Bio


Dr. Mary T. Hawn is the Stanford Medicine Professor of Surgery and Chair of the Department of Surgery at Stanford University. Dr. Hawn, a native of Michigan, received her education and surgical training at the University of Michigan. Her clinical area of specialty is minimally invasive foregut surgery. Dr. Hawn is a funded health services researcher and her projects focus on quality measurement and policy in surgical populations. She is a Director for the American Board of Surgery and serves on the editorial board of Annals of Surgery, Journal of the American College of Surgeons, Journal of Gastrointestinal Surgery and the American Journal of Surgery. Dr. Hawn has several additional leadership roles in American Surgery including Chair of the American College of Surgeons Scientific Forum Committee and as a Trustee and Treasurer for the Surgical Society of the Alimentary Tract. She is the co-Editor of a new surgical textbook Operative Techniques in Surgery.

Clinical Focus


  • General Surgery
  • Gastroesophageal Reflux Disease
  • Achalasia
  • Hiatal Hernias
  • Gallbladder Disease
  • Hernias

Academic Appointments


Administrative Appointments


  • Professor and Chair, Department of Surgery (2015 - Present)

Honors & Awards


  • Distinguished Alumni of the Year, Department of Surgery, Oregon Health Sciences University (2016)
  • Honor Society, Alpha Omega Alpha

Boards, Advisory Committees, Professional Organizations


  • Director, American Board of Surgery (2015 - Present)
  • Treasurer, Surgical Society of the Alimentary Tract (2016 - Present)
  • Chair, Scientific Forum Committee, American College of Surgeons (2014 - Present)
  • Member, American Surgical Association
  • Member, Society of Clinical Chairs

Professional Education


  • Residency: University of Michigan (1998) MI
  • Internship: University of Michigan (1992) MI
  • Board Certification: American Board of Surgery, General Surgery (1999)
  • Fellowship: Oregon Health and Science University (2001) OR United States of America
  • Medical Education: University Of Michigan (1991) MI
  • M.P.H., University of Michigan School of Public Health, MPH Epidemiology (1996)
  • M.D., University of Michigan Medical School (1991)
  • B.S., University of Michigan, Biomedical Sciences (1987)

Current Research and Scholarly Interests


My area of research is health services researcher focusing on surgical quality measurement and policy. I have a background and training in epidemiology coupled with my leadership roles in surgical quality measurement. My expertise and extensive experience in evaluation of surgical quality process and outcome linkage has impacted national policy and changed guidelines. We performed a comprehensive evaluation of the Surgical Care Improvement Project (SCIP) implementation using national VA data. Defining robust metrics of surgical quality that are actionable and can lead to sustained improvement in our field are of utmost importance. I also have experience with risk prediction modeling for surgical patients. Our Decision Support for Safer Surgery study developed models of real-time risk prediction for major complications and prospectively validated our models in patients and with expert surgeons. We were able to discern where computational risk prediction has added value and where it falls short. We currently have a national study investigating readmissions following major surgical procedures to identify opportunities for improving care and reducing costs.

2023-24 Courses


Stanford Advisees


All Publications


  • Festschrift for Dr. Jeffrey A. Norton, 12-13 October 2023, Stanford, CA, USA. Annals of surgical oncology Poultsides, G. A., Kebebew, E., Hawn, M. T. 2024

    View details for DOI 10.1245/s10434-024-15160-9

    View details for PubMedID 38488895

    View details for PubMedCentralID 1876967

  • 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

  • Philanthropic support of academic programs. Surgery Hawn, M. T. 2024

    Abstract

    Academic surgical departments must subsidize the research mission, as most funded research does not fully support the faculty effort and true costs of the investigation. Most departments support their research program with the margin from clinical revenue; however, increased pressure on clinical income poses a challenge to this strategy. Philanthropy is an increasingly important revenue source to fund academic missions. The opportunities and challenges of this funding source are discussed in this article.

    View details for DOI 10.1016/j.surg.2023.12.017

    View details for PubMedID 38281853

  • 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

  • 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

  • Mixed Esophageal Disease (MED): A New Concept. Digestive diseases and sciences Triadafilopoulos, G., Mashimo, H., Tatum, R., O'Clarke, J., Hawn, M. 2023

    Abstract

    We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.

    View details for DOI 10.1007/s10620-023-08008-x

    View details for PubMedID 37470896

    View details for PubMedCentralID 3035917

  • Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. Journal of general internal medicine Harris, A. H., Finlay, A. K., Hagedorn, H. J., Manfredi, L., Jones, G., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Pershing, S., Mudumbai, S. 2023

    Abstract

    BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.DESIGN: Qualitative study of semi-structured telephone interviews.PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

    View details for DOI 10.1007/s11606-023-08287-0

    View details for PubMedID 37407767

  • Serendipity Strikes: How Pursuing Novel Hypotheses Shifted the Paradigm Regarding the Genetic Basis of Colorectal Cancer and Changed Cancer Therapy. Digestive diseases and sciences Boland, C. R., Koi, M., Hawn, M. T., Carethers, J. M., Yurgelun, M. B. 2023

    Abstract

    In this installment of the "Paradigm Shifts in Perspective" series, the authors, all scientists who have been involved in colorectal cancer (CRC) research for most or all of their careers, have watched the field develop from early pathological descriptions of tumor formation to the current understanding of tumor pathogenesis that informs personalized therapies. We outline how our understanding of the pathogenetic basis of CRC began with seemingly isolated discoveries-initially with the mutations in RAS and the APC gene, the latter of which was initially found in the context of intestinal polyposis, to the more complex process of multistep carcinogenesis, to the chase for tumor suppressor genes, which led to the unexpected discovery of microsatellite instability (MSI). These discoveries enabled the authors to better understand how the DNA mismatch repair (MMR) system not only recognizes DNA damage but also responds to damage by DNA repair or by triggering apoptosis in the injured cell. This work served, in part, to link the earlier findings on the pathogenesis of CRC to the development of immune checkpoint inhibitors, which has been transformative-and curative-for certain types of CRCs and other cancers as well. These discoveries also highlight the circuitous routes that scientific progress takes, which can include thoughtful hypothesis testing and at other times recognizing the importance of seemingly serendipitous observations that substantially change the flow and direction of the discovery process. What has happened over the past 37 years was not predictable when this journey began, but it does speak to the power of careful scientific experimentation, following the facts, perseverance in the face of opposition, and the willingness to think outside of established paradigms.

    View details for DOI 10.1007/s10620-023-08006-z

    View details for PubMedID 37402979

    View details for PubMedCentralID 6747691

  • Lessons learned from Dr. Kirby Bland. American journal of surgery Hawn, M. 2023

    View details for DOI 10.1016/j.amjsurg.2023.06.008

    View details for PubMedID 37344252

  • Addressing the Surgical Workplace: An Opportunity to Create a Culture of Belonging. Annals of surgery Pugh, C. M., Kirton, O. C., Tuttle, J. E., Maier, R. V., Hu, Y., Stewart, J. H., Freischlag, J. A., Sosa, J. A., Vickers, S. M., Hawn, M. T., Eberlein, T. J., Farmer, D. L., Higgins, R. S., Pellegrini, C. A., Roman, S. A., Crandall, M. L., De Virgilio, C. M., Tsung, A., Britt, L. D. 2022

    View details for DOI 10.1097/SLA.0000000000005773

    View details for PubMedID 36575980

  • 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

  • Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioperative medicine (London, England) Harris, A. H., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H. J., Mudumbai, S. 2022; 11 (1): 33

    Abstract

    BACKGROUND: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures.METHODS: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined.RESULTS: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476.CONCLUSIONS: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.

    View details for DOI 10.1186/s13741-022-00265-0

    View details for PubMedID 36096937

  • To Wait or Not to Wait? Covid-19 Vaccination Mitigates Adverse Surgical Outcomes. Annals of surgery Baiu, I., Hawn, M. 2022

    View details for DOI 10.1097/SLA.0000000000005675

    View details for PubMedID 35943196

  • 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

  • Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA internal medicine Sun, E. C., Mello, M. M., Vaughn, M. T., Kheterpal, S., Hawn, M. T., Dimick, J. B., Jena, A. B. 2022

    Abstract

    Importance: The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations.Objective: To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day.Design, Setting, and Participants: In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020.Exposures: Whether the attending surgeon for the current day's procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all).Main Outcomes and Measures: The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection).Results: Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, -0.47% to 0.51%; P=.93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, -4.7 minutes; 95% CI, -8.7 to -0.8, P=.02), although this difference is unlikely to be meaningful.Conclusions and Relevance: The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.

    View details for DOI 10.1001/jamainternmed.2022.1563

    View details for PubMedID 35604661

  • Assessing the sustainability of compliance with surgical site infection prophylaxis after discontinuation of mandatory active reporting: study protocol. Implementation science communications Branch-Elliman, W., Elwy, A. R., Lamkin, R. L., Shin, M., Engle, R. L., Colborn, K., Rove, J., Pendergast, J., Hederstedt, K., Hawn, M., Mull, H. J. 2022; 3 (1): 47

    Abstract

    BACKGROUND: Surgical site infections are common. Risk can be reduced substantially with appropriate preoperative antimicrobial administration. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) in the setting of high rates of non-compliance with antimicrobial prophylaxis guidelines. SCIP included public reporting of evidenced-based antimicrobial guideline compliance metrics in high-risk surgeries. SCIP was highly successful and led to high rates of adoption of preoperative antimicrobials and early discontinuation of postoperative antimicrobials (>95%). The program was retired in 2015, as the manual measurement and reporting process was costly with limited expected additional benefit. To our knowledge,no studies have assessed whether the gains achieved by SCIP were sustained since active support for the program was discontinued. Furthermore, there has been no investigation of the spread of antimicrobial prophylaxis guideline adoption beyond the limited set of procedures that were included in the program.METHODS: Using a mixed methods sequential exploratory approach, this study will (1) quantitatively measure compliance with SCIP metrics over time and across all procedures in the five major surgical specialties targeted by SCIP and (2) collect qualitative data from stakeholders to identify strategies that were effective for sustaining compliance. Diffusion of Innovation Theory will guide assessment of whether improvements achieved spread to procedures not included under the umbrella of the program. Electronic algorithms to measure SCIP antimicrobial use will be adapted from previously developed methodology. These highly novel data mining algorithms leverage the rich VA electronic health record and capture structured and text data and represent a substantial technological advancement over resource-intensive manual chart review or incomplete electronic surveillance based on pharmacy data. An interrupted time series analysis will be used to assess whether SCIP compliance was sustained following program discontinuation. Generalized linear models will be used to assess whether compliance with appropriate prophylaxis increased in all SCIP targeted and non-targeted procedures by specialty over the duration the program's active reporting. The Dynamic Sustainability Framework will guide the qualitative methods to assess intervention, provider, facility, specialty, and contextual factors associated with sustainability over time. Barriers and facilitators to sustainability will be mapped to implementation strategies and the study will yield an implementation playbook to guide future sustainment efforts.RELEVANCE: Sustainability of practice change has been described as one of the most important, but least studied areas of clinical medicine. Learning how practices spread is also a critically important area of investigation. This study will use novel informatics strategies to evaluate factors associated with sustainability following removal of active policy surveillance and advance our understanding about these important, yet understudied, areas.

    View details for DOI 10.1186/s43058-022-00288-0

    View details for PubMedID 35468871

  • Delivering Better Solutions for Women Physicians Who Experience Pregnancy, Childbirth, and Childrearing. Academic medicine : journal of the Association of American Medical Colleges Buyske, J., Hawn, M. T. 2022

    Abstract

    As the number of women physicians entering the field of medicine has increased over the past decades, pregnancy and maternity leave are becoming common place during both training and independent practice. However, the current system is not designed for extended leaves of absence from the clinical environment. In this commentary, the authors review recent changes in regulatory requirements impacting women physicians in postgraduate training who experience pregnancy, childbirth, and childrearing and identify solutions that may result in more optimal work environments for women physicians in practice who experience pregnancy, childbirth, and childrearing.

    View details for DOI 10.1097/ACM.0000000000004642

    View details for PubMedID 35234718

  • Laparoscopic Heller Myotomy and Toupet Fundoplication. World journal of surgery Alimi, Y. R., Esquivel, M. M., Hawn, M. T. 2022

    Abstract

    Esophageal achalasia is a primary motility disorder of unknown origin. The goal of treatment is to eliminate the resistance caused by a non-relaxing lower esophageal sphincter, therefore allowing passage of foodand liquid from the esophagus into the stomach. A myotomy with a partial fundoplication (anterior Doror posteriorToupet) is considered the standard of care for patients with achalasia. In the following review, we describe the indications and technique for a posterior partial fundoplication (Toupet).

    View details for DOI 10.1007/s00268-022-06471-7

    View details for PubMedID 35220453

  • Development of a Preliminary Question Prompt List as a Communication Tool for Adults With Achalasia: A Modified Delphi Study. Journal of clinical gastroenterology Zhuo, J., Triadafilopoulos, G., Bredenoord, A. J., Clarke, J. O., Fass, R., Gyawali, C. P., Hawn, M., Hwang, J. H., Kahrilas, P. J., Katzka, D. A., Low, D., Massey, B. T., Patel, D., Penagini, R., Roman, S., Savarino, E., Smout, A. J., Swanstrom, L., Tatum, R., Vela, M. F., Zaninotto, G., Kamal, A. N. 2022

    Abstract

    BACKGROUND: Question prompt lists (QPLs) are structured sets of disease-specific questions that enhance patient-physician communication by encouraging patients to ask questions during consultations.AIM: The aim of this study was to develop a preliminary achalasia-specific QPL created by esophageal experts.METHODS: The QPL content was derived through a modified Delphi method consisting of 2 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of achalasia" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" In round 2, experts rated questions on a 5-point Likert scale. Questions considered "essential" or "important" were accepted into the QPL. Feedback regarding the QPL was obtained in a pilot study wherein patients received the QPL before their consultation and completed surveys afterwards.RESULTS: Nineteen esophageal experts participated in both rounds. Of 148 questions from round 1, 124 (83.8%) were accepted into the QPL. These were further reduced to 56 questions to minimize redundancy. Questions were categorized into 6 themes: "What is achalasia," "Risks with achalasia," "Symptom management in achalasia," "Treatment of achalasia," "Risk of reflux after treatment," and "Follow-up after treatment." Nineteen patients participated in the pilot, most of whom agreed that the QPL was helpful (84.2%) and recommended its wider use (84.2%).CONCLUSIONS: This is the first QPL developed specifically for adults with achalasia. Although well-received in a small pilot, follow-up studies will incorporate additional patient feedback to further refine the QPL content and assess its usability, acceptability, and feasibility.

    View details for DOI 10.1097/MCG.0000000000001671

    View details for PubMedID 35180150

  • Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19. Plastic and reconstructive surgery Ma, I. T., Dayani, F., Yesantharao, P., Chang, J., Hawn, M. T., Wald, S., Lee, G. K., Nazerali, R. 2021

    View details for DOI 10.1097/PRS.0000000000008657

    View details for PubMedID 34878421

  • 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

  • Steps to a Culturally Conscious Workspace in the Modern Surgical Era. Journal of the American College of Surgeons Ahmed, S. M., Hawn, M. T. 2021; 233 (2): 327-328

    View details for DOI 10.1016/j.jamcollsurg.2021.05.006

    View details for PubMedID 34304824

  • 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

  • Life Happens, Even to Surgical Trainees. JAMA surgery George, E. L., Fox, P., Hawn, M. T. 2021

    View details for DOI 10.1001/jamasurg.2021.1811

    View details for PubMedID 34009251

  • Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA network open Mudumbai, S. C., Pershing, S., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M. T., Eisenberg, D., Finlay, A. K., Hagedorn, H., Harris, A. H. 2021; 4 (5): e217470

    Abstract

    Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P<.001) at the facility level and 0.06 (P<.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

    View details for DOI 10.1001/jamanetworkopen.2021.7470

    View details for PubMedID 33956131

  • From Listening to Action: Academic Surgcial Departmental Response to Social Injustice Through Curricular Development. Annals of surgery Korndorffer, J. R., Wren, S. M., Pugh, C. M., Hawn, M. T. 2021

    Abstract

    OBJECTIVES: To describe the development and evaluation of a structured department wide cultural competency curriculum.SUMMARY BACKGROUND DATA: Despite numerous organizational policies and statements, social injustice and bias still exists. Our department committed to assist individuals of the entire department to develop foundational knowledge and skills to combat implicit bias and systemic racism through the creation of a cultural competency curriculum. The purpose of this manuscript is to detail our curriculum and the evaluation of its effectiveness.METHODS: Using a well-established curriculum development framework, a cultural competency curriculum was developed focusing on knowledge, skills and attitudes at the individual level, for all members of the department. The curriculum was implemented through six, hour-long sessions over a nine-week period. Effectiveness was assessed through a post curriculum survey.RESULTS: 20% of the respondents had experienced bias based on race, ethnicity or sexual orientation in the past 12 months while 30% had experienced bias based on gender. 71% independently explored related topics. The curriculum was overall well received and generally achieved the goals and objectives.CONCLUSIONS: Using a standard curriculum development framework, an effective department-wide cultural competency curriculum can be developed and implemented.

    View details for DOI 10.1097/SLA.0000000000004891

    View details for PubMedID 33856378

  • Board certification - A remnant of days past or reflection of a commitment to lifelong learning and professionalism? Annals of surgery Abdullah, F., Ghomrawi, H. M., Hawn, M. 2021

    View details for DOI 10.1097/SLA.0000000000004881

    View details for PubMedID 33856376

  • 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

  • Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians. JAMA network open Shanafelt, T. D., Wang, H., Leonard, M., Hawn, M., McKenna, Q., Majzun, R., Minor, L., Trockel, M. 2021; 4 (2): e2035622

    Abstract

    Importance: Although misalignment of values between physicians and their organization is associated with increased risk of burnout, actionable organizational factors that contribute to perceived values alignment are poorly understood.Objective: To evaluate the association between the leadership behaviors of immediate supervisors and physicians' perception of personal-organizational values alignment.Design, Setting, and Participants: This survey study of faculty physicians and physician leaders at Stanford University School of Medicine was conducted from April 1 to May 13, 2019. The survey included assessments of perceived personal-organizational values alignment, professional fulfillment, and burnout. Physicians also evaluated the leadership behaviors of their immediate supervisor (eg, division chief) using a standardized assessment. Data analysis was performed from May to December 2020.Main Outcomes and Measures: Association between mean leadership behavior score (range, 0-10) of each supervisor and the mean personal-organizational values alignment scores (range, 0-12) for the physicians in their work unit.Results: Of 1924 physicians eligible to participate, 1285 (67%) returned surveys. Among these, 651 (51%) were women and 729 (57%) were aged 40 years or older. Among the 117 physician leaders evaluated, 66 (56%) had their leadership behavior independently evaluated by at least 5 physicians and were included in analyses. The mean (SD) personal-organizational values alignment score on the 0 to 12 scale was 6.19 (3.21). As the proportion of work effort devoted to clinical care increased, values alignment scores decreased. Personal-organizational values alignment scores demonstrated an inverse correlation with burnout (r=-0.39; P<.001) and a positive correlation with professional fulfillment (r=0.52; P<.001). The aggregate leader behavior score of the 66 leaders evaluated correlated with the mean values alignment score for physicians in their work unit (r=0.53; P<.001). Aggregate leader behavior score was associated with 21.6% of the variation in personal-organizational values alignment scores between work units. After adjusting for age, gender, academic rank, work hours, physician-leader gender concordance, and time devoted to clinical care, each 1-point increase in leadership score of immediate supervisor was associated with a 0.56-point (95% CI, 0.46-0.66; P<.001) increase in personal-organizational values alignment score.Conclusions and Relevance: This survey study's results suggest that physicians experience their organization through the prism of their work unit leader. Organizational efforts to improve values alignment should attend to the development of first-line physician leaders.

