioid analgesics. Frequencies, χ2 tests (χ2), range, and interquartile range (IQR) were used to describe variation in MMA practice over time, by patient and procedure characteristics, across hospitals, and across anesthesiologists. Multivariable logistic regression was conducted to understand the independent contributions of patient and procedural factors to MMA use.We identified 25,386 procedures among 21,227 patients. Overall, 46.9% of cases met our definition of MMA. Patients who received MMA were more likely to be younger females with a lower comorbidity burden undergoing longer and more complex procedures that included an inpatient admission. MMA use has increased steadily by an average of 3.0% each year since 2017 (95% confidence interval =2.6%-3.3%). There was significant variation in use across hospitals (n = 6, range =25.9%-68.6%, χ2 = 3774.9, P < .001) and anesthesiologists (n = 190, IQR =29.8%-65.8%, χ2 = 1938.5, P < .001), as well as by procedure characteristics. The most common MMA protocols contained acetaminophen plus regional anesthesia (13.0% of protocols) or acetaminophen plus dexamethasone (12.2% of protocols). During the study period, the use of opioids during the preoperative or intraoperative period decreased from 91.4% to 86.0% of cases; acetaminophen use increased (41.9%-70.5%, P < .001); dexamethasone use increased (24.0%-36.1%, P < .001) and nonsteroidal anti-inflammatory drugs (NSAIDs) increased (6.9%-17.3%, P < .001). Gabapentinoids and IV lidocaine were less frequently used but also increased (0.8%-1.6% and 3.4%-5.3%, respectively, P < .001).In a large integrated US health care system, approximately 50% of noncardiac surgery patients received MMA. Still, there was wide variation in MMA use by patient and procedure characteristics and across hospitals and anesthesiologists. Our findings highlight a need for further research to understand the reasons for these variations and guide the safe and effective adoption of MMA into routine practice.

  View details for DOI 10.1213/ANE.0000000000007299

  View details for PubMedID 39453849

• Use of natural language processing method to identify regional anesthesia from clinical notes. Regional anesthesia and pain medicine Graham, L. A., Illarmo, S. S., Wren, S. M., Odden, M. C., Mudumbai, S. C. 2024

  Abstract

  INTRODUCTION: Accurate data capture is integral for research and quality improvement efforts. Unfortunately, limited guidance for defining and documenting regional anesthesia has resulted in wide variation in documentation practices, even within individual hospitals, which can lead to missing and inaccurate data. This cross-sectional study sought to evaluate the performance of a natural language processing (NLP)-based algorithm developed to identify regional anesthesia within unstructured clinical notes.METHODS: We obtained postoperative clinical notes for all patients undergoing elective non-cardiac surgery with general anesthesia at one of six Veterans Health Administration hospitals in California between January 1, 2017, and December 31, 2022. After developing and executing our algorithm, we compared our results to a frequently used referent, the Corporate Data Warehouse structured data, to assess the completeness and accuracy of the currently available data. Measures of agreement included sensitivity, positive predictive value, false negative rate, and accuracy.RESULTS: We identified 27,713 procedures, of which 9310 (33.6%) received regional anesthesia. 96.6% of all referent regional anesthesia cases were identified in the clinic notes with a very low false negative rate and good accuracy (false negative rate=0.8%, accuracy=82.5%). Surprisingly, the clinic notes documented more than two times the number of regional anesthesia cases that were documented in the referent (algorithm n=9154vs referent n=4606).DISCUSSION: While our algorithm identified nearly all regional anesthesia cases from the referent, it also identified more than two times as many regional anesthesia cases as the referent, raising concerns about the accuracy and completeness of regional anesthesia documentation in administrative and clinical databases. We found that NLP was a promising alternative for identifying clinical information when existing databases lack complete documentation.

  View details for DOI 10.1136/rapm-2024-105340

  View details for PubMedID 38580338

• Mapping the Discharge Process After Surgery. JAMA surgery Graham, L. A., Illarmo, S., Gray, C. P., Harris, A. H., Wagner, T. H., Hawn, M. T., Iannuzzi, J. C., Wren, S. M. 2024

  Abstract

  Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process.To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery.This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide.Postoperative hospital discharge.Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings.At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination.These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

  View details for DOI 10.1001/jamasurg.2023.7539

  View details for PubMedID 38381415

• Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans. Health affairs (Project Hope) Decker, H. C., Graham, L. A., Titan, A., Hawn, M. T., Kanzaria, H. K., Wick, E., Kushel, M. B. 2024; 43 (2): 234-241

  Abstract

  Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.

  View details for DOI 10.1377/hlthaff.2023.01003

  View details for PubMedID 38315919

• Applying Cognitive Task Analysis to Health Services Research. Health services research Graham, L. A., Gray, C., Wagner, T. H., Illarmo, S., Hawn, M. T., Wren, S. M., Iannuzzi, J., Harris, A. H. 2022

  Abstract

  OBJECTIVE: Designing practical decision support tools and other healthcare technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study.DATA SOURCES AND STUDY SETTING: Observations and interviews of healthcare providers involved in discharge planning at 6 hospitals in the Veterans Health Administration.STUDY DESIGN: Qualitative study of discharge planning using CTA.DATA COLLECTION / EXTRACTION METHODS: Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis.PRINCIPAL FINDINGS: We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: 1) Planning, 2) Environmental Analysis, 3) Knowledge Elicitation, and 4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task.CONCLUSIONS: A better understanding of the cognitive processes that underly clinical tasks is key to developing healthcare technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/1475-6773.14106

  View details for PubMedID 36421922

• Exploring Trajectories of Healthcare Utilization Before and After Surgery. Journal of the American College of Surgeons Graham, L. A., Wagner, T. H., Richman, J. S., Morris, M. S., Copeland, L. A., Harris, A. H., Itani, K. M., Hawn, M. T. 2018

  Abstract

  INTRO: Long-term trajectories of healthcare utilization in the context of surgery have not been well characterized. The objective of this study was to examine healthcare utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated following surgical admissions.METHODS: Hospital medical-surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (10/1/2007-9/30/2014) were identified. Group-based trajectory analysis identified five distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression.RESULTS: Of 280,681 surgery inpatients, most underwent orthopedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of healthcare utilization were identified with 5.2% of patients among consistently high inpatient utilizers accounting for 34.0% of inpatient days. Male (95.4% vs. 93.5%, p<0.01), African American (21.6% vs. 17.3%, p<0.01), or unmarried patients (61.6% vs. 52.5%, p<0.01) were more likely to be high utilizers as compared to other trajectories. High utilizers also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs. 16.3%; bipolar disorder: 5.3% vs. 2.1%, p<0.01), social/behavioral risk factors (smoker: 41.1% vs. 33.6%, p<0.01; alcohol use disorder: 28.9% vs. 12.9%, p<0.01), and chronic pain (6.4% vs. 2.8%, p<0.01).CONCLUSION: Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative healthcare utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.

  View details for PubMedID 30359825

• Improved Adverse Postoperative Outcomes With Revised American College of Cardiology/American Heart Association Guidelines for Patients With Cardiac Stents JAMA SURGERY Graham, L. A., Singletary, B. A., Richman, J. S., Maddox, T. M., Itani, K. M., Hawn, M. T. 2014; 149 (11): 1113-1120

  Abstract

  In 2007, the American College of Cardiology/American Heart Association guidelines were revised for patients with cardiac stents in need of subsequent surgery to recommend delaying elective noncardiac surgery by 365 days in patients with drug-eluting stents (DESs).To examine the effect of the guidelines on postoperative major adverse cardiac events (MACEs) in subsequent noncardiac surgery.Patients receiving a cardiac stent between fiscal years 2005 and 2010 were identified by International Classification of Diseases, Ninth Revision diagnosis codes in the Veterans Affairs Medical SAS data sets. The Veterans Affairs Surgical Quality Improvement Program data were used to identify subsequent operations in the 2 years following stenting. The preguideline period was defined as fiscal years 2005 through 2007 and the postguideline period was defined as fiscal years 2008 through 2010. Surgery patients admitted through the emergency department or transferred from another hospital were excluded from analyses. Overall, 16,634 elective noncardiac operations were identified (8034 [48.3%] in the preguideline period; 8600 [51.7%] in the postguideline period).Composite 30-day postoperative MACEs. We used χ² tests to examine differences in bivariate frequencies and used logistic models to examine adjusted associations with 2-year postoperative MACEs.The median time to surgery was 364 days (interquartile range, 184-528 days). A total of 11,026 operations (66.3%) followed DES placement, and 5608 (33.7%) followed bare metal stent placement. After the guidelines' publication, surgery timing increased following DES placement from 323 to 404 days (P < .001) and decreased following bare metal stent placement from 402 to 309 days (P < .001). In addition, postoperative MACE rates decreased from 4.2% to 3.3% (P = .002). After adjusting for cardiac risk factors and procedure characteristics, there was an overall absolute risk reduction of 0.9% for MACEs (odds ratio = 0.74; 95% CI, 0.62-0.89). On further examination of trends across time, MACE rates with DES placement began to decrease prior to the guidelines' publication from 5.5% in 2005 to 4.3% in 2006 and remained stable through 2010. In contrast, MACE rates with bare metal stent placement increased from 4.3% in 2005 to 8.0% in 2007 but decreased to 4.8% following the guidelines' publication.After the guidelines' publication, noncardiac surgery was delayed in patients with DESs but not bare metal stents. With a 26% reduction in MACEs following the guidelines, it would appear that the guidelines did improve postoperative outcomes; however, when examined over time, it becomes evident that there are many more factors influencing management of patients with cardiac stents in need of subsequent surgery.

  View details for DOI 10.1001/jamasurg.2014.2044

  View details for Web of Science ID 000345443800005

  View details for PubMedID 25188466

• Antihypertensive Deprescribing and Cardiovascular Events Among Long-Term Care Residents. JAMA network open Odden, M. C., Graham, L. A., Liu, X., Dave, C. V., Lee, S. J., Li, Y., Jing, B., Fung, K., Peralta, C. A., Steinman, M. A. 2024; 7 (11): e2446851

  Abstract

  The practice of deprescribing antihypertensive medications is common among long-term care residents, yet the effect on cardiovascular outcomes is unclear.To compare the incidence of hospitalization for myocardial infarction (MI) or stroke among long-term care residents who are deprescribed or continue antihypertensive therapy.This comparative effectiveness research study used target trial emulation with observational electronic health record data from long-term care residents aged 65 years or older admitted to US Department of Veterans Affairs community living centers between October 1, 2006, and September 30, 2019, and taking at least 1 antihypertensive medication. Analyses were conducted between August 2023 and August 2024.A reduction in the number of antihypertensive medications or dose (by ≥30%), assessed using barcode medication administration data.Incidence of MI and stroke hospitalization up to 2 years was assessed using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. A pooled logistic regression model with inverse probability of treatment weighting (IPTW) and inverse probability of censoring weighting (IPCW) was used to estimate per-protocol effects.Of 13 096 long-term care residents (97.4% men; median age, 77 years [IQR, 70-84 years]) taking antihypertensive medication, 17.8% were deprescribed antihypertensive medication over a period of 12 weeks. The estimated unadjusted cumulative incidence of stroke or MI hospitalization over 2 years was similar among residents who were and were not deprescribed antihypertensives in per-protocol analyses (11.2% vs 8.8%; difference, 2.4 percentage points [95% CI, -2.3 to 7.1 percentage points]). Participant characteristics were balanced after applying IPTW and IPCW; all standardized mean differences were less than 0.05. After full adjustment for confounding and informative censoring, the per-protocol analysis results showed no association of antihypertensive deprescribing with MI or stroke hospitalization (hazard ratio, 0.93; 95% CI, 0.70-1.26).In this comparative effectiveness research study, deprescribing antihypertensive medication was not associated with risk of hospitalization for MI or stroke in long-term care residents. These findings may be informative for long-term care residents and clinicians who are considering deprescribing antihypertensive medications.

  View details for DOI 10.1001/jamanetworkopen.2024.46851

  View details for PubMedID 39585693

• Deprescribing of Antihypertensive Medications and Cognitive Function in Nursing Home Residents. JAMA internal medicine Jing, B., Liu, X., Graham, L. A., Dave, C. V., Li, Y., Fung, K., Liu, C. K., Abdel Magid, H. S., Growdon, M. E., Deardorff, W. J., Boscardin, W. J., Lee, S. J., Steinman, M. A., Odden, M. C. 2024

  Abstract

  Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain.To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024.Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks.Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

  View details for DOI 10.1001/jamainternmed.2024.4851

  View details for PubMedID 39312220

  View details for PubMedCentralID PMC11420821

• Health Insurance Enrollment Among US Veterans, 2010-2021. JAMA network open Wagner, T. H., Schmidt, A., Belli, F., Aouad, M., Gehlert, E., Desai, M., Graham, L., Rose, L. 2024; 7 (8): e2430205

  Abstract

  Importance: Department of Veterans Affairs (VA) health care spending has increased in the past decade, in part due to legislative changes that expanded access to VA-purchased care.Objective: To understand how insurance coverage and enrollment in VA has changed between 2010 and 2021.Design, Setting, and Participants: This cross-sectional study used data from surveys conducted from 2010 to 2021. Participants were respondents across 4 national surveys who reported being a US veteran and reported on health insurance enrollment. Data were analyzed from October 2023 to June 2024.Main Outcomes and Measures: Self-reported health insurance coverage, reliance on VA insurance, and self-reported health.Results: Among a total of 3 644 614 survey respondents (mean [SE] age, 60 [0.04] years; 91.3% [95% CI, 91.2%-91.5%] male) included, 52.2% (95% CI, 52.0%-52.4%) were out of the labor market and 63.1% (95% CI, 62.9%-63.3%) were married. In 2010, 94% of all veterans and 94% of veterans younger than age 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment increased over time, and by 2020, 97% of all veterans and 95% of veterans younger than 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment estimates were similar across the surveys. Approximately one-third of veterans reported being enrolled in VA health coverage. Of those who enrolled in VA insurance, more than 75% had more than 1 form of coverage, with Medicare and private insurance being the most common second insurance sources. VA insurance enrollment was negatively associated with income and health status. Veterans without insurance tended to be unemployed and younger.Conclusions and Relevance: This study of veterans who responded to 4 national surveys found that veterans enrolled in VA health coverage had high rates of dual coverage. Further legislative efforts to increase access without recognizing the high rates of dual coverage may yield unintended consequences, such payer shifting.

