17.07 Morbidity and Mortality from Traumatic Brain Injury in Older Adults, 2000-2011

Posted on December 22, 2014

R. Haring1,2,3, K. Narang1, J. K. Canner1, A. O. Asemota1,4, B. P. George1,5, S. Selvarajah1, A. H. Haider1,3, E. B. Schneider1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Lake Erie College Of Osteopathic Medicine,Bradenton, FL, USA 3Johns Hopkins University Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Department Of Neurology And Neurosurgery,Baltimore, MD, USA 5University Of Rochester School Of Medicine And Dentistry,Rochester, NY, USA

Introduction:  The increase in TBI-related morbidity and mortality have led the CDC to call it “the silent epidemic.” Adults age 65+ are more prone to falls and other mechanisms of injury, and may thus be at a higher risk of TBI-related morbidity and mortality. This study seeks to identify factors contributing to TBI and related mortality among the elderly.

Methods:  We analyzed data from the Nationwide Inpatient Sample, and included records that described hospitalizations occurring among individuals age 65 and older from 2000-2010 and contained data on patient age, sex, mechanism of injury, payer status, as well as descriptive data relating to the hospital involved.  A subset of patients was compiled whose records also contained race information. Logistic regression analyses were conducted to produce both crude and adjusted odds ratios (OR) of death. Population-based TBI incidence and mortality rates were calculated.

Results: A total of 950,132 hospitalizations were identified that met inclusion criteria. TBI incidence increased both with time and patient age. Falls were by far the most common mechanism of injury, leading to 65.3% of hospitalizations. Multivariable logistic regression models showed that female sex and younger age, as well as having Medicare or Medicaid vs. private insurance/HMO, self-pay, or no-charge designations as primary payer, were all associated with lower odds of death. Self-pay status was associated with 91% greater odds of in-hospital mortality; however, female sex was associated with 33% lower odds of mortality compared with males. Population-based rates of admission increased 105.8% from 2000-2010; the TBI-associated population-level mortality rate, however, increased by only 33.7% over the same period, while injury severity remained stable.

Conclusion: The trends in TBI-related hospitalization from 2000-2010 suggest that while TBI incidence is climbing, the odds of death after admission for TBI are falling. Further interventions, possibly to include government and institutional policy aimed at fall prevention and insurance coverage, may further reduce morbidity and mortality associated with TBI among older adults.

 

17.08 National Trends in the Elderly (65-84) and the Supra-Elderly (>85) Trauma: 1997-2012

Posted on December 22, 2014

L. Podolsky2, V. Polcz1,2, O. Sizar1, A. Farooq1,2, M. Bukur1, I. Puente1, R. Farrington1, M. Polcz2, C. Orbay2, F. Habib1  1Broward Health Medical Center,Trauma,Ft Lauderdale, FL, USA 2Florida International University,Surgery,Miami, FL, USA

Introduction:
Trends in incidence and outcomes of traumatic injury among the elderly (age 65-84) and the supra-elderly (age > 85) are unknown. This information has the potential to offer insight into informed trauma system planning and improve outcomes in this highly vulnerable population. 

Methods:
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with ICD codes for a traumatic injury. Data, stratified by age group was then abstracted for incidence, lengths of stay, charges, mortality and discharge status for patients for the period 1997-2012. The study period was divided into four periods of 4-years each. Statistical analysis was performed using the ANOVA, t test, and chi square test as appropriate. A p value of <0.05 was used to determine significance. 

Results:

Over the 16-year study period, traumatic events in the elderly have increased by 6.8% (p=0.0005) and by 29% in the supra elderly (p<0.001). In contrast, admissions for injury decreased in both adults and children (6%, and 29.5% respectively, p=0.0005). A decrease in length of stay was seen with decrease from 6.0 to 5.2 days (p<0.0001) in the elderly and 6.2 to 5.0 days (p<0.0001) in the supra-elderly. Length of stay for adults on the other hand has increased from 4.83 to 5.1 (p=0.06). Pediatric patient in-hospital mortality has decreased significantly (p=0.001) with concurrent increases in discharge to home (p=0.003). Adult in-hospital mortality rates and discharges home have remained stable (p=0.83, p=0.24 respectively). Elderly patients have shown stable in-hospital mortality rates (p=0.149) with decreased discharges home (p=0.0003). The supra-elderly have shown the worst trend in outcomes, with significant increases in in-hospital mortality (p=0.0003) and significantly fewer patients being discharged home (p=0.0004). Costs have risen for patients of all age groups over the study period (p<0.0001). 

Conclusion:

Geriatric trauma is rising at an exponential rate, with the elderly and supra-elderly patients forming an increasing proportion of the trauma population. These elderly and supra-elderly patients have been shown to have poorer outcomes, as demonstrated by in-hospital mortality and discharge status. Geriatric specific trauma programs are urgently needed to address this evolving epidemic. 