    View details for DOI 10.1001/jamanetworkopen.2020.35622

    View details for PubMedID 33560424

  • COVID-19 Impact on Surgical Resident Education and Coping. The Journal of surgical research Wise, C. E., Bereknyei Merrell, S. n., Sasnal, M. n., Forrester, J. D., Hawn, M. T., Lau, J. N., Lin, D. T., Schmiederer, I. S., Spain, D. A., Nassar, A. K., Knowlton, L. M. 2021; 264: 534–43

    Abstract

    Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19.We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic.Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19.Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

    View details for DOI 10.1016/j.jss.2021.01.017

    View details for PubMedID 33862581

  • Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis. World journal of gastrointestinal surgery Farber, O. N., Gomez, G. I., Titan, A. L., Fisher, A. T., Puntasecca, C. J., Arana, V. T., Kempinsky, A., Wise, C. E., Bessoff, K. E., Hawn, M. T., Korndorffer, J. R., Forrester, J. D., Esquivel, M. M. 2021; 13 (8): 859-870

    Abstract

    The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson's r correlation coefficient. Variables were compared using the Welch's t-Test, Chi-squared tests, and Fisher's exact test as appropriate.Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

    View details for DOI 10.4240/wjgs.v13.i8.859

    View details for PubMedID 34512909

    View details for PubMedCentralID PMC8394376

  • Concerns about Proposed Update to COVID-19 Screening Protocols before Surgery In Reply to Yenigun and Colleagues JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Forrester, J. D., Hawn, M. T. 2020; 231 (6): 789–90
  • Situating Artificial Intelligence in Surgery A Focus on Disease Severity ANNALS OF SURGERY Korndorffer, J. R., Hawn, M. T., Spain, D. A., Knowlton, L. M., Azagury, D. E., Nassar, A. K., Lau, J. N., Arnow, K. D., Trickey, A. W., Pugh, C. M. 2020; 272 (3): 523–28
  • The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020; 272 (2): e79-e80

    View details for DOI 10.1097/SLA.0000000000003998

    View details for PubMedID 32675504

  • 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

  • Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surgical endoscopy Podboy, A. J., Hwang, J. H., Rivas, H., Azagury, D., Hawn, M., Lau, J., Kamal, A., Friedland, S., Triadafilopoulos, G., Zikos, T., Clarke, J. O. 2020

    Abstract

    INTRODUCTION: Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM).AIMS: To compare the long-term clinical efficacy of POEM versus HM.METHODS: Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score>3 for at least 4weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed.RESULTS: 98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94years, and 5.44years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p=0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p<0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications.CONCLUSION: POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.

    View details for DOI 10.1007/s00464-020-07450-6

    View details for PubMedID 32157405

  • 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

  • Precautions for Operating Room Team Members during the COVID-19 Pandemic. Journal of the American College of Surgeons Forrester, J. D., Nassar, A. K., Maggio, P. M., Hawn, M. T. 2020

    Abstract

    The novel corona virus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).An interventional platform (operating room, interventional suites, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infection disease experts, we developed our guidelines based upon potential patterns of spread, risk of exposure and conservation of PPE.A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing.Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal healthcare worker safety.

    View details for DOI 10.1016/j.jamcollsurg.2020.03.030

    View details for PubMedID 32247836

  • Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nature reviews. Cardiology Cao, D. n., Chandiramani, R. n., Capodanno, D. n., Berger, J. S., Levin, M. A., Hawn, M. T., Angiolillo, D. J., Mehran, R. n. 2020

    Abstract

    Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.

    View details for DOI 10.1038/s41569-020-0410-z

    View details for PubMedID 32759962

  • Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level. The Journal of surgical research Kent, T. S., Freischlag, J. n., Minter, R. n., Hawn, M. n., Al-Refaie, W. n., James, B. C., Eskander, M. n., Chu, D. n. 2020

    Abstract

    Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.

    View details for DOI 10.1016/j.jss.2019.12.055

    View details for PubMedID 32439143

  • The Effect of Surgical Trainee Education on Opioid Prescribing: An International Evaluation. Journal of surgical education Prigoff, J. G., Titan, A. L., Fields, A. C., Shwaartz, C. n., Melnitchouk, N. n., Bleday, R. n., Hawn, M. T., Wiechmann, L. n. 2020

    Abstract

    Up to 6% of opioid naive patients who undergo surgery become chronic opioid users. The aim of this study was to determine if formal opioid prescribing education of general surgery residents is associated with decreased opioid prescribing postoperatively.We surveyed surgery residents at 3 general surgery programs in the United States and 1 in Israel. Residents were divided into 2 groups based on whether or not they received formal opioid prescribing education.Of those surveyed, 107 (50%) responded. 45% of residents had formal opioid prescribing education, which included instructional videos, current literature, and hospital guidelines. For the 4 operations analyzed, residents who received no formal teaching prescribed a higher number of opioids (lumpectomy p = 0.001, open inguinal hernia repair p = 0.004, laparoscopic appendectomy p = 0.007, thyroidectomy p = 0.002). The largest difference in opioid prescribing was seen in "high prescribers," defined as residents prescribing 15 or more opioid pills. For thyroidectomy, 24.4% of residents without formal education prescribed 20 or more oxycodone 5mg pills compared to 0% of residents with formal education. The Israeli cohort was less likely to receive a pain focused education and was also less likely to prescribe opioids to their patients for all 4 procedures evaluated.Although a minority of general surgery residents are receiving an opioid prescribing education, a formal educational program was associated with significantly decreased opioid prescribing. There is a need for a generalizable educational opioid program for surgery residents.

    View details for DOI 10.1016/j.jsurg.2020.04.009

    View details for PubMedID 32446768

  • 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

  • American Surgical Association Statement in Support of Science and on Keeping Politics Out of Science. Annals of surgery Hawn, M. T. 2020; Publish Ahead of Print

    View details for DOI 10.1097/SLA.0000000000004665

    View details for PubMedID 33351454

  • GERD: Other Treatment Modalities FOREGUT SURGERY: ACHALASIA, GASTROESOPHAGEAL REFLUX DISEASE AND OBESITY Dorsey, A., Hawn, M., Patti, M. G., DiCorpo, M., Schlottmann, F. 2020: 173–90
  • Concerns about Proposed Update to COVID-19 Screening Protocols before Surgery: In Reply to Yenigun and Colleagues. Journal of the American College of Surgeons Forrester, J. D., Hawn, M. T. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.08.757

    View details for PubMedID 32951984

  • International classification of abdominal wall planes (ICAP) todescribe mesh insertion for ventral hernia repair. The British journal of surgery Parker, S. G., Halligan, S., Liang, M. K., Muysoms, F. E., Adrales, G. L., Boutall, A., de Beaux, A. C., Dietz, U. A., Divino, C. M., Hawn, M. T., Heniford, T. B., Hong, J. P., Ibrahim, N., Itani, K. M., Jorgensen, L. N., Montgomery, A., Morales-Conde, S., Renard, Y., Sanders, D. L., Smart, N. J., Torkington, J. J., Windsor, A. C. 2019

    Abstract

    BACKGROUND: Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes.METHODS: A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed.RESULTS: Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes.CONCLUSION: Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

    View details for DOI 10.1002/bjs.11400

    View details for PubMedID 31875954

  • Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons. World journal of surgery Parker, S. G., Halligan, S., Liang, M. K., Muysoms, F. E., Adrales, G. L., Boutall, A., de Beaux, A. C., Dietz, U. A., Divino, C. M., Hawn, M. T., Heniford, T. B., Hong, J. P., Ibrahim, N., Itani, K. M., Jorgensen, L. N., Montgomery, A., Morales-Conde, S., Renard, Y., Sanders, D. L., Smart, N. J., Torkington, J. J., Windsor, A. C. 2019

    Abstract

    BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons.METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring<20% were removed.RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery.CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

    View details for DOI 10.1007/s00268-019-05317-z

    View details for PubMedID 31848677

  • 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
  • Mandatory Use of Perioperative Disposable Jackets-Things We Do for No Good Reason. JAMA surgery Maggio, P. M., Hawn, M. T. 2019

    View details for DOI 10.1001/jamasurg.2019.4086

    View details for PubMedID 31642892

  • 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

  • Decade in Surgical Education and Simulation Fellowship: A New Pathway for the Surgical Education Leader Anderson, T. N., Lee, E. W., Korndorffer, J. R., Hawn, M. T., Lau, J. N. ELSEVIER SCIENCE INC. 2019: S237–S238
  • Reducing Postoperative Opioid Prescribing Through Education: A Multicenter Survey of Surgical Residents Prigoff, J. G., Fields, A. C., Titan, A. L., Hawn, M. T., Jambhekar, A., Melnitchouk, N., Bleday, R., Wiechmann, L. ELSEVIER SCIENCE INC. 2019: S249
  • 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
  • Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019; 129 (3): 804-811

    Abstract

    The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

    View details for DOI 10.1213/ANE.0000000000004291

    View details for PubMedID 31425223

  • Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium NEUROGASTROENTEROLOGY AND MOTILITY Gyawali, C., Sifrim, D., Carlson, D. A., Hawn, M., Katzka, D. A., Pandolfino, J. E., Penagini, R., Roman, S., Savarino, E., Tatum, R., Vaezi, M., Clarke, J. O., Triadafilopoulos, G. 2019; 31 (9)

    View details for DOI 10.1111/nmo.13584

    View details for Web of Science ID 000481574000003

  • 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

  • Balancing the Risks and Benefits of Surgical Prophylaxis Timing and Duration Do Matter JAMA SURGERY Hawn, M. T., Knowlton, L. 2019; 154 (7): 598–99
  • 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

  • PER-ORAL ENDOSCOPIC MYOTOMY HAS SIMILAR EFFICACY COMPARED TO LAPAROSCOPIC HELLER MYOTOMY AFTER 4 YEARS: A SINGLE CENTER EXPERIENCE Podboy, A. J., Hwang, J., Rivas, H., Azagury, D., Hawn, M. T., Kamal, A., Triadafilopoulos, G., Zikos, T., Clarke, J. O. MOSBY-ELSEVIER. 2019: AB201–AB202
  • Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA network open Rothenberg, K. A., Stern, J. R., George, E. L., Trickey, A. W., Morris, A. M., Hall, D. E., Johanning, J. M., Hawn, M. T., Arya, S. 2019; 2 (5): e194330

    Abstract

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

    View details for DOI 10.1001/jamanetworkopen.2019.4330

    View details for PubMedID 31125103

  • Beyond Readmission: Improving Patient-Centered Care JOURNAL OF SURGICAL RESEARCH Morris, M. S., Hawn, M. T. 2019; 237: 106–7

    View details for PubMedID 29631754

  • Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society Gyawali, C. P., Sifrim, D., Carlson, D. A., Hawn, M., Katzka, D. A., Pandolfino, J. E., Penagini, R., Roman, S., Savarino, E., Tatum, R., Vaezi, M., Clarke, J. O., Triadafilopoulos, G. 2019: e13584

    Abstract

    BACKGROUND: Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450mm Hgcms) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

    View details for PubMedID 30974032

  • 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)
  • 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

  • Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (New York, N.Y.) Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Marshall, N., Mudumbai, S. C. 2019: 1558944719828006

    Abstract

    BACKGROUND: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities.METHODS: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques.RESULTS: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients.CONCLUSIONS: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.

    View details for PubMedID 30789047

  • Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019

    Abstract

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

    View details for PubMedID 30660819

  • Association between postoperative opioid use and outpatient surgical adverse events. American journal of surgery Dasinger, E. A., Branch-Elliman, W., Pizer, S. D., Abdulkerim, H., Rosen, A. K., Charns, M. P., Hawn, M. T., Itani, K. M., Mull, H. J. 2019

    Abstract

    BACKGROUND: Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs).METHODS: VA Corporate Data Warehouse was used to identify opioid use within 48 h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively.RESULTS: Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR = 1.1 95% CI 0.79-1.54). Only procedure RVUs were associated with higher odds of postoperative AEs.CONCLUSIONS: Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs.

    View details for PubMedID 30639132

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

    Abstract

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

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

    View details for PubMedID 31752856

  • Meckel's Diverticulum Fistulization: Another Complication to Consider. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Choi, J. n., Hawn, M. n. 2019

    View details for DOI 10.1007/s11605-019-04378-8

    View details for PubMedID 31468335

  • Patient expectations for recovery after elective surgery: a common-sense model approach. Journal of behavioral medicine Gehring, M. B., Lerret, S. n., Johnson, J. n., Rieder, J. n., Nelson, D. n., Copeland, L. n., Titan, A. n., Hawn, M. n., Morris, M. n., Whittle, J. n., Burns, E. n. 2019

    Abstract

    Patient perceptions of the causes of preoperative symptoms, expected impact of surgery on symptoms and anticipated timeline of recovery are likely to affect the risk of readmission following elective surgical procedures. However, these perceptions have not been studied. A qualitative study was designed to explore these perceptions, using the common-sense model of self-regulation (CSM) as the conceptual framework. CSM is grounded in illness representations, describing how patients make sense of changes in physical well-being (e.g. symptoms) and develop and assess management plans. It also establishes a broader framework for examining patients' a priori expectations and timelines for outcomes based on comparisons to prior experiences and underlying self-prototypes, or "Self as Anchor". A convenience sample of 14 patients aged 56-81 who underwent elective surgery was recruited. Semi-structured interviews informed by the CSM were completed on the day of discharge. Content analysis with deductive coding was used, and emerging themes were fit to components of the CSM, including the five domains of Illness Representations-identity, cause, timeline, control, and consequences. Two additional themes, outlook (toward the health care system, providers and recovery efforts), and motivation (external or internal for recovering), relate to self-prototypes, expectations for outcomes, and search for coherence. Misattribution of symptoms, unrealistic expectations for outcomes (e.g. expecting complete resolution of symptoms unrelated to the surgical procedure) and timelines for recovery (unrealistically short), and the (baseline) "normal healthy self" as distinct from the (temporarily) "sick self" were recurrent themes. Findings suggest that patient perceptions and the actual recovery process may be misaligned. The results underscore the importance of assessing patients' perceptions and expectations, actively engaging patients in their own healthcare, and providing adequate support during the transition to home.

    View details for DOI 10.1007/s10865-019-00097-2

    View details for PubMedID 31512105

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

    View details for DOI 10.1001/jamanetworkopen.2019.9991

    View details for PubMedID 31441933

  • Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study. Antimicrobial resistance and infection control Branch-Elliman, W., Pizer, S. D., Dasinger, E. A., Gold, H. S., Abdulkerim, H., Rosen, A. K., Charns, M. P., Hawn, M. T., Itani, K. M., Mull, H. J. 2019; 8: 49

    Abstract

    Background: Guidelines recommend discontinuation of antimicrobial prophylaxis within 24h after incision closure in uninfected patients. However, how facility and surgical specialty factors affect the implementation of these evidence-based surgical prophylaxis guidelines in outpatient surgery is unknown. Thus, we sought to measure how facility complexity, including ambulatory surgical center (ASC) status and availability of ancillary services, impact adherence to guidelines for timely discontinuation of antimicrobial prophylaxis after outpatient surgery. A secondary aim was to measure the association between surgical specialty and guideline compliance.Methods: A multi-center, national Veterans Health Administration retrospective cohort from 10/1/2015-9/30/2017 including any Veteran undergoing an outpatient surgical procedure in any of five specialties (general surgery, urology, ophthalmology, ENT, orthopedics) was created. The primary outcome was the association between facility complexity and proportion of surgeries not compliantwith discontinuation of antimicrobials within 24h of incision closure. Data were analyzed using logistic regression with adjustments for patient and procedural factors.Results: Among 153,097 outpatient surgeries, 7712 (5.0%) received antimicrobial prophylaxis lasting >24h after surgery; rates ranged from 0.4% (eye surgeries) to 13.7% (genitourinary surgeries). Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates (16 and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2-0.3%). In an adjusted logistic regression model, lower complexity ASC and hospital outpatient departments had higher odds of prolonged antimicrobial prophylaxis compared to complex hospitals (OR ASC, 1.3, 95% CI: 1.2-1.5). Patient factors associated with higher odds of noncompliance with antimicrobial discontinuation included younger age, female sex, and white race. Genitourinary and ear/nose/throat surgeries were associated with the highest odds of prolonged antimicrobial prophylaxis.Conclusions: Facility complexity appears to play a role in adherence to surgical infection prevention guidelines. Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. Such interventions may be especially useful for genitourinary and ear/nose/throat surgical subspecialties. Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety.