  View details for DOI 10.1001/jamanetworkopen.2024.30205

  View details for PubMedID 39186266

• Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents. Journal of the American Medical Directors Association Liu, X., Jing, B., Graham, L. A., Liu, C. K., Lee, S. J., Steinman, M. A., Dave, C. V., Manja, V., Li, Y., Fung, K., Odden, M. C. 2024: 105119

  Abstract

  Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors.Retrospective cohort study.A total of 24,870 Department of Veterans Affairs (VA) nursing home residents ≥65 years with long-term stays (≥180 days) from 2006 to 2019.We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission.More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years).Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.

  View details for DOI 10.1016/j.jamda.2024.105119

  View details for PubMedID 38950584

• Effects of residential socioeconomic polarization on high blood pressure among nursing home residents. Health & place Abdel Magid, H. S., Jaros, S., Li, Y., Steinman, M. A., Lee, S., Peralta, C., Jing, B., Fung, K., Liu, C. K., Liu, X., Graham, L. A., Odden, M. C. 2024; 87: 103243

  Abstract

  Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home.41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders.We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain.We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.

  View details for DOI 10.1016/j.healthplace.2024.103243

  View details for PubMedID 38663339

• Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA internal medicine Dave, C. V., Li, Y., Steinman, M. A., Lee, S. J., Liu, X., Jing, B., Graham, L. A., Marcum, Z. A., Fung, K. Z., Odden, M. C. 2024

  Abstract

  Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents.To assess the association between antihypertensive medication initiation and risk of fracture.This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023.Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]).Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.

  View details for DOI 10.1001/jamainternmed.2024.0507

  View details for PubMedID 38648065

  View details for PubMedCentralID PMC11036308

• Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA network open Decker, H. C., Graham, L. A., Titan, A., Kanzaria, H. K., Hawn, M. T., Kushel, M., Wick, E. 2023; 6 (12): e2349143

  Abstract

  Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

  View details for DOI 10.1001/jamanetworkopen.2023.49143

  View details for PubMedID 38127343

• ANTIHYPERTENSIVE DEPRESCRIBING AND DISABILITY IN VA NURSING HOME RESIDENTS WITH AND WITHOUT DEMENTIA Liu, X., Graham, L., Jing, B., Dave, C., Li, Y., Fung, K., Odden, M. OXFORD UNIV PRESS. 2023: 703-704

  View details for Web of Science ID 001178258403333

• ANTIHYPERTENSIVE DEPRESCRIBING AND COGNITIVE FUNCTION IN VA NURSING HOME RESIDENTS: A TARGET TRIAL EMULATION Jing, B., Liu, X., Odden, M., Dave, C., Graham, L., Li, Y., Fung, K., Steinman, M. OXFORD UNIV PRESS. 2023: 646

  View details for Web of Science ID 001178258403150

• Managing Competing Risks for Surgical Patients With Complex Medical Problems-Considering Confounding. JAMA surgery Graham, L. A., Hawn, M. T. 2023

  View details for DOI 10.1001/jamasurg.2023.5952

  View details for PubMedID 37991777

• Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System. Journal of the American Heart Association Yong, C. M., Graham, L., Beyene, T. J., Sadri, S., Hong, J., Burdon, T., Fearon, W. F., Asch, S. M., Turakhia, M., Heidenreich, P. 2023: e029910

  Abstract

  Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

  View details for DOI 10.1161/JAHA.123.029910

  View details for PubMedID 37421288

• Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees. JAMA network open Rose, L., Schmidt, A., Gehlert, E., Graham, L. A., Aouad, M., Wagner, T. H. 2023; 6 (7): e2323884

  Abstract

  This cross-sectional study using survey data investigates the association between level of reliance on the Department of Veterans Affairs for health care and self-reported health by type of insurance coverage among VA enrollees.

  View details for DOI 10.1001/jamanetworkopen.2023.23884

  View details for PubMedID 37459100

• Association Between Preoperative Diabetes Control and Postoperative Adverse Events Among Veterans Health Administration Patients With Diabetes Who Underwent Elective Ambulatory Hernia Surgery. JAMA network open Shanahan, J., Vimalananda, V. G., Graham, L., Schumann, R., Mull, H. J. 2023; 6 (3): e236318

  View details for DOI 10.1001/jamanetworkopen.2023.6318

  View details for PubMedID 37000453

• Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents. Journal of the American Geriatrics Society Liu, X., Steinman, M. A., Lee, S. J., Peralta, C. A., Graham, L. A., Li, Y., Jing, B., Fung, K. Z., Odden, M. C. 2023

  Abstract

  Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications.Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications).More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group).The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

  View details for DOI 10.1111/jgs.18301

  View details for PubMedID 36826917

• 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

  Abstract

  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

• Quality Reporting Windows May Not Capture the Effects of Surgical Site Infections After Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Shapiro, L. M., Graham, L. A., Hawn, M. T., Kamal, R. N. 2022; 104 (14): 1281-1291

  Abstract

  BACKGROUND: Postoperative surgical site infections (SSIs) and the associated complications impact morbidity and mortality and result in substantial burden to the health-care system. These complications are typically reported during the 90-day surveillance period, with implications for reimbursement and quality measurement; however, the long-term effects of SSI are not routinely assessed. We evaluated the long-term effects of SSI on health-care utilization and cost following orthopaedic surgery in an observational cohort study.METHODS: Patients in the Veterans Affairs health-care system who underwent an orthopaedic surgical procedure were included. The exposure of interest was an SSI within 90 days after the index procedure. The primary outcome was health-care utilization in the 2 years after discharge. Data for inpatient admission, inpatient days, outpatient visits, emergency room visits, total costs, and subsequent surgeries were also obtained. After adjusting for factors affecting SSI, we examined differences in each health-care utilization outcome by postoperative SSI occurrence and across time with use of differences-in-differences analysis. Cost differences were modeled with use of a gamma distribution with a log link.RESULTS: A total of 96,983 patients were included, of whom 4,056 (4.2%) had an SSI within 90 days of surgery. After adjusting for factors known to impact SSI and preoperative health-care utilization, SSI was associated with a greater risk of outpatient visits (relative risk [RR], 1.29; 95% confidence interval [CI], 1.26 to 1.32), emergency room visits (RR, 1.18; 95% CI, 1.15 to 1.21), and inpatient admission (RR, 1.35; 95% CI, 1.32 to 1.38) at 2 years postoperatively. The average cost among patients with an SSI was $148,824 ± $268,358 compared with $42,125 ± $124,914 among those without an SSI (p < 0.001). In the adjusted analysis, costs for patients with an SSI were 64% greater at 2 years compared with those without an SSI (RR, 1.64; 95% CI, 1.57 to 1.70). Overall, of all subsequent surgeries conducted within the 2-year postoperative period, 37% occurred within the first 90 days.CONCLUSIONS: The reported effects of a postoperative SSI on health-care utilization and cost are sustained at 2 years post-surgery-a long-term impact that is not recognized in quality-measurement models. Efforts, including preoperative care pathways and optimization, and policies, including reimbursement models and risk-adjustment, should be made to reduce SSI and to account for these long-term effects.LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.21.01278

  View details for PubMedID 35856929

• Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018. Journal of the American Geriatrics Society Odden, M. C., Li, Y., Graham, L. A., Steinman, M. A., Marcum, Z. A., Liu, C. K., Jing, B., Fung, K. Z., Peralta, C. A., Lee, S. J. 2022

  Abstract

  BACKGROUND: Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms.METHODS: Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs.RESULTS: The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90mmHg). The age-adjusted prevalence of chronic low BP (average <90/60mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90mmHg.CONCLUSIONS: Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

  View details for DOI 10.1111/jgs.17821

  View details for PubMedID 35524763

• Association of Antihypertensives and Cognitive Impairment in Long-Term Care Residents. Journal of Alzheimer's disease : JAD Marcum, Z. A., Li, Y., Lee, S. J., Steinman, M. A., Graham, L., Jing, B., Fung, K., Peralta, C. A., Odden, M. C. 2022

  Abstract

  Certain classes of antihypertensive medication may have different associations with cognitive impairment.To examine the association between prevalent use of antihypertensive medications that stimulate (thiazides, dihydropyridine calcium channel blockers, angiotensin type I receptor blockers) versus inhibit (angiotensin-converting enzyme inhibitors, beta-blockers, non-dihydropyridine calcium channel blockers) type 2 and 4 angiotensin II receptors on cognitive impairment among older adults residing in Veterans Affairs (VA) nursing homes for long-term care.Retrospective cohort study. Long-term care residents aged 65 + years admitted to a VA nursing home from 2012 to 2019 using blood pressure medication and without cognitive impairment at admission. Main exposure was prevalent use of angiotensin II receptor type 2 and 4-'stimulating' (N = 589), 'inhibiting' (N = 3,219), or 'mixed' (N = 1,715) antihypertensive medication regimens at admission. Primary outcome was any cognitive impairment (Cognitive Function Scale).Over an average of 5.4 months of follow-up, prevalent use of regimens containing exclusively 'stimulating' antihypertensives was associated with a lower risk of any incident cognitive impairment as compared to prevalent use of regimens containing exclusively 'inhibiting' antihypertensives (HR 0.83, 95% CI 0.74-0.93). Results for the comparison between 'mixed' versus 'inhibiting' regimens were in the same direction but not statistically significant (HR 0.96, 95% CI 0.88-1.06).For residents without cognitive impairment at baseline, prevalent users of regimens containing exclusively antihypertensives that stimulate type 2 and 4 angiotensin II receptors had lower rates of cognitive impairment as compared to prevalent users of regimens containing exclusively antihypertensives that inhibit these receptors. Residual confounding cannot be ruled out.

  View details for DOI 10.3233/JAD-215393

  View details for PubMedID 35147539

• Timing and Cost of Wound Complications After Colorectal Resection. Diseases of the colon and rectum Graham, L. A., Wagner, T. H., Sambare, T. D., Hawn, M. T. 2021; 64 (12): 1551-1558

  Abstract

  BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery.OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications.DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data.SETTING: This study was conducted at a Veterans Affairs medical center.SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014.MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery.RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001).LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system.CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient.TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Mas del 50% de complicaciones postoperatorias de la herida ocurren despues del alta. Es la complicacion postoperatoria mas comun y el motivo mas frecuente de reingreso despues del procedimiento quirurgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida despues del alta quirurgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las caracteristicas de las complicaciones de la herida, identificadas despues del alta hospitalaria, en pacientes sometidos a cirugia colorrectal, en comparacion con las complicaciones intrahospitalarias.DISENO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirurgica de la Administracion de Salud de Veteranos.ENTORNO CLINICO:Administracion de Veteranos.PACIENTES:Pacientes sometidos a reseccion colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACION:Costos de atencion ajustados al alta, 30 dias y 90 dias despues de la cirugia.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicacion de la herida dentro de los 30 dias de la cirugia. (49,2% indice hospitalario, 50,8% despues del alta). En comparacion con los pacientes, del indice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), mas infecciones de organos/espacios quirurgicos (14,3% frente a 10,1%, p <0,01), tasas mas altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberian de haber tenido un abordaje laparoscopico para su cirugia (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugia a los 30 dias, fue de $ 37,315 (desviacion estandar = $ 29,319). En comparacion con el indice de complicaciones de las herida hospitalaria, las complicaciones de la herida despues del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 dias y $ 9,736 (15%, p<0,001) y menor costo a los 90 dias. Los pacientes con indice de complicacion de la herida hospitalaria, tenian un 40% menos de probabilidades de requerir reingreso a los 30 dias, pero sus reingresos eran $ 12,518 mas costosos que los reingresos entre los pacientes presentando complicacion de la herida recien identificada despues del alta (p <0,001).LIMITACIONES:Limitado a las caracteristicas del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 dias, que aquellos con complicaciones de la herida identificadas durante su indice de hospitalizacion y aproximadamente la mitad fueron tratados de forma ambulatoria.

  View details for DOI 10.1097/DCR.0000000000002065

  View details for PubMedID 34747918

• Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals. Surgery Rajasingh, C. M., Graham, L. A., Richman, J., Mell, M. W., Morris, M. S., Hawn, M. T. 2021

  Abstract

  BACKGROUND: Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay.METHODS: We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay.RESULTS: We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001).CONCLUSION: Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.

  View details for DOI 10.1016/j.surg.2021.09.033

  View details for PubMedID 34736786

• Association of Expanded Health Care Networks With Utilization Among Veterans Affairs Enrollees. JAMA network open Rose, L., Aouad, M., Graham, L., Schoemaker, L., Wagner, T. 2021; 4 (10): e2131141

  Abstract

  Importance: Health insurers alter the size of their networks, offering lower premiums in exchange for a more limited set of care choices. However, little is known about the association of network size with health care utilization and outcomes, particularly outside of the context of private insurance plans.Objective: To evaluate changes in health care utilization after an expansion in the Veterans Affairs Health Care System (VA) health care network.Design, Setting, and Participants: This cross-sectional study included individuals enrolled in the VA from 2015 to 2018. Considering that the health care network expansion only affected a portion of enrollees, only those who lived between 20 and 60 miles from a VA facility were included. Data analysis was conducted from September 2020 to February 2021.Exposures: Individuals who lived 40 or more miles away from a VA facility were automatically eligible for an expanded health care network through non-VA practitioners (VA community care); those living less than 40 miles away from a VA facility were not automatically eligible.Main Outcomes and Measures: A regression discontinuity analysis of individuals who became eligible for an expanded network based on geographic residence was performed. Inpatient and outpatient utilization rates per VA enrollee during the study period, with utilization differentiated by whether services were provided by a VA or non-VA practitioner, were calculated.Results: The study included more than 2.7 million unique individuals whose characteristics largely reflected the demographic characteristics of the VA system (mean [SD] age, 62 [17] years; 2 589 252 [90%] men; 282 168 [10%] Black; 2 203 352 [77%] White). Patient characteristics (age, race, and comorbidities) did not vary significantly by eligibility status. Outpatient utilization was 3.2% higher (95% CI, 1.0% to 5.3%) among those with access to an expanded network. Increased utilization was most pronounced among those with a higher VA disability rating (3.1%; 95% CI, 0.5% to 5.7%) and among younger individuals without service-connected disabilities (7.0%, 95% CI, 1.7% to 12.3%). There was no evidence of changes to inpatient utilization (1.2%; 95% CI. -2.5% to 4.9%; P=.37) for those with access to the expanded network.Conclusions and Relevance: In this study, expanded network access was associated with increased total health care utilization among affected enrollees in the VA. Understanding how network size affects utilization is immediately informative for the VA, but it can also help to guide policies for insurance markets.

