Caprice K. Christian

A Multi-Institutional Analysis of the Socioeconomic Determinants of Breast Reconstruction: A Study of the National Comprehensive Cancer Network

Objective:To determine the rate of postmastectomy reconstruction and investigate the impact of socioeconomic status on the receipt of reconstruction. Summary Background Data:The National Comprehensive Cancer Network (NCCN) Outcomes Project is a prospective, multi-institutional database that contains data on all newly diagnosed breast cancer patients treated at one of the participating comprehensive cancer centers. Methods:The study cohort consisted of 2174 patients with DCIS and stage I, II, and III invasive breast cancer who underwent mastectomy at one of 8 NCCN centers. Rates of reconstruction were determined. Logistic regression analyses were used to evaluate whether socioeconomic characteristics are associated with breast reconstruction. Results:Overall, 42% of patients had breast reconstruction following mastectomy. Patients with Medicaid and Medicare were less likely to undergo reconstruction than those with managed care insurance; however, there was no difference for indemnity versus managed care insurance. Homemakers and retired patients had fewer reconstructions than those employed outside the home. Patients with a high school education or less were less likely to have reconstruction than those with more education. Race and ethnicity were not significant predictors of reconstruction. Conclusions:The reconstruction rate in this study (42%) is markedly higher than those previously reported. The type of insurance, education level, and employment status of a patient, but not her race or ethnicity, appear to influence the use of breast reconstruction. Because all patients were treated at an NCCN institution, these socioeconomic differences cannot be explained by access to care.

The Leapfrog Volume Criteria May Fall Short in Identifying High-Quality Surgical Centers

Objective: The original Leapfrog Initiative recommends selective referral based on procedural volume thresholds (500 coronary artery bypass graft [CABG] surgeries, 30 abdominal aortic aneurysm [AAA] repairs, 100 carotid endarterectomies [CEA], and 7 esophagectomies annually). We tested the volume-mortality relationship for these procedures in the University HealthSystem Consortium (UHC) Clinical DatabaseSM, a database of all payor discharge abstracts from UHC academic medical center members and affiliates. We determined whether the Leapfrog thresholds represent the optimal cutoffs to discriminate between high- and low-mortality hospitals. Methods: Logistic regression was used to test whether volume was a significant predictor of mortality. Volume was analyzed in 3 different ways: as a continuous variable, a dichotomous variable (above and below the Leapfrog threshold), and a categorical variable. We examined all possible thresholds for volume and observed the optimal thresholds at which the odds ratio is the highest, representing the greatest difference in odds of death between the 2 groups of hospitals. Results: In multivariate analysis, a relationship between volume and mortality exists for AAA in all 3 models. For CABG, there is a strong relationship when volume is tested as a dichotomous or categorical variable. For CEA and esophagectomy, we were unable to identify a consistent relationship between volume and outcome. We identified empirical thresholds of 250 CABG, 15 AAA, and 22 esophagectomies, but were unable to find a meaningful threshold for CEA. Conclusions: In this group of academic medical centers and their affiliated hospitals, we demonstrated a significant relationship between volume and mortality for CABG and AAA but not for CEA and esophagectomy, based on the Leapfrog thresholds. We described a new methodology to identify optimal data-based volume thresholds that may serve as a more rational basis for selective referral.

Risk Factors for Perineal Wound Complications Following Abdominoperineal Resection

PURPOSEPerineal wound complications are common following abdominoperineal resection. This study investigates the factors contributing to these complications.METHODSPatients undergoing abdominoperineal resection at our institution from June 1997 to May 2003 were reviewed. Significant predictors associated with minor (separation <2 cm, stitch abscesses, or sinus tracts) or major (>2 cm of separation, reoperation required, or readmission) wound complications were ascertained.RESULTSOf 153 patients, there were 22 major (14 percent) and 32 minor (24 percent) wound complications. Patients with anal cancer had a higher rate of major complications than those with rectal cancer or inflammatory bowel disease. Minor wound complications were more common in patients with anal cancer and inflammatory bowel disease than those with rectal cancer. Factors associated with a higher rate of major wound complications included flap closure, tumor size, body mass index, diabetes, and indication for the procedure. When the subset of patients with rectal cancer was considered, higher rates of major wounds were associated with increased body mass index, diabetes, and stage. Minor complications were associated with a two-team approach and increasing body mass index.CONCLUSIONSThis is currently the largest review of perineal wound complications following abdominoperineal resection. Patients with anal cancer and inflammatory bowel disease were at higher risk for perineal wound complications than those with rectal cancer. Preoperative radiation and primary closure were not associated with increased complications following abdominoperineal resection for rectal cancer.

The Volume–Outcome Relationship: Don’t Believe Everything You See

This paper investigates methodological limitations of the volume–outcome relationship. A brief overview of quality measurement is followed by a discussion of two important aspects of the relationship.

Using field observations as a tool for discovery: analys ing cognitive and collaborative demands in the operating room

Field observation studies can be an important tool during the discovery phase of the scientific process. They enable observers to identify and document patterns of interaction among practitioners, complications that arise and adaptive strategies developed in response to the exigencies of the work environment. We conducted an observational study that examined operating room (OR) team performance during ten lengthy and complex surgical procedures. The study allowed us to identify latent factors that complicate the cognitive and collaborative performance of OR teams and can contribute to adverse events, and the strategies that medical practitioners have developed to coordinate performance and to minimis e the potential for adverse events. The paper describes the methodology employed, presents illustrative results and discusses issues unique to the design and analysis of observational studies. While video recordings were not used in this study, the data analysis method and results are illustrative of exploratory data analysis approaches that lend themselves to video analysis.

Healthcare safety: the impact of Disabling "safety" protocols

With increasing attention to patient safety, hospitals and other clinical facilities are developing practice guidelines and protocols with the specific intent of reducing harm to patients. However, the introduction of these protocols can have unanticipated negative consequences and if followed rigidly can become disabling. We use the manual count procedure that was designed to improve patient safety by reducing the likelihood of leaving an object (e.g., needle, sponge, or instrument) inside a patient body cavity during a surgical procedure to illustrate this point. Using results from a focus group of seven operating room nurses and an observational study of nine complex operations, we show that the count protocol has unanticipated negative consequences that need to be considered in evaluating the net positive gain in patient safety. The study highlights the importance of evaluating the overall impact of proposed protocols in assessing its potential benefits to patient safety.

Erratum: The volume-outcome relationship: Don't believe everything you see (World Journal of Surgery (October 2005) 29, 10, (1243) DOI: 10.1007/s00268-005-7993-8)

This paper investigates methodological limitations of the volume-outcome relationship. A brief overview of quality measurement is followed by a discussion of two important aspects of the relationship.

Healthcare Safety: The Impact of Disabling ‘Safety’ Protocols

With increasing attention to patient safety, hospitals and other clinical facilities are developing practice guidelines and protocols with the specific intent of reducing harm to patients. However, the introduction of these protocols can have unanticipated negative consequences and if followed rigidly can become ‘disabling’. We use the manual count procedure that was designed to improve patient safety by reducing the likelihood of leaving an object (e.g., needle, sponge or instrument) inside a patient body cavity during a surgical procedure to illustrate this point. Using results from an observational study of nine complex operations we show that the count protocol can have unanticipated negative consequences that need to be considered in evaluating the net positive gain in patient safety. The study highlights the importance of evaluating the overall impact of proposed protocols when assessing their potential benefits to patient safety.