    View details for DOI 10.1186/s13756-019-0503-9

    View details for PubMedID 30886702

  • Balancing the Risks and Benefits of Surgical Prophylaxis: Timing and Duration Do Matter. JAMA surgery Hawn, M. T., Knowlton, L. M. 2019

    View details for PubMedID 31017641

  • INTER-HOSPITAL VARIABILITY IN TIME TO DISCHARGE TO REHABILITATION AMONG INSURED TRAUMA PATIENTS. The journal of trauma and acute care surgery Knowlton, L. M., Harris, A. H., Tennakoon, L., Hawn, M. T., Spain, D. A., Staudenmayer, K. L. 2018

    Abstract

    BACKGROUND: Hospital costs are partly a function of length of stay (LOS), which can be impacted by the local availability of post-acute care (PAC) resources (inpatient rehabilitation and skilled nursing facilities), particularly for injured patients. We hypothesized that LOS for trauma patients destined for PAC would be variable based on insurance type and hospitals from which they are discharged.METHODS: We used the 2014-2015 National Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP). We included all adult admissions with a primary diagnosis of trauma (ICD-9CM codes), who were insured and discharged to PAC. We then ranked hospitals based upon mean LOS and divided them into quartiles to determine differences. The primary outcome was inpatient LOS; secondary outcome was cost.RESULTS: 958,005 trauma patients met inclusion criteria. Mean LOS varied based upon insurance type (Medicaid vs. Private vs. Medicare: 12.7 days vs. 8.8 and 5.7: p<0.001). Shortest LOS hospitals had a marginal variation in LOS (Medicaid vs. Private vs. Medicare: 5.5 days vs. 4.8 vs. 4.2, p<0.001). Longest LOS hospitals had mean LOS that varied substantially (16.4 vs. 11.0 vs. 6.7 days, p<0.001). Multivariate regression controlling for patient and hospital characteristics revealed that Medicaid patients spent Medicaid patients spent an additional 0.4 days in shortest LOS hospitals and an additional 2.6 days in longest LOS hospitals (p<0.001). The average daily cost of inpatient care was $3,500 (SD $132). Even with conservative estimates, Medicaid patients at hospitals without easy access to rehabilitation incur significant additional inpatient costs over $10,000 in some hospitals.CONCLUSION: Prolonged LOS is likely a function of access to post-acute facilities, which is largely out of the hands of trauma centers. Efficiencies in care are magnified by access to post-acute beds, suggesting that increased availability of rehabilitation facilities, particularly for Medicaid patients, might help to reduce length of stay.LEVEL OF EVIDENCE: Epidemiologic, level III.

    View details for PubMedID 30531207

  • Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration HEALTH SERVICES RESEARCH Mull, H. J., Itani, K. F., Pizer, S. D., Charns, M. P., Rivard, P. E., McIntosh, N., Hawn, M. T., Rosen, A. K. 2018; 53 (6): 4507–28

    Abstract

    Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.Veterans Health Administration's Corporate Data Warehouse.Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

    View details for PubMedID 30151826

    View details for PubMedCentralID PMC6232409

  • 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

  • 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

  • Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration Sox-Harris, A., Meerwijk, E. L., Kamal, R. N., Sears, E., Finlay, A. K., Hawn, M. T., Eisenberg, D., Mudumbai, S. ELSEVIER SCIENCE INC. 2018: E32
  • Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery Stern, J. R., Blum, K., Trickey, A. W., Hall, D. E., Johanning, J. M., Morris, A. M., Hawn, M. T., Arya, S. ELSEVIER SCIENCE INC. 2018: E25
  • Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration HEALTH SERVICES RESEARCH Mull, H. J., Rosen, A. K., O'Brien, W. J., McIntosh, N., Legler, A., Hawn, M. T., Itani, K. F., Pizer, S. D. 2018; 53 (5): 3855–80

    Abstract

    To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry.We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission.2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data.Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties.As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems.

    View details for PubMedID 29363106

    View details for PubMedCentralID PMC6153177

  • Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228–S229
  • Emotional Intelligence as a Possible Safeguard to Surgeon Wellness Lee, E. W., Hasty, B. N., Lau, J. N., Merrell, S., Hawn, M. T., Shanafelt, T., Salles, A., Lin, D. T. ELSEVIER SCIENCE INC. 2018: S145
  • Surgeon Emotional Intelligence Is Strongly Correlated with Patient Satisfaction Lee, E. W., Hasty, B. N., Lau, J. N., Merrell, S., Hawn, M. T., Shanafelt, T., Salles, A., Lin, D. T. ELSEVIER SCIENCE INC. 2018: S164–S165
  • 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

  • How to Predict 30-Day Readmission. Advances in surgery Wahl, T. S., Hawn, M. T. 2018; 52 (1): 101-111

    View details for DOI 10.1016/j.yasu.2018.03.015

    View details for PubMedID 30098606

  • The Nature and Severity of Adverse Events in Select Outpatient Surgical Procedures in the Veterans Health Administration. Quality management in health care Mull, H. J., Itani, K. M., Charns, M. P., Pizer, S. D., Rivard, P. E., Hawn, M. T., Rosen, A. K. 2018; 27 (3): 136–44

    Abstract

    BACKGROUND: Research on adverse events (AEs) in outpatient surgery has been limited. As part of a Veterans Health Administration (VA) project on AE surveillance, we chart-reviewed selected outpatient surgical cases to characterize the nature and severity of AEs.METHODS: We abstracted financial year 2012-2015 VA outpatient surgery cases selected with high (n = 1185) and low (n = 1072) likelihood of an AE based on postoperative health care utilization. The abstraction tool included established AE definitions and validated harm and severity scales.RESULTS: We found AEs in 608 high-likelihood (51%) and 126 low-likelihood outpatient surgical procedures (12%). Among 1010 unique AEs, the most common were wound issues (n = 261, 26%), urinary retention (23%), and urinary tract infections (12%). While 63% of all AEs involved minimal harm, 28% required hospitalization, and 9% were severely harmful including 8 AEs requiring intervention to sustain life and 2 deaths. Overall, 102 AEs (10%) required, at minimum, a repeat surgery to treat.CONCLUSIONS: Among VA outpatient surgical procedures selected based on likelihood of an AE, nearly 40% of identified events carried more than minimal patient harm, undermining the claim that outpatient surgery is relatively safe. Prevalent and preventable AEs such as wound dehiscence and urinary retention may be useful targets for quality improvement.

    View details for PubMedID 29944625

  • Anti-reflux procedures: complications, radiologic findings, and surgical and gastroenterologic perspectives ABDOMINAL RADIOLOGY Zarzour, J. G., Morgan, D. E., Callaway, J. P., Hawn, M. T., Canon, C. L., Koehler, R. E. 2018; 43 (6): 1308–18

    Abstract

    This article provides an overview of the current surgical anti-reflux procedures and their imaging findings, as well as the surgical complications. Accurate and timely clinical assessment requires an engaged radiologist fluoroscopist who understands the perspectives of their interdisciplinary colleagues, including the surgeon and gastroenterologist. The complex pathophysiology calls for an interdisciplinary approach, and the radiologist needs to tailor their evaluation to answer the specific questions posed by their clinical colleagues and by the presenting symptomatology.

    View details for PubMedID 29302737

  • The Hospital Readmission Reduction Program for Surgical Conditions: Impactful or Harmful? Annals of surgery Staudenmayer, K. L., Hawn, M. T. 2018; 267 (4): 606–7

    View details for PubMedID 28953553

  • Trends and surgical outcomes of laparoscopic versus open pyloromyotomy. Surgical endoscopy Kethman, W. C., Harris, A. H., Hawn, M. T., Wall, J. K. 2018

    Abstract

    Hypertrophic pyloric stenosis (HPS) is one of the most common pediatric illnesses necessitating surgical intervention. Controversy remains over the optimal surgical approach between laparoscopic pyloromyotomy (LP) and open pyloromyotomy (OP). LP has gained acceptance for management of HPS in an era of expanding minimal access surgical approaches to pediatric conditions. Several studies suggest advantages of LP over OP; however, selection bias and small sample sizes remain a concern. This study compares the outcomes of LP versus OP using propensity score methods.The 2013-2015 ACS NSQIP Pediatric PUF was queried for all infants undergoing pyloromyotomy. The trend in the proportion of infants undergoing LP was described and perioperative outcomes between the OP and LP cohorts were compared using propensity score weighted regression models.4847 infants were identified to have undergone surgical pyloromyotomy. The proportion of LP performed increased significantly from 59% in 2013 to 65.5% in 2015 (p < 0.001). LP was associated with lower overall complications (1.4% vs 2.9%) (ORadj 0.52, 95% CI 0.34-0.80), surgical site-related complications (1.1% vs 2.1%) (ORadj 0.52, 95% CI 0.32-0.84), and post-operative length of stay (1.5 days vs 1.9 days) (ORadj 0.89, 95% CI 0.81-0.98) without significant differences in related re-operation (0.9% vs 0.9%) (ORadj 1.01, 95% CI 0.52-1.93) or readmissions (1.4% vs 2.1%) (ORadj 0.73, 95% CI 0.46-1.17).Our study demonstrates that LP is increasingly utilized for management of hypertrophic pyloric stenosis and is associated with shorter length of stay, and lower odds of surgical site-specific and overall complications without differences in related re-operations. This study supports LP as a safe and effective method for management of HPS.

    View details for PubMedID 29340829

  • 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

  • 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 Bakaeen, F. G., Shroyer, A., Zenati, M. A., Badhwar, V., Thourani, V. H., Gammie, J. S., Suri, R. M., Sabik, J. F., Gillinov, A., Chu, D., Omer, S., Hawn, M. T., Almassi, G., Cornwell, L. D., Grover, F. L., Rosengart, T. K., Graham, L. MOSBY-ELSEVIER. 2018: 105-+
  • Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development". Annals of surgery Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2017

    View details for PubMedID 29064907

  • Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases DISEASES OF THE ESOPHAGUS Triadafilopoulos, G., Clarke, J., Hawn, M. 2017; 30 (10): 1–9

    Abstract

    An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.

    View details for DOI 10.1093/dote/dox084

    View details for Web of Science ID 000414363600015

    View details for PubMedID 28859396

  • Precision GERD management for the 21st century DISEASES OF THE ESOPHAGUS Triadafilopoulos, G., Clarke, J. O., Hawn, M. 2017; 30 (9): 1–6

    Abstract

    The highly heterogeneous nature of gastroesophageal reflux disease (GERD), together with the multiplicity of available diagnostic and therapeutic options (lifestyle, pharmacologic, endoscopic and surgical) available today call for a new approach that funnels the multidimensionality of the disease into precise and effective algorithms - reviewed herein- aimed at improving clinical outcomes.

    View details for PubMedID 28859369

  • How Do We Prevent Readmissions After Major Surgery? Advances in surgery Wahl, T. S., Hawn, M. T. 2017; 51 (1): 89-100

    View details for DOI 10.1016/j.yasu.2017.03.007

    View details for PubMedID 28797348

  • To Bleed or Not to Bleed: Is That the Question? Annals of surgery Mell, M. W., Hawn, M. T. 2017

    View details for PubMedID 28692473

  • Racial disparities in length-of-stay persist even with no postoperative complications. The Journal of surgical research Giglia, M. D., DeRussy, A., Morris, M. S., Richman, J. S., Hawn, M. T., Vickers, S. M., Knight, S. J., Chu, D. I. 2017; 214: 14-22

    Abstract

    To determine the contribution of race to postoperative length-of-stay in elective colorectal surgery without complications.The 2012-2013 National Surgical Quality Improvement Program Colectomy-Targeted Database was queried for patients undergoing elective colorectal surgery without complications. After stratifying by race, univariate/bivariate comparisons were made. On adjusted comparison, predictors of postoperative length-of-stay were identified along with incident rate ratios and Least Squares Means for predicted length-of-stays.Of 28,480 elective colorectal surgeries, 19,898 patients had no postoperative complications. Patients stratified to white (84%), black (8%), Hispanic (3%), and Asian (3%). Overall mean postoperative length-of-stay was 4.8 d, with black patients having the longest at 5.3 d (P < 0.05). After covariate adjustment, black race increased postoperative length-of-stay by 9%, 7%, and 6% compared to white, Hispanic, and Asian patients, respectively (P < 0.05). No statistical difference existed in postoperative length-of-stay for Hispanic and Asian patients versus white patients. Adjusted postoperative length-of-stay was 5.1 d for black patients compared to 4.7, 4.8, and 4.8 d for white, Hispanic, and Asian patients, respectively (P < 0.05).Black patients have significantly longer postoperative length-of-stay after elective colorectal surgery even if no postoperative complications occur. Further studies are needed to understand the mechanism(s) for these disparities.

    View details for DOI 10.1016/j.jss.2017.02.063

    View details for PubMedID 28624035

  • 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

  • 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

  • Comparing definitions of outpatient surgery: Implications for quality measurement. American journal of surgery Mull, H. J., Rivard, P. E., Legler, A., Pizer, S. D., Hawn, M. T., Itani, K. M., Rosen, A. K. 2017

    Abstract

    Adverse event (AE) rates in outpatient surgery are inconsistently reported, partly because of the lack of a standard definition of outpatient surgery. We compared the types and rates of surgical procedures defined by two national healthcare agencies: Health Care Cost Institute (HCCI) and the Healthcare Cost and Utilization Project (HCUP) and considered implications for quality measurement.We used HCCI and HCUP definitions to identify FY2012-14 VA outpatient surgeries.There were six times as many HCCI surgeries as HCUP (6,575,830 versus 1,086,640). Ninety-nine percent of HCUP-defined surgeries were also identified by HCCI. More HCUP surgeries had higher average Medicare Relative Value Units then HCCI surgeries [5.3 (SD = 4.4) versus 1.6 (SD = 2.3) RVUs].Rates and types of procedures vary widely between definitions. Quality measurement using HCCI versus HCUP may produce significantly lower AE rates because many of the surgeries included reflect low complexity and potentially low risk of AEs.

    View details for DOI 10.1016/j.amjsurg.2017.01.021

    View details for PubMedID 28233538

  • 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

  • New Approaches to Gastroesophageal Reflux Disease. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Kethman, W. n., Hawn, M. n. 2017; 21 (9): 1544–52

    Abstract

    Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series.Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.

    View details for PubMedID 28623447

  • 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

  • Oncologic Procedures Amenable to Fluorescence-guided Surgery. Annals of surgery Tipirneni, K. E., Warram, J. M., Moore, L. S., Prince, A. C., de Boer, E., Jani, A. H., Wapnir, I. L., Liao, J. C., Bouvet, M., Behnke, N. K., Hawn, M. T., Poultsides, G. A., Vahrmeijer, A. L., Carroll, W. R., Zinn, K. R., Rosenthal, E. 2016

    Abstract

    Although fluorescence imaging is being applied to a wide range of cancers, it remains unclear which disease populations will benefit greatest. Therefore, we review the potential of this technology to improve outcomes in surgical oncology with attention to the various surgical procedures while exploring trial endpoints that may be optimal for each tumor type.For many tumors, primary treatment is surgical resection with negative margins, which corresponds to improved survival and a reduction in subsequent adjuvant therapies. Despite unfavorable effect on patient outcomes, margin positivity rate has not changed significantly over the years. Thus, patients often experience high rates of re-excision, radical resections, and overtreatment. However, fluorescence-guided surgery (FGS) has brought forth new light by allowing detection of subclinical disease not readily visible with the naked eye.We performed a systematic review of clinicatrials.gov using search terms "fluorescence," "image-guided surgery," and "near-infrared imaging" to identify trials utilizing FGS for those received on or before May 2016.fluorescence surgery for tumor debulking, wide local excision, whole-organ resection, and peritoneal metastases.fluorescence in situ hybridization, fluorescence imaging for lymph node mapping, nonmalignant lesions, nonsurgical purposes, or image guidance without fluorescence.Initial search produced 844 entries, which was narrowed down to 68 trials. Review of literature and clinical trials identified 3 primary resection methods for utilizing FGS: (1) debulking, (2) wide local excision, and (3) whole organ excision.The use of FGS as a surgical guide enhancement has the potential to improve survival and quality of life outcomes for patients. And, as the number of clinical trials rise each year, it is apparent that FGS has great potential for a broad range of clinical applications.

    View details for DOI 10.1097/SLA.0000000000002127

    View details for PubMedID 28045715

  • Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery. Journal of laparoendoscopic & advanced surgical techniques. Part A Hollis, R. H., Cannon, J. A., Singletary, B. A., Korb, M. L., Hawn, M. T., Heslin, M. J. 2016; 26 (11): 850-856

    Abstract

    Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.

    View details for PubMedID 27398733

  • 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

  • Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease. AJR. American journal of roentgenology Levine, M. S., Carucci, L. R., DiSantis, D. J., Einstein, D. M., Hawn, M. T., Martin-Harris, B., Katzka, D. A., Morgan, D. E., Rubesin, S. E., Scholz, F. J., Turner, M. A., Wolf, E. L., Canon, C. L. 2016; 207 (5): 1009-1015

    Abstract

    The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition.Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

    View details for PubMedID 27490234

  • 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. 2016: -?

    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 PubMedID 27734083

  • 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

  • Transitional care interventions and hospital readmissions in surgical populations: a systematic review. American journal of surgery Jones, C. E., Hollis, R. H., Wahl, T. S., Oriel, B. S., Itani, K. M., Morris, M. S., Hawn, M. T. 2016; 212 (2): 327-335

    Abstract

    Despite hospital readmission being a targeted quality metric, few studies have focused on the surgical patient population. We performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery.PubMed was searched for studies evaluating transitional care interventions in surgical populations within the years 1995 to 2015. Of 3,527 abstracts identified, 3 randomized controlled trials and 7 observational cohort studies met inclusion criteria.Discharge planning programs reduced readmissions by 11.5% (P = .001), 12.5% (P = .04), and 23% (P = .26). Patient education interventions reduced readmissions by 14% (P = .28) and 23.5% (P < .05). Primary care follow-up reduced readmissions by 8.3% for patients after high-risk surgeries (P < .001). Home visits reduced readmissions by 7.69% (P = .023) and 4% (P = .161), respectively. Therefore, improving discharge planning, patient education, and follow-up communication may reduce readmissions.

    View details for DOI 10.1016/j.amjsurg.2016.04.004

    View details for PubMedID 27353404

  • 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

  • White Paper: SSAT Commitment to Workforce Diversity and Healthcare Disparities JOURNAL OF GASTROINTESTINAL SURGERY Walsh, R. M., Jeyarajah, D. r., Matthews, J. B., Telem, D., Hawn, M. T., Michelassi, F., Reid-Lomardo, K. M. 2016; 20 (5): 879-884

    Abstract

    The Society for Surgery of the Alimentary Track (SSAT) is committed to diversity and inclusiveness of its membership, promotion of research related to healthcare disparities, cultural competency of practicing gastrointestinal surgeons, and cultivation of leaders with unique perspectives. The SSAT convened a task force to assess the current state of diversity and inclusion and recommend sustainable initiatives to promote these goals. Working through the current committee structure of the Society, and by establishing a permanent Diversity and Inclusion liaison committee, the SSAT will maintain its commitment and strive towards diversity of thought and inclusiveness on every level to improve the well-being and betterment of its membership and the patients they serve.