  View details for DOI 10.1001/jamanetworkopen.2021.31141

  View details for PubMedID 34698845

• Exploring the Dynamics of Week-to-Week Blood Pressure in Nursing Home Residents Before Death. American journal of hypertension Graham, L. A., Lee, S. J., Steinman, M., Peralta, C. A., Rubinsky, A., Jing, B., Fung, K., Odden, M. C. 2021

  Abstract

  BACKGROUND: Aging is accompanied by an overall dysregulation of many dynamic physiologic processes including those related to blood pressure (BP). While year-to-year BP variability is associated with cardiovascular events and mortality, no studies have examined this trend with more frequent BP assessments. Our study objective is to take the next step to examine week-to-week BP dynamics - pattern, variability, and complexity - before death.METHODS: Using a retrospective study design, we assessed BP dynamics in the 6 months before death in long-term nursing home residents between 10/1/2006 and 9/30/2017. Variability was characterized using standard deviation and mean square error after adjusting for diurnal variations. Complexity (i.e., amount of novel information in a trend) was examined using Shannon's entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability.RESULTS: We identified 17,953 nursing home residents (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mmHg). Despite a slight trend of decreasing systolic week-to-week BP over time (delta=7.2mmHg), week-to-week complexity did not change in the six months before death (delta=0.02 bits). Average weekly BP variability was stable until the last 3-4 weeks of life, at which point variability increased by 30% for both systolic and diastolic BP. Factors associated with BP variability include average weekly systolic/diastolic BP, days in the nursing home, days in the hospital, and changes to antihypertensive medications.CONCLUSIONS: Week-to-week BP variability increases substantially in the last month of life, but complexity does not change. Changes in care patterns may drive the increase in BP variability as one approaches death.

  View details for DOI 10.1093/ajh/hpab142

  View details for PubMedID 34505872

• Deprescribing Blood Pressure Treatment in Long-Term Care Residents. Journal of the American Medical Directors Association Odden, M. C., Lee, S. J., Steinman, M. A., Rubinsky, A. D., Graham, L., Jing, B., Fung, K., Marcum, Z., Peralta, C. A. 2021

  Abstract

  OBJECTIVES: To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events.DESIGN: Retrospective cohort study.SETTING AND PARTICIPANTS: Long-term care residents aged 65years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission.METHODS: Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls.RESULTS: Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay= 6months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4weeks after admission and the last 4weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference= 30.3%, P < .001). A fall in the past 30days was associated with the smallest magnitude increased risk of deprescribing (risk difference= 3.8%, P < .001) of the events considered.CONCLUSIONS AND IMPLICATIONS: Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.

  View details for DOI 10.1016/j.jamda.2021.07.009

  View details for PubMedID 34364847

• Psychosocial Determinants of Readmission After Surgery. Medical care Graham, L. A., Hawn, M. T., Dasinger, E. A., Baker, S. J., Oriel, B. S., Wahl, T. S., Richman, J. S., Copeland, L. A., Itani, K. M., Burns, E. A., Whittle, J., Morris, M. S. 2021

  Abstract

  BACKGROUND: Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood.OBJECTIVE: We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population.RESEARCH DESIGN: This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital.SUBJECTS: We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017).MEASURES: We assessed unplanned readmission to any medical facility within 30 days of hospital discharge.RESULTS: A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery.CONCLUSIONS: Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.

  View details for DOI 10.1097/MLR.0000000000001600

  View details for PubMedID 34149017

• Impact of policy-based and institutional interventions on postoperative opioid prescribing practices. American journal of surgery Titan, A., Doyle, A., Pfaff, K., Baiu, I., Lee, A., Graham, L., Shelton, A., Hawn, M. 2021

  Abstract

  BACKGROUND: We assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing.METHODS: Retrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort.RESULTS: Comparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5±8.9 vs. 16.2±7.0 vs. 12.8±4.9, p<0.01) and mean OME dosage (148.0±68.0 vs. 108.6±51.8 vs. 95.4±38.0, p<0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control.CONCLUSION: Formalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.

  View details for DOI 10.1016/j.amjsurg.2021.02.004

  View details for PubMedID 33593614

• The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality From COVID-19. Frontiers in medicine Rose, L., Graham, L., Koenecke, A., Powell, M., Xiong, R., Shen, Z., Mench, B., Kinzler, K. W., Bettegowda, C., Vogelstein, B., Athey, S., Vogelstein, J. T., Konig, M. F., Wagner, T. H. 2021; 8: 637647

  Abstract

  Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and pre-clinical data suggest alpha-1 adrenergic receptor antagonists (alpha1-AR antagonists) may be effective in reducing mortality related to hyperinflammation independent of etiology. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between baseline use of alpha1-AR antagonists and likelihood of death due to COVID-19 during hospitalization. Having an active prescription for any alpha1-AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 18%; odds ratio 0.73; 95% CI 0.63-0.85; p ≤ 0.001) and death within 28 days of admission (relative risk reduction 17%; odds ratio 0.74; 95% CI 0.65-0.84; p ≤ 0.001). In a subset of patients on doxazosin specifically, an inhibitor of all three alpha-1 adrenergic receptors, we observed a relative risk reduction for death of 74% (odds ratio 0.23; 95% CI 0.03-0.94; p = 0.028) compared to matched controls not on any alpha1-AR antagonist at the time of admission. These findings suggest that use of alpha1-AR antagonists may reduce mortality in COVID-19, supporting the need for randomized, placebo-controlled clinical trials in patients with early symptomatic infection.

  View details for DOI 10.3389/fmed.2021.637647

  View details for PubMedID 33869251

• BLOOD PRESSURE CONTROL AND CARDIOVASCULAR AND MORTALITY RISK IN VA NURSING HOME RESIDENTS Liu, X., Lee, S., Steinman, M., Graham, L., Li, Y., Jing, B., Odden, M. OXFORD UNIV PRESS. 2021: 605

  View details for Web of Science ID 000842009903012

• BLOOD PRESSURE VARIABILITY AND COMPLEXITY IN NURSING HOME RESIDENTS BEFORE DEATH Graham, L., Lee, S., Steinman, M., Peralta, C., Rubinsky, A., Jing, B., Fung, K., Odden, M. OXFORD UNIV PRESS. 2021: 137

  View details for Web of Science ID 000842009900534

• DEPRESCRIBING BLOOD PRESSURE TREATMENT IN VA LONG-TERM CARE RESIDENTS Odden, M., Lee, S., Steinman, M., Rubinsky, A., Jing, B., Fung, K., Graham, L., Peralta, C. OXFORD UNIV PRESS. 2021: 333

  View details for Web of Science ID 000842009901547

• Asymptomatic SARS-CoV-2 Transmission from Community Contacts in Healthcare Workers. Annals of surgery Graham, L. A., Maldonado, Y. A., Tompkins, L. S., Wald, S. H., Chawla, A., Hawn, M. T. 2020

  View details for DOI 10.1097/SLA.0000000000003968

  View details for PubMedID 32487801

• Impact of Gastrointestinal Surgical Site Wound Complications on Long-term Healthcare Utilization. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Sambare, T. D., Graham, L. A., Itani, K. M., Morris, M. S., Moshrefi, S., Hawn, M. T. 2020

  Abstract

  IMPORTANCE: Wound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied.OBJECTIVE: We assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2years after gastrointestinal (GI) surgery.DESIGN: An observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014.SETTING: Population-based PARTICIPANTS: A total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0years (interquartile range (IQR) 57.0-70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse.EXPOSURE: VASQIP-assessed or ICD-9-coded wound complication in the 30days after surgery MAIN OUTCOME MEASUREMENTS: Inpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2years after discharge from index admission RESULTS: Patients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P<.001), inpatient bed days (mean 41.0 vs. 25.0; P<.001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P<.001) and emergency department visits (mean 3.5 vs. 2.7; P<.001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P<.001); inpatient bed days (21.4 vs. 3.7; P<.001); and outpatient visits (56.2 vs. 9.7; P<.001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P<.001).CONCLUSIONS: Surgical wound complications impact healthcare utilization patterns for up to 2years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.

  View details for DOI 10.1007/s11605-019-04489-2

  View details for PubMedID 31993964

• Patient-reported health literacy scores are associated with readmissions following surgery. American journal of surgery Baker, S. n., Malone, E. n., Graham, L. n., Dasinger, E. n., Wahl, T. n., Titan, A. n., Richman, J. n., Copeland, L. n., Burns, E. n., Whittle, J. n., Hawn, M. n., Morris, M. n. 2020

  Abstract

  Health literacy (HL) impacts medical care. We hypothesized that patients with low HL would have higher readmission rates following surgery.We conducted a prospective, multi-institutional study from 8/2015-6/2017 within the Veterans Affairs (VA) System including veterans who underwent general, vascular, or thoracic surgery. HL was assessed by Brief Health Literacy Screener and stratified into adequate vs. low. Patients were followed for 30 days post-discharge. Multivariable analyses examined correlations and logistic regression models adjusted for covariates.736 patients were enrolled in the study; 98% (n = 722) completed the HL survey. At discharge, 33.2% of patients had low HL. The overall 30-day readmission rate was 16.3%, with a significant difference by HL (Adequate HL: 13.3% vs. Low HL: 22.5%, p < 0.01). After adjusting for clinical and demographic covariates, patients with low HL were 59% more likely to be readmitted (OR = 1.59, 95% CI = 1.02-2.50).Low HL is common among VA surgery patients and is associated with readmission. Future studies should be focused on interventions to target this vulnerable patient population.

  View details for DOI 10.1016/j.amjsurg.2020.06.071

  View details for PubMedID 32682501

• The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality from COVID-19. medRxiv : the preprint server for health sciences Rose, L. n., Graham, L. n., Koenecke, A. n., Powell, M. n., Xiong, R. n., Shen, Z. n., Kinzler, K. W., Bettegowda, C. n., Vogelstein, B. n., Athey, S. n., Vogelstein, J. T., Konig, M. F., Wagner, T. H. 2020

  Abstract

  Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and preclinical data suggest alpha-1 adrenergic receptor antagonists (α 1 -AR antagonists) may be effective in reducing mortality related to hyperinflammation. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between use of α 1 -AR antagonists at time of hospitalization and likelihood of death due to COVID-19 during an inpatient stay. Having an active prescription for an α 1 -AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 14%; odds ratio 0.75; 95% CI 0.66 to 0.86; p ≤ 0.001). These effects were also found in an expanded cohort of suspected COVID-19 patients, supporting the need for clinical trials.

  View details for DOI 10.1101/2020.12.18.20248346

  View details for PubMedID 33398294

  View details for PubMedCentralID PMC7781337

• Preoperative opioid use and postoperative pain associated with surgical readmissions AMERICAN JOURNAL OF SURGERY Dasinger, E. A., Graham, L. A., Wahl, T. S., Richman, J. S., Baker, S. J., Hawn, M. T., Hernandez-Boussard, T., Rosen, A. K., Mull, H. J., Copeland, L. A., Whittle, J. C., Burns, E. A., Morris, M. S. 2019; 218 (5): 828–35

  View details for DOI 10.1016/j.amjsurg.2019.02.033

  View details for Web of Science ID 000490752400004

• Learning Curves and the Challenges of Adopting New Surgical Techniques. JAMA network open Graham, L. A., Hawn, M. T. 2019; 2 (10): e1913569

  View details for DOI 10.1001/jamanetworkopen.2019.13569

  View details for PubMedID 31626309

• Association between Timing and Cost of Postoperative Wound Complication Graham, L. A., Wagner, T. H., Sambare, T. D., Hawn, M. T. ELSEVIER SCIENCE INC. 2019: S143

  View details for Web of Science ID 000492740900262

• Trends in the Inclusion of Black and Female Surgeons in Invited Visiting Professorships. JAMA surgery Tabata, M. M., Rosenthal, E. L., Arbaugh, C. J., Kin, C., Kim, E., Graham, L. A., Hawn, M. T. 2019

  View details for DOI 10.1001/jamasurg.2019.2137

  View details for PubMedID 31290945

• Perioperative opioid use and pain-related outcomes in the Veterans Health Administration. American journal of surgery Hernandez-Boussard, T., Graham, L. A., Carroll, I., Dasinger, E. A., Titan, A. L., Morris, M. S., Hawn, M. T. 2019

  Abstract

  Understanding variation in perioperative opioid exposure and its effect on patients' outcomes is critical for pain management. This study characterized perioperative exposure to morphine and its association with postoperative pain and 30-day readmissions. We utilized nationwide Veterans Healthcare Administration (VHA) data on four high-volume surgical procedures, 2007-2014. We identified 235,239 Veterans undergoing orthopedic, general, or vascular surgery; 5.4% high trajectories (116.1 OME/Day), 53.2% medium trajectories (39.7 OME/Day), and 41.4% low trajectories (19.1 OME/Day). Modeled estimates suggest that patients in the high OME group had higher risk of a pain-related readmission (OR: 1.59; CI: 1.39, 1.83) compared to the low OME trajectory. Yet when stratified by pain trajectory, patients with high pain and high OME had lower risk of a pain-related readmission compared to patients in the high pain low OME group (OR: 0.76, CI: 0.62, 0.94). In conclusion, patients receiving high perioperative OME are more likely to return to care for pain-related problems. This study highlights opportunities to reduce the amount of prescriptions opioids in the communities.

  View details for DOI 10.1016/j.amjsurg.2019.06.022

  View details for PubMedID 31280840

• Databases for surgical health services research: Veterans Health Administration data SURGERY Graham, L. A. 2019; 165 (5): 876–78

  View details for DOI 10.1016/j.surg.2018.07.029

  View details for Web of Science ID 000468125100006

• Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission. JAMA network open Graham, L. A., Mull, H. J., Wagner, T. H., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J., Burns, E., Copeland, L. A., Itani, K. M., Hawn, M. T. 2019; 2 (4): e191313

  Abstract

  Importance: The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care.Objective: To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population.Design, Setting, and Participants: Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019.Main Outcomes and Measures: Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure.Results: The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with rho coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement-associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty-associated penalties in 26.0% of hospitals.Conclusions and Relevance: In this study, surgical quality-associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.