17.09 Towards a Single-Payer System in Trauma: More Than Halfway There Already.

Posted on December 22, 2014

V. Polcz1, L. Podolsky1,2, m. bukur1, M. Polcz2, c. orbay2, I. Puente1, r. Farrington1, o. sizar1, a. Farooq1, F. Habib1,2  1Broward Health Medical Center,Trauma,Ft Lauderdale, FL, USA 2Florida International University,Surgery,Miami, FL, USA

Introduction:
Delivery of trauma care is financially challenging. Financial viability is largely dependent on the payer mix, which changes over time. We therefore sought to determine the changing payer mix for the period of 1997-2012. This information has the potential to offer insight into informed trauma system planning, and may improve outcomes and quality of care for patients regardless of payer status.

Methods:
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify payer status for total trauma admissions from 1997-2012. Data, stratified by payer status, was then abstracted for incidence, lengths of stay, charges, mortality and discharge status for patients within this period. The study period was divided into quartiles of 4 years each. Statistical analysis was performed using the ANOVA, and a p value of <0.05 was used to determine significance. 

Results:
Over the 16-year study period, trauma admissions for patients with government-funded payer status have increased significantly over the time period assessed, with both Medicare (p<0.0001) and Medicaid (p<0.0001) showing a significant increase as a proportion of the total patient population. Admissions of patients to trauma with private insurance status, in contrast, have shown a significant decrease in proportion of the total patient population over the time period studied (p=0.002). Patients with no insurance (p=0.921) or other payer status (p=0.406) were observed to have no significant change in proportion of trauma patient population from 1997-2012. The results of this analysis are summarized in Table 1.

Conclusion:
Government-funded trauma care is rising at a significant rate, with Medicare and Medicaid-funded patients forming an increasing proportion of the trauma population. Funding from private insurers continues to decline, and the uninsured continue to impose a constant financial burden on trauma centers nationwide. 

17.10 Uncompensated “Charity” Care in the Context of Trauma Center Designation

Posted on December 22, 2014

O. Mansuri1, C. Steffen1, L. Nelson1, C. Gonzalez2, B. England1, C. Boje1, K. Fenn1, E. Myers1, J. Stothert1  1University Of Nebraska Medical Center,Trauma & Surgical Critical Care / Department Of Surgery,Omaha, NE, USA 2Boston Medical Center,Boston, MA, USA

Introduction:
This study investigates in a hybrid qualitative/quantiative approach how state designation of trauma centers impacts general finances, uncompensated “charity” care and community investment. This is significant given many states are reassessing the definition of charity care in the context of how not-for-profit hospitals are evaluated, and the financial implications thereof.

Methods:
The Return of Organization Exempt From Income Tax (IRS Form 990) for state designated level 2 and level 3 trauma centers in Nebraska were reviewed for a three year period. Number of state licensed hospital beds was also gathered for each trauma center. IRS 990 forms were reviewed for number of employees, volunteers, revenue, assets, charity care, community benefits, bad debt, and Medicare surplus and shortfall. This data was then first analyzed in a descriptive fashion, followed by regression analysis. The relative financial metrics were controlled by hospital bed size.

Results:
When comparing level 2 and level 3 general financial variables, total revenue variance was 7.8%, salaries 2.9%, total expenses 6.0%, total assets 3.9%, total liabilities 17.2%, and net assets 3.4%.  These variances were nominal when compared to the variances seen in level 2 and level 3 charity care variables: charity care cost 43.3%, un-reimbursed Medicaid 37.9%, community health improvement 36.6%, health professions education 64.7%, cash-in-kind 82.6%, bad debt expense 6.2%, and Medicare shortfall 28%.  Level 2 centers reported higher amounts spent on charity care, un-reimbursed Medicaid, health professions education, cash-in-kind contributions, and had larger Medicare shortfalls.

Conclusion:
This preliminary hybrid qualitative/quantitative pilot study into the charity care of trauma centers demonstrates that level of trauma center influences uncompensated “charity” care financial variables when taking into account size and general financial variables.  This raises important considerations for level 1 trauma center funding mechanisms.  A broader study of national trauma centers with increased focus on uncompensated care financial variables is in planning to better understand the role and impact of trauma centers on charity care.
 

17.11 Using Research Electronic Data Capture to Simplify Institutional Research Efforts

Posted on December 22, 2014

A. H. Healy1, K. A. Frappier1, J. L. Madden1, A. Elmer1, S. H. McKellar1, C. H. Selzman1  1University Of Utah,Salt Lake City, UT, USA

Introduction:  Many institutions submit patient data to national registries while simultaneously maintaining their own institutional databases, creating substantial duplication of effort. Research Electronic Data Capture (REDCap) is a free technology available to academic centers in the United States to help in the storage and management of research data sets. REDCap can be customized to facilitate importation of data from various sources. We report the use of REDCap to create a comprehensive institutional data set created from submissions to a national registry.