    View details for DOI 10.1007/s11605-016-3107-1

    View details for Web of Science ID 000375462500001

    View details for PubMedID 26940942

  • 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

  • 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

  • A Role for the Early Warning Score in Early Identification of Critical Postoperative Complications. Annals of surgery Hollis, R. H., Graham, L. A., Lazenby, J. P., Brown, D. M., Taylor, B. B., Heslin, M. J., Rue, L. W., Hawn, M. T. 2016; 263 (5): 918-923

    Abstract

    We examined whether an early warning score (EWS) could predict inpatient complications in surgical patients.Abnormal vitals often precede in-hospital mortality. The EWS calculated using vital signs has been developed to identify patients at risk for mortality.Inpatient general surgery procedures with National Surgical Quality Improvement Project data from 2013 to 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of major complications, unplanned intensive care unit transfer, and medical emergency team activation were classified using the Clavien-Dindo system as grade I to V. Relationship with EWS and timing of complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation.Among 552 patients admitted to the ward postsurgery, 68 (12.3%) developed at least one grade I to III complication and 37 (6.7%) developed a grade IV/V complication. The mean maximum EWS was significantly higher preceding grade IV/V complications (10.1) compared with grade I to III complications (6.4) or across the hospital stay in patients without complications (5.4; P < 0.01). EWS significantly increased in the 3 days preceding grade IV/V complications (P < 0.001) and declined in patients without complications in the 3 days before discharge (P < 0.001). A threshold EWS of 8 predicted occurrence of grade IV/V complications with 81% sensitivity and 84% specificity.Critical postoperative complications can be preceded by rising EWS. Interventional studies are needed to evaluate whether EWS can reduce the severity of postoperative complications and mortality for surgical patients through early identification and intervention.

    View details for DOI 10.1097/SLA.0000000000001514

    View details for PubMedID 26692076

  • Racial Disparities in Readmissions for Patients with Inflammatory Bowel Disease (IBD) After Colorectal Surgery JOURNAL OF GASTROINTESTINAL SURGERY Gunnells, D. J., Morris, M. S., DeRussy, A., Gullick, A. A., Malik, T. A., Cannon, J. A., Hawn, M. T., Chu, D. I. 2016; 20 (5): 985-993

    Abstract

    The incidence of inflammatory bowel disease (IBD) in minorities is increasing, and health outcome disparities are becoming more apparent. Our aim was to investigate the contribution of race to readmissions in IBD patients undergoing colorectal surgery.The National Surgical Quality Improvement Program database from 2012 to 2013 was queried for all patients with IBD undergoing elective colorectal surgery. After stratifying by race, unadjusted univariate and bivariate comparisons were made. Primary outcome was all-cause 30-day readmission. Predictors of readmission were identified using multivariable logistic regression.Of the 2523 patients with IBD who underwent elective colon surgery, 15.0 % were readmitted within 30 days of index operation. Black patients constituted 7.7 % of the entire cohort. Black patients were significantly different in smoking status (27 vs. 22 %) and Crohn's diagnosis (84 vs. 73 %) (p < 0.05). Black patients had significantly higher readmission rates (20 vs. 15 %) and longer length-of-stays (8 vs. 6 days) after surgery (p < 0.05). On multivariable analysis, black race remained a significant predictor for 30-day readmissions in patients with IBD (odds ratio 1.6, 95 % confidence interval 1.1-2.5).Black patients with IBD have an increased risk for readmission after colorectal surgery. Efforts to reduce readmissions need to target not only well-studied risk factors such as postoperative complications, but also investigate non-NSQIP-measured elements such as social and behavioral determinants of health.

    View details for DOI 10.1007/s11605-015-3068-9

    View details for Web of Science ID 000375462500016

    View details for PubMedID 26743885

  • Robotic Esophagectomy for Cancer: Early Results and Lessons Learned. Seminars in thoracic and cardiovascular surgery Cerfolio, R. J., Wei, B., Hawn, M. T., Minnich, D. J. 2016; 28 (1): 160-169

    Abstract

    Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

    View details for DOI 10.1053/j.semtcvs.2015.10.006

    View details for PubMedID 27568155

  • 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

  • Hospital Acquired Conditions Are the Strongest Predictor for Early Readmission: An Analysis of 26,710 Arthroplasties JOURNAL OF ARTHROPLASTY Raines, B. T., Ponce, B. A., Reed, R. D., Richman, J. S., Hawn, M. T. 2015; 30 (8): 1299-1307

    Abstract

    Hospital readmission is a metric of hospital quality of care, yet little is known what factors predict hospital readmission following arthroplasty. Our aim was to identify variables associated with early readmission following knee and hip arthroplasty, with focus upon hospital acquired conditions (HACs). Retrospective cohort analysis using Surgical Care Improvement Project (SCIP) and Veteran's Affairs Surgical Quality Improvement Program (VASQIP) data was performed over a five-year period. Following 26,710 total and partial primary arthroplasties (16,808 knees and 9902 hips), the overall 30-day readmission was 7.3% (1940) with readmission rates of 6.6% for knee arthroplasty and 8.4% for hip arthroplasty. HACs accounted for 42% of all complications and were the strongest predictor of readmission. Efforts to reduce these events may improve cost and safety of arthroplasty.

    View details for DOI 10.1016/j.arth.2015.02.024

    View details for Web of Science ID 000358083400002

    View details for PubMedID 25770864

  • Acceptability of the decision support for safer surgery tool AMERICAN JOURNAL OF SURGERY Norton, W. E., Hosokawa, P. W., Henderson, W. G., Volckmann, E. T., Pell, J., Tomeh, M. G., Glasgow, R. E., Min, S., Neumayer, L. A., Hawn, M. T. 2015; 209 (6): 977-984

    Abstract

    We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events.The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests.During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably.The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.

    View details for DOI 10.1016/j.amjsurg.2014.06.037

    View details for Web of Science ID 000355120700009

    View details for PubMedID 25457241

  • Association Between Inpatient Surveillance and Venous Thromboembolism Rates After Hospital Discharge JAMA SURGERY Holcomb, C. N., DeRussy, A., Richman, J. S., Hawn, M. T. 2015; 150 (6): 520-527

    Abstract

    Venous thromboembolism (VTE) surveillance practices in hospitals, but not adherence to Surgical Care Improvement Program VTE prophylaxis measures, have been reported to explain the variation in VTE rates in hospitals.To examine the relationship between inpatient surveillance testing for VTE and postdischarge VTE rates at the hospital level to determine whether more frequent inpatient surveillance is associated with reduced occurrence of postdischarge VTEs.Retrospective study of a US national cohort of Veterans Affairs (VA) patients. National VA Surgical Quality Improvement Program outcome data were linked to VA administrative data on patients undergoing inpatient surgery from 2005 to 2009 and were included in the Surgical Care Improvement Program VTE measurement population.Surveillance was identified using Current Procedural Terminology codes for diagnostic VTE imaging. Relationships between hospital-level surveillance and VTE rates were assessed with Pearson correlation coefficients, and the postdischarge VTE rate was modeled using linear regression, adjusting for hospital volume, inpatient VTE rate, inpatient surveillance rate, and case mix.Of 25 975 patients at 79 VA facilities, 296 (1.4%) experienced a VTE during the index hospitalization, and 114 (0.4%) experienced a postdischarge VTE within 30 days after surgery. The median length of stay was 11 days for those with a positive surveillance test result and 9 days for those with a negative test result. There was a positive correlation between inpatient surveillance and inpatient VTE rates (R = 0.33, P = .003) but no significant correlation of inpatient surveillance with either postdischarge surveillance (R = 0.11, P = .29) or postdischarge VTE rates (R = 0.03, P = .76). In an adjusted regression model of the postdischarge VTE rate, only the inpatient VTE rate was significant (β = 0.13, P = .05).Hospitals with higher VTE surveillance rates have higher inpatient VTE rates but not decreased postdischarge VTE rates. However, hospitals with higher inpatient VTE rates have higher postdischarge VTE rates, which suggests that surveillance may be influenced by higher observed rates and not surveillance practices alone.

    View details for DOI 10.1001/jamasurg.2015.35

    View details for Web of Science ID 000356615400007

    View details for PubMedID 25831412

  • 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

  • Unintended Consequences of the Hospital Readmission Reduction Program ANNALS OF SURGERY Hawn, M. T. 2015; 261 (6): 1032-1033

    View details for DOI 10.1097/SLA.0000000000001150

    View details for Web of Science ID 000369611600028

    View details for PubMedID 25647062

  • Intraoperative Nerve Monitoring and Vocal Cord Paralysis: Controlling Bias In reply to Nguyen and Wang JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Chung, T. K., Rosenthal, E. L., Porterfield, J. R., Carroll, W. R., Richman, J., Hawn, M. T. 2015; 220 (5): 973-974

    View details for Web of Science ID 000353342200036

    View details for PubMedID 25907881

  • The Significance of Preoperative Impaired Sensorium on Surgical Outcomes in Nonemergent General Surgical Operations JAMA SURGERY Gajdos, C., Kile, D., Hawn, M. T., Finlayson, E., Henderson, W. G., Robinson, T. N. 2015; 150 (1): 30-36

    Abstract

    With an aging population, preoperative assessment of the frail older adult requires evaluation beyond simply accounting for chronic diseases. Impaired cognition is a recognized characteristic of the frail older adult.To examine the effect of preoperative impaired sensorium (IS) on general surgical outcomes.Retrospective cohort study using data between January 2005 and December 2010 at academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients undergoing nonemergent general surgical operations were studied. Multivariable logistic regression involving 45 preoperative patient-level risk factors and comorbidities was used to calculate the conditional probability of having IS. Patients having and not having preoperative IS were matched on their propensity scores using a 1:1 greedy matching technique. Propensity score matching resulted in almost all (n = 1765) patients with IS uniquely matching to a patient without IS, resulting in a cohort size of 3530. Complication rates between patients with and without IS were compared.Rates of postoperative complications and death following nonemergent general surgical operations.In total, 294 037 patients were studied, of whom 1771 (0.6%) had preoperative IS. Patients with IS were older and had more significant preoperative risk factors and comorbidities. As a result, unadjusted analysis found that 22 of 23 postoperative complications were significantly more likely to occur in patients with IS. Within the matched cohort, rates of postoperative pneumonia, ventilator dependence, progressive renal insufficiency, urinary tract infection, stroke, venous thromboembolism, and postoperative death continued to be significantly (P < .05) elevated in patients with IS.Impaired sensorium significantly increases postoperative morbidity and mortality independent of other preoperative risk factors and comorbidities following nonemergent general surgical operations. Incorporation of impaired cognitive function into routine preoperative risk assessment and decision making could be an important addition to traditional risk assessment strategies.

    View details for DOI 10.1001/jamasurg.2014.863

    View details for Web of Science ID 000348232900008

    View details for PubMedID 25409305

  • Surgical quality measurement: the good, the bad, and the ugly. JAMA surgery Hawn, M. T. 2015; 150 (1): 58-?

    View details for DOI 10.1001/jamasurg.2014.2914

    View details for PubMedID 25427257

  • The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following Coronary Stenting JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Holcomb, C. N., Graham, L. A., Richman, J. S., Rhyne, R. R., Itani, K. M., Maddox, T. M., Hawn, M. T. 2014; 64 (25): 2730-2739

    Abstract

    Recent coronary stent placement and noncardiac surgery contribute to the risk of adverse cardiac events, but the relative contributions of these two factors have not been quantified.This research was designed to determine the incremental risk of noncardiac surgery on myocardial infarction (MI) and coronary revascularization following coronary stenting.A U.S. retrospective cohort study of patients receiving coronary stents at Veterans Affairs medical centers between 2000 and 2010 was used to match patients undergoing noncardiac surgery within 24 months of stent placement to two patients with stents not undergoing surgery. Patients were matched on stent type and cardiac risk factors present at the time of stent placement. A composite endpoint of MI and/or cardiac revascularization for the 30-day interval post-surgery was calculated. Adjusted risk differences (RD) were compared across time periods following stent implantation, using generalized estimating equations.We matched 20,590 surgical patients to 41,180 nonsurgical patients. During the 30-day interval following noncardiac surgery, the surgical cohort had higher rates of the composite cardiac endpoint (3.1% vs. 1.9%; RD: 1.3%; 95% confidence interval: 1.0% to 1.5%). The incremental risk of noncardiac surgery adjusted for surgical characteristics ranged from 3.5% immediately following stent implantation to 1% at 6 months, after which it remained stable out to 24 months. Factors associated with a significant reduction in risk following surgery more than 6 months post-stent included elective inpatient procedures (ΔRD: 1.8%; p = 0.01), high-risk surgery (ΔRD: 3.7%; p = 0.01), and drug-eluting stent (DES) (ΔRD: 1.3%; p = 0.01).The incremental risk of noncardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilizes at 1.0% after 6 months. Elective, high-risk, inpatient surgery, and patients with DES may benefit most from delay from a 6-month delay after stent placement.

    View details for DOI 10.1016/j.jacc.2014.09.07

    View details for Web of Science ID 000346734900003

    View details for PubMedID 25541124

  • Occult Gastrointestinal Bleeding JAMA SURGERY Holcomb, C. N., Hawn, M. T. 2014; 149 (12): 1335-1336

    View details for DOI 10.1001/jamasurg.2014.109

    View details for Web of Science ID 000346477400028

    View details for PubMedID 25337720

  • 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

  • Perioperative Management of the Patient with a Coronary Artery Stent ANESTHESIOLOGY Vetter, T. R., Short, R. T., Hawn, M. T., Marques, M. B. 2014; 121 (5): 1093-1098

    View details for DOI 10.1097/ALN.0000000000000451

    View details for Web of Science ID 000344368700028

    View details for PubMedID 25211171

  • Examining National Outcomes after Thyroidectomy with Nerve Monitoring JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Chung, T. K., Rosenthal, E. L., Porterfield, J. R., Carroll, W. R., Richman, J., Hawn, M. T. 2014; 219 (4): 765-770

    Abstract

    Previous intraoperative nerve monitoring (IONM) studies have demonstrated modest-to-no benefit and did not include a nationwide sample of hospitals representative of broad thyroidectomy practices. This national study was designed to compare vocal cord paralysis (VCP) rates between thyroidectomy with IONM and without monitoring (conventional).We performed a retrospective analysis of 243,527 thyroidectomies during 2008 to 2011 using the Nationwide Inpatient Sample.Use of IONM increased yearly throughout the study period (2.6% [2008], 5.6% [2009], 6.1% [2010], 6.9% [2011]) and during this time, VCP rates in the IONM group initially increased year-over-year (0.9% [2008], 2.4% [2009], 2.5% [2010], 1.4% [2011]). In unadjusted analyses, IONM was associated with significantly higher VCP rates (conventional 1.4% vs IONM 1.9%, p < 0.001). After propensity score matching, IONM remained associated with higher VCP rates in partial thyroidectomy and lower VCP rates for total thyroidectomy with neck dissection. Hospital-level analysis revealed that VCP rates were not explained by differential laryngoscopy rates, decreasing the likelihood of ascertainment bias. Additionally, for hospitals in which IONM was applied to more than 50% of thyroidectomies, lower VCP rates were observed (1.1%) compared with hospitals that applied IONM to less than 50% (1.6%, p = 0.016). Higher hospital volume correlated with lower VCP rates in both groups (<75, 75 to 299, >300 thyroidectomies/year: IONM, 2.1%, 1.7%, 1.7%; conventional, 1.5%, 1.3%, 1.0%, respectively).According to this study, IONM has not been broadly adopted into practice. Overall, IONM was associated with a higher rate of VCP even after correction for numerous confounders. In particular, low institutional use of IONM and use in partial thyroidectomies are associated with higher rates of VCP. Further studies are warranted to support the broader application of IONM in patients where benefit can be reliably achieved.

    View details for DOI 10.1016/j.jamcollsurg.2014.04.013

    View details for Web of Science ID 000342422500022

    View details for PubMedID 25158909

    View details for PubMedCentralID PMC4370365

  • Improved Outcomes Associated With a Revised Quality Measure for Continuing Perioperative beta-Blockade JAMA SURGERY Richman, J. S., Itani, K. M., Deierhoi, R. J., Henderson, W. G., Hawn, M. T. 2014; 149 (10): 1031-1037

    Abstract

    The Surgical Care Improvement Project perioperative β-blocker (BB) (SCIP-BB) continuation measure was revised in 2012 to incorporate inpatient BB continuation after discharge from the postanesthesia care unit.To determine whether adherence to the original or revised SCIP-BB measure is associated with decreased adverse events.Retrospective cohort study using national Veterans Affairs patient-level data on adherence to the original SCIP-BB measure and inpatient BB continuation for operations between July 2006 and August 2009.Data for SCIP-BB measure adherence, inpatient BB continuation, and patient and procedure risk variables were used to estimate the associations between adherence to the original and revised SCIP-BB measures and outcomes of major adverse cardiovascular or cerebrovascular events (MACCEs) and their components of cardiovascular events, cerebrovascular events, and 30-day mortality. In addition to unadjusted estimates, propensity score matching and bootstrapping were used to estimate the associations and generate 95% CIs.Major adverse cardiovascular or cerebrovascular events.Of 14,420 nonemergent operations with at least 2 postoperative inpatient days, 13,170 (91.3%) adhered to the original SCIP-BB measure, and 480 (3.3%) experienced a MACCE. Propensity score-matched analyses showed that adherence to the original SCIP-BB measure was not associated with MACCEs (odds ratio [OR], 1.00; 95% CI, 0.66-1.54) but was associated with increased cerebrovascular events (OR, 3.01; 95% CI, 1.00-10.07). Adherence to the revised SCIP-BB measure occurred in 11,597 (80.4%), and in matched analysis adherence was associated with decreased MACCEs (OR, 0.75; 95% CI, 0.57-0.95), cardiovascular events (OR, 0.66; 95% CI, 0.46-0.93), and 30-day mortality (OR, 0.74; 95% CI, 0.53-0.98). Adherence to the revised SCIP-BB measure was not associated with increased cerebrovascular events (OR, 1.22; 95% CI, 0.62-2.38).Adherence to the original SCIP-BB measure was associated with increased cerebrovascular events but not improved cardiovascular event outcomes. β-Blocker continuation consistent with the revised SCIP-BB measure is associated with reduced MACCEs, cardiovascular events, and 30-day mortality. These data provide a cautionary tale of implementing performance measures before they have been rigorously tested. Although the observed associations between adherence to the revised SCIP-BB measure and outcomes are promising, they should be evaluated in the postimplementation period.