  View details for PubMedID 31002316

• Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission JAMA NETWORK OPEN Graham, L. A., Mull, H. J., Wagner, T. H., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J., Burns, E., Copeland, L. A., Itani, K. F., Hawn, M. T. 2019; 2 (4)

  View details for DOI 10.1001/jamanetworkopen.2019.1313

  View details for Web of Science ID 000476798700006

• Preoperative opioid use and postoperative pain associated with surgical readmissions. American journal of surgery Dasinger, E. A., Graham, L. A., Wahl, T. S., Richman, J. S., Baker, S. J., Hawn, M. T., Hernandez-Boussard, T., Rosen, A. K., Mull, H. J., Copeland, L. A., Whittle, J. C., Burns, E. A., Morris, M. S. 2019

  Abstract

  BACKGROUND: The extent of preoperative opioid utilization and the relationship with pain-related readmissions are not well understood.METHODS: VA Surgical Quality Improvement Program data on general, vascular, and orthopedic surgeries (2007-2014) were merged with pharmacy data to evaluate preoperative opioid use and pain-related readmissions. Opioid use in the 6-month preoperative period was categorized as none, infrequent, frequent, and daily.RESULTS: In the six-month preoperative period, 65.7% had no opioid use, 16.7% had infrequent use, 6.3% frequent use, and 11.4% were daily opioid users. Adjusted odds of pain-related readmission were higher for opioid-exposed groups vs the opioid-naive group: infrequent (OR 1.17; 95% CI:1.04-1.31), frequent (OR 1.28; 95% CI:1.08-1.52), and daily (OR 1.49; 95% CI:1.27-1.74). Among preoperative opioid users, those with a pain-related readmission had higher daily preoperative oral morphine equivalents (mean 44.5 vs. 36.1, p < 0.001).CONCLUSIONS: Patients using opioids preoperatively experienced higher rates of pain-related readmissions, which increased with frequency and dosage of opioid exposure.

  View details for PubMedID 30879796

• Facility-level association of preoperative stress testing and postoperative adverse cardiac events HEART Valle, J. A., Graham, L., Thiruvoipati, T., Grunwald, G., Armstrong, E. J., Maddox, T. M., Hawn, M. T., Bradley, S. M. 2018; 104 (24): 2018-+

  Abstract

  Despite limited indications, preoperative stress testing is often used prior to non-cardiac surgery. Patient-level analyses of stress testing and outcomes are limited by case mix and selection bias. Therefore, we sought to describe facility-level rates of preoperative stress testing for non-cardiac surgery, and to determine the association between facility-level preoperative stress testing and postoperative major adverse cardiac events (MACE).We identified patients undergoing non-cardiac surgery within 2 years of percutaneous coronary intervention in the Veterans Affairs (VA) Health Care System, from 2004 to 2011, facility-level rates of preoperative stress testing and postoperative MACE (death, myocardial infarction (MI) or revascularisation within 30 days). We determined risk-standardised facility-level rates of stress testing and postoperative MACE, and the relationship between facility-level preoperative stress testing and postoperative MACE.Among 29 937 patients undergoing non-cardiac surgery at 131 VA facilities, the median facility rate of preoperative stress testing was 13.2% (IQR 9.7%-15.9%; range 6.0%-21.5%), and 30-day postoperative MACE was 4.0% (IQR 2.4%-5.4%). After risk standardisation, the median facility-level rate of stress testing was 12.7% (IQR 8.4%-17.4%) and postoperative MACE was 3.8% (IQR 2.3%-5.6%). There was no correlation between risk-standardised stress testing and composite MACE at the facility level (r=0.022, p=0.81), or with individual outcomes of death, MI or revascularisation.In a national cohort of veterans undergoing non-cardiac surgery, we observed substantial variation in facility-level rates of preoperative stress testing. Facilities with higher rates of preoperative stress testing were not associated with better postoperative outcomes. These findings suggest an opportunity to reduce variation in preoperative stress testing without sacrificing patient outcomes.

  View details for PubMedID 29934371

• Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission Wahl, T. S., Graham, L. A., Morris, M. S., Richman, J. S., Hollis, R. H., Jones, C. E., Itani, K. M., Wagner, T. H., Mull, H. J., Whittle, J. C., Telford, G. L., Rosen, A. K., Copeland, L. A., Burns, E. A., Hawn, M. T. AMER MEDICAL ASSOC. 2018: e182009

  Abstract

  Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission.To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes.A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded.Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL).Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome.Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR.Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.

  View details for PubMedID 29971429

• Homeless Status, Postdischarge Health Care Utilization, and Readmission After Surgery. Medical care Titan, A. n., Graham, L. n., Rosen, A. n., Itani, K. n., Copeland, L. A., Mull, H. J., Burns, E. n., Richman, J. n., Kertesz, S. n., Wahl, T. n., Morris, M. n., Whittle, J. n., Telford, G. n., Wilson, M. n., Hawn, M. n. 2018; 56 (6): 460–69

  Abstract

  Homeless Veterans are vulnerable to poor care transitions, yet little research has examined their risk of readmission following inpatient surgery. This study investigates the predictors of surgical readmission among homeless relative to housed Veteran patients.Inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration from 2008 to 2014 were identified. Administrative International Classification of Diseases, Ninth Revision, Clinical Modification codes and Veterans Health Administration clinic stops were used to identify homeless patients. Bivariate analyses examined characteristics and predictors of readmission among homeless patients. Multivariate logistic models were used to estimate the association between homeless experience and housed patients with readmission following surgery.Our study included 232,373 surgeries: 43% orthopedic, 39% general, and 18% vascular with 5068 performed on homeless patients. Homeless individuals were younger (56 vs. 64 y, P<0.01), more likely to have a psychiatric comorbidities (51.3% vs. 19.4%, P<0.01) and less likely to have other medical comorbidities such as hypertension (57.1% vs. 70.8%, P<0.01). Homeless individuals were more likely to be readmitted [odds ratio (OR), 1.43; confidence interval (CI), 1.30-1.56; P<0.001]. Discharge destination other than community (OR, 0.57; CI, 0.44-0.74; P<0.001), recent alcohol abuse (OR, 1.45; CI, 1.15-1.84; P<0.01), and elevated American Society Anesthesiologists classification (OR, 1.86; CI, 1.30-2.68; P<0.01) were significant risk factors associated with readmissions within the homeless cohort.Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.

  View details for PubMedID 29746348

• Mitral valve surgery in the US Veterans Administration health system: 10-year outcomes and trends. The Journal of thoracic and cardiovascular surgery Bakaeen, F. G., Shroyer, A. L., Zenati, M. A., Badhwar, V., Thourani, V. H., Gammie, J. S., Suri, R. M., Sabik, J. F., Gillinov, A. M., Chu, D., Omer, S., Hawn, M. T., Almassi, G. H., Cornwell, L. D., Grover, F. L., Rosengart, T. K., Graham, L. 2018; 155 (1): 105-117.e5

  Abstract

  To compare mitral valve repair (MVRepair) and mitral valve replacement (MVReplace) trends in the Veterans Affairs (VA) Surgical Quality Improvement Program.Trends were compared by bivariate analyses, followed by backward stepwise selection and multivariable logistic modeling to determine the effect of preoperative comorbidities and facility-level factors on MVRepair (vs MVReplace) rate. A subgroup analysis focused on patients who underwent elective surgery for isolated primary degenerative mitral regurgitation. Propensity matching was done in the overall and primary degenerative cohorts.From October 2000 to October 2013, 4165 veterans underwent MVRepair (n = 2408) or MVReplace (n = 1757) for MV disease of any cause at 40 VA medical centers (procedural volume, 0-29/y; median 7/y). The MVRepair percentage increased from 48% in 2001 to 63% in 2013 (P < .001). MVRepair rates varied widely among centers; center volume explained only 19% of this variation after adjustment for case mix (R2 = 0.19, P = .005). Unadjusted 30-day and 1-year mortality rates were lower after MVRepair than after MVReplace (3.5% vs 4.8%, P = .04; 9.8% vs 12.1%, P = .02). Among the propensity-matched patients (n = 2520), 30-day and 1-year mortality were similar after MVRepair and MVReplace. In the propensity-matched primary degenerative subgroup (n = 664), unadjusted long-term mortality for up to 10 years postoperatively was lower after MVRepair (28% vs 37%, P = .003), as was risk-adjusted long-term mortality (hazard ratio, 0.78; 95% confidence interval, 0.61-1.01).In the VA Health System, mortality after MV operations is low. Despite the survival advantage associated with MV repair in primary mitral regurgitation, repair is infrequent at some centers, representing an opportunity for quality improvement.

  View details for DOI 10.1016/j.jtcvs.2017.07.089

  View details for PubMedID 29074046

• Association of Postoperative Readmissions With Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes. JAMA surgery Mull, H. J., Graham, L. A., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J. n., Burns, E. n., Wagner, T. H., Copeland, L. A., Wahl, T. n., Jones, C. n., Hollis, R. H., Itani, K. M., Hawn, M. T. 2018

  Abstract

  Postoperative readmission data are used to measure hospital performance, yet the extent to which these readmissions reflect surgical quality is unknown.To establish expert consensus on whether reasons for postoperative readmission are associated with the quality of surgery in the index admission.In a modified Delphi process, a panel of 14 experts in medical and surgical readmissions comprising physicians and nonphysicians from Veterans Affairs (VA) and private-sector institutions reviewed 30-day postoperative readmissions from fiscal years 2008 through 2014 associated with inpatient surgical procedures performed at a VA medical center between October 1, 2007, and September 30, 2014. The consensus process was conducted from January through May 2017. Reasons for readmission were grouped into categories based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Panelists were given the proportion of readmissions coded by each reason and median (interquartile range) days to readmission. They answered the question, "Does the readmission reason reflect possible surgical quality of care problems in the index admission?" on a scale of 1 (never related) to 5 (directly related) in 3 rounds of consensus building. The consensus process was completed in May 2017 and data were analyzed in June 2017.Consensus on proportion of ICD-9-coded readmission reasons that reflected quality of surgical procedure.In 3 Delphi rounds, the 14 panelists achieved consensus on 50 reasons for readmission; 12 panelists also completed group telephone calls between rounds 1 and 2. Readmissions with diagnoses of infection, sepsis, pneumonia, hemorrhage/hematoma, anemia, ostomy complications, acute renal failure, fluid/electrolyte disorders, or venous thromboembolism were considered associated with surgical quality and accounted for 25 521 of 39 664 readmissions (64% of readmissions; 7.5% of 340 858 index surgical procedures). The proportion of readmissions considered to be not associated with surgical quality varied by procedure, ranging from to 21% (613 of 2331) of readmissions after lower-extremity amputations to 47% (745 of 1598) of readmissions after cholecystectomy.One-third of postoperative readmissions are unlikely to reflect problems with surgical quality. Future studies should test whether restricting readmissions to those with specific ICD-9 codes might yield a more useful quality measure.

  View details for PubMedID 29710234

• Perioperative beta blockers and statins for noncardiac surgery patients with coronary stents. American journal of surgery Richman, J. S., Graham, L. A., DeRussy, A., Maddox, T. M., Itani, K. M., Hawn, M. T. 2017; 214 (2): 180-185

  Abstract

  Recent publications report that perioperative initiation of statin therapy is associated with improved outcomes particularly among patients with increased cardiac risk. However, findings on associations with beta blocker (BB) initiation are mixed.This study examines associations between perioperative statin and BB use in a national sample of patients with cardiac stents.Retrospective cohort study.VA Medical Centers nationwide.We identified Veterans Affairs (VA) patients undergoing non-cardiac surgery in the within two years after stent placement between October 2002 and September 2011 with BB and/or statin prescriptions within one year prior to surgery. Using VA inpatient data we identified major adverse cardiac or cerebrovascular events (MACCE) within 30 days of surgery. General usage patterns and percent of days covered by medication were calculated as additional markers of medication use. Adjusted logistic regression was used to examine associations between medication use and 30-day postoperative outcomes.23,537 patients underwent surgery within 2 years following stent placement, of whom 20,566 (88.6%) had prescriptions for beta blockers and statins within 365 days prior to surgery. Of those, 13,501 (65.6%) used both BB and statins prior to surgery, while 2626 (12.8%) used only BB, 2346 (11.4%) used only statins, and 2093 (10.2%) used neither. In fully adjusted models, the only significant association was between perioperative statin use and decreased mortality (OR 0.65, 95% CI 0.48-0.87).Our results suggest that maintaining statin therapy perioperatively is associated with reduced 30 day mortality in stented patients undergoing non-cardiac surgery who have previously been prescribed both beta blockers and statins.

  View details for DOI 10.1016/j.amjsurg.2017.05.001

  View details for PubMedID 28641862

• Association of the Modified Frailty Index With 30-Day Surgical Readmission. JAMA surgery Wahl, T. S., Graham, L. A., Hawn, M. T., Richman, J., Hollis, R. H., Jones, C. E., Copeland, L. A., Burns, E. A., Itani, K. M., Morris, M. S. 2017

  Abstract

  Frail patients are known to have poor perioperative outcomes. There is a paucity of literature investigating how the Modified Frailty Index (mFI), a validated measure of frailty, is associated with unplanned readmission among military veterans following surgery.To understand the association between frailty and 30-day postoperative unplanned readmission.A retrospective cohort study was conducted among adult patients who underwent surgery and were discharged alive from Veterans Affairs hospitals for orthopedic, general, and vascular conditions between October 1, 2007, and September 30, 2014, with a postoperative length of stay between 2 and 30 days.Frailty, as calculated by the 11 variables on the mFI.The primary outcome of interest is 30-day unplanned readmission. Secondary outcomes included any 30-day predischarge or postdischarge complication, 30-day postdischarge mortality, and 30-day emergency department visit.The study sample included 236 957 surgical procedures (among 223 877 men and 13 080 women; mean [SD] age, 64.0 [11.3] years) from high-volume surgical specialties: 101 348 procedures (42.8%) in orthopedic surgery, 92 808 procedures (39.2%) in general surgery, and 42 801 procedures (18.1%) in vascular surgery. The mFI was associated with readmission (odds ratio [OR], 1.11; 95% CI, 1.10-1.12; R2 = 10.3%; C statistic, 0.71). Unadjusted rates of overall 30-day readmission (26 262 [11.1%]), postdischarge emergency department visit (34 204 [14.4%]), any predischarge (13 855 [5.9%]) or postdischarge (14 836 [6.3%]) complication, and postdischarge mortality (1985 [0.8%]) varied by frailty in a dose-dependent fashion. In analysis by individual mFI components using Harrell ranking, impaired functional status, identified as nonindependent functional status (OR, 1.16; 95% CI, 1.11-1.21; P < .01) or having a residual deficit from a prior cerebrovascular accident (OR, 1.17; 95% CI, 1.11-1.22; P < .01), contributed most to the ability of the mFI to anticipate readmission compared with the other components. Acutely impaired sensorium (OR, 1.12; 95% CI, 0.99-1.27; P = .08) and history of a myocardial infarction within 6 months (OR, 0.93; 95% CI, 0.81-1.06; P = .28) were not significantly associated with readmission.The mFI is associated with poor surgical outcomes, including readmission, primarily due to impaired functional status. Targeting potentially modifiable aspects of frailty preoperatively, such as improving functional status, may improve perioperative outcomes and decrease readmissions.