Methods:  Institutional data for patients with left ventricular assist devices (LVADs) was regularly submitted to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) beginning in 2006. Using INTERMACS entry forms as a template, corresponding REDCap forms were created. Care was taken to match REDCap variable names to those used in INTERMACs. An institutional request for INTERMACs data was then made. This data was then uploaded to REDCap, populating the previously created forms with retrospective data. 

Results: The data upload from INTERMACS to REDCap was successful in 90 LVAD patients comprising data from an eight-year period, creating a data set that was identical to the data in the national database without duplication of effort. With the REDCap forms created and populated, it was also confirmed that this information could be regularly updated through serial data requests. This data could then be combined with other patient-based REDCap forms that store data not collected by INTERMACS, such as the results of tissue-based biologic studies performed at an institutional level. REDCap data exports, which can be easily deidentified to maintain patient confidentiality, can be customized depending on the topic of interest.

Conclusion: REDCap is a user-friendly research data management tool that can be used to store data submitted to national registries through data importation to forms identical to those used in the national registry. Periodic updates to the REDCap database can be easily made by requesting institutional data from the national registry, eliminating duplication of effort in maintaining institutional databases and data transcription errors, such as keystroke errors. Though this method is vulnerable to changes in forms at the national registry level, it makes large sets of institutional data quickly available to facilitate institutional research projects.

 

17.12 Surgeons’ Perspective of a Newly Implemented Electronic Medical Record

Posted on December 22, 2014

R. C. Frazee1, H. T. Papaconstaninou1, R. C. Frazee1  1Baylor Scott & White Healthcare,Department Of Surgery,Temple, TEXAS, USA

Introduction:   The American Recovery and Reinvestment Act mandates “meaningful use” of an electronic medical record (EMR) to receive current financial incentives and to avoid future financial penalties.  Surgeons’ ongoing adoption of an EMR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records.  In February 2014, our institution adopted EPIC™ as our primary mode of patient documentation and order entry.  We queried surgeons at our institution regarding their perception of the EMR at 3 months after institutional implementation.

 

Methods:   A written survey was obtained from senior staff and residents of a multispecialty department of surgery.  Surgeons were asked to respond on a Likert Scale ranging from 1-strongly disagree to 5-strongly agree.

 

Results:  Fifty-nine surveys were obtained from 24 senior staff and 35 residents with average scores to each inquiry below:

 

 

 

Conclusion:  Surgeons’ perspective of the EMR in their early experience is that it is more effective providing billing documentation than clinical documentation.  There is concern regarding the impact of the EMR on patient satisfaction.  In spite of these drawbacks, the surgeons were satisfied with EPIC™ as the choice of EMR.

 

17.13 LACE Index Fails to Predict Readmissions in General Surgery

Posted on December 22, 2014

A. Gbegnon1, J. G. Armstrong1, J. Monestina1, J. W. Cromwell1  1University Of Iowa,General Surgery,Iowa City, IA, USA

Introduction: Hospital readmissions are costly and rates of these are increasingly being used as measures of quality.  Several predictive models have been developed to aid in the identification of patients at high risk of readmission so that valuable readmission-prevention resources may be appropriately assigned.  The LACE index (LI) has become the most widely used of these tools because of its ease-of-implementation using electronic health record data, even being embedded into some EHR systems.  A LI of 10 or higher is frequently used to identify patients at high risk of readmission.  The LI was developed primarily on non-surgical patients and has not been validated in the surgical populations to which it is now being applied.  Poor discrimination of readmission risk in this population would likely result in under-resourcing of this group of patients.  Our goal is to evaluate the performance of the LI on encounters of general surgery patients in our hospital.

Methods: We performed a retrospective analysis of patients who underwent a general surgery operation between January 2011 and March 2014, and whose readmission data was submitted to the National Surgical Quality Improvement Program (NSQIP).  The primary outcome measure was unplanned, related readmissions within 30 days of operation. Exclusion criteria included patients who did not have a LI, who died within 30 days of their operation, and patients who had not been discharged within 30 days of their operation.  To examine LI discrimination we generated a receiver operative characteristic (ROC) curve, and calculated the area under the curve (AUC). The LI was calculated by the method of van Walraven et al. from discrete elements within the EHR.

Results: There were 219 patient encounters that met inclusion criteria.  The overall readmission rate in the study population was 12.8%.  The readmission rate for encounters with a LI=<9 was 13.6%, while the readmission rate for LI >=10 was 9.5%. The positive predictive value using this threshold was 0.14.  The AUC (c-statistic) for the LI was 0.51, indicative of poor discrimination.

Conclusion: This study is the first to attempt to validate the LI for identifying patients at high risk of readmission in a general surgery population.  The LI exhibited poor positive predictive value and discrimination approaching that of random guesses in this population.  With the LI being widely applied to hospital populations for the purpose of identifying patients in need of readmission prevention resources, general surgery patients may be under-resourced where this index is being used.  Surgeons and hospitals should be aware of the limitations of the LI and seek other strategies for identifying surgical patients at high risk of readmission.