    View details for DOI 10.1001/jamasurg.2014.351

    View details for Web of Science ID 000343987300009

    View details for PubMedID 25141795

  • Adoption of Preoperative Oral Antibiotics Decreases Surgical Site Infection for Elective Colorectal Surgery AMERICAN SURGEON Korb, M. L., Hawn, M. T., Singletary, B. A., Cannon, J. A., Heslin, M. J., O'Brien, D. M., Morris, M. S. 2014; 80 (9): E270-E273

    View details for Web of Science ID 000342615200006

    View details for PubMedID 25197859

  • Effect of elective inguinal hernia repair on urinary symptom burden in men AMERICAN JOURNAL OF SURGERY Reed, R. D., Poston, T. L., Kerby, J. D., Richman, J. S., Colli, J. L., Hawn, M. T. 2014; 208 (2): 180-186

    Abstract

    Our study sought to examine the prevalence of urinary symptoms in men undergoing hernia repair and whether there is an association between symptoms and short-term outcomes.This is a prospective cohort study of male veterans consenting to inguinal hernia repair. The American Urological Association Symptom Score (AUASS) was administered preoperatively at 48 hours and again at 30 days after surgery.Median preoperative AUASS was 6 (interquartile range [IQR]: 3 to 12); at 48 hours, the median score increased significantly to 10 (IQR: 4 to 16, P < .01) and at 30 days, the median score dropped below baseline to 3 (IQR: 1 to 8, P < .0001). Multivariable linear regression modeling revealed that the use of an intraoperative urinary catheter was significantly associated with an increase in AUASS from preop to both 48 hours and 30 days.Elective repair of an inguinal hernia is associated with reduction in urinary symptom burden at 30 days, whereas the use of an intraoperative foley catheter is associated with no improvement at 30 days.

    View details for DOI 10.1016/j.amjsurg.2014.02.004

    View details for Web of Science ID 000341149400005

    View details for PubMedID 24815528

  • Identification of Process Measures to Reduce Postoperative Readmission JOURNAL OF GASTROINTESTINAL SURGERY Halverson, A. L., Sellers, M. M., Bilimoria, K. Y., Hawn, M. T., Williams, M. V., McLeod, R. S., Ko, C. Y. 2014; 18 (8): 1407-1415

    Abstract

    Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates.Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology.Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication.An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.

    View details for DOI 10.1007/s11605-013-2429-5

    View details for Web of Science ID 000339420600005

    View details for PubMedID 24912913

  • Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics Do Surgical Care Improvement Project Guidelines Need to Be Updated? JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ponce, B., Raines, B. T., Reed, R. D., Vick, C., Richman, J., Hawn, M. 2014; 96A (12): 970-977
  • Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics: Do Surgical Care Improvement Project Guidelines Need to Be Updated? journal of bone and joint surgery. American volume Ponce, B., Raines, B. T., Reed, R. D., Vick, C., Richman, J., Hawn, M. 2014; 96 (12): 970-977

    Abstract

    Prophylactic antibiotics decrease surgical site infection (SSI) rates, and their timing, choice, and discontinuation are measured and reported as part of the Surgical Care Improvement Project (SCIP). The aim of this study was to assess the comparative effectiveness of the SCIP-approved antibiotics for SSI prevention.METHODS: This retrospective cohort study utilized national Veterans Affairs (VA) data on patients undergoing elective hip or knee arthroplasty from 2005 to 2009. Data on prophylactic antibiotics were merged with VA Surgical Quality Improvement Program data to identify patient and procedure-related risk factors for SSI. Patients were stratified by documented penicillin allergy. Chi-square and Wilcoxon rank-sum tests were used to compare SSI rates among patients receiving SCIP-approved prophylactic antibiotics.RESULTS: A total of 18,830 elective primary arthroplasties (12,823 knee and 6007 hip) were included. Most patients received prophylactic cefazolin as the sole agent (81.9%), followed by vancomycin as the sole agent (8.0%), vancomycin plus cefazolin (5.6%), and clindamycin (4.5%). Documented penicillin allergy accounted for 54.1% of cases involving vancomycin administration compared with 94.6% of cases involving clindamycin. The overall thirty-day SSI rate was 1.4%, and the unadjusted rate was 2.3% with vancomycin only, 1.5% with vancomycin plus cefazolin, 1.3% with cefazolin only, and 1.1% with clindamycin. Unadjusted analysis of penicillin-allergic patients revealed an SSI rate of 2.0% with vancomycin only compared with 1.0% with clindamycin (p = 0.18). For patients without penicillin allergy, the SSI rate was 2.6% with vancomycin only compared with 1.6% with vancomycin plus cefazolin (p = 0.17) and 1.3% with cefazolin only (p < 0.01).CONCLUSIONS: Current SCIP guidelines address antibiotic timing but not antibiotic dosage. (The generally accepted recommendation for vancomycin is 15 mg/kg.) Although vancomycin is a narrower-spectrum antibiotic than either cefazolin or clindamycin, our finding of higher SSI rates following prophylaxis with vancomycin only may suggest a failure to use an appropriate dosage rather than an inequality of antibiotic effectiveness.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

    View details for PubMedID 24951731

  • The Relationship Between Timing of Surgical Complications and Hospital Readmission JAMA SURGERY Morris, M. S., Deierhoi, R. J., Richman, J. S., Altom, L. K., Hawn, M. T. 2014; 149 (4): 348-354

    Abstract

    Readmissions after surgery are costly and may reflect quality of care in the index hospitalization.To determine the timing of postoperative complications with respect to hospital discharge and the frequency of readmission stratified by predischarge and postdischarge occurrence of complications.This is a retrospective cohort study of national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcome data on the Surgical Care Improvement Project cohort for operations performed from January 2005 to August 2009, including colorectal, arthroplasty, vascular, and gynecologic procedures. The association between timing of complication with respect to index hospitalization and 30-day readmission was modeled using generalized estimating equations.All-cause readmission within 30 days of the index surgical hospitalization discharge. RESULTS Our study of 59 273 surgical procedures performed at 112 Department of Veterans Affairs (VA) hospitals found an overall complication rate of 22.6% (predischarge complications, 71.9%; postdischarge complications, 28.1%). The proportion of postdischarge complications varied significantly, from 8.7% for respiratory complications to 55.7% for surgical site infection (P < .001). The overall 30-day readmission rate was 11.9%, of which only 56.0% of readmissions were associated with a currently assessed complication. Readmission was predicted by patient comorbid conditions, procedure factors, and the occurrence of postoperative complications. Multivariable generalized estimating equation models of readmission adjusting for patient and procedure characteristics, hospital, and index length of stay found that the occurrence of postdischarge complications had the highest odds of readmission (odds ratio, 7.4-20.8) compared with predischarge complications (odds ratio, 0.9-1.48).More than one-quarter of assessed complications are diagnosed after hospital discharge and strongly predict readmission. Hospital discharge is an insufficient end point for quality assessment. Although readmission is associated with complications, almost half of readmissions are not associated with a complication currently assessed by the Veterans Affairs Surgical Quality Improvement Program.

    View details for DOI 10.1001/jamasurg.2013.4064

    View details for Web of Science ID 000334609900008

    View details for PubMedID 24522747

  • A 100% Departmental Mortality Review Improves Observed-to-Expected Mortality Ratios and University HealthSystem Consortium Rankings JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Heslin, M. J., Taylor, B., Hawn, M. T., Davies, J. E., Heslin, R. T., Mims, A. H., Morgan, J. E., Rabun, R. L., Smedley, W. A., Morris, M. S., Reiff, D. A., McGwin, G., Bland, K. I., Rue, L. W. 2014; 218 (4): 554-562

    Abstract

    Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics.From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression.Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013.A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.

    View details for DOI 10.1016/j.jamcollsurg.2013.12.023

    View details for Web of Science ID 000333250300008

    View details for PubMedID 24529804

  • Alabama Veterans Rural Health Initiative: A Pilot Study of Enhanced Community Outreach in Rural Areas JOURNAL OF RURAL HEALTH Hilgeman, M. M., Mahaney-Price, A. F., Stanton, M. P., McNeal, S. F., Pettey, K. M., Tabb, K. D., Litaker, M. S., Parmelee, P., Hamner, K., Martin, M. Y., Hawn, M. T., Kertesz, S. G., Davis, L. L. 2014; 30 (2): 153-163

    Abstract

    Access, enrollment, and engagement with primary and specialty health care services present significant challenges for rural populations worldwide. The Alabama Veterans Rural Health Initiative evaluated an innovative outreach intervention combining motivational interviewing, patient navigation, and health services education to promote utilization of the United States Veterans Administration Healthcare System (VA) by veterans who live in rural locations.Community outreach workers completed the intervention and assessment, enrolling veterans from 31 counties in a southern state. A total 203 participants were randomized to either an enhanced enrollment and engagement outreach condition (EEE, n = 101) or an administrative outreach (AO, n = 102) condition.EEE participants enrolled and attended VA appointments at higher rates and within fewer days than those who received AO. Eighty-seven percent of EEE veterans attended an appointment within 6 months, compared to 58% of AO veterans (P < .0001). The median time to first appointment was 12 days for the EEE group and 98 days for the AO group (P < .0001). Additionally, a race by outreach group interaction emerged: black and white individuals benefited equally from the EEE intervention; however, black individuals who received AO took significantly longer to attend appointments than their white counterparts.Results provide needed empirical support for a specific outreach intervention that speeds enrollment and engagement for rural individuals in VA services. Planned interventions to improve service utilization should ameliorate ambivalence about accessing health care in addition to addressing traditional systems or environmental-level barriers.

    View details for DOI 10.1111/jrh.12054

    View details for Web of Science ID 000333691800005

    View details for PubMedID 24330220

  • Cardiovascular Event Risk After Noncardiac Surgery Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hawn, M. T., Richman, J. S., Maddox, T. M. 2014; 311 (5): 525-526

    View details for Web of Science ID 000330589800028

    View details for PubMedID 24496541

  • Comparison of Prospective Risk Estimates for Postoperative Complications: Human vs Computer Model JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Glasgow, R. E., Hawn, M. T., Hosokawa, P. W., Henderson, W. G., Min, S., Richman, J. S., Tomeh, M. G., Campbell, D., Neumayer, L. A. 2014; 218 (2): 237-?

    Abstract

    Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk.This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes.The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity.Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.

    View details for DOI 10.1016/j.jamcollsurg.2013.10.027

    View details for Web of Science ID 000329763900013

    View details for PubMedID 24440066

  • Choice of Intravenous Antibiotic Prophylaxis for Colorectal Surgery Does Matter JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Deierhoi, R. J., Dawes, L. G., Vick, C., Itani, K. M., Hawn, M. T. 2013; 217 (5): 763-769

    Abstract

    The Surgical Care Improvement Program endorses mandatory compliance with approved intravenous prophylactic antibiotics; however, oral antibiotics are optional. We hypothesized that surgical site infection (SSI) rates may vary depending on the choice of antibiotic prophylaxis.A retrospective cohort study of elective colorectal procedures using Veterans Affairs Surgical Quality Improvement Program (VASQIP) and SSI outcomes data was linked to the Office of Informatics and Analytics (OIA) and Pharmacy Benefits Management (PBM) antibiotic data from 2005 to 2009. Surgical site infection rates by type of IV antibiotic agent alone (IV) or in combination with oral antibiotic (IV + OA) were determined. Generalized estimating equations were used to examine the association between type of antibiotic prophylaxis and SSI for the entire cohort and stratified by use of oral antibiotics.After 5,750 elective colorectal procedures, 709 SSIs (12.3%) developed within 30 days. Oral antibiotic + IV (n = 2,426) had a lower SSI rate than IV alone (n = 3,324) (6.3% vs 16.7%, p < 0.0001). There was a significant difference in the SSI rate based on type of preoperative IV antibiotic given (p ≤ 0.0001). Generalized estimating equations adjusting for significant covariates of age, body mass index, procedure work relative value units, and operation duration demonstrated an independent protective effect of oral antibiotics (odds ratio [OR] 0.37, 95% CI 0.29 to 0.46), as well as increased rates of SSI associated with ampicillin/sulbactam (OR 2.21, 95% CI 1.37 to 3.56) and second generation cephalosporins (cefoxitin, OR 2.50, 95% CI 1.83 to 3.42; cefotetan, OR 2.70, 95% CI 1.72 to 4.22) when compared with first generation cephalosporin/metronidazole.The choice of IV antibiotic was related to the SSI rate; however, oral antibiotics were associated with reduced SSI rate for every antibiotic class.

    View details for DOI 10.1016/j.jamcollsurg.2013.07.003

    View details for Web of Science ID 000325759500003

    View details for PubMedID 24045142

  • 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

  • Postoperative risks associated with alcohol screening depend on documented drinking at the time of surgery DRUG AND ALCOHOL DEPENDENCE Rubinsky, A. D., Bishop, M. J., Maynard, C., Henderson, W. G., Hawn, M. T., Harris, A. H., Beste, L. A., Tonnesen, H., Bradley, K. A. 2013; 132 (3): 521-527

    Abstract

    Both AUDIT-C alcohol screening scores up to a year before surgery and clinical documentation of drinking over 2 drinks per day immediately prior to surgery ("documented drinking >2d/d") are associated with increased postoperative complications and health care utilization. The purpose of this study was to evaluate whether documented drinking >2d/d contributed additional information about postoperative risk beyond past-year AUDIT-C screening results.Male Veterans Affairs (VA) patients who had a non-emergent, non-cardiac, major surgery assessed by the VA's Surgical Quality Improvement Program 10/2003-9/2006 and completed the AUDIT-C by mailed survey in the prior year were eligible for this study. Linear or logistic regression models compared 30-day postoperative complication(s), return to operating room (OR), hospital length of stay (LOS), and intensive care unit (ICU) days across eight groups defined by past-year AUDIT-C score and clinically documented drinking >2d/d, with AUDIT-C scores 1-4 and no documented drinking >2d/d as the referent, after adjusting for important covariates.Overall 8811 patients met inclusion criteria. Among patients with documented drinking >2d/d immediately prior to surgery, postoperative risk varied widely depending on past-year AUDIT-C score; scores ≥5 were associated with increased risk of complication(s), and scores ≥9 with increased hospital LOS and ICU days. Among patients without documentation of drinking >2d/d, increasing AUDIT-C scores were not associated with these outcomes.Clinical documentation of drinking >2d/d immediately prior to surgery contributed additional information about postoperative risk beyond past-year AUDIT-C score. However, among patients with documented drinking >2d/d, postoperative risk varied widely depending on the AUDIT-C score.

    View details for DOI 10.1016/j.drugalcdep.2013.03.022

    View details for Web of Science ID 000325510700018

    View details for PubMedID 23683792

  • Advancing age and 30-day adverse outcomes after nonemergent general surgeries. Journal of the American Geriatrics Society Gajdos, C., Kile, D., Hawn, M. T., Finlayson, E., Henderson, W. G., Robinson, T. N. 2013; 61 (9): 1608-1614

    Abstract

    To determine whether 30-day postoperative mortality, complications, failure-to-rescue (FTR) rates, and postoperative length of stay increase with advancing age.Retrospective cohort study.Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.Individuals undergoing nonemergent major general surgeries between 2005 and 2008 were studied (N = 165,600).Postoperative outcomes of interest were complications occurring within 30 days of the index operation, return to the operating room within 30 days, FTR after a postoperative complication, postsurgical length of stay, and 30-day mortality.Postoperative mortality, overall morbidity, and each type of postoperative complication increased with increasing age. Rates of FTR after each type of postoperative complication also increased with age. Mortality in individuals aged 80 and older after renal insufficiency (43.3%), stroke (36.5%), myocardial infarction (MI) (35.6%), and pulmonary complications (25-39%) were particularly high. Median postoperative length of stay increased with age after surgical site infection, urinary tract infection, pneumonia, return to the operating room, and overall morbidity but not after venous thromboembolism, stroke, MI, renal insufficiency, failure to wean from the ventilator, or reintubation.Thirty-day mortality and complication and FTR rates increase with age after nonemergent general surgeries. Individuals aged 80 and older have especially high mortality after renal, cardiovascular, and pulmonary complications. Surgeons need to be more selective with advancing age regarding who will benefit from the surgical intervention.

    View details for DOI 10.1111/jgs.12401

    View details for PubMedID 23927841

  • Advancing Age and 30-Day Adverse Outcomes After Nonemergent General Surgeries JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Gajdos, C., Kile, D., Hawn, M. T., Finlayson, E., Henderson, W. G., Robinson, T. N. 2013; 61 (9): 1608-1614

    View details for DOI 10.1111/jgs.12401

    View details for Web of Science ID 000324307200023

  • 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

  • The Risk of Major Elective Vascular Surgical Procedures in Patients With End-Stage Renal Disease ANNALS OF SURGERY Gajdos, C., Hawn, M. T., Kile, D., Henderson, W. G., Robinson, T., McCarter, M., Nehler, M. 2013; 257 (4): 766-773

    Abstract

    To examine the postoperative complications and death rate of major elective vascular surgery procedures in patients with end-stage renal disease (ESRD).Patients with ESRD undergoing elective major vascular surgical procedures are thought to have a high rate of postoperative complications and death.The American College of Surgeons-National Surgical Quality Improvement Program database was used to select ESRD and non-ESRD patients who had elective major vascular surgical procedures between 2004 and 2008. Multivariable logistic regression analysis was used to examine the impact of ESRD on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiology class, and recent operations (within the past 30 days).ESRD patients undergoing elective major vascular surgery were significantly more likely than non-ESRD patients to develop surgical site infection, unplanned intubation, ventilator dependence, combined pulmonary outcome, and a need for reoperation within 30 days of surgery. Importantly, ESRD patients undergoing elective major vascular surgery were also at higher risk for composite outcome and death within 30 days from surgery. ESRD patients above age 65 years undergoing elective major vascular surgery had far worse 30-day outcomes when compared with the younger ESRD cohort. Examining these data by their anatomic site (carotid, aortic, and peripheral) demonstrated elevated rates of postoperative complications and death in patients with ESRD undergoing open abdominal aortic aneurysm repair, carotid endarterectomies, and peripheral vascular operations compared with the non-ESRD cohort. Endovascular abdominal aortic aneurysm repair in ESRD patients had complications and death rates comparable with non-ESRD patients.Patients with ESRD undergoing elective vascular surgery have a significantly elevated risk of postoperative complications and death after major vascular surgical operations--particularly in patients over age 65. These data, in combination with well-established reduced survival for the older ESRD population, call into question the utility of most carotid and aortic operations in these patients in the absence of symptoms or a rapidly enlarging aneurysm.

    View details for DOI 10.1097/SLA.0b013e3182686b87

    View details for Web of Science ID 000315990100034

    View details for PubMedID 22982978

  • Oral Antibiotic Bowel Preparation Reduces Length of Stay and Readmissions after Colorectal Surgery JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Toneva, G. D., Deierhoi, R. J., Morris, M., Richman, J., Cannon, J. A., Altom, L. K., Hawn, M. T. 2013; 216 (4): 756-762

    Abstract

    Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery.This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission.Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38).Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.