  View details for DOI 10.1001/jamasurg.2017.1025

  View details for PubMedID 28467535

• Venous thromboembolic events: How low can you go? American journal of surgery Jones, C. E., Hollis, R. H., Gullick, A. A., Wahl, T., Richman, J. S., Graham, L. A., Lucy, A. T., Chu, D. I., Morris, M. S. 2017; 213 (4): 706-710

  Abstract

  We evaluated postoperative venous thromboembolism (VTE) chemical prophylaxis adherence to assess the preventability of VTEs.A case-control study was performed using the 2011-2015 ACS-NSQIP single institution database. Cases were identified as patients who experienced postoperative VTE within 30 days following surgery. Controls were matched 2:1 on procedure, age, and BMI. Association between inpatient chemical prophylaxis adherence and postoperative VTE was evaluated with conditional logistic regression.Seventy-three cases were matched to 145 controls. Complete inpatient VTE chemical prophylaxis adherence did not differ between cases and controls (45.2% vs. 46.2%, p = 1.00). Odds of postoperative VTE increased if a patient's prophylaxis was interrupted (OR 6.34, 95% CI 1.82-22.13). However, 53.7% of instances of interrupted prophylaxis were medically justified by concern for bleeding, spine operation, or for additional upcoming procedure.Nearly half of patients who experienced postoperative VTEs received appropriate guideline-driven care. Most interruptions in chemical prophylaxis were justified medically. This further questions the preventability of postoperative VTEs and the utility of this outcome as a valid measure of hospital quality.

  View details for DOI 10.1016/j.amjsurg.2016.10.037

  View details for PubMedID 28122661

• A study to reduce readmissions after surgery in the Veterans Health Administration: design and methodology BMC HEALTH SERVICES RESEARCH Copeland, L. A., Graham, L. A., Richman, J. S., Rosen, A. K., Mull, H. J., Burns, E. A., Whittle, J., Itani, K. M., Hawn, M. T. 2017; 17

  Abstract

  Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability.Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007-2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015-2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability.ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care.

  View details for DOI 10.1186/s12913-017-2134-2

  View details for Web of Science ID 000396085500005

  View details for PubMedID 28288681

• Patient and Lesion-Specific Characteristics Predict Risk of Major Adverse Cardiovascular Events Among Patients with Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Armstrong, E. J., Graham, L., Waldo, S. W., Valle, J. A., Maddox, T. M., Hawn, M. T. 2017; 89 (4): 617-627

  View details for DOI 10.1002/ccd.26624

  View details for Web of Science ID 000397300300012

• Incomplete Revascularization Is Associated With an Increased Risk for Major Adverse Cardiovascular Events Among Patients Undergoing Noncardiac Surgery. JACC. Cardiovascular interventions Armstrong, E. J., Graham, L. A., Waldo, S. W., Valle, J. A., Maddox, T. M., Hawn, M. T. 2017; 10 (4): 329-338

  Abstract

  The aim of this study was to determine whether incomplete revascularization is associated with a higher risk for major adverse cardiovascular events (MACE) and myocardial infarction (MI) among patients undergoing noncardiac surgery.Patients with coronary artery disease and prior percutaneous coronary intervention (PCI) frequently undergo noncardiac surgery. These patients may have had PCI either on all obstructive lesions (i.e., complete revascularization) or only on some (i.e., incomplete revascularization).Patients were identified using the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. Veterans Affairs and non-Veterans Affairs surgical records were used to link patients who underwent noncardiac surgery within 2 years after stent placement. Incomplete revascularization was defined as a residual stenosis of ≥50% in the left main coronary artery or ≥70% in another major epicardial coronary artery on the basis of operator visual estimate.In total, 4,332 patients (34.7%) had incomplete revascularization. A total of 567 MACE occurred within 1 month post-operatively. Patients with incomplete revascularization had an unadjusted 19% increased odds of post-operative MACE, compared with those with complete revascularization (odds ratio: 1.19; 95% confidence interval [CI]: 1.00 to 1.41). Among the MACE components, post-operative MI appears to contribute the most, with a 37% increased risk for post-operative MI among patients with incomplete revascularization (odds ratio: 1.37; 95% CI: 1.10 to 1.70). After adjustment, there was a significant interaction between time from PCI and outcomes after noncardiac surgery; incomplete revascularization was associated with significantly increased risk for post-operative MI primarily if surgery was performed within 6 weeks after PCI (adjusted odds ratio: 1.84; 95% CI: 1.04 to 2.38). The number of vessels with incomplete revascularization was also associated with an increased risk for post-operative MI: for each additional vessel with incomplete revascularization, there was a 17% increased odds of post-operative MI.Incomplete revascularization among patients with coronary artery disease is associated with an increased risk for MI after noncardiac surgery.

  View details for DOI 10.1016/j.jcin.2016.11.001

  View details for PubMedID 28161261

• Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery WORLD JOURNAL OF SURGERY Valle, J. A., Graham, L., DeRussy, A., Itani, K., Hawn, M. T., Maddox, T. M. 2017; 41 (2): 423-432

  Abstract

  Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown.We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics.Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients.One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.

  View details for DOI 10.1007/s00268-016-3725-5

  View details for Web of Science ID 000393967600011

• Hospital Readmissions after Surgery: How Important Are Hospital and Specialty Factors? Journal of the American College of Surgeons Hollis, R. H., Graham, L. A., Richman, J. S., Morris, M. S., Mull, H. J., Wahl, T. S., Burns, E., Copeland, L. A., Telford, G. L., Rosen, A. K., Itani, K. F., Whittle, J., Wagner, T. H., Hawn, M. T. 2017

  Abstract

  Hospital readmission rates after surgery can represent an overall hospital effect or a combination of specialty and patient effects. We hypothesized that hospital readmission rates for procedures within specialties were more strongly correlated than rates across specialties within the same hospital.For general, orthopaedic, and vascular specialties at Veterans Affairs hospitals during 2008 to 2014, 30-day risk-adjusted readmission rates were estimated for 6 high-volume procedures and each specialty. Relationships were assessed using the Pearson correlation coefficient.At 84 hospitals, 64,724 orthopaedic, 24,963 general, and 10,399 vascular inpatient procedures were performed; mean readmission rates were 6.3%, 13.6%, and 16.4%, respectively. There was no correlation between specialty-specific adjusted hospital readmission rates: general and orthopaedic (r = 0.21; p = 0.06), general and vascular (r = 0.15; p = 0.19), and vascular and orthopaedic surgery (r = 0.07; p = 0.55). Within specialties, we found modest correlations between knee and hip arthroplasty readmission rates (r = 0.39; p < 0.01) and colectomy and ventral hernia repair (r = 0.24; p = 0.03), but not between lower-extremity bypass and endovascular aortic repair (r = 0.13; p = 0.26). Overall, controlling for patient-level factors, 1.9% of the variation in readmissions was attributable to specialty-level factors; only 0.6% was attributable to hospital-level factors.Hospital readmission rates for orthopaedic, vascular, and general surgery were not correlated between specialties; within each of the 3 specialties, modest correlations were found between 2 procedures within 2 of these specialties. These findings suggest that hospital surgical readmission rates are primarily explained by patient- and procedure-specific factors and less by broader specialty and/or hospital effects.

  View details for DOI 10.1016/j.jamcollsurg.2016.12.034

  View details for PubMedID 28088603

• The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits. Annals of surgery Hernandez-Boussard, T. n., Graham, L. A., Desai, K. n., Wahl, T. S., Aucoin, E. n., Richman, J. S., Morris, M. S., Itani, K. M., Telford, G. L., Hawn, M. T. 2017

  Abstract

  We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits.Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management.National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables.Our sample included 211,231 surgeries-45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (χ trend P < 0.001).Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.

  View details for PubMedID 28657940

• Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery. JAMA surgery Jones, C. E., Graham, L. A., Morris, M. S., Richman, J. S., Hollis, R. H., Wahl, T. S., Copeland, L. A., Burns, E. A., Itani, K. M., Hawn, M. T. 2017; 152 (11): 1031–38

  Abstract

  Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature.To examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission.In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery.Postoperative complications and 30-day unplanned readmission following discharge.Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA1c of more than 6.5% had lower thresholds for postoperative insulin use.Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.

  View details for PubMedID 28746706

  View details for PubMedCentralID PMC5710419

• Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery. American journal of surgery Hollis, R. H., Holcomb, C. N., Valle, J. A., Smith, B. P., DeRussy, A. J., Graham, L. A., Richman, J. S., Itani, K. M., Maddox, T. M., Hawn, M. T. 2016; 212 (5): 814-822 e1

  Abstract

  We evaluated coronary angiography use among patients with coronary stents suffering postoperative myocardial infarction (MI) and the association with mortality.Patients with prior coronary stenting who underwent inpatient noncardiac surgery in Veterans Affairs hospitals between 2000 and 2012 and experienced postoperative MI were identified. Predictors of 30-day post-MI mortality were evaluated.Following 12,096 operations, 353 (2.9%) patients had postoperative MI and 58 (16.4%) died. Post-MI coronary angiography was performed in 103 (29.2%) patients. Coronary angiography was not associated with 30-day mortality (odds ratio [OR]: .70, 95% CI: .35-1.42). Instead, 30-day mortality was predicted by revised cardiac risk index ≥3 (OR 1.91, 95% CI: 1.04-3.50) and prior bare metal stent (OR 2.12, 95% CI: 1.04-4.33).Less than one-third of patients with coronary stents suffering postoperative MI underwent coronary angiography. Significant predictors of mortality were higher revised cardiac risk index and prior bare metal stent. These findings highlight the importance of comorbidities in predicting mortality following postoperative MI.

  View details for DOI 10.1016/j.amjsurg.2016.07.023

  View details for PubMedID 27640120

• Outcomes associated with preoperative weight loss after laparoscopic Roux-en-Y gastric bypass SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Blackledge, C., Graham, L. A., Gullick, A. A., Richman, J., Stahl, R., Grams, J. 2016; 30 (11): 5077-5083

  Abstract

  Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for achieving and maintaining weight loss and for improving obesity-related comorbidities. As part of the approval process for bariatric surgery, many insurance companies require patients to have documented recent participation in a supervised weight loss program. The goal of this study was to evaluate the relationship of preoperative weight changes with outcomes following LRYGB.A retrospective review was conducted of adult patients undergoing LRYGB between 2008 and 2012 at a single institution. Patients were stratified into quartiles based on % excess weight gain (0-4.99 % and ≥5 % EWG) and % excess weight loss (0-4.99 % and ≥5 % EWL). Generalized linear models were used to examine differences in postoperative weight outcomes at 6, 12, and 24 months. Covariates included in the final adjusted models were determined using backwards stepwise selection.Of the 300 patients included in the study, there were no significant demographic differences among the quartiles. However, there was an increased time to operation for patients who gained or lost ≥5 % excess body weight (p < 0.001). Although there was no statistical significance in postoperative complications, there was a higher rate of complications in patients with ≥5 % EWG compared to those with ≥5 % EWL (12.5 vs. 4.8 %, respectively; p = 0.29). Unadjusted and adjusted generalized linear models showed no statistically significant association between preoperative % excess weight change and weight loss outcomes at 24 months.Patients with the greatest % preoperative excess weight change had the longest intervals from initial visit to operation. No significant differences were seen in perioperative and postoperative outcomes. This study suggests preoperative weight loss requirements may delay the time to operation without improving postoperative outcomes or weight loss.

  View details for DOI 10.1007/s00464-016-4856-3

  View details for Web of Science ID 000387225600048

  View details for PubMedID 26969666

  View details for PubMedCentralID PMC5119630

• Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital. Annals of surgery Morris, M. S., Graham, L. A., Richman, J. S., Hollis, R. H., Jones, C. E., Wahl, T., Itani, K. M., Mull, H. J., Rosen, A. K., Copeland, L., Burns, E., Telford, G., Whittle, J., Wilson, M., Knight, S. J., Hawn, M. T. 2016; 264 (4): 621-631

  Abstract

  The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions.Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk.National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R and c-statistics with cross-validation to estimate predictive discrimination.Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R 9.0%, c-statistic 0.69) and postoperative variables (R 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R 19.6%, c-statistic 0.76).Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

  View details for DOI 10.1097/SLA.0000000000001855

  View details for PubMedID 27355263

• Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Catheterization and cardiovascular interventions Armstrong, E. J., Graham, L., Waldo, S. W., Valle, J. A., Maddox, T. M., Hawn, M. T. 2016

  Abstract

  To identify predictors of major adverse cardiovascular outcomes (MACE) among patients with prior percutaneous coronary intervention (PCI) who require noncardiac surgery.Patients with prior PCI who undergo noncardiac surgery have an increased risk of postoperative MACE, but few studies have examined the association of PCI lesion characteristics with subsequent operative risk.Patients were identified using the VA Clinical Assessment, Reporting, and Tracking (CART) program. Patients who underwent noncardiac surgery within 2 years after stent placement were linked to VA and non-VA surgical records. A multivariable logistic regression model was developed to identify predictors of postoperative MACE.Among 12,621 patients with a history of prior PCI who underwent subsequent noncardiac surgery, 570 (4.5%) developed postoperative MACE. The median time from stent placement to surgery was 368 days (IQR 181-528). The strongest predictors of postoperative MACE were urgency of the operation, revised cardiac risk index, the indication for the prior PCI, and timing of the surgery after the PCI. Lesion characteristics independently associated with postoperative MACE included PCI to a distal (AOR 1.43, 95% CI 1.11-1.83) or ostial lesion (AOR 1.52, 95% CI 1.11-2.08), and lesion calcification (AOR 1.29, 95% CI 1.03-1.61), but stent length and target vessel were not independently associated with outcomes. Placement of a bare metal stent was also an independent predictor of MACE after noncardiac surgery (AOR 1.29, 95% CI 1.06-1.57).While patient and operative characteristics are the strongest predictors of MACE after noncardiac surgery, specific lesion characteristics including ostial or distal lesion location and calcification are novel risk factors for postoperative MACE. © 2016 Wiley Periodicals, Inc.