 

17.14 An Emerging Public Health Concern: Dialysis Patients Returning to the OR After Common Procedures

Posted on December 22, 2014

K. Brakoniecki1, S. Tam1, P. Chung2, A. Alfonso2, G. Sugiyama2  1SUNY Downstate College Of Medicine,Brooklyn, NY, USA 2SUNY Downstate Medical Center,Surgery,Brooklyn, NY, USA

Introduction:
Improvements in care of patients with end-stage renal disease (ESRD) have resulted in decreased mortality rates since 2001.  A greater number of those on dialysis are living longer and undergo common general surgery procedures. The few studies which have investigated surgical outcomes in patients with ESRD have shown rates of return to the operating room (OR) nearly 3 times of those not on dialysis.  Subsequently returning to the OR is associated with postoperative mortality and morbidity. Our objective was to assess the morbidity and mortality of patients with ESRD undergoing the most common general surgery procedures, and determine the risk factors for returning to the OR.

Methods:
Data was extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients that underwent appendectomy, cholecystectomy, ventral hernia repair, and colectomy from 2005-2010 were selected by CPT codes and then separated based on dialysis status. Matched cohorts based on age, gender and procedure type, were created randomly using SPSS. Multivariate logistic regression was used to analyze the effect of dialysis on mortality, morbidity, and returning to the OR. The dialysis group was further stratified into “return to OR” and “no return to OR”, and compared in terms of pre-operative and surgical profiles. Multivariate logistic regression analysis was performed to analyze the effect of returning to the OR on postoperative mortality and morbidity in dialysis patients.

Results:
A total of 195,585 patients underwent the described procedures, of which 1,163 dialysis patients were identified, and matched with non-dialysis patients.  Dialysis was associated with a higher risk of returning to the OR, (odds ratio [OdR] 2.97 [1.99-4.46]), mortality (OdR 9.05 [4.09-20.00]), and morbidity (OdR 1.66 [1.29-2.13]). Of the dialysis patients, 94 (8%) returned to the OR, and return to the OR was associated with increased mortality (OdR 4.35 [2.11-8.99]) and morbidity (OdR 7.62 [4.68-12.41]). Those with post-operative infection complication were over 8 times (OdR 8.23 [4.92-13.75]) more likely to return to the OR.

Conclusion:
Using the ACS-NSQIP database we describe increased rates of return to the OR in dialysis patients, for the most common general surgery procedures. Furthermore, within this population, returning to the OR is associated with significantly increased morbidity and mortality. Surgeons should be aware of the risk of returning to the OR, and subsequently the high risk of mortality and morbidity in dialysis patients. Further study is needed to elucidate preventable risk factors to protect patients from this emerging public health issue.
 

17.15 Developing a Tiered Method to Link Health Information Technology Attributes with Patient Outcomes

Posted on December 22, 2014

M. A. Zapf1, A. Kothari1, P. Kuo1, G. Gupta1, P. Wai1, J. Driver1, T. Markossian2  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Public Health Sciences,Maywood, IL, USA

Introduction: Linkage of large administrative datasets containing information at the hospital and patient levels offers the opportunity to conduct timely research on the impact of organizational characteristics including health information technology (HIT) on surgical outcomes. We aimed to develop a methodology to create a tiered dataset to study the impact of HIT on surgical outcomes.

Methods: One patient-level dataset was linked with two hospital-level datasets for the years 2007-2009. These were: 1) the Healthcare Cost and Utilization Project – State Inpatient Database (HCUP-SID) from Florida containing patient-level hospitalizations including surgical outcomes, 2) the Dorenfest Institute for Health Information Technology (HIMSS) database that contains data about hospitals’ HIT adoption and use, and 3) the American Hospital Association (AHA) Annual Survey which contains detailed hospital information. The goal was to maximize the number of hospitalizations in HCUP-SID having hospital IT information. Hospital unique identifiers were used to link the HCUP-SID to the AHA database. The AHA database was linked to the HIMSS data via hospital Medicare number. After primary linkage, manual matching with ZIP code and hospital name increased the number of hospitalizations in HCUP by including observations that did not initially match with the HIMSS.

Results:Hospitalizations were generated from 247 (2007) and 246 (2009) hospitals in the HCUP-SID. Exactly 196 (79.3%, 2007) and 206 (83.7%, 2009) hospitals were directly matched. After manual matching, the numbers increased to 211 (85.4%, 2007) and 220 hospitals (89.4%, 2009). In the final dataset, hospital-level IT characteristics from 2,486,167 of 2,563,383 (97.0%) and 2,502,342 of 2,606,165 (96.0%) hospitalizations were identified. Of these, manual merging was responsible for linking 36,880 (1.5%, 2007) and 33,282 observations (1.3%, 2009). Manually merged hospitals had a smaller number of hospitalizations per hospital compared to directly matched (2,459 v 12,890 in 2007 & 2,377 v 11,985 in 2009, both p<0.05). In the final database, the number of common general surgery operations (appendectomy, hemorrhoidectomy, cholecystectomy, inguinal hernia, and thyroidectomy) tallied 64,213 and 65,942, while complex operations (colorectal resection, gastrectomy, esophagectomy, and kidney/liver transplant) were 25,812 and 25,917 in 2007 and 2009. In total, the linked databases contain over 100 patient-level variables and 1,288 possibly clinically associated hospital-level characteristics.