    View details for DOI 10.1016/j.jamcollsurg.2012.12.039

    View details for Web of Science ID 000316727400049

    View details for PubMedID 23521958

  • Risk of Major Nonemergent Inpatient General Surgical Procedures in Patients on Long-term Dialysis JAMA SURGERY Gajdos, C., Hawn, M. T., Kile, D., Robinson, T. N., Henderson, W. G. 2013; 148 (2): 137-143

    Abstract

    Patients on long-term dialysis undergoing major nonemergent general surgical procedures are thought to have high rates of postoperative complications and death.Retrospective cohort study.Academic and private hospitals.The American College of Surgeons National Surgical Quality Improvement Program database was used to select dialysis and nondialysis patients who had undergone nonemergent major general surgical procedures between 2005 and 2008. Multivariable logistic regression analysis was used to examine the effect of dialysis on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiologists class, and recent operations (within the past 30 days).Patient morbidity, mortality, and failure-to-rescue rates.Dialysis patients undergoing major nonemergent general surgical procedures were significantly more likely to develop pneumonia, unplanned intubation, ventilator dependence, and need for a reoperation within 30 days from the index procedure. Dialysis patients also had a higher risk of vascular complications and postoperative death. Older dialysis patients (aged ≥ 65 years) had a significantly higher postoperative mortality rate compared with their younger counterparts. Dialysis patients were significantly more likely to die after any complication occurred, and mortality rates were especially high following stroke, myocardial infarction, and reintubation. Abnormalities in potentially modifiable preoperative variables (blood urea nitrogen level, albumin level, and hematocrit) did not increase the risk of postoperative complications or death in dialysis patients compared with nondialysis patients.Dialysis patients undergoing nonemergent general surgery have significantly elevated risks of postoperative complications and death, particularly if they are aged 65 years or older.

    View details for DOI 10.1001/2013.jamasurg.347

    View details for Web of Science ID 000316681300005

    View details for PubMedID 23560284

  • Technical aspects and early results of robotic esophagectomy with chest anastomosis JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Cerfolio, R. J., Bryant, A. S., Hawn, M. T. 2013; 145 (1): 90-96

    Abstract

    Minimally invasive esophagectomy with a chest anastomosis has advantages. We present technical lessons learned and early results.A retrospective review was conducted of minimally invasive laparoscopic and robotic Ivor Lewis esophagectomy.Over 10 months, 22 patients (19 men) underwent laparoscopic gastric mobilization, with robotic esophagectomy. All had the thoracic portion completed robotically and 21 had the stomach mobilized laproscopically. All had esophageal cancer and 20 received neoadjuvant chemoradiotherapy. All had R0 resection with a median of 18 lymph nodes removed and a blood loss of 40 mL. The first 6 patients underwent a stapled posterior and hand-sewn anterior anastomosis; five of these patients experienced a major morbidity, including 1 anastomotic leak and 1 leak from the gastric staple line. The last 16 patients had a 2-layered completely hand-sewn anastomosis, and there were no anastomotic leaks or major morbidities. There were no 30- or 90-day mortalities. Technical improvements included placing a loop around the esophagus in the abdomen for third arm retraction, advancing the gastric conduit into the chest using nonrobotic instruments, using 10-cm nonabsorbable interrupted sutures for the outer layer, and a running 22-cm long absorbable suture for the inner layer.Robotic thoracic esophagectomy using ports only is feasible, safe, and affords R0 resection with thorough thoracic lymph node dissection. It also allows the sewing of a 2-layered chest anastomosis with good early results.

    View details for DOI 10.1016/j.jtcvs.2012.04.022

    View details for Web of Science ID 000312386300023

    View details for PubMedID 22910197

  • Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)-a cohort study BMJ OPEN Singh, J. A., Hawn, M., Campagna, E. J., Henderson, W. G., Richman, J., Houston, T. K. 2013; 3 (4)

    Abstract

    To assess the mediation of smoking-associated postoperative mortality by postoperative complications.Observational cohort study.Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality.Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation).There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%.Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.

    View details for DOI 10.1136/bmjopen-2012-002157

    View details for Web of Science ID 000329809200016

    View details for PubMedID 23604347

  • Preoperative screening and case cancellation in cocaine-abusing veterans scheduled for elective surgery. Anesthesiology research and practice Elkassabany, N., Speck, R. M., Oslin, D., Hawn, M., Chaichana, K., Sum-Ping, J., Sepulveda, J., Whitley, M., Sakawi, Y. 2013; 2013: 149892-?

    Abstract

    Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery.

    View details for DOI 10.1155/2013/149892

    View details for PubMedID 24069030

  • Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events AMERICAN JOURNAL OF SURGERY Altom, L. K., Deierhoi, R. J., Grams, J., Richman, J. S., Vick, C. C., Henderson, W. G., Itani, K. M., Hawn, M. T. 2012; 204 (5): 591-597

    Abstract

    In 2006, the Surgical Care Improvement Program (SCIP) implemented measures to reduce venous thromboembolism (VTE). There are little data on whether these measures reduce VTE rates. This study proposed to examine associations between SCIP-VTE adherence and VTE rates.SCIP-VTE adherence for 30,531 surgeries from 2006 to 2009 was linked with VA Surgical Quality Improvement Program data. Patient demographics, comorbidities, and surgical characteristics associated with VTE were summarized. VTE rates were compared by SCIP-VTE adherence. Multivariable logistic regression was used to model VTE by adherence, adjusting for multiple associated factors.Of 30,531 surgeries, 89.9% adhered to SCIP-VTE; 1.4% experienced VTE. Logistic regression identified obesity, smoking, functional status, weight loss, emergent status, age older than 64 years, and surgical time as associated with VTE. SCIP-VTE was not associated with VTE (1.4% vs 1.33%; P = .3), even after adjustment.This study identified several important risk factors for VTE but found no association with SCIP-VTE adherence.

    View details for DOI 10.1016/j.amjsurg.2012.07.006

    View details for Web of Science ID 000311734000013

    View details for PubMedID 22906249

  • Factors influencing emergency department preference for access to healthcare. The western journal of emergency medicine Brown, L. E., Burton, R., Hixon, B., Kakade, M., Bhagalia, P., Vick, C., Edwards, A., Hawn, M. T. 2012; 13 (5): 410-415

    Abstract

    African-Americans are more likely than Caucasians to access healthcare through the emergency department (ED); however, the reasons behind this pattern are unclear. The objective is to investigate the effect of race, insurance, socioeconomic status, and perceived health on the preference for ED use.This is a prospective study at a tertiary care ED from June to July 2009. Patients were surveyed to capture demographics, healthcare utilization, and baseline health status. The primary outcome of interest was patient-reported routine place of healthcare. Other outcomes included frequency of ED visits in the previous 6 months, barriers to primary care and patient perception of health using select questions from the Medical Outcomes Study Short Form 36 (SF-36).Two hundred and ninety-two patients completed the survey of whom 58% were African-American and 44% were uninsured. African-Americans were equally likely to report 3 or more visits to the ED, but more likely to state a preference for the ED for their usual place of care (24% vs. 13%, p < 0.01). No significant differences between groups were found for barriers to primary care, including insurance. African-Americans less often reported comorbidities or hospitalization within the previous 6 months (23% vs. 34%, p = 0.04). On logistic regression modeling, African-Americans were more than 2 times as likely to select the ED as their usual place of healthcare (OR 2.24, 95% CI 1.22 - 4.08).African-Americans, independent of health insurance, are more likely than Caucasians to designate the ED as their routine place of healthcare.

    View details for DOI 10.5811/westjem.2011.11.6820

    View details for PubMedID 23359637

  • Individual surgical decision-making and comparative effectiveness research SURGERY Kaafarani, H. M., Hawn, M. T., Itani, K. M. 2012; 152 (5): 787-789

    View details for DOI 10.1016/j.surg.2012.03.023

    View details for Web of Science ID 000310943900001

    View details for PubMedID 22657726

  • Preoperative Oral Antibiotics Reduce Surgical Site Infection Following Elective Colorectal Resections DISEASES OF THE COLON & RECTUM Cannon, J. A., Altom, L. K., Deierhoi, R. J., Morris, M., Richman, J. S., Vick, C. C., Itani, K. M., Hawn, M. T. 2012; 55 (11): 1160-1166

    Abstract

    Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation.The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort.This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery.This study was conducted in 112 Veterans Affairs hospitals.Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009.The primary outcome measured was the incidence of surgical site infection.Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21-0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34-0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement Project-1) had a modest protective effect, with no effect observed for other Surgical Care Improvement Project measures. Hospitals with higher rates of oral antibiotics use had lower surgical site infection rates (R = 0.274, p < 0.0001).Determination of the use of oral antibiotics and mechanical bowel preparation is based on retrospective prescription data, and timing of actual administration cannot be determined.Use and type of preoperative bowel preparation varied widely. These results strongly suggest that preoperative oral antibiotics should be administered for elective colorectal resections. The role of oral antibiotics independent of mechanical bowel preparation should be examined in a prospective randomized trial.

    View details for DOI 10.1097/DCR.0b013e3182684fac

    View details for Web of Science ID 000309818400015

    View details for PubMedID 23044677

  • 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

  • Toward prospective identification of high-risk surgical patients. American surgeon Richman, J. S., Hosokawa, P. W., Min, S., Tomeh, M. G., Neumayer, L., Campbell, D. A., Henderson, W. G., Hawn, M. T. 2012; 78 (7): 755-760

    Abstract

    The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.

    View details for PubMedID 22748533

  • Toward Prospective Identification of High-Risk Surgical Patients AMERICAN SURGEON Richman, J. S., Hosokawa, P. W., Min, S., Tomeh, M. G., Neumayer, L., Campbell, D. A., Henderson, W. G., Hawn, M. T. 2012; 78 (7): 755-760
  • Prevalence of alcohol misuse among men and women undergoing major noncardiac surgery in the Veterans Affairs health care system SURGERY Bradley, K. A., Rubinsky, A. D., Sun, H., Blough, D. K., Tonnesen, H., Hughes, G., Beste, L. A., Bishop, M. J., Hawn, M. T., Maynard, C., Harris, A. S., Hawkins, E. J., Bryson, C. L., Houston, T. K., Henderson, W. G., Kivlahan, D. R. 2012; 152 (1): 69-81

    Abstract

    Patients who screen positive for alcohol misuse on the Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C ≥5 points) have significantly increased postoperative complications. Severe alcohol misuse (AUDIT-C ≥9 points) is associated with increased postoperative health care use; however, little is known about the prevalence of alcohol misuse in demographic and clinical subgroups of surgical patients.The prevalence of alcohol misuse was evaluated among 10,284 patients (9,771 men and 513 women) who underwent major noncardiac surgery in Veterans Affairs (VA) hospitals during the fiscal years 2004 to 2006 and completed the AUDIT-C. Sex-stratified analyses evaluated prevalence rates of alcohol misuse (AUDIT-C ≥5) and severe misuse (AUDIT-C ≥9) across demographic and clinical subgroups.Overall, 1,607 (16%) men and 24 (5%) women screened positive for alcohol misuse (AUDIT-C ≥5) in the year before operation, with 4% and 2% screening positive for severe misuse (AUDIT-C ≥9), respectively. Alcohol misuse was more common among men who were <60 years of age, divorced or separated, current smokers, or American Stoke Association class 1 or 2, and those with cirrhosis/hepatitis or substance use disorders. Among patients with alcohol misuse, 36% of men and 58% of women were American Society of Anesthesiologists class 1 or 2, and most did not have diagnoses that were commonly associated with alcohol misuse.Alcohol misuse is relatively common in male surgical patients. Moreover, surgical patients undergoing operation who screen positive for alcohol misuse are often relatively healthy, without health problems that might alert providers to their alcohol misuse in the absence of screening.

    View details for DOI 10.1016/j.surg.2012.02.007

    View details for Web of Science ID 000305853800011

    View details for PubMedID 22503319

  • All-Cause Mortality after Tracheostomy at a Tertiary Care Hospital over a 10-Month Period OTOLARYNGOLOGY-HEAD AND NECK SURGERY Kejner, A. E., Castellanos, P. F., Rosenthal, E. L., Hawn, M. T. 2012; 146 (6): 918-922

    Abstract

    To evaluate perioperative mortality after tracheostomy in intensive care unit (ICU) patients undergoing routine tracheostomy over a 10-month period.Case series with planned data collection.Tertiary care hospital.Mechanically ventilated patients.Prospective analysis of ICU patients undergoing tracheostomy placement over 10 months was performed. Variables evaluated were demographics, pretracheostomy length of stay, time on ventilator, time to death, preoperative comorbidities, and cause of death.There were 129 consultations resulting in 115 tracheostomies, of which 100 were included for study. The overall 30-day postoperative mortality rate was 25%, including palliative care deaths. Cause of death in all cases was due to a preexisting condition and not from tracheostomy. Patients who died within the 30-day postoperative period were found to have significant differences in age, pretracheostomy length of stay, location of tracheostomy, and preoperative comorbidity scores. No significant difference was found in time on ventilator, sex, or race/ethnicity. Mean time from consultation to tracheostomy was 2.5 days (range, 0-12 days).High rates of mortality after tracheostomy can possibly affect hospital quality ratings for surgical services. There were no deaths directly related to surgery. Despite this, the mortality rate in this population was quite high. This illustrates the significant disease burden in these patients and the need to stratify postoperative mortality as well as to consider comorbidity and age when evaluating patients for tracheostomy.

    View details for DOI 10.1177/0194599812437316

    View details for Web of Science ID 000305522400008

    View details for PubMedID 22344290

  • Adverse Effects of Smoking on Postoperative Outcomes in Cancer Patients ANNALS OF SURGICAL ONCOLOGY Gajdos, C., Hawn, M. T., Campagna, E. J., Henderson, W. G., Singh, J. A., Houston, T. 2012; 19 (5): 1430-1438

    Abstract

    The possible negative effects of smoking on postoperative outcomes have not been well studied in cancer patients.We used the VA Surgical Quality Improvement Program (VASQIP) database for the years 2002-2008, which assesses preoperative risk factors and postoperative outcomes for patients undergoing major surgery within the VA healthcare system.Compared with never smokers, prior smokers and current smokers with GI malignancies were significantly more likely to have surgical site infection (SSI) (odds ratio [OR], 1.25; 95% confidence interval [95% CI], 1.09-1.44) (OR, 1.20; 95% CI, 1.05-1.38), combined pulmonary complications (combined pulmonary outcome [CPO]: pneumonia, failure to wean from ventilator, reintubation) (OR, 1.60; 95% CI, 1.38-1.87) (OR, 1.96; 95% CI, 1.68-2.29), and return to the operating room (OR, 1.20; 95% CI, 1.03-1.39) (OR, 1.31; 95% CI, 1.13-1.53), respectively. Both prior and current smokers had a significantly higher mortality at 30 days (OR, 1.50; 95% CI, 1.19-1.89) (OR, 1.41; 95% CI, 1.08-1.82) and 1 year (OR, 1.22; 95% CI, 1.08-1.38) (OR, 1.62; 95% CI, 1.43-1.85). Thoracic surgery patients who were current smokers were more likely to develop CPO (OR, 1.62; 95% CI, 1.25-2.11) and mortality within 1 year (OR, 1.50; 95% CI, 1.17-1.92) compared with nonsmokers, but SSI rates were not affected by smoking status. Current smokers had a significant increase in postsurgical length of stay (overall 4.3% [P < .001], GI 4.7% [P = .003], thoracic 9.0% [P < .001]) compared with prior smokers.Prior and current smoking status is a significant risk factor for major postoperative complications and mortality following GI cancer and thoracic operations in veterans. Smoking cessation should be encouraged prior to all major cancer surgery in the VA population to decrease postoperative complications and length of stay.

    View details for DOI 10.1245/s10434-011-2128-y

    View details for Web of Science ID 000303375400011

    View details for PubMedID 22065194

  • 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

  • AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Rubinsky, A. D., Sun, H., Blough, D. K., Maynard, C., Bryson, C. L., Harris, A. H., Hawkins, E. J., Beste, L. A., Henderson, W. G., Hawn, M. T., Hughes, G., Bishop, M. J., Etzioni, R., Tonnesen, H., Kivlahan, D. R., Bradley, K. A. 2012; 214 (3): 296-U69

    Abstract

    Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission.This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group.Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0-6.7] vs 5.0 [95% CI, 4.7-5.3] days), more ICU days (4.5 [95% CI, 3.2-5.8] vs 2.8 [95% CI, 2.6-3.1] days), and increased probability of return to the operating room (10% [95% CI, 6-13%] vs 5% [95% CI, 4-6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group.AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

    View details for DOI 10.1016/j.jamcollsurg.2011.11.007

    View details for Web of Science ID 000301770100008

    View details for PubMedID 22244208

  • 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

  • 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
  • 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

  • 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
  • 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

  • A functional colonic obstruction: Cannon's point. Radiology case reports McKnight, S. T., Myers, A., Canon, C. L., Hawn, M. 2011; 6 (4): 557

    Abstract

    A patient presented with a large bowel obstruction after laparoscopic hernia repair converted to open inguinal hernia repair. A contrast enema examination revealed an area of narrowing in the midtransverse colon, consistent with Cannon's point. This represents a physiologic sphincter with focal narrowing of the colon lumen.

    View details for DOI 10.2484/rcr.v6i4.557

    View details for PubMedID 27307934

    View details for PubMedCentralID PMC4899988

  • 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

  • Smoking As a Risk Factor for Short-Term Outcomes Following Primary Total Hip and Total Knee Replacement in Veterans ARTHRITIS CARE & RESEARCH Singh, J. A., Houston, T. K., Ponce, B. A., Maddox, G., Bishop, M. J., Richman, J., Campagna, E. J., Henderson, W. G., Hawn, M. T. 2011; 63 (10): 1365-1374

    Abstract

    To assess the effect of smoking on postoperative complications following elective primary total hip replacement (THR) or primary total knee replacement (TKR).We used data from the national Veterans Affairs Surgical Quality Improvement Program to examine the association of smoking status at surgery with 30-day postoperative complication rates (including surgical site and other infections, pneumonia, stroke, myocardial infarction, mortality, and other complications) in veterans undergoing primary elective THR or TKR. Multilevel multivariable-adjusted logistic regression models, adjusted for age, race/ethnicity, work relative value units, American Society of Anesthesiology classification, and year of surgery, with additional adjustment for wound classification for surgical site infections, were used.A total of 33,336 patients, 95% men and 80% white with a mean age of 64 years, underwent elective primary THR/TKR between October 2001 and September 2008. Fifty-seven percent never smoked, 19% were prior smokers, and 24% were current smokers. Current smokers undergoing THR/TKR were significantly more likely than never smokers to have surgical site infections (odds ratio [OR] 1.41, 95% CI 1.16-1.72), pneumonia (OR 1.53, 95% CI 1.10-2.14), stroke (OR 2.61, 95% CI 1.26-5.41), and 1-year mortality (OR 1.63, 95% CI 1.31-2.02). Prior smokers were significantly more likely than nonsmokers to have pneumonia, (OR 1.34, 95% CI 1.00-1.80), stroke (OR 2.14, 95% CI 1.12-4.10), and urinary tract infection (OR 1.26, 95% CI 1.02-1.55).Current smoking at the time of elective THR or TKR is associated with increased postarthroplasty complications, especially surgical site infections and pneumonia. Preoperative smoking cessation programs should be considered in patients undergoing elective THR or TKR.