  View details for DOI 10.1002/ccd.26624

  View details for PubMedID 27315550

• Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery JAMA SURGERY Holcomb, C. N., Hollis, R. H., Graham, L. A., Richman, J. S., Valle, J. A., Itani, K. M., Maddox, T. M., Hawn, M. T. 2016; 151 (5): 462-469

  Abstract

  Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE).To determine whether the clinical indication for a coronary stent is associated with postoperative MACE.Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors.Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS).Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization.Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P < .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication.Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.

  View details for DOI 10.1001/jamasurg.2015.4545

  View details for Web of Science ID 000376011600018

  View details for PubMedID 26720292

  View details for PubMedCentralID PMC4893305

• The Incremental Risk of Coronary Stents on Postoperative Adverse Events: A Matched Cohort Study. Annals of surgery Holcomb, C. N., Graham, L. A., Richman, J. S., Itani, K. M., Maddox, T. M., Hawn, M. T. 2016; 263 (5): 924-930

  Abstract

  To determine the incremental risk of coronary stents on adverse events in surgical patients and whether it varies over time from stent placement.Postoperative adverse cardiac events decrease as the time from stent placement increases, but the risk attributable to the stent versus the underlying cardiac disease is uncertain, as prior studies lack a control surgical population.Data for patients with coronary stents implanted in a VA hospital from 2000 to 2010 were matched with VA Surgical Quality Improvement Program data to identify noncardiac surgery within 24 months of stent placement. Each patient with stent was matched with 2 surgical patients without stent on surgical characteristics and cardiac risk factors. Outcomes of myocardial infarction (MI), revascularization, and death within 30 days after surgery were modeled using logistic regression. Adjusted risk differences between stented and nonstented populations were compared across time after stent placement.Adverse cardiac events followed surgery in 531 (5.7%) of the 9391 patients with stent and 680 (3.6%) of the 18,782 patients without stent (P < 0.001). In adjusted models, 30-day postoperative MI (odds ratio = 1.90; 95% confidence interval, 1.57-2.30) and revascularization (odds ratio = 2.03; 95% confidence interval, 1.65-2.50) but not mortality (odds ratio = 0.84; 95% confidence interval, 0.69-1.02) were higher in the stented cohort. Assessing trends over the 2 years after stent placement, the incremental risk for MI decreased from 5% immediately after stent placement to 2% at 1 year and then was no longer significantly elevated. The incremental risk did not vary by stent type.Surgery after coronary stent placement is associated with an approximate 2% absolute risk for postoperative MI but no difference in mortality compared with nonstented matched controls.

  View details for DOI 10.1097/SLA.0000000000001246

  View details for PubMedID 25894416

• Blood Transfusion and 30-Day Mortality in Patients With Coronary Artery Disease and Anemia Following Noncardiac Surgery JAMA SURGERY Hollis, R. H., Singletary, B. A., McMurtrie, J. T., Graham, L. A., Richman, J. S., Holcomb, C. N., Itani, K. M., Maddox, T. M., Hawn, M. T. 2016; 151 (2): 139-145

  Abstract

  Although liberal blood transfusion thresholds have not been beneficial following noncardiac surgery, it is unclear whether higher thresholds are appropriate for patients who develop postoperative myocardial infarction (MI).To evaluate the association between postoperative blood transfusion and mortality in patients with coronary artery disease and postoperative MI following noncardiac surgery.Retrospective cohort study involving Veterans Affairs facilities from January 1, 2000, to December 31, 2012. A total of 7361 patients with coronary artery disease who underwent inpatient noncardiac surgery and had a nadir postoperative hematocrit between 20% and 30%. Patients with significant bleeding, including any preoperative blood transfusion or transfusion of greater than 4 units during the intraoperative or postoperative setting, were excluded. Mortality rates were compared using both logistic regression and propensity score matching. Patients were stratified by postoperative nadir hematocrit and the presence of postoperative MI.Initial postoperative blood transfusion.The 30-day postoperative mortality rate.Of the 7361 patients, 2027 patients (27.5%) received at least 1 postoperative blood transfusion. Postoperative mortality occurred in 267 (3.6%), and MI occurred in 271 (3.7%). Among the 5334 patients without postoperative blood transfusion, lower nadir hematocrit was associated with an increased risk for mortality (hematocrit of 20% to <24%: 7.3%; 24% to <27%: 3.7%; and 27% to 30%: 1.6%; P < .01). In patients with postoperative MI, blood transfusion was associated with lower mortality, for those with hematocrit of 20% to 24% (odds ratio, 0.28; 95% CI, 0.13-0.64). In patients without postoperative MI, transfusion was associated with significantly higher mortality for those with hematocrit of 27% to 30% (odds ratio, 3.21; 95% CI, 1.85-5.60).These findings support a restrictive postoperative transfusion strategy in patients with stable coronary artery disease following noncardiac surgery. However, interventional studies are needed to evaluate the use of a more liberal transfusion strategy in patients who develop postoperative MI.

  View details for DOI 10.1001/jamasurg.2015.3420

  View details for Web of Science ID 000371319200009

  View details for PubMedID 26444569

• Delays in Surgery for Patients With Coronary Stents Placed After Diagnosis of Colorectal Cancer. JAMA surgery Killian, J. T., Holcomb, C. N., Graham, L. A., Richman, J. S., Hawn, M. T. 2016; 151 (1): 86-88

  View details for DOI 10.1001/jamasurg.2015.3130

  View details for PubMedID 26501344

• Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study. BMC cardiovascular disorders Levitan, E. B., Graham, L. A., Valle, J. A., Richman, J. S., Hollis, R., Holcomb, C. N., Maddox, T. M., Hawn, M. T. 2016; 16 (1): 173-?

  Abstract

  Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000-2012.Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.

  View details for DOI 10.1186/s12872-016-0357-5

  View details for PubMedID 27596717

  View details for PubMedCentralID PMC5011899

• Frequency of Surgery Cancellations Associated With Myocardial Infarction or Death 6 Months After Coronary Stent Placement JAMA SURGERY Graham, L. A., Hollis, R. H., Richman, J. S., Hawn, M. T. 2015; 150 (12): 1199-1201

  View details for DOI 10.1001/jamasurg.2015.3078

  View details for Web of Science ID 000367990700024

  View details for PubMedID 26443936

• Oral Antibiotic Bowel Preparation Significantly Reduces Surgical Site Infection Rates and Readmission Rates in Elective Colorectal Surgery ANNALS OF SURGERY Morris, M. S., Graham, L. A., Chu, D. I., Cannon, J. A., Hawn, M. T. 2015; 261 (6): 1034-1040

  Abstract

  To determine the relationship between oral antibiotic bowel preparation (OABP) and surgical site infection (SSI) rates in a national colectomy cohort.OABP for elective colorectal surgery has fallen out of favor. Large cohort studies show that OABP is associated with a 50% reduction in SSI after colectomy.A retrospective analysis of the National Surgical Quality Improvement Program colectomy cohort from 2011 to 2012 was performed to examine the association between use of OABP and outcomes of SSI, length of stay (LOS), and readmission after elective colectomy. Univariate and multivariable analyses for SSI were performed.The cohort included 8415 colorectal operations of which 5291 (62.9%) had a minimally invasive surgical (MIS) approach. Overall, 25.6% had no bowel preparation, 44.9% had mechanical bowel preparation (MBP) only, and 29.5% received OABP. The SSI rate was 11.1%, and it varied by preparation type: 14.9% no preparation, 12.0% MBP, and 6.5% OABP (P < 0.001). OABP group had significantly shorter hospital LOS: (median = 4, interquartile range: 3-6) versus other preparations (median LOS = 5) (P < 0.001). Readmission rates were lowest in OABP (8.1%) and highest in the no preparation group (11.8%). Multivariable logistic regressions found OABP associated with lower SSI [adjusted odds ratio (ORadj) = 0.46, 95% confidence interval (CI): 0.36-0.59]. Stratified models found OABP protective for SSI for both open procedures (ORadj = 0.40, 95% CI: 0.30-0.53) and MIS procedures (ORadj = 0.48, 95% CI: 0.36-0.65).OABP is associated with reduced SSI rates, shorter LOS, and fewer readmissions. Adoption of OABP before elective colectomy would reduce SSI without effecting LOS. The practice of MBP alone should be abandoned.

  View details for DOI 10.1097/SLA.0000000000001125

  View details for Web of Science ID 000369611600029

  View details for PubMedID 25607761

• Association of Race and Socioeconomic Status with Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass OBESITY SURGERY Gullick, A. A., Graham, L. A., Richman, J., Kakade, M., Stahl, R., Grams, J. 2015; 25 (4): 705-711

  Abstract

  Obesity poses serious health consequences, and bariatric surgery remains the most effective and durable treatment. The goal of this study was to identify the association of race and socioeconomic characteristics with clinical outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB).A retrospective review of all patients who underwent LRYGB between 2004 and 2010 was conducted. Outcomes analyzed included percent excess weight loss (%EWL), percent weight loss (%WL), change in body mass index (ΔBMI), and improvement or remission of obesity-associated medical conditions.In total, 663 patients met inclusion criteria with 170 (25.6%) African Americans and 493 (74.4%) European Americans. When compared to European Americans, the African American group included significantly more women and had a significantly higher preoperative BMI and lower socioeconomic status. In adjusted analyses, African Americans had significantly lower %EWL, %WL, and ΔBMI than the European Americans at 1-, 2-, and 5-year intervals of follow-up. Adjusted spline models including all follow-up visits for all patients also demonstrated a significant difference between the races in %EWL, %WL, and ΔBMI. Both races had similar improvement or remission of type 2 diabetes mellitus, obstructive sleep apnea, hyperlipidemia, and hypertension.Although African Americans had a statistically significant lower %EWL, %WL, and ΔBMI, both groups had durable weight loss and comparable rates of improvement or remission of obesity-associated comorbidities. Thus, both groups have significant improvement in their overall health after LRYGB.

  View details for DOI 10.1007/s11695-014-1447-z

  View details for Web of Science ID 000351771500016

  View details for PubMedID 25304222

• Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hawn, M. T., Graham, L. A., Richman, J. S., Itani, K. M., Henderson, W. G., Maddox, T. M. 2013; 310 (14): 1462-1472

  Abstract

  Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 1 year after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). The evidence underlying these recommendations is limited and conflicting.To determine risk factors for adverse cardiac events in patients undergoing noncardiac surgery following coronary stent implantation.A national, retrospective cohort study of 41,989 Veterans Affairs (VA) and non-VA operations occurring in the 24 months after a coronary stent implantation between 2000 and 2010. Nonlinear generalized additive models examined the association between timing of surgery and stent type with major adverse cardiac events (MACE) adjusting for patient, surgery, and cardiac risk factors. A nested case-control study assessed the association between perioperative antiplatelet cessation and MACE.A composite 30-day MACE rate of all-cause mortality, myocardial infarction, and cardiac revascularization.Within 24 months of 124,844 coronary stent implantations (47.6% DES, 52.4% BMS), 28,029 patients (22.5%; 95% CI, 22.2%-22.7%) underwent noncardiac operations resulting in 1980 MACE (4.7%; 95% CI, 4.5%-4.9%). Time between stent and surgery was associated with MACE (<6 weeks, 11.6%; 6 weeks to <6 months, 6.4%; 6-12 months, 4.2%; >12-24 months, 3.5%; P < .001). MACE rate by stent type was 5.1% for BMS and 4.3% for DES (P < .001). After adjustment, the 3 factors most strongly associated with MACE were nonelective surgical admission (adjusted odds ratio [AOR], 4.77; 95% CI, 4.07-5.59), history of myocardial infarction in the 6 months preceding surgery (AOR, 2.63; 95% CI, 2.32-2.98), and revised cardiac risk index greater than 2 (AOR, 2.13; 95% CI, 1.85-2.44). Of the 12 variables in the model, timing of surgery ranked fifth in explanatory importance measured by partial effects analysis. Stent type ranked last, and DES was not significantly associated with MACE (AOR, 0.91; 95% CI, 0.83-1.01). After both BMS and DES placement, the risk of MACE was stable at 6 months. A case-control analysis of 284 matched pairs found no association between antiplatelet cessation and MACE (OR, 0.86; 95% CI, 0.57-1.29).Among patients undergoing noncardiac surgery within 2 years of coronary stent placement, MACE were associated with emergency surgery and advanced cardiac disease but not stent type or timing of surgery beyond 6 months after stent implantation. Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated.

  View details for DOI 10.1001/jama.2013.278787

  View details for Web of Science ID 000325354100022

  View details for PubMedID 24101118

• Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection JAMA SURGERY Hawn, M. T., Richman, J. S., Vick, C. C., Deierhoi, R. J., Graham, L. A., Henderson, W. G., Itani, K. M. 2013; 148 (7): 649-657

  Abstract

  Timing of prophylactic antibiotic administration for surgical procedures is a nationally mandated and publicly reported quality metric sponsored by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. Numerous studies have failed to demonstrate that adherence to the Surgical Care Improvement Project prophylactic antibiotic timely administration measure is associated with decreased surgical site infection (SSI). OBJECTIVE; To determine whether prophylactic antibiotic timing is associated with SSI occurrence.Retrospective cohort study using national Veterans Affairs patient-level data on prophylactic antibiotic timing for orthopedic, colorectal, vascular, and gynecologic procedures from 2005 through 2009.National Veterans Affairs Surgical Care Improvement Project data from 112 Veterans Affairs hospitals and matched Veterans Affairs Surgical Quality Improvement Program data.Patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy.Timing of prophylactic antibiotic administration with respect to surgical incision time.Data for prophylactic antibiotic agent, prophylactic antibiotic timing with respect to surgical incision, and patient and procedure risk variables were assessed for their relationship with the occurrence of a composite superficial or deep incisional SSI within 30 days after the procedure. Nonlinear generalized additive models were used to examine the association between antibiotic timing and SSI.Of the 32,459 operations, prophylactic antibiotics were administered at a median of 28 minutes (interquartile range, 17-39 minutes) prior to surgical incision, and 1497 cases (4.6%) developed an SSI. Compared with procedures with antibiotic administration within 60 minutes prior to incision, higher SSI rates were observed for timing more than 60 minutes prior to incision (unadjusted odds ratio [OR] = 1.34; 95% CI, 1.08-1.66) but not after incision (unadjusted OR = 1.26; 95% CI, 0.92-1.72). In unadjusted generalized additive models, we observed a significant nonlinear relationship between prophylactic antibiotic timing and SSI when considering timing as a continuous variable (P = .01). In generalized additive models adjusted for patient, procedure, and antibiotic variables, no significant association between prophylactic antibiotic timing and SSI was observed. Vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures (adjusted OR = 1.75; 95% CI, 1.16-2.65). Cefazolin sodium and quinolone in combination with an anaerobic agent were associated with fewer SSI events (cefazolin: adjusted OR = 0.49; 95% CI, 0.34-0.71; quinolone: adjusted OR = 0.55; 95% CI, 0.35-0.87) for colorectal procedures.The SSI risk varies by patient and procedure factors as well as antibiotic properties but is not significantly associated with prophylactic antibiotic timing. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.