Conclusion:We demonstrated the feasibility of creating a tiered database using the HCUP-SID, HIMSS, and AHA Annual Survey datasets with a high match rate and minimal lost patient encounters. Manual merging was essential for capturing lower volume hospitals. Using the same approach, additional datasets at the hospital or area levels could be appended to our dataset with the goal of expanding our analytical scope.

17.16 Feasibility of a Symptom Tracking Smartphone Application

Posted on December 22, 2014

A. R. Scott1,2, G. K. Low1, A. D. Naik1,2, D. H. Berger1,2, J. W. Suliburk1  1Baylor College Of Medicine,Houston, TX, USA 2VA Center For Innovations In Quality, Effectiveness And Safety,Houston, TX, USA

Introduction:
Limited communication and care coordination following discharge may contribute to surgical complications. Smartphone applications (“apps”) offer a new mechanism for communicating with patients and directing their care. It is unclear, however, whether or not patients are willing and able to use apps as part of their surgical care. To better understand patient factors which could prevent app use in a surgical setting, we performed a feasibility study on an app designed to facilitate self-care following colorectal surgery.

Methods:
This was a prospective mixed-methods feasibility study performed at an urban public safety net hospital. Following colorectal surgery, patients were approached for enrollment and offered a smartphone app which uses previously validated content to provide recommendations based on symptoms. Patients were asked to use the app daily for 14 days after discharge. Demographics and usability data were collected at enrollment. The System Usability Scale (SUS) was used to measure usability. The SUS was repeated at follow up and then we performed a structured interview covering domains such as ease of use, willingness to use, and utility of use. Chart and app log review identified phone calls and ER visits related to surgery.

Results:
We screened 75 patients, enrolled 14 (19%), and completed follow up interviews with 10 (13%). Reasons for non-enrollment included: lack of a suitable device (16 patients, 21%), willingness to participate (14, 19%), language barriers (12, 16%), inclusion criteria (11, 15%), and other reasons (8, 11%). The unplanned ER visit rate was 43% (6/14), with a 14% (2/14) readmission rate. The app addressed 67% (4/6) of the presenting complaints in the ER, but no patients reported those complaints in the app. The app was used once or not at all by 4/14 patients (29%); the remaining 10 (71%) used it a median of 7 times (6-13). SUS scores were >90th percentile at first use (raw score 94, IQR 86-96) and follow up (88, 83-95). Four patients who were interviewed (40%) reported daily app use. Feeling ill was the most common (3/6, 50%) reason for less frequent use. All 10 patients interviewed reported being able to fill out the app themselves, 9 denied difficult or confusing questions, 8 felt the app fit into their daily routine, and 1 felt there were too many questions. Six felt the app’s recommendations could be trusted, 3 weren’t sure, and 1 did not trust the app.

Conclusion:
Smartphone based interventions have the potential to improve care coordination and patient perceptions of communication. Patient barriers to app use include device availability, interest, compliance when feeling ill, and incomplete or inaccurate symptom reporting. Use patterns in this study fell short of goals outlined at enrollment, suggesting the need for highly engaging apps. Further study is needed to find ways to overcome these barriers as well as methods of integrating apps into surgical care pathways.

17.17 Assessment of the Quality of Google Glass Images For Burn Wound Assessment

Posted on December 22, 2014

P. H. Chang1,2,3, P. H. Chang1,2,3  1Shriners Hospitals For Children-Boston,Boston, MA, USA 2Massachusetts General Hospital,Boston, MA, USA 3Harvard School Of Medicine,Brookline, MA, USA

Introduction:   Wearable technology has emerged as a new source of medical devices.  Google Glass has been trialed by several surgeons of various specialties for its unique combination of video and photographic recording and transmission, portability, and hands-free use which offers obvious advantages for the surgeon who is sterilely scrubbed in.  Our department sought to assess the use of Google Glass as an image capturing device for assessment of burn wounds especially with regards to quality of images and ease of use. 

Methods:
A retrospective analysis of pediatric burn patients admitted between May 2014 and June 2014 was performed.  Inclusion criteria included all burn patients with at least 1% TBSA and a minimum depth of injury of partial thickness.  Photographic consent was obtained from all parents of patients as per hospital regulations.   The Glass device was used to take pictures of the patient's burn wounds.  The hospital photographer then took pictures using a Nikon D7100 24 MP camera.  The two images were compared side by side by an experienced burn surgeon and assessed as to the quality of image and ability to make an accurate diagnosis based on the images.  Notes were taken by the Glass user as to issues that arose while taking the pictures.

