Yanik J. Bababekov

Race/Ethnicity and Age Distribution of Breast Cancer Diagnosis in the United States

This study assesses the age distribution of breast cancer diagnosis across race/ethnicity in US female patients using the Surveillance, Epidemiology, and End Results Program database.

Fifteen years of adrenalectomies: impact of specialty training and operative volume

Background. Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess the effect of surgeon volume and specialty on clinical outcomes. Methods. Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000–2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in‐hospital mortality, duration of stay, and in‐hospital complications. Results. A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high‐volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High‐volume surgeons had significantly lower mortality compared with low‐volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002). Conclusion. Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high‐volume for the procedure.

Is Annual Volume Enough? The Role of Experience and Specialization on Inpatient Mortality After Hepatectomy

Objective: To investigate the effect of subspecialty practice and experience on the relationship between annual volume and inpatient mortality after hepatic resection. Background: The impact of annual surgical volume on postoperative outcomes has been extensively examined. However, the impact of cumulative surgeon experience and specialty training on this relationship warrants investigation. Methods: The New York Statewide Planning and Research Cooperative System inpatient database was queried for patients’ ≥18 years who underwent wedge hepatectomy or lobectomy from 2000 to 2014. Primary exposures included annual surgeon volume, surgeon experience (early vs late career), and surgical specialization—categorized as general surgery (GS), surgical oncology (SO), and transplant (TS). Primary endpoint was inpatient mortality. Hierarchical logistic regression was performed accounting for correlation at the level of the surgeon and the hospital, and adjusting for patient demographics, comorbidities, presence of cirrhosis, and annual surgical hospital volume. Results: A total of 13,467 cases were analyzed. Overall inpatient mortality was 2.35%. On unadjusted analysis, late career surgeons had a mortality rate of 2.62% versus 1.97% for early career surgeons. GS had a mortality rate of 2.98% compared with 1.68% for SO and 2.67% for TS. Once risk-adjusted, annual volume was associated with reduced mortality only among early-career surgeons (odds ratio 0.82, P = 0.001) and general surgeons (odds ratio 0.65, P = 0.002). No volume effect was seen among late-career or specialty-trained surgeons. Conclusions: Annual volume alone likely contributes only a partial assessment of the volume-outcome relationship. In patients undergoing hepatic resection, increased annual volume did not confer a mortality benefit on subspecialty surgeons or late career surgeons.

Distance is associated with mortality on the waitlist in pediatric liver transplantation

The distance to liver transplant centers affects outcomes in adult liver transplantation. Because pediatric patients are particularly vulnerable, we hypothesized that distance adversely affects the time to transplantation and waitlist mortality. The SRTR was queried for isolated pediatric liver transplant registrants (under age 18) with valid ZIP code information from 2003 to 2012. Distance was measured from home ZIP code to listing transplant center. Competing events analysis, adjusted for demographic factors, indication, and PELD, was undertaken for transplantation and death while on the waitlist. The median distance to listing transplant center for 6924 children was 65 (IQR 17.5‐189) miles. Median distance traveled increased by listing volume (73.9 vs 33.8 miles, highest vs lowest volume quartile, P<.001 for trend) and varied across the country. Longer distance was not associated with time to transplantation (HR 0.99, longest vs shortest distance quartile, P=.80), but was associated with increased mortality (HR 1.75, P<.001). Larger centers attract patients from a distance, while smaller centers serve local populations. Increasing distance is associated with a higher risk of waitlist death, which may reflect decreased access to specialist and tertiary care associated with a transplant center.

Pediatric kidney transplantation and mortality: Distance to transplant center matters

Distance from pediatric kidney transplant centers may be a significant barrier in accessing care for patients and families, particularly due to the lower number of pediatric kidney transplant centers compared with the number of adult centers. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients to determine the effect of distance on pediatric kidney transplant waitlist outcomes. We found that distance did not play a role in the likelihood of transplantations for patients who were placed on the waitlist. However, living a greater distance from the transplant center was associated with a greater risk of death while on the waitlist. Larger volume centers attracted patients from greater distances, many of whom had other centers closer to their home. Further investigation on the role of distance to transplant center and the likelihood of being evaluated and listed for a kidney transplant would elucidate whether there are additional barriers these patients face.

Is liver transplant education patient‐centered?

In 2015, the scarcity of donor organs meant that liver transplantation was a lifesaving therapy for only 7127 of the 14,046 patients with end-stage liver disease (ESLD) on the waiting list. The Centers for Medicaid and Medicare Services certifies transplant centers based in part on their provision of patient education as part of the informed consent process. Liver transplant recipients must understand complex medical information to care for themselves and their grafts. Poor comprehension is associated with involuntary nonadherence, which accounts for up to 50% of late acute rejection episodes, 15% of graft losses, and increased risk of death in solid organ transplant recipients. Patients’ understanding of information is hampered if transplant education material is not tailored to the patients’ literacy level, defined as the “degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” We hypothesize that current liver transplant education may not be patient-centered because it does not address the literacy needs of patients or their caregivers. The Rapid Estimate of Adult Literacy in Medicine–Transplantation (REALM-T) is a word recognition test validated to assess reading ability and comprehension in renal transplant recipients. We adapted the REALM-T to include liver-specific terms to form the Rapid Estimate of Adult Literacy in Medicine–Liver (REALM-Liver). Content validity of the REALM-Liver was reviewed by transplant surgeons, physicians, researchers, and coordinators. We administered the REALM-Liver from 2013 to 2014 to 52 liver transplant candidates and 48 caregivers before and after routine transplant education during the evaluation process at a single center in United Network for Organ Sharing region 1 (please see Supporting Information for educational materials). The REALM-Liver assessments were administered over the course of 1 clinic day during which patients and caregivers present for transplant evaluation. We used dictionary pronunciation as the scoring standard (please see Supporting Information for the REALM-Liver). The mean age of all participants was 57.06 13.0 years, and only 65.0% reported an education level of high school or higher. Of the patients, 79.6% were male, whereas only 19.6% of caregivers were male (P< 0.001). There was no significant difference between the educational attainment of caregivers and patients. Of caregivers, 58.3% self-identified as a significant other/spouse. The patients’ median Model for End-Stage Liver Disease score at the time of testing was 15 (interquartile range, 7; range, 6-28). Alcohol and/or hepatitis C virus represented 58.0% of the primary diagnoses. A Student t test was used to assess the difference between REALM-Liver scores across patient and caregiver groups. A paired Student t test was performed to assess the paired difference between