  View details for DOI 10.1001/jamasurg.2013.134

  View details for Web of Science ID 000323556600018

  View details for PubMedID 23552769

• Coronary Stents and Subsequent Surgery: Reported Provider Attitudes and Practice Patterns AMERICAN SURGEON Graham, L. A., Maddox, T. M., Itani, K. M., Hawn, M. T. 2013; 79 (5): 514-523

  Abstract

  Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.

  View details for Web of Science ID 000317947000013

  View details for PubMedID 23635588

• Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review AMERICAN JOURNAL OF SURGERY Hollis, R. H., Graham, L. A., Richman, J. S., Deierhoi, R. J., Hawn, M. T. 2012; 204 (4): 494-501

  Abstract

  When patients with drug-eluting stents (DES) present for surgery, current guidelines recommend delaying elective surgeries until 1 year of dual antiplatelet therapy has been completed.We performed a systematic literature review of the major adverse cardiac events (MACE) associated with noncardiac surgery in patients with DES.Twenty-eight of 358 studies met inclusion criteria. Overall, MACE rates decreased as time to surgery increased and varied from 0% to 18% for surgeries within 1 year as compared with 0% to 12% for surgery more than 1 year after a stent. In addition, the current literature showed limited evidence for a protective effect of continuing perioperative dual antiplatelet therapy on MACE rates.The current literature supports a significant decrease in MACE when surgery is performed 1 year after DES placement; however, the level of evidence is weak. Larger studies are needed to determine the safe interval for surgery after stent placement.

  View details for DOI 10.1016/j.amjsurg.2012.04.008

  View details for Web of Science ID 000309805500014

  View details for PubMedID 22867724

• The Incidence and Timing of Noncardiac Surgery after Cardiac Stent Implantation JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hawn, M. T., Graham, L. A., Richman, J. R., Itani, K. M., Plomondon, M. E., Altom, L. K., Henderson, W. G., Bryson, C. L., Maddox, T. M. 2012; 214 (4): 658-666

  Abstract

  In November 2007, national guidelines were released recommending delay of elective noncardiac surgery after cardiac revascularization with drug eluting stents (DES) for 12 months compared with 6 weeks after implantation of bare metal stents (BMS).To determine the incidence of noncardiac surgery within 24 months after stent placement, national VA data on cardiac stent implantation were merged with data from the VA National Surgery Office and Medicare. Using chi-square tests and log-rank analyses, we measured the incidence of noncardiac surgery after BMS and DES in relation to guideline release and surgical characteristics.From 2000 to 2010, 126,773 stent procedures were followed by 25,977 (20.5%) noncardiac operations within 24 months. Overall, 11.8% of the BMS surgery cohort had early surgery (less than 6 weeks) compared with 46.7% of the DES surgery cohort, which had early surgery (less than 12 months). The incidence of surgery differed significantly by stent type (BMS 24.1% vs DES 17.5%, p < 0.001) and in relation to guideline release (pre- 24.6% vs postguideline 13.1%, p < 0.001). Higher complexity operations (work relative value units) were more likely to occur in the early period for both BMS (p < 0.0001) and DES (p < 0.003). After guideline release, the incidence of surgery within 12 months decreased from 16.7% to 10.0% (p < 0.0001).We found evidence that guidelines recommending delaying surgery appear to be effective in decreasing the incidence of early surgery; however, early surgery is still a frequent occurrence. Additional research is needed to better define the risk of cardiac and bleeding complications in patients undergoing subsequent noncardiac surgery, as well as the optimal time for surgery and method of antiplatelet management.

  View details for DOI 10.1016/j.jamcollsurg.2011.12.011

  View details for Web of Science ID 000302485300055

  View details for PubMedID 22341201

• Outcomes for incisional hernia repair in patients undergoing concomitant surgical procedures. American surgeon Altom, L. K., Graham, L. A., Gray, S. H., Snyder, C. W., Vick, C. C., Hawn, M. T. 2012; 78 (2): 243-249

  Abstract

  The safety and efficacy of performing concomitant surgical procedures with an incisional hernia repair (IHR) is not well understood. There are conflicting reports on the outcomes for permanent mesh implantation in the setting of clean-contaminated procedures. The purpose of this study was to review the effect of concomitant surgical procedures on IHR outcomes. This is a retrospective multisite cohort of patients undergoing elective IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Concomitant procedure status, hernia characteristics, and operative details were determined using physician-abstracted operative notes. Hernia outcomes of recurrence and mesh explantation were determined from the medical chart. χ(2) tests, Kaplan-Meier curves, and Cox regression were used to evaluate the effects of concomitant status on hernia outcomes. Of the 1495 elective IHRs, 75 (4.8%) were same site and 56 (3.8%) different site concomitant procedures. At median follow-up of 69.3 months (range 19.1-98.3), 33.6 per cent of patients had a recurrence, mesh explantation, or both. Permanent mesh placement was less likely among concomitant procedures as compared with nonconcomitant procedures (P < 0.0001). Adjusted Cox proportional hazards models of hernia outcomes resulted in an increased hazard for recurrence among same site clean procedures (Hazard Ratio (HR) = 1.8, P = 0.03) and an increased hazard for mesh explantation among same site clean-contaminated procedures (HR = 8.4, P = 0.002). Concomitant same site procedures are significantly associated with adverse hernia outcomes as compared with isolated IHR or IHR with other site concomitant procedures. The high failure rate of hernia repairs among same site concomitant procedures should be taken into account during the surgical decision-making process.

  View details for PubMedID 22369837

• Translating preoperative smoking cessation interventions into routine clinical care of veterans: provider beliefs. Translational behavioral medicine Vick, C. C., Graham, L. A., Henderson, W. G., Houston, T. K., Hawn, M. T. 2011; 1 (4): 604-608

  Abstract

  Smoking among veterans undergoing surgery is estimated to be 36%. Smoking has been linked to postoperative surgical complications including ischemia and cardiac arrhythmias, pneumonia, deep venous thrombosis, pulmonary embolism, and surgical site infection. Preoperative smoking cessation interventions, in which smokers quit at least 6 weeks prior to surgery, have been shown to be effective both in smoking cessation and reduction of postoperative complications; however, little is known about physician beliefs regarding the optimal location and the responsible provider for intervention, or whether surgery should be postponed or delayed based on smoking status. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? To better inform the translation of preoperative best practices for smoking cessation into clinical care in VA, a survey regarding preoperative smoking cessation beliefs and practices was administered to primary care physicians, surgeons, and anesthesia providers. Chi-square tests were used to examine differences in proportions by provider type. Most providers agreed that the primary care clinic is the best location for intervention, with preoperative and surgical clinics ranked by few as the optimal location (13% and 11%, respectively); most respondents (82%) reported that they would refuse or delay surgery in some cases based on smoking status. There were no differences in either beliefs on location or delay based on provider type. Primary care providers were most likely to advise (86.7%) and assess (80.0%) while anesthesia providers were least likely (59.1% and 22.7%, respectively). Taking time to counsel and the belief that dedicated resources would improve quit rates were associated with advising patients to quit smoking, while being uncomfortable with counseling, the belief that acute health takes precedence and the belief that there is not always time to counsel were identified as barriers to assessing patients for smoking cessation intervention. Primary care providers were more optimistic (100%) that patients would quit if counseled, more often (73.3%) reported having time to counsel, and were less likely to report that acute health takes precedence. Most providers believe that smoking cessation would reduce postoperative complications, with the ideal location for the intervention being the primary care clinic, and that some surgical cases should be delayed for this intervention.

  View details for DOI 10.1007/s13142-011-0096-1

  View details for PubMedID 24073083

  View details for PubMedCentralID PMC3717664

• The Attributable Risk of Smoking on Surgical Complications ANNALS OF SURGERY Hawn, M. T., Houston, T. K., Campagna, E. J., Graham, L. A., Singh, J., Bishop, M., Henderson, W. G. 2011; 254 (6): 914-920

  Abstract

  This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes.Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention.A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression.Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications.This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.

  View details for DOI 10.1097/SLA.0b013e31822d7f81

  View details for Web of Science ID 000297375200012

  View details for PubMedID 21869677

• Descriptive Operative Reports: Teaching, Learning, and Milestones to Safe Surgery JOURNAL OF SURGICAL EDUCATION Porterfield, J. R., Altom, L. K., Graham, L. A., Gray, S. H., Urist, M. M., Hawn, M. T. 2011; 68 (6): 452-458

  Abstract

  Few tasks are more ingrained within the minds of practicing surgeons than the dictation of the narrative report of an operation. However, the construct of these reports varies widely among surgeons and is rarely formally taught and not tested formally during surgical training or board certification.A cohort of patients undergoing incisional hernia repair (IHR) over a 5-year period from 16 academically affiliated Veterans' Administration (VA) hospitals was identified. Technical details of the operative approach were obtained only from operative notes. Frequency of missing elements was analyzed by postgraduate year of the resident.Overall, 1367 IHR operative reports were analyzed, comprising 456 (33%) suture repairs, 802 (59%) open mesh repairs, 97 (7%) laparoscopic repairs, and 12 (1%) where repair type could not be determined. Hernia size in any dimension was absent in 63.5% of dictations and was similar regardless of PGY, (54%, 56%, 71%, 67%, and 66% for PGY 1-5, respectively). Among the 906 mesh repairs, 65% failed to mention the mesh size. This absence was similar across PGY (64%, 69%, 65%, 66%, and 68% for PGY 1-5, respectively), and attending reports were only marginally better, with mesh size absent in 57% of reports. In the 456 cases repaired by suture alone, 76% did not record the type of suture used with significant variation by PGY (78%, 59%, 87%, 89%, and 69% for PGY 1-5, attending - 86%).Resident dictation of the operative report represents an opportunity to understand current cognitive deficits regarding the procedure and to allow for intervention. Future studies to validate that internalization of the cognitive aspects of operations can be measured by audit of operative notes are needed. These endeavors will ensure that not only the technical but also the mental guides to safe surgery are acquired.

  View details for DOI 10.1016/j.jsurg.2011.06.015

  View details for Web of Science ID 000296268600002

  View details for PubMedID 22000530

• Agreement between patient survey and medical chart: Pitfalls in measurement strategies for hernia recurrence SURGERY Graham, L. A., Altom, L. K., Vick, C. C., Snyder, C. W., Deierhoi, R. J., Hawn, M. T. 2011; 150 (3): 371-378

  Abstract

  Little information is available on agreement between patient-reported outcomes and data collected from medical chart abstraction (MCA) for recurring events. Recurring conditions pose a risk of misclassification, especially when events occur relatively close together in time. We examined agreement, predictors of agreement, and relative accuracy of patient survey and MCA for assessment of outcomes of incisional hernia repair (IHR).Surveys to assess hernia outcomes were mailed to 1,124 living patients who underwent ≥ 1 IHR during 1998-2002 at 16 Veteran's Affairs Medical Center study sites. Patients were asked if they developed a recurrence or an infection at their hernia site. Physician-abstracted data from the medical chart were compared with patient response. Chi-square tests were used to assess significance.Of 487 (43.3%) individuals responding to the survey, 33 (6.8%) with >1 re-repair during 1998-2002 and 98 (20.5%) with a repair before the 1998-2002 period were excluded from the analysis. Although recurrence rates derived from self-reported data and data abstracted from the medical chart were similar (29.3% and 26.1%, respectively), overall concordance was low. Only 49% (n = 54) of self-reported recurrences were confirmed by data abstracted from the medical chart. In addition, 16 (8.3%) recurrences abstracted from the medical chart were not reported by the patient. Factors associated with discordance were high reported pain intensity (P = .02), poorer general health (P = .03), and poorer perceived repair results (P < .0001).Multiple recurrences and subsequent operations across the study period complicate the interpretation of both patient response and data abstracted from the medical chart when referring to a hernia repair. Further study on how best to assess treatment outcomes for recurring conditions is warranted.

  View details for DOI 10.1016/j.surg.2011.06.007

  View details for Web of Science ID 000295108300002

  View details for PubMedID 21783217

• Surgical Site Infection Prevention Time to Move Beyond the Surgical Care Improvement Program ANNALS OF SURGERY Hawn, M. T., Vick, C. C., Richman, J., Holman, W., Deierhoi, R. J., Graham, L. A., Henderson, W. G., Itani, K. M. 2011; 254 (3): 494-501

  Abstract

  The objective of this study was to evaluate whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates using national data at the patient level for both SCIP adherence and SSI occurrence.The SCIP was established in 2006 with the goal of reducing surgical complications by 25% in 2010.National Veterans' Affairs (VA) data from 2005 to 2009 on adherence to 5 SCIP SSI prevention measures were linked to Veterans' Affairs Surgical Quality Improvement Program SSI outcome data. Effect of SCIP adherence and year of surgery on SSI outcome were assessed with logistic regression using generalized estimating equations, adjusting for procedure type and variables known to predict SSI. Correlation between hospital SCIP adherence and SSI rate was assessed using linear regression.There were 60,853 surgeries at 112 VA hospitals analyzed. SCIP adherence ranged from 75% for normothermia to 99% for hair removal and all significantly improved over the study period (P < 0.001). Surgical site infection occurred after 6.2% of surgeries (1.6% for orthopedic surgeries to 11.3% for colorectal surgeries). None of the 5 SCIP measures were significantly associated with lower odds of SSI after adjusting for variables known to predict SSI and procedure type. Year was not associated with SSI (P = 0.71). Hospital SCIP performance was not correlated with hospital SSI rates (r = -0.06, P = 0.54).Adherence to SCIP measures improved whereas risk-adjusted SSI rates remained stable. SCIP adherence was neither associated with a lower SSI rate at the patient level, nor associated with hospital SSI rates. Policies regarding continued SCIP measurement and reporting should be reassessed.