Results:
5 patients had burn wounds assessed in this time period using both the Google Glass and the traditional hospital photographer.  Despite the lower resolution of the Glass device (5 MP), 5 of 5 patients' Glass images were assessed by the experienced burn surgeon to be of adequate quality to provide the same information as the higher resolution pictures obtained by the hospital photographer.  The hospital photographer was able to obtain pictures faster on average (approximately 1 second per image) compared to the Glass device (approximately 5 seconds per image).   Issues that arose from use of the Glass included:

1)  overheating and subsequent shutdown of the Glass device while in the heated environment of the burn operating room.
2)  the lack of ability to focus the Glass lens and thus require the Glass user to be in close proximity to the burn wounds to obtain optimal pictures

3)  the need to take extra care to disable automatic upload of images to Google Plus account to prevent transfer of sensitive patient information to Google servers which are by definition non HIPPA compliant.

Conclusion:
The Google Glass device is able to capture clinically accurate images of burn wounds.  However, there are limiting factors to the technology as it currently stands that would need to be addressed before it could be fully utilized in a burn surgery practice.
 

17.18 What Happened Last Night?! – Variability in Night Shift ICU Care

Posted on December 22, 2014

J. Driver1, P. Y. Wai1, M. A. Zapf1, A. Kothari1, K. Y. Wolin1, P. C. Kuo1  1Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA

Introduction: ICU patients comprise the sickest patient population in the hospital. They are presumed to receive unwavering "around the clock" care. However, this assumption has not been previously investigated and anecdotal observations suggest that night time care is variable.  To determine potential differences in night time ICU care, patient care parameters were analyzed comparing hourly data from day, evening and night shifts. We hypothesized that variability in ICU care occurs during the night shift and impacts important patient outcomes. 

Methods: EPIC electronic medical record data from 15,493 patients in 5 ICUs from 2008-2013 at a major urban academic medical center were retrospectively analyzed for hourly urine output (U/O), mean arterial pressure (MAP), frequency of MD and RN EMR access and total fluid output during day, evening and night shifts. Variation in hourly U/O was selected as a surrogate marker for overall attention to care.  ICUs included: CCU, NeuroICU, CardiothoracicICU, MICU, and SICU. Mean night shift values were compared to the mean combined day and evening shift values. Statistical analysis was performed using paired t-tests or linear mixed effect modeling; p values < 0.05 were considered significant.

 

Results: There was reduced MAP (-0.75 mmHg/hr*) and reduced U/O (-18.9 mL/hr*) during the night shift. Paradoxically, frequency of care giver EMR access was significantly decreased at night (-33.4 times/hr*) and correlated with decreased U/O*, increased length of stay* and increased overall in-hospital mortality*. The model of resident and attending MD coverage and ICU specialty did not correlate with these parameters. (*p<0.0001) 

Conclusion: Our results demonstrate that attentiveness (measured by frequency of EMR access) correlated with surrogate care parameters (U/O) and outcome measures (length of stay and mortality). We conclude that variations in night shift ICU care may be due to caregiver inattention. Corrective strategies to increase patient monitoring, such as scheduled night shift ICU team rounding, should be identified.  

15.15 The publication gender gap in academic surgery

Posted on December 22, 2014

R. C. Wright1, C. Mueller1  1Stanford University,Pediatric Surgery,Palo Alto, CA, USA

Introduction:  Terms such as “glass ceiling” and “sticky floor” are still commonly used to describe the role of women in academic surgery, and multiple studies have documented disparities between men and women in the field.  In spite of the awareness and continued efforts to alleviate this gap within surgery, gender inequalities remain. 

Methods:  In this investigation the researchers examined the differences in published literature by male and female academic surgeons according to amount and impact. Websites for departments of surgery of three large academic centers were reviewed. Only full-time faculty were included in the analysis. Surgeons’ gender and academic rank were determined by their online biographies. Over a two week span all H-indexes, number of articles published, and other bibliometrics were determined using the Web of Science database. 

Results: A one-way ANOVA showed a significantly higher H-index for men than women (p<.05). In addition, one-way ANOVA showed significantly more articles published by men than women (p<.05). These differences are most dramatic at the rank of associate professor where the H-index for men is three times that of the women. The rank of full professor showed men had double the number of articles published. 

Conclusion: These findings align with previous research which shows a disparity between males and females as they climb the academic ladder. Since publishing research articles is a vital part of advancement in academic medicine, gender disparities in this realm may have major effects on the promotion process.  Future investigations may focus on the reasons behind this publication disparity.