    View details for DOI 10.1002/acr.20555

    View details for Web of Science ID 000295255200002

    View details for PubMedID 21770042

  • 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

  • Outcomes of Emergent Incisional Hernia Repair AMERICAN SURGEON Altom, L. K., Snyder, C. W., Gray, S. H., Graham, L. A., Vick, C. C., Hawn, M. T. 2011; 77 (8): 971-976

    Abstract

    This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repaired emergently. Patients undergoing emergent repair were older (P = 0.02), more likely to be black (P = 0.02), and have congestive heart failure (P = 0.001) or chronic obstructive pulmonary disease (P = 0.001). Of emergent repairs, 76.2 per cent involved intestinal incarceration versus 7.2 per cent of elective repairs (P < 0.0001), and 17.5 per cent had concomitant bowel resection compared with 3.9 per cent of elective cases (P < 0.0001). Patients undergoing emergent repair were also more likely to receive primary suture repair (49.2 vs 31.1%, P = 0.003), develop a postoperative complication (26.0 vs 11.3%, P = 0.002), and have increased postoperative length of stay (7 vs 4 days, P < 0.0001). There were nine (14.3%) deaths at 30 days for the emergent group compared with 10 (0.7%) in the elective group (P < 0.001). However, there was no significant difference between emergent and elective repairs in long-term complications. Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases. These data suggest that technical outcomes for emergent repairs approach those of elective operations.

    View details for Web of Science ID 000293927200002

    View details for PubMedID 21944508

  • Predictors of mesh explantation after incisional hernia repair AMERICAN JOURNAL OF SURGERY Hawn, M. T., Gray, S. H., Snyder, C. W., Graham, L. A., Finan, K. R., Vick, C. C. 2011; 202 (1): 28-33

    Abstract

    Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known.This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002.Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4-22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation.Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.

    View details for DOI 10.1016/j.amjsurg.2010.10.011

    View details for Web of Science ID 000293593700009

    View details for PubMedID 21741517

  • 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

  • Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery JOURNAL OF GENERAL INTERNAL MEDICINE Bradley, K. A., Rubinsky, A. D., Sun, H., Bryson, C. L., Bishop, M. J., Blough, D. K., Henderson, W. G., Maynard, C., Hawn, M. T., Tonnesen, H., Hughes, G., Beste, L. A., Harris, A. H., Hawkins, E. J., Houston, T. K., Kivlahan, D. R. 2011; 26 (2): 162-169

    Abstract

    Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications.This is a cohort study.Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10.AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

    View details for DOI 10.1007/s11606-010-1475-x

    View details for Web of Science ID 000287668800015

    View details for PubMedID 20878363

    View details for PubMedCentralID PMC3019325

  • Effects of Virtual Reality Simulator Training Method and Observational Learning on Surgical Performance WORLD JOURNAL OF SURGERY Snyder, C. W., Vandromme, M. J., Tyra, S. L., Porterfield, J. R., Clements, R. H., Hawn, M. T. 2011; 35 (2): 245-252

    Abstract

    Virtual reality (VR) simulators and Web-based instructional videos are valuable supplemental training resources in surgical programs, but it is unclear how to optimally integrate them into minimally invasive surgical training.Medical students were randomized to proficiency-based training on VR laparoscopy and endoscopy simulators by two different methods: proctored training (automated simulator feedback plus human expert feedback) or independent training (simulator feedback alone). After achieving simulator proficiency, trainees performed a series of laparoscopic and endoscopic tasks in a live porcine model. Prior to their entry into the animal lab, all trainees watched an instructional video of the procedure and were randomly assigned to either observe or not observe the actual procedure before performing it themselves. The joint effects of VR training method and procedure observation on time to successful task completion were evaluated with Cox regression models.Thirty-two students (16 proctored, 16 independent) completed VR training. Cox regression modeling with adjustment for relevant covariates demonstrated no significant difference in the likelihood of successful task completion for independent versus proctored training [Hazard Ratio (HR) 1.28; 95% Confidence Interval (CI) 0.96-1.72; p=0.09]. Trainees who observed the actual procedure were more likely to be successful than those who watched the instructional video alone (HR 1.47; 95% CI 1.09-1.98; p=0.01).Proctored VR training is no more effective than independent training with respect to surgical performance. Therefore, time-consuming human expert feedback during VR training may be unnecessary. Instructional videos, while useful, may not be adequate substitutes for actual observation when trainees are learning minimally invasive surgical procedures.

    View details for DOI 10.1007/s00268-010-0861-1

    View details for Web of Science ID 000285998400001

    View details for PubMedID 21086125

  • Surgical Registries Effective, but How to Pay for Them? ARCHIVES OF SURGERY Hawn, M. T. 2011; 146 (1): 17-17

    View details for Web of Science ID 000286235500008

    View details for PubMedID 21305707

  • Retention of Colonoscopy Skills after Virtual Reality Simulator Training by Independent and Proctored Methods AMERICAN SURGEON Snyder, C. W., Vandromme, M. J., Tyra, S. L., Hawn, M. T. 2010; 76 (7): 743-746

    Abstract

    Virtual reality (VR) simulators may enhance surgical resident colonoscopy skills, but the duration of skill retention and the effects of different simulator training methods are unknown. Medical students participating in a randomized trial of independent (automated simulator feedback only) versus proctored (human expert feedback plus simulator feedback) simulator training performed a standardized VR colonoscopy scenario at baseline, at the end of training (posttraining), and after a median 4.5 months without practice (retention). Performances were scored on a 10-point scale based on expert proficiency criteria and compared for the independent and proctored groups. Thirteen trainees (8 proctored, 5 independent) were included. Performance at retention testing was significantly better than baseline (median score 10 vs. 5, P < 0.0001), and no different from posttraining (median score 10 vs. 10, P = 0.19). Score changes from baseline to retention and from posttraining to retention were no different for the proctored and independent groups. Overinsufflation and excessive force were the most common reasons for nonproficiency at retention. After proficiency-based VR simulator training, colonoscopy skills are retained for several months, regardless of whether an independent or proctored approach is used. Error avoidance skills may not be retained as well as speed and efficiency skills.

    View details for Web of Science ID 000279416500017

    View details for PubMedID 20698383

  • Surgical Care Improvement Should Performance Measures Have Performance Measures JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hawn, M. T. 2010; 303 (24): 2527-2528

    View details for DOI 10.1001/jama.2010.854

    View details for Web of Science ID 000279010900034

    View details for PubMedID 20571022

  • 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

  • Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia JOURNAL OF GASTROINTESTINAL SURGERY Snyder, C. W., Burton, R. C., Brown, L. E., Kakade, M. S., Finan, K. R., Hawn, M. T. 2009; 13 (12): 2095-2102

    Abstract

    The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions.This cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure.One hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p < 0.01). Greater improvements in gastrointestinal symptoms and health-related quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio = 5.1, 95% confidence interval 1.6-15.8, p = 0.005).Multiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.

    View details for DOI 10.1007/s11605-009-1049-6

    View details for Web of Science ID 000272303000001

    View details for PubMedID 19789928

  • 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

  • Unplanned Intubation after Surgery: Risk Factors, Prognosis, and Medical Emergency Team Effects AMERICAN SURGEON Snyder, C. W., Patel, R. D., Roberson, E. P., Hawn, M. T. 2009; 75 (9): 834-838

    Abstract

    Unplanned intubation after surgery is a marker for severe adverse events. We investigated the incidence, risk factors, and prognosis of unplanned intubation after general and vascular surgery and sought to determine whether the deployment of a hospital-wide medical emergency team (MET) had a preventive effect. We included all patients undergoing general and vascular surgical procedures between April 1, 2006, and June 30, 2008, from our American College of Surgeons National Surgical Quality Improvement Program data. Risk factors and incidence rates of unplanned intubation were compared before (preMET) and after (postMET) June 7, 2007. Chart review identified case details and fatality rates. There were 2426 patients included (1815 preMET, 611 postMET). The overall incidence of unplanned intubation was 2.6 per cent; significant risk factors included chronic obstructive pulmonary disease, dependent functional status, and emergent operation. Most (84%) unplanned intubations occurred in a critical care setting and the most common underlying reason was sepsis (40%). The overall case fatality rate was 43 per cent but varied significantly depending on the underlying reason for unplanned intubation. Incidence rates of unplanned intubation did not change significantly after MET deployment, suggesting that other strategies are needed to prevent this rare but highly morbid and mortal event.

    View details for Web of Science ID 000269346700026

    View details for PubMedID 19774957

  • Proficiency-Based Laparoscopic and Endoscopic Training With Virtual Reality, Simulators: A Comparison of Proctored and Independent Approaches JOURNAL OF SURGICAL EDUCATION Snyder, C. W., Vandromme, M. J., Tyra, S. L., Hawn, M. T. 2009; 66 (4): 201-207

    Abstract

    Virtual reality (VR) simulators for laparoscopy and endoscopy may be valuable tools for resident education. However, the cost of such training in terms of trainee and instructor time may vary depending upon whether an independent or proctored approach is employed.We performed a randomized controlled trial to compare independent and proctored methods of proficiency-based VR simulator training. Medical students were randomized to independent or proctored training groups. Groups were compared with respect to the number of training hours and task repetitions required to achieve expert level proficiency on laparoscopic and endoscopic simulators. Cox regression modeling was used to compare time to proficiency between groups, with adjustment for appropriate covariates.Thirty-six medical students (18 independent, 18 proctored) were enrolled. Achievement of overall simulator proficiency required a median of 11 hours of training (range, 6-21 hours). Laparoscopic and endoscopic proficiency were achieved after a median of 11 (range, 6-32) and 10 (range, 5-27) task repetitions, respectively. The number of repetitions required to achieve proficiency was similar between groups. After adjustment for covariates, trainees in the independent group achieved simulator proficiency with significantly fewer hours of training (hazard ratio, 2.62; 95% confidence interval, 1.01-6.85; p = 0.048).Our study quantifies the cost, in instructor and trainee hours, of proficiency-based laparoscopic and endoscopic VR simulator training, and suggests that proctored instruction does not offer any advantages to trainees. The independent approach may be preferable for surgical residency programs desiring to implement VR simulator training.

    View details for DOI 10.1016/j.jsurg.2009.07.007

    View details for Web of Science ID 000271984600006

    View details for PubMedID 19896624

  • Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis HERNIA Finan, K. R., Kilgore, M. L., Hawn, M. T. 2009; 13 (2): 173-182

    Abstract

    Despite 100,000 ventral hernia repairs (VHR) being performed annually, no gold standard for the technique exists. Mesh has been shown to decrease recurrence rates, yet, concerns of increased complications and costs prevent its systematic use. We examined the cost-effectiveness of open suture (OS) versus open mesh (OM) in primary VHR.A decision analysis model from the payer's perspective comparing OS to OM was constructed for calculating the total costs and cost-effectiveness. Probabilities for complications and outcomes were derived from the literature. The costs represented institutional fixed costs. The outcome measure of effectiveness was recurrence. One-way sensitivity analysis and a probabilistic analysis using Monte Carlo simulation were performed.OS was associated with a total cost of $16,355 (+/-6,041) per repair, while OM was $16,947 (+/-7,252). At 3-year follow-up, OM was the more effective treatment with 73.8% being recurrence-free, compared with 56.3% in the OS group. The incremental cost to prevent one recurrence by the placement of mesh was $1,878. OM became the less effective treatment strategy when the infection rate exceeded 35%. At a willingness to pay level of $5,500, OM was the more cost-effective treatment strategy.In subjects without contraindication to mesh placement, OM repair is the more effective surgical treatment for VHR, with a lower risk of recurrence at a small cost to the payer.

    View details for DOI 10.1007/s10029-008-0462-1

    View details for Web of Science ID 000264810800010

    View details for PubMedID 19142563

  • Prevention of Post-operative Leak Following Laparoscopic Heller Myotomy JOURNAL OF GASTROINTESTINAL SURGERY Finan, K. R., Renton, D., Vick, C. C., Hawn, M. T. 2009; 13 (2): 200-205

    Abstract

    Laparoscopic Heller myotomy is the preferred treatment for achalasia. Post-operative leaks cause significant morbidity and impair functional outcome. This study assesses the efficacy of intra-operative leak testing on post-operative leak rate.A retrospective analysis of 106 consecutive patients undergoing laparoscopic Heller myotomy by a single surgeon between November 2001 and August 2006 was undertaken. Intra-operative leak testing was performed in all patients. Variables associated with intra-operative mucosotomy were assessed by univariate analysis and logistic regression modeling.Intra-operative mucosotomy occurred in 25% of patients. All mucosotomies were repaired primarily and tested with methylene-blue-stained saline. Dor fundoplication was performed in 74% of the patients. There were no post-operative leaks and patients were started on diet day of surgery. Mean LOS was 1.4(+/-0.7) days. Logistic regression modeling demonstrated that prior myotomy was associated with a statistically significant increase in the rate of mucosotomy (p = 0.033), while previous botox injection (p = 0.193), pneumatic dilation (p = 0.599) or concomitant hiatal hernia (p = 0.874) were not significantly associated with mucosotomy.Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites post-operative management. Prior endoscopic treatment does not impair operative results.

    View details for DOI 10.1007/s11605-008-0687-4

    View details for Web of Science ID 000262987400004

    View details for PubMedID 18781365

  • 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

  • Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome? AMERICAN SURGEON Gray, S. H., Hawn, M. T., Kilgore, M. L., Yun, H., Christein, J. D. 2008; 74 (7): 602-605

    Abstract

    Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58-0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.

    View details for Web of Science ID 000256967700010

    View details for PubMedID 18646477

  • Percutaneous transhepatic duodenal diversion for the management of duodenal fistulae JOURNAL OF GASTROINTESTINAL SURGERY Zarzour, J. G., Christein, J. D., Drelichman, E. R., Oser, R. F., Hawn, M. T. 2008; 12 (6): 1103-1109

    Abstract

    The aim of this study was to determine the success of the nonoperative management of persistent duodenal fistulae (DF) with percutaneous transhepatic duodenal diversion (PTDD).Retrospective chart review identified six patients with DF managed by PTDD from 2006 to 2007. Patient outcomes and complications were assessed.The etiology of DF included pancreatic surgery (three patients), gastrectomy (two patients), and Crohn's disease (one patient). PTDD was performed by interventional radiology at a median time of 37 days after fistula recognition. After PTDD, fistula drainage decreased from 775 cc/day (range 200 to 2,525 cc/day) to <50 cc/day at a median of 8 days. Patients were discharged 32 days (median) after PTDD. One patient with Crohn's disease required definitive surgical treatment. Of the remaining five patients, the PTDD tube was capped at 27 days (median) after placement and was removed on an outpatient basis at 79 days (median) after placement. There was no mortality, no fistula recurrence, or complications associated with PTDD placement.We present an algorithm for the nonoperative management of persistent postoperative DF. In this limited series, PTDD was highly effective at definitively treating DF, especially in the acute setting. PTDD should be considered by surgeons facing the management of postoperative DF.

    View details for DOI 10.1007/s11605-007-0456-9

    View details for Web of Science ID 000255629100017

    View details for PubMedID 18172607

  • 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

  • Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hawn, M. T., Itani, K. M., Gray, S. H., Vick, C. C., Henderson, W., Holiston, T. K. 2008; 206 (5): 814-821

    Abstract

    Prophylactic antibiotic (PA) administration 1 to 2 hours before surgical incision (SIP-1) is a publicly reported process measure proposed for performance pay. We performed an analysis of patients undergoing major surgical operations to determine if SIP-1 was associated with surgical site infection (SSI) rates in Department of Veterans Affairs (VA) hospitals.Patients with External Peer Review Program Surgical Care Improvement Project (SCIP)-1 data with matched National Surgical Quality Improvement Program data were included in the study. Patient and facility level analyses comparing SCIP-1 and SSI were performed. We adjusted for clustering effects within hospitals, validated SSI risk score, and procedure type (percentage of colon, vascular, orthopaedic) using generalized estimating equations and linear modeling.The study population included 9,195 elective procedures (5,981 orthopaedic, 1,966 colon, and 1,248 vascular) performed in 95 VA hospitals. Timely PA occurred in 86.4% of patients. Untimely PA was associated with a rate of SSI of 5.8%, compared with 4.6% in the timely group (odds ratio = 1.29, 95% CI 0.99, 1.67) in bivariable unadjusted analysis. Patient level risk-adjusted multivariable generalized estimating equation modeling found the SSI risk score was predictive of SSI (p < 0.001); SIP-1 was not associated with SSI. Hospital level multivariable generalized linear modeling found procedure mix (p < 0.0001), but not SIP-1 rate or facility volume, to be associated with facility SSI rate. The study had 80% power to detect a 1.75% difference for patient level SSI rates.Timely PA did not markedly contribute to overall patient or facility SSI rates. These data are important for the ongoing discourse on how to measure and pay for quality of surgical care.

    View details for DOI 10.1016/j.jamcollsurg.2007.12.013

    View details for Web of Science ID 000255624400006

    View details for PubMedID 18471703

  • 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

  • Surgical progress in inguinal and ventral incisional hernia repair SURGICAL CLINICS OF NORTH AMERICA Gray, S. H., Hawn, M. T., Itani, K. M. 2008; 88 (1): 17-?

    Abstract

    The goals of this article are to describe the history of hernia repair and how innovations in surgical technique, prosthetics, and technology have shaped current practice.