  View details for DOI 10.1097/SLA.0b013e31822c6929

  View details for Web of Science ID 000294252500012

  View details for PubMedID 21817889

• Effect of Mesh Type and Position on Subsequent Abdominal Operations after Incisional Hernia Repair JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Snyder, C. W., Graham, L. A., Gray, S. H., Vick, C. C., Hawn, M. T. 2011; 212 (4): 496-502

  Abstract

  The frequency of subsequent abdominal operations (SAO) and complications attributable to earlier ventral incisional hernia repair (VIHR) are unknown. We examined the effect of repair type and technique on the difficulty and complications of subsequent surgery.A cohort of VIHRs at 16 Veterans Affairs hospitals between 1998 and 2002 was examined for postrepair abdominal operation by chart review. The primary independent variable was type and technique of the index VIHR: suture or mesh repair stratified by mesh type and position in relation to abdominal wall musculature. Subsequent surgery characteristics including operative time, inadvertent enterotomy, mesh removal, and length of postoperative stay were determined by chart review. Regression modeling was used to adjust for potential confounding variables.At a median of 80 months after VIHR in 1,444 patients, 366 (25.3%) experienced SAO. Nearly two-thirds of these involved rerepair of the VIHR with or without a concomitant procedure. Mesh removal was significantly more likely in expanded polytetrafluoroethylene repairs as compared with polypropylene repairs, regardless of technique (odds ratio = 3.6; p = 0.01). On multivariable regression modeling, polypropylene underlay (p = 0.03) and inlay (p = 0.001) and absorbable/biologic mesh (p = 0.05) significantly increased operative time for SAO. Repair type, mesh type, or position had no significant effect on risk of inadvertent enterotomy during the SAO (p≥0.27).Subsequent abdominal operations after VIHR are common. Underlay or inlay polypropylene mesh increases SAO operative time, but there was no increased risk of intestinal injury. Earlier repair with expanded polytetrafluoroethylene did not increase operative time, but there was equivalent risk for intestinal injury and increased risk for mesh removal.

  View details for DOI 10.1016/j.jamcollsurg.2010.12.004

  View details for Web of Science ID 000289430000015

  View details for PubMedID 21463777

• Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique HERNIA Snyder, C. W., Graham, L. A., Vick, C. C., Gray, S. H., Finan, K. R., Hawn, M. T. 2011; 15 (2): 123-129

  Abstract

  To determine the effects of repair technique and hernia recurrence on patient-reported outcomes after incisional hernia repair.This cohort study included patients from sixteen Veteran's Affairs Medical Centers across the United States who underwent elective incisional hernia repair between 1997 and 2002. Technical details and outcomes (repair type and recurrence status) were determined by physician chart review. Patient satisfaction, chronic pain (McGill pain scale and visual analogue scale), and health-related quality of life (Short Form 36) were evaluated with a mailed survey at a median of five years after repair. Multivariable regression modeling was performed to evaluate the effect of repair type and recurrence status on patient-reported outcomes.Of 854 patients alive at the time of survey mailing, 371 responded (43.4%). Patients with active recurrence were more likely to be dissatisfied with their results (odds ratio (OR) 6.2, P < 0.0001), to have chronic sensory hernia site pain (OR 3.2, P = 0.01), to report disturbance from pain (OR 2.1, P = 0.04), and to have significantly worse quality of life on the Physical Function, General Health, and Physical Component Score domains. Repair technique with permanent mesh versus suture had no independent effect on patient satisfaction, chronic pain, or QOL.Recurrence has a substantial negative effect on patient-reported outcomes after incisional hernia repair, whereas the repair technique has no independent effect.

  View details for DOI 10.1007/s10029-010-0750-4

  View details for Web of Science ID 000288803700002

  View details for PubMedID 21072550

• Hospital-level variability in incisional hernia repair technique affects patient outcomes SURGERY Hawn, M. T., Snyder, C. W., Graham, L. A., Gray, S. H., Finan, K. R., Vick, C. C. 2011; 149 (2): 185-191

  Abstract

  Mesh placement during ventral incisional hernia repair has been shown to result in superior outcomes; however, significant variation persists in the adoption of this technique. We performed a multi-institutional study to understand how variation in surgical technique influences outcomes.This study is a retrospective, facility-level analysis of incisional hernia repairs performed at 16 veteran's administration medical centers between 1997 and 2002. Operative notes and a postoperative course were physician-abstracted from the medical record. Hospital rates for the type of hernia repair, mesh placement, and recurrence were calculated. Spearman's correlation and generalized linear models were performed.A total of 1,612 incisional hernia repairs with a median follow-up of 66.2 months were included in the study. The mean rate of mesh implantation was 63.7% but ranged from 37.5% to 90%. The 5-year recurrence rate was 25.6% and ranged from 16.0% to 38.4%. The rate of mesh use for the incisional hernia repair at the hospital level was associated significantly with the hospital recurrence rate for all cases (R(2) = .27; P = .04) and elective cases (R(2) = .31; P = .02). For every 10% increase in the rate of mesh placement, a corresponding 3.1% decrease was noted in the recurrence rates (P = .001). The hospital rate of mesh use was not associated significantly with rates of complications or patient satisfaction.Hospitals that adopted a higher rate of mesh repair for incisional hernia repairs had lower recurrence rates. These data support that the efficacy of mesh repair previously proven in clinical trials is highly translatable to effective practice in the field. Continued studies on the attributable risk of complications to mesh placement are ongoing.

  View details for DOI 10.1016/j.surg.2010.07.001

  View details for Web of Science ID 000286713200006

  View details for PubMedID 21238712

• Long-Term Follow-Up of Technical Outcomes for Incisional Hernia Repair JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hawn, M. T., Snyder, C. W., Graham, L. A., Gray, S. H., Finan, K. R., Vick, C. C. 2010; 210 (5): 648-655

  Abstract

  Incisional hernia repair (IHR) is plagued by high recurrence rates and lack of long-term outcomes data to guide repair technique. Mesh repair reduces recurrence rates but lacks standardization of technique. We investigated long-term outcomes of elective IHR, focusing on technical predictors of recurrence.This retrospective multicenter cohort study included elective IHR performed at 16 Veterans Affairs hospitals between 1997 and 2002. Hernia characteristics and operative details were abstracted from operative notes, and chart review was performed to identify recurrence and complications. Kaplan-Meier curves and Cox regression models were used to evaluate the effects of hernia characteristics and operative technique on recurrence.There were 1,346 elective IHRs, of which 22% were recurrent hernias. Repair technique was primary suture in 31%, open inlay or onlay mesh in 30%, open underlay in 30%, and laparoscopic in 9%. At median follow-up of 73.4 months, there were 383 recurrences (28.5%), 23 mesh removals (1.7%), and 7 enterocutaneous fistulas (ECF) (0.5%). On Cox regression modeling with adjustment for hernia and Veterans Affairs site characteristics, the effectiveness of mesh varied by position. Compared with suture repair, laparoscopic (hazard ratio = 0.49; 95% CI, 0.28-0.84) and open underlay mesh repair (hazard ratio = 0.72; 95% CI, 0.53-0.98) substantially reduced the recurrence risk, but onlay or inlay mesh repair did not. Mesh position did not affect mesh removal or ECF rates.Underlay technique, either laparoscopic or open, for mesh implantation during elective IHR substantially reduces the risk of recurrence, without increasing the risk of serious mesh infection or ECF.

  View details for DOI 10.1016/j.jamcollsurg.2009.12.038

  View details for Web of Science ID 000277528700022

  View details for PubMedID 20421023

• Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement AMERICAN JOURNAL OF SURGERY Argo, J. L., Vick, C. C., Graham, L. A., Itani, K. M., Bishop, M. J., Hawn, M. T. 2009; 198 (5): 600-606

  Abstract

  This study evaluated elective surgical case cancellation (CC) rates, reasons for these cancellations, and identified areas for improvement within the Veterans Health Administration (VA) system.CC data for 2006 were collected from the scheduling software for 123 VA facilities. Surveys were distributed to 40 facilities (10 highest and 10 lowest CC rates for high- and low-volume facilities). CC reasons were standardized and piloted at 5 facilities.Of 329,784 cases scheduled by 9 surgical specialties, 40,988 (12.4%) were cancelled. CC reasons (9,528) were placed into 6 broad categories: patient (35%), work-up/medical condition change (28%), facility (20%), surgeon (8%), anesthesia (1%), and miscellaneous (8%). Survey results show areas for improvement at the facility level and a standardized list of 28 CC reasons was comprehensive.Interventions that decrease cancellations caused by patient factors, inadequate work-up, and facility factors are needed to reduce overall elective surgical case cancellations.

  View details for DOI 10.1016/j.amjsurg.2009.07.005

  View details for Web of Science ID 000271997900005

  View details for PubMedID 19887185

• Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure. Interactive cardiovascular and thoracic surgery Snyder, C. W., Graham, L. A., Byers, R. E., Holman, W. L. 2009; 9 (5): 763-766

  Abstract

  Sternal closure with rigid titanium plates (primary sternal plating) may reduce sternal wound complications in high-risk patients. We began performing primary sternal plating for the following indications: obesity, manual laborer, osteoporotic sternum, or intraoperative transverse sternal fracture. Patients receiving plate closure were compared to a risk-matched control group receiving wire closure. Outcomes of interest were postoperative length of stay and sternal wound complications [sterile dehiscence or deep sternal wound infection (DSWI)]. Wound complications were classified by time of occurrence as early (30 days postoperation). Of 445 total cardiac cases during the 5-year study period, 129 (29%) met inclusion criteria. The plate group (n=30) and wire group (n=99) were generally well-matched in terms of risk factors. Postoperative length of stay was significantly shorter in the plate group (median 7 vs. 8 days, P=0.023). No early sternal wound complications occurred in the plate group, compared to 12 (12%) in the wire group (P=0.067). The incidence of late sternal wound complications was 10% in both groups (P=1.0). Primary sternal plating appears to provide benefits over wire closure during the early postoperative period, but may not prevent late wound complications in patients with osteoporosis or extreme obesity.

  View details for DOI 10.1510/icvts.2009.214023

  View details for PubMedID 19710069

• Variation in mesh placement for ventral hernia repair: an opportunity for process improvement? AMERICAN JOURNAL OF SURGERY Gray, S. H., Vick, C. C., Graham, L. A., Finan, K. R., Neumayer, L. A., Hawn, M. T. 2008; 196 (2): 201-206

  Abstract

  Incisional hernia repair (IHR) with mesh has been associated with decreased hernia recurrence. We analyzed variation in mesh use for IHR.A cohort undergoing IHR from 16 Veterans' Administration (VA) Hospitals was identified. Patient-specific variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analyses were used to model mesh implantation predictors.A total of 1,123 IHR cases were analyzed; Mesh was implanted in 69.6% (n = 781). Regression models demonstrated repair at a high performing facility was associated with a nearly 4-fold increase in mesh utilization. Other significant predictors include repair of recurrent hernia, chronic steroid use, and multiple fascial defects.There is variation in the rate of mesh placement for IHR by VA facility, even after accounting for key explanatory variables. Patterns of mesh placement in IHR appear to be based on practice style.

  View details for DOI 10.1016/j.amjsurg.2007.09.041

  View details for Web of Science ID 000258248200010

  View details for PubMedID 18513688

• Risk of complications from enterotomy or unplanned bowel resection during elective hernia repair ARCHIVES OF SURGERY Gray, S. H., Vick, C. C., Graham, L. A., Finan, K. R., Neumayer, L. A., Hawn, M. T. 2008; 143 (6): 582-586

  Abstract

  Enterotomy or unplanned bowel resection (EBR) may occur during elective incisional hernia repair (IHR) and significantly affects surgical outcomes and hospital resource use.Retrospective review of patients undergoing IHR between January 1998 and December 2002.Sixteen tertiary care Veterans Affairs medical centers.A total of 1124 elective incisional hernia repairs identified in the National Surgical Quality Improvement Program data set.Elective IHR.Thirty-day postoperative complication rate, return to operating room, length of stay, and operative time.Of the 1124 elective procedures, 74.1% were primary IHR, 13.3% were recurrent prior mesh IHR, and 12.6% were recurrent prior suture. Overall, 7.3% had an EBR. The incidence of EBR was increased in patients with prior repair: 5.3% for primary repair, 5.7% for recurrent prior suture, and 20.3% for prior mesh repair (P < .001). The occurrence of EBR was associated with increased postoperative complications (31.7% vs 9.5%; P < .001), rate of reoperation within 30 days (14.6% vs 3.6%; P < .001), and development of enterocutaneous fistula (7.3% vs 0.7%; P < .001). After adjusting for procedure type, age, and American Society of Anesthesiologists class, EBR was associated with an increase in median operative time (1.7 to 3.5 hours; P < .001) and mean length of stay (4.0 to 6.0 days; P < .001).Enterotomy or unplanned bowel resection is more likely to complicate recurrent IHR with prior mesh. The occurrence of EBR is associated with increased postoperative complications, return to the operating room, risk of enterocutaneous fistula, length of hospitalization, and operative time.

  View details for Web of Science ID 000256795200015

  View details for PubMedID 18559752

• Umbilical herniorrhapy in cirrhosis: Improved outcomes with elective repair JOURNAL OF GASTROINTESTINAL SURGERY Gray, S. H., Vick, C. C., Graham, L. A., Finan, K. R., Neumayer, L. A., Hawn, M. T. 2008; 12 (4): 675-681

  Abstract

  This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes.Procedures were identified from the Veterans' Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables.Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1-9.4), diabetes (OR 2.1; 95% CI 1.2-3.8), congestive heart failure (OR 4.0; 95% CI 1.4-11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1-3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3-14.3) was strongly associated with postoperative complications.Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.

  View details for DOI 10.1007/s11605-008-0496-9

  View details for Web of Science ID 000253994400012

  View details for PubMedID 18270782