 

15.16 Readmissions Following Major Cancer Surgery in Older Adults Within a Large Multihospital System

Posted on December 22, 2014

R. C. Langan1,2, C. Huang3, K. Harris1,2,3, S. Colton1, A. L. Potosky2,3,4, L. B. Johnson1,2,3,4, N. M. Shara2,3,5, W. B. Al-Refaie1,2,3,4  1Georgetown University Hospital,Department Of Surgery,Washington, DC, USA 2MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3MedStar Health Research Institute,Washington, DC, USA 4Lombardi Comprehensive Cancer Center,Washington, DC, USA 5Georgetown-Howard Universities Center For Clinical And Translational Sciences,Washington, DC, USA

Introduction:  Readmissions are a focus of emerging efforts to improve the quality and affordability of healthcare. Yet, little is known about reasons for readmissions after major cancer surgery in the expanding elderly population (≥ 65 years) who are also at increased risk of adverse operative events. We sought to identify 1) the extent to which older age impacts readmissions and 2) factors predictive of 30- and 90-day readmissions after major cancer surgery among older adults. 

Methods:  We identified 2,797 older adults who underwent seven types of major thoracic or abdomino-pelvic cancer surgery within a large multihospital system from 2003-2012.  Multivariate logistic regression analyses were conducted to identify predictors of 30- and 90-day hospital readmission. 

Results: Overall 30-day and 90-day readmission rates were 16% and 24% with the majority of readmissions occuring within 15-days of discharge. Principal diagnoses of 30-day readmissions included gastrointestinal, pulmonary and infections complications. 30-day readmissions were associated with > 2 comorbid conditions and ≥ 2 postoperative complications. Readmissions significanctly varied according to cancer surgery type and across treating hospitals. Readmissions did not vary by increasing age. Factors associated with 90-day readmission were comparable to those observed at 30-days (Table 1). 

Conclusion: In this large multi-hospital study of older adults, multi-morbidities, procedure type, increased complications and the treating hospital predicted 30- and 90-day readmissions. These findings point toward the potential impact of hospital-level factors behind these readmissions. Our results also point towards the importance of assessing the influence of readmission on other important cancer care metrics; patient reported outcomes and the completion of adjuvant systemic therapies.

 

15.17 The Readability, Complexity, and Suitability of Online Patient Material for Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, P. Koolen1, D. J. Chuang1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Limited health literacy affects nearly half of American adults and has been shown to adversely affect patient participation, satisfaction, healthcare costs, and overall outcomes.  As unprecedented numbers of patients search the internet for health information, the accessibility of online material is more important than ever before.  The aim of this study was to evaluate available breast reconstruction resources on the internet with regard to reading grade level, degree of complexity, and suitability for the intended patient audience using three validated tools.

Methods:
The ten most popular patient websites for "breast reconstruction" were identified using the largest internet search engine.  The content of each site was assessed for readability using the Simple Measure of Gobbledygook (SMOG) analysis, complexity using the PMOSE/iKIRSCH formula, and suitability using the Suitability Assessment of Materials (SAM) instrument.  Resulting scores were analyzed both overall and by website.

Results:
Readability analysis revealed an overall average grade level of 13.4, with a range from 10.7 (MedlinePlus) to 15.8 (Wikipedia).  All sites exceeded the recommended 6th grade reading level.  Complexity evaluation revealed a mean PMOSE/iKIRSCH score of 6.2, consistent with "Low" complexity and equivalent to a high school level.  Websites ranged from "Very Low" complexity (BreastReconstruction.org, WebMD, National Cancer Institute, MedicineNet.com) to "High" complexity (Wikipedia).  Suitability assessment overall produced a mean 39.7% score, interpreted as "Not Suitable" for the intended patient audience.  Four sites (American Society of Plastic Surgeons, American Cancer Society, MedlinePlus, and National Cancer Institute) were found to have "Adequate" suitability scores when examined individually; the remaining six were "Not suitable".

Conclusion:
Available online patient material for breast reconstruction is too difficult for many patients to read.  Although overall table and list complexity of the websites is acceptable for average Americans, the content, literacy demand, and format is largely unsuitable for the intended patient audiences.  Attention to specific measures shown to improve readability and suitability is needed in designing appropriate material and minimizing disparities related to limited patient health literacy.

15.18 Patient Preferences in Access to Post-Mastectomy Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, M. Paul1, O. Ganor1, M. Semack1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery/Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
There is currently considerable variability at our institution in the timing of consultation with a plastic and reconstructive surgeon following initial diagnosis of breast cancer and meeting with a breast surgeon.  Providers in both specialties have expressed differing opinions regarding the ideal method of scheduling, and no published data exists regarding what patients prefer.  We aim to elucidate patients' preferences for the timing of plastic surgery consultation as part of the preoperative evaluation and planning process that follows a new diagnosis of breast cancer.

Methods:
A 16-question electronic survey instrument was developed based on formative patient comments and discussion between the breast and plastic surgery teams.  The survey was administered to all patients referred to the plastic and reconstructive surgery clinic during their initial consultation visit to discuss immediate post-mastectomy breast reconstruction between December 2013 and July 2014.  Surveys were administered in private consultation rooms by the clinic nurse and all data was collected anonymously.  Descriptive analysis was performed for each survey question.