Training for our digital future: a human-centered design approach to graduate medical education for aspiring clinician-innovators

In the current era of value-based healthcare with increasing emphasis on delivering higher quality care at lower costs, US healthcare innovation as a metric is at a premium. However, an implementation gap exists between technology-enabled innovations and patient-centered care secondary to a lack of formal training rooted in implementation science, healthcare operations, and clinical informatics for healthcare providers. We illustrate the application of human-centered design principles with focus on medical trainees as the end-user in a unique approach to developing clinician-innovators best suited to bridge the implementation gap.

How Much Data are Good Enough? Using Simulation to Determine the Reliability of Estimating POMR for Resource-Constrained Settings

AbstractIntroductionPerioperative mortality rate (POMR) is a suggested indicator for surgical quality worldwide. Currently, POMR is often sampled by convenience; a data-driven approach for calculating sample size has not previously been attempted. We proposed a novel application of a bootstrapping sampling technique to estimate how much data are needed to be collected to reasonably estimate POMR in low-resource countries where 100% data capture is not possible. Material and methodsSix common procedures in low- and middle-income countries were analysed by using population database in New York and California. Relative margin of error by dividing the absolute margin of error by the true population rate was calculated. Target margin of error was ±50%, because this level of precision would allow us to detect a moderate-to-large effect size.Results and discussionTarget margin of error was achieved at 0.3% sampling size for abdominal surgery, 7% for fracture, 10% for craniotomy, 16% for pneumonectomy, 26% for hysterectomy and 60% for C-section. POMR may be estimated with fairly good reliability with small data sampling. This method demonstrates that it is possible to use a data-driven approach to determine the necessary sampling size to accurately collect POMR worldwide.

Is it time to reconsider the Milan Criteria for selecting patients with hepatocellular carcinoma for deceased‐donor liver transplantation?

Liver transplantation (LT) is considered the optimal treatment for hepatocellular carcinoma (HCC) because it removes tumor as well as the underlying cirrhotic liver. Because of a global organ shortage, LT for patients with HCC is limited to patients with expected survival comparable to that of nonmalignant indications. Therefore, identifying patients with lower rates of HCC recurrence and higher rates of survival is critical. International guidelines have considered the Milan Criteria (MC) the standard for selecting patients with HCC for deceased‐donor LT (DDLT). However, several alternative criteria have been reported in the Western world. Interestingly, the two most recent models combining α‐fetoprotein level, number of nodules, and size of the largest nodule have been shown to outperform MC in identifying patients with low risk of HCC recurrence or those who will survive for 5 years after liver transplantation. In addition, new models overcome limitations of MC in improving classification of high‐ versus low‐risk patients with HCC for DDLT. These recent scoring systems also provide clinicians with user‐friendly tools to better identify patients at lower risk of recurrence. Conclusion: Although most Western countries still select patients based on MC, there is a mounting change in recent practice patterns regarding the selection of patients with HCC for DDLT. Herein, we describe how alternative criteria should lead to reconsideration of MC as it applies to selecting patients with HCC for DDLT in international guidelines.

Potential impact of a volume pledge on spatial access: A population-level analysis of patients undergoing pancreatectomy

Background. A minimum‐volume policy restricting hospitals not meeting the threshold from performing complex operation may increase travel burden and decrease spatial access to operation. We aim to identify vulnerable populations that would be sensitive to an added travel burden. Methods. We performed a retrospective analysis of the database of the California Office of Statewide Health Planning and Development for patients undergoing pancreatectomy from 2005 to 2014. Number of hospitals bypassed was used as a metric for travel. Patients bypassing fewer hospitals were deemed to be more sensitive to an added travel burden. Results. There were 13,374 patients who underwent a pancreatectomy, of whom 2,368 (17.7%) were nonbypassers. On unadjusted analysis, patients >80 year old travelled less than their younger counterparts, bypassing a mean of 10.9 ± 9.5 hospitals compared with 14.2 ± 21.3 hospitals bypassed by the 35–49 year old age group (P < .001). Racial minorities travelled less when compared with non‐Hispanic whites (P < .001). Patients identifying their payer status as self‐pay (8.9 ± 15.6 hospitals bypassed) and Medicaid (10.1 ± 17.2 hospitals bypassed) also travelled less when compared with patients with private insurance (13.8 ± 20.4 hospitals bypassed, P < .001). On multivariate analysis, advanced age, racial minority, and patients with self‐pay or Medicaid payer status were associated independently with increased sensitivity to an added travel burden. Conclusion. In patients undergoing pancreatectomy, the elderly, racial minorities, and patients with self‐pay or Medicaid payer status were associated with an increased sensitivity to an added travel burden. This vulnerable cohort may be affected disproportionately by a minimum‐volume policy.