    View details for DOI 10.1016/j.suc.2007.11.007

    View details for Web of Science ID 000254084400004

    View details for PubMedID 18267159

  • Advances in abdominal wall hernia repair - Preface SURGICAL CLINICS OF NORTH AMERICA Itani, K. M., Hawn, M. T. 2008; 88 (1): XVII-XIX

    View details for DOI 10.1016/j.suc.2008.01.002

    View details for Web of Science ID 000254084400002

    View details for PubMedID 18267157

  • Timely administration of prophylactic antibiotics for major surgical procedures JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hawn, M. T., Gray, S. H., Vick, C. C., Itani, K. M., Bishop, M. J., Ordin, D. L., Houston, T. K. 2006; 203 (6): 803-811

    Abstract

    Prophylactic antibiotics (PA) given within 60 minutes before surgical incision decrease risk of subsequent surgical site infection. Nationwide quality improvement initiatives have focused on improving the proportion of patients who receive timely prophylactic antibiotics.This is a cohort study of major surgical procedures performed in 108 Veterans Affairs hospitals between January and December 2005. Using data from the External Peer Review Program and the National Surgical Quality Improvement Program, we examined factors associated with timely PA administration. Univariate and multivariable analyses were performed.There were 8,137 major surgical procedures: cardiac (2,664), hip and knee arthroplasty (3,603), colon (1,142), arterial vascular (606), and hysterectomy (122). Timely PA occurred in 76.2% of patients, 18.2% received them too early, and 5.4% received them too late. Early administration accounted for 79% of untimely PA. Differences in timeliness were seen by procedure type (68% to 87%; p < 0.0001), admission status (67% to 80%; p < 0.0001), and antibiotic class (65% to 89%; p < 0.0001). PA administration occurred in the operating room for 63.5% of patients. When PA administration occurred in the operating room, they were timely in 89% of patients, compared with 54% of patients where administration was outside the operating room (odds ratio, 7.74; 95% CI = 6.49 to 9.22).Early PA administration accounted for the majority of inappropriately timed PA. Efforts to improve performance on this measure should focus on administering antibiotics in the operating room.

    View details for DOI 10.1016/j.jamcollsurg.2006.08.010

    View details for Web of Science ID 000242567300003

    View details for PubMedID 17116547

  • Treating obesity - There is no free lunch MEDICAL CARE Hawn, M. T. 2006; 44 (8): 703-705

    View details for Web of Science ID 000239357200001

    View details for PubMedID 16862030

  • Improvement in gastrointestinal symptoms and quality of life after cholecystectomy AMERICAN JOURNAL OF SURGERY Finan, K. R., Leeth, R. R., Whitley, B. M., Klapow, J. C., Hawn, M. T. 2006; 192 (2): 196-202

    Abstract

    Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL).A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests.Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01).This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

    View details for DOI 10.1016/j.amjsurg.2006.01.020

    View details for Web of Science ID 000239580900010

    View details for PubMedID 16860629

  • Patient-reported outcomes after inguinal herniorrhaphy SURGERY Hawn, M. T., Itani, K. M., Giobbie-Hurder, A., McCarthy, M., Jonasson, O., Neumayer, L. A. 2006; 140 (2): 198-205

    Abstract

    Patient-reported outcomes (PRO) reflect the functional outcomes of inguinal herniorrhaphy. We studied the effect of hernia recurrence and complications on PRO for participants in the Veterans Affairs trial of Open or Laparoscopic Repair of Inguinal Hernia.Analyzed PRO included (1) the Medical Outcomes Study Short Form 36, version 2, (2) the Surgical Pain Scale, (3) the Activities Assessment Scale, and (4) patient satisfaction. Recurrences and complications were recorded at follow-up visits. Complications were categorized by (1) hematoma/seroma, (2) orchitis, (3) neuralgia, and (4) other. Univariate and multivariable regression analyses identified variables significantly associated with postoperative PRO.Of the 1603 patients with PRO data, 105 had a recurrence and 342 had a complication at 2 years. Multivariable analyses showed neuralgia (P < .0005) adversely affected all PRO, and recurrence (P < .05) affected patient-reported pain, activity, and satisfaction, but not the score for the Medical Outcomes Study Short Form 3. Patients with a recurrence after open repair had more pain than those with a recurrence after laparoscopic repair (P = .0001). Patients with other complications after laparoscopic repair reported more pain and less activity than those with other complications after open repair (P = .003 and P = .009, respectively).The effectiveness of inguinal herniorrhaphy should be measured by the rate of recurrence and neuralgia. Postoperative neuralgias have a deleterious effect on all patient-reported outcomes.

    View details for DOI 10.1016/j.surg.2006.02.003

    View details for Web of Science ID 000240043200010

    View details for PubMedID 16904970

  • Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: Wait and see or surgery? AMERICAN JOURNAL OF GASTROENTEROLOGY Drake, B. B., Arguedas, M. R., Kilgore, M. L., Hawn, M. T., Wilcox, C. M. 2006; 101 (4): 746-752

    Abstract

    Common bile duct stones (CBDS) are especially prevalent in the elderly population. Although the standard of care for stone removal is endoscopic retrograde cholangiography with sphincterotomy (ERC-S), the clinician's decision to refer a patient for cholecystectomy after ERC-S depends on several factors including potential for future biliary symptoms and complications, morbidity and mortality related to cholecystectomy, and costs associated with referral for cholecystectomy versus conservative approach. Using decision analysis, we explored the economic implications of cholecystectomy versus expectant management following ERC-S in elderly patients with CBDS.A decision tree was constructed with DATA 3.5 (Williamstown, MA) to estimate the costs and outcomes associated with two treatment strategies following ERC-S for CBDS in patients age 60 yr and older: (1) elective cholecystectomy, and (2) expectant management. Probabilities for potential complications and outcomes were derived from the medical literature and cost reflected Medicare reimbursement rates at our institution. The time horizon of the analysis was 2 yr.Elective cholecystectomy was associated with total costs of 5,259 dollars with 94.3% of the cohort alive (1.886 life-years) at 2 yr, whereas expectant management was associated with total costs of 1,173 dollars with 94.7% of the cohort alive (1.894 life-years). The results were sensitive to the probability of recurrent biliary symptoms in patients treated conservatively. Compared to elective cholecystectomy, expectant management became less effective and more expensive at a yearly probability of recurrent symptoms greater than 40% and 90%, respectively.In patients aged 60 and older, expectant management after ERC-S for CBDS is a reasonable approach, but the economic attractiveness of this strategy is highly dependent on the probability of recurrent symptoms.

    View details for DOI 10.1111/j.1572-0241.2006.00491.x

    View details for Web of Science ID 000236666800013

    View details for PubMedID 16494588

  • Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis Annual Meeting of the Society-of-American-Gastrointestinal-and-Endoscopic-Surgeons (SAGES) Allen, N. L., Leeth, R. R., Finan, K. R., Tishler, D. S., Vickers, S. M., Wilcox, C. M., Hawn, M. T. SPRINGER. 2006: 292–96

    Abstract

    Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84-22.5) and conversion rate (OR = 3.45; 95% CI, 1.56-7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.

    View details for DOI 10.1016/j.gassur.2005.05.013

    View details for Web of Science ID 000235388700025

    View details for PubMedID 16455464

  • Variation in Institutional Review processes for a multisite observational study AMERICAN JOURNAL OF SURGERY Vick, C. C., Finan, K. R., Kiefe, C., Neumayer, L., Hawn, M. T. 2005; 190 (5): 805-809

    Abstract

    The Veterans Administration is an ideal setting for multisite studies; however, individual VA Institutional Review Board (IRB) approval is necessary. This study examines the burden of multisite IRB approval on a Health Services Research and Development (HSRD) ventral hernia outcomes observational study.Data gathered on the IRB process per site included time required for application completion, staff training and compliance, IRB affiliation (VA or university), approval status, and time to IRB approval. Wilcoxon rank sum tests were used to determine differences in median times for application completion and approval. Financial and temporal expenses were calculated.Significant differences were found in median time to complete applications by IRB affiliation (P < .01) and median time to approval by changes required to the consent letter (P < .05).The IRB process for a multisite observational study is expensive in both time and money. A VA national IRB for multisite studies would significantly decrease the financial and temporal burden for observational studies.

    View details for DOI 10.1016/j.amjsurg.2005.07.024

    View details for Web of Science ID 000232935200027

    View details for PubMedID 16226962

  • Predictors of wound infection in ventral hernia repair AMERICAN JOURNAL OF SURGERY Finan, K. R., Vick, C. C., Kiefe, C. I., Neumayer, L., Hawn, M. T. 2005; 190 (5): 676-681

    Abstract

    Postoperative wound infection is a significant risk factor for recurrence after ventral hernia repair (VHR). The current study examines patient- and procedure-specific variables associated with wound infection.A cohort of subjects undergoing VHR from 13 regional Veterans Health Administration (VHA) sites was identified. Patient-specific risk 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 analysis was used to model predictors of postoperative wound infection.A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% (n = 74). Best-fit logistic regression models demonstrated that steroid use, smoking, prolonged operative time, and use of absorbable mesh, acting as a surrogate marker for a more complex procedure, were significant independent predictors of wound infection.Permanent mesh placement was not associated with postoperative wound infection. Smoking was the only modifiable risk factor and preoperative smoking cessation may improve surgical outcomes in VHR.

    View details for DOI 10.1016/j.amjsurg.2005.06.041

    View details for Web of Science ID 000232935200003

    View details for PubMedID 16226938

  • Surgical approach to gastroesophageal reflux disease: What the radiologist needs to know RADIOGRAPHICS Canon, C. L., Morgan, D. E., Einstein, D. M., Herts, B. R., Hawn, M. T., Johnson, L. F. 2005; 25 (6): 1485-1499

    Abstract

    Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

    View details for DOI 10.1148/rg.256055016

    View details for Web of Science ID 000236951800005

    View details for PubMedID 16284130

  • Obesity status and use of general surgery resources AMERICAN SURGEON Finan, K. R., Leeth, R. R., Ritchie, G., Vickers, S. M., Hawn, M. T. 2005; 71 (11): 963-969

    Abstract

    Obesity is a rapidly growing epidemic. This study assesses the impact of obesity on surgeon workload for general surgical services. A retrospective study of patients undergoing cholecystectomy, unilateral mastectomy, and colectomy between January 2000 and December 2003 was undertaken. Obesity was defined as body mass index > or = 30. The proportion of obese patients was compared to the 2002 BRFSS obesity prevalence data for Alabama. Data were adjusted to control for potential confounders. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 1,385 patients were included in analysis. The prevalence of obesity in the study population was 35.5 per cent compared to the statewide prevalence of 25.2 per cent (OR = 1.73, 95% CI = 1.51, 1.98). These data were stratified by procedure, age, and gender. The cholecystectomy group had a significantly higher proportion of obese for all age groups and female gender. The mastectomy group had a higher proportion of obese in the 45-64 age group. The stratified colectomy group did not reach statistical significance. There was no evidence of referral bias to explain these findings. This study demonstrates there is a greater use of general surgery services, particularly cholecystectomy and mastectomy, in obese patients than predicted by the prevalence of obesity in the population.

    View details for Web of Science ID 000233398200021

    View details for PubMedID 16372616

  • Colon cancer in pregnancy. Cancer control Minter, A., Malik, R., Ledbetter, L., Winokur, T. S., Hawn, M. T., Saif, M. W. 2005; 12 (3): 196-202

    View details for PubMedID 16062167

  • Impact of obesity on resource utilization for general surgical procedures ANNALS OF SURGERY Hawn, M. T., Bian, J., Leeth, R. R., Ritchie, G., Allen, N., Bland, K. I., Vickers, S. M. 2005; 241 (5): 821-828

    Abstract

    To determine the impact of the obesity epidemic on workload for general surgeons.In 2001, the prevalence of obesity in the United States reached 26%, more than double the rate in 1990. This study focuses on the impact of obesity on surgical practice and resource utilization.A retrospective analysis was done on patients undergoing cholecystectomy, unilateral mastectomy, and colectomy from January 2000 to December 2003 at a tertiary care center. The main outcome variables were operative time (OT), length of stay (LOS), and complications. The key independent variable was body mass index. We analyzed the association of obesity status with OT, LOS, and complications for each surgery, using multivariate regression models controlling for surgeon time-invariant characteristics.There were 623 cholecystectomies, 322 unilateral mastectomies, and 430 colectomies suitable for analysis from 2000 to 2003. Multivariable regression analyses indicated that obese patients had statistically significantly longer OT (P < 0.01) but not longer LOS (P > 0.05) or more complications (P > 0.05). Compared with a normal-weight patient, an obese patient had an additional 5.19 (95% confidence interval [CI], 0.15-10.24), 23.67 (95% CI, 14.38-32.96), and 21.42 (95% CI, 9.54-33.30) minutes of OT with respect to cholecystectomy, unilateral mastectomy, and colectomy. These estimates were robust in sensitivity analyses.Obesity significantly increased OT for each procedure studied. These data have implications for health policy and surgical resource utilization. We suggest that a CPT modifier to appropriately reimburse surgeons caring for obese patients be considered.

    View details for DOI 10.1097/01.sla.0000161044.20857.24

    View details for Web of Science ID 000228681700016

    View details for PubMedID 15849518

  • Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract AMERICAN SURGEON Hawn, M. T., Canon, C. L., Lockhart, M. E., Gonzalez, Q. H., Shore, G., Bondora, A., Vickers, S. M. 2004; 70 (1): 19-23

    Abstract

    Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.

    View details for Web of Science ID 000188597200007

    View details for PubMedID 14964540

  • Duplicate publications in the otolaryngology literature LARYNGOSCOPE Rosenthal, E. L., Masdon, J. L., Buckman, C., Hawn, M. 2003; 113 (5): 772-774

    Abstract

    A duplicate publication duplicates other published work by the same author(s). The purpose of the study was to define the extent of this problem within the otolaryngology literature.Retrospective review of the literature.Original articles published in Archives of Otolaryngology-Head and Neck Surgery and Laryngoscope in 1999 were reviewed using the OVID search engine. Titles and abstracts from English articles written by the same first, second, or last author were analyzed, and suspected publications were evaluated. Duplicate publications were classified as dual (identical data set and conclusions) or suspected dual (nearly identical data set and conclusions) publications.Of the 492 articles evaluated, 40 index articles were identified. These led to a total of 42 (8.5%) duplicate articles of which 27 were classified as dual and 15 as suspected dual publications. Approximately half of the duplicate publications were published by authors in the United States (55%). Duplicate articles usually appeared within 12 months of the each other (74%) and failed to cross-reference the earlier publication (83%).Journal editors have become aware of an increase in the number of duplicate publications in the medical literature. The incidence of duplicate publications in the otolaryngology literature appears to be similar to that in other specialties.

    View details for Web of Science ID 000182729200002

    View details for PubMedID 12792309

  • Gallbladder and biliary tract disease in the intensive care unit. Seminars in gastrointestinal disease Hawn, M. T. 2003; 14 (1): 28-33

    Abstract

    Intensive care unit patients present a difficult challenge in the diagnosis and treatment of complications related to the biliary tract. Altered mental status interferes with the patient's ability to communicate symptoms and give a reliable physical examination. Laboratory data are often nonspecific in diagnosing complications of biliary tract disease because of the high incidence of cholestasis in intensive care unit patients. Likewise, routine radiographic evaluation has a marked decreased sensitivity and specificity in evaluating biliary tract disorders. Taken together, these factors often lead to a delay in diagnosis of biliary tract problems in the intensive care unit patient. Intervention in these patients is associated with high morbidity and mortality when compared to the ambulatory setting. This article reviews the clinical presentation, differential diagnosis, and management options of biliary tract complications in this complex patient population.

    View details for PubMedID 12610852

  • Quality of life after laparoscopic bilateral adrenalectomy for Cushing's disease SURGERY Hawn, M. T., Cook, D., Deveney, C., Sheppard, B. C. 2002; 132 (6): 1064-1068

    Abstract

    Bilateral adrenalectomy to control symptoms of Cushing's disease after failed transsphenoidal operation is effective. We examined surgical outcomes and quality of life after laparoscopic bilateral adrenalectomy for the treatment of Cushing's disease.Eighteen patients underwent laparoscopic bilateral adrenalectomy from November 1994 through December 2000. Patient data were obtained from chart reviews. Patients completed a follow-up survey including the SF-36 health survey (QualityMetric Inc, Lincoln, Neb).Laparoscopic bilateral adrenalectomy was accomplished in all 18 patients. There was 1 intraoperative complication of a colotomy, and 2 postoperative complications including 1 pancreatic pseudocyst and 1 hemorrhage. Three patients died at 12, 19, and 50 months after operation. At a median follow-up of 29 months, patients reported improvement in all Cushing's-related symptoms. Nine of 11 patients who responded to the survey stated their heath was improved after adrenalectomy. Results of the SF-36 health survey showed significantly lower scores in all 8 measured parameters when compared with the general population.Results of laparoscopic bilateral adrenalectomy show this procedure is comparable with open adrenalectomy in controlling symptoms of Cushing's disease. Despite patient reported improvement in health after adrenalectomy, this patient population continues to experience poor health as measured by the SF-36 when compared with the general population.

    View details for DOI 10.1067/msy.2002.128482

    View details for PubMedID 12490856

  • Emergency Department Use After Outpatient Surgery Among Dually Enrolled VA and Medicare Patients. Quality management in health care Mull, H. J., Rosen, A. K., Charns, M. P., OʼBrien, W. J., Hawn, M. T., Itani, K. M., Pizer, S. D. ; 28 (4): 191–99

    Abstract

    Emergency department (ED) use following outpatient surgery may be associated with a surgery-related patient safety problem. We characterized ED use within 7 days of general, urology, orthopedic, ear/nose/throat, and podiatry surgical procedures and assessed factors associated with these visits by specialty.We calculated the 2011-2013 postoperative ED visit rate for Veterans older than 65 years dually enrolled in the Veterans Health Administration (VA) and Medicare, examined diagnoses, and used logistic regression to model patient, procedure, and facility factors associated with ED care.Among 63 279 outpatient surgical procedures, 2778 (4.4%) resulted in an ED visit within 7 days; 23% of these were to non-VA facilities. Rates varied from more than 5% for urology and ear/nose/throat, to less than 3% for orthopedic and podiatry specialties. Genitourinary symptoms and surgical complications were common diagnoses across specialties. No patient, procedure, or facility factors were associated with ED use for every specialty.A small proportion of VA outpatient surgical procedures result in ED use. Notably, nearly one-fourth of the postoperative ED visits may be missed by the VA because they occur in non-VA facilities. ED visits for urinary issues or surgical complications may be preventable; however, factors associated with ED use vary by specialty, suggesting different approaches may be needed to improve outcomes.

    View details for DOI 10.1097/QMH.0000000000000225

    View details for PubMedID 31567842