Results:
A total of 31 unique responses were collected during the 7 month study period.  The largest number of patients (48%) indicated that they would prefer to see a plastic surgeon one week after their first consultation with a breast surgeon.  Only one patient reported a desire to see both surgeons on the same day.  Most patients indicated that having a family member or friend accompany them to the appointment (45%) and having time to process their cancer diagnosis before seeing the plastic surgeon (32%) were the key factors in deciding when they would like to discuss reconstruction.  All patients reported having had a discussion with their breast surgeon about reconstruction during the first appointment, and 55% said they had researched reconstructive options independently prior to consultation with the plastic surgeon.  All patients reported being "satisfied" or "very satisfied" with the process of meeting with both surgeons as well as with the information they received.

Conclusion:
The majority of patients in our study indicated a preference for delay between initial consultation with a breast surgeon and initial consultation with a plastic surgeon.  Overall, patients were satisfied with the process of meeting with each surgeon separately and with the information they received.  Incorporating patient preferences into the preoperative evaluation and planning process allows patients to optimize available support from loved ones and to begin coping with their diagnosis.
 

15.19 Spatial Interactions of Market and Socioeconomic Factors in Kidney Transplantation

Posted on December 22, 2014

J. T. Adler1,2, H. Yeh2,4, J. F. Markmann2,4, L. L. Nguyen1,3,4  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Massachusetts General Hospital,Transplant Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,Vascular Surgery,Boston, MA, USA 4Harvard School Of Medicine,Brookline, MA, USA

Introduction: Prior work has demonstrated that the number of kidney transplants per population (KTP) is dependent on market factors such as competition and the number of transplant centers.  Socioeconomic status (SES) also plays a role in KTP.  We hypothesize that both of these important factors are spatially correlated in KTP, demonstrable by neighboring areas influencing each other more than remote areas.

Methods: The Herfindahl Hirschman Index (HHI), a standard measure of market competition, was calculated for each Health Service Area (HSA from Dartmouth Atlas) from 2000-2013 using zip code information of kidney transplant recipients from the Scientific Registry of Transplant Recipients.  Global Moran’s I, a measure of spatial dependency, was used to test market competition for spatial autocorrelation.  Areal interpolation was used to identify areas of concentrated market competition. Three standard spatial regression models were constructed to analyze the relationship between market competition and KTP adjusted for SES.

Results: Market competition exhibits moderate spatial autocorrelation (Global Moran’s I 0.27, P < 0.0001).  It is unevenly distributed in the United States and mirrors the general population (Figure).  The spatial lag model was the best fit by AIC criterion, suggesting a diffusion model among neighboring HSAs.  Under the spatial lag model, market competition was strongly associated with an increase in KTP by 27.5 ± 1.7 (P < 0.0001).  Markers of SES associated with an increase KTP included percent crowding (1.2 ± 0.2, P < 0.0001), percent with a college education or greater (0.39 ± 0.12, P = 0.0001), and percent unemployed (0.89 ± 0.21, P < 0.0001).  Lower median property value (per ten thousand dollars) was associated with slightly decreased KTP (0.03 ± 0.0007, P < 0.0001).

Conclusions: Competition and SES effects diffuse among neighboring HSAs in KTP.  This emphasizes a role understanding spatial autocorrelation in factors influencing KTP beyond market and SES factors.  Efforts to improve access to kidney transplantation should consider such issues in planning transplant center location, organ allocation, and organ sharing.

15.20 Does Transplant Center Flagging have Unintended Consequences? Spillover Effects of Medicare Policy

Posted on December 22, 2014

L. H. Nicholas1,2, D. Segev2  1Johns Hopkins University School Of Public Health,Health Policy & Management,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: The Center for Medicare and Medicaid Services (CMS) increasingly uses its role as one of the largest healthcare payers to influence quality of care.  Despite good intentions, policies designed to purchase high-quality care may have unintended consequences.  In 2007, CMS instituted aggressive Conditions of Participation (COP) for Transplant Centers, which flag transplant programs with worse than expected patient or graft survival for reviews that can be time-consuming and have major financial consequences; CMS can require low-performing centers to stop treating Medicare and Medicaid patients or enter into a Systems Improvement Agreement limiting the scope of transplant programs.  It is unknown whether flagging within a particular organ impacts the volume or quality of transplants of non-flagged organs.

Methods: We use data from the Scientific Registry of Transplant Recipients from 2004 – 2011 to study the intended and unintended consequences of CMS flagging for kidney and liver transplants, the most commonly transplanted organs, on other transplant programs within a center.  We used difference-in-differences regression models to compare outcomes at 130 transplant centers that were versus were not flagged (or informed of poor performance) before and after COP implementation.  Prior to the COP, hospitals received regular performance report cards but there were no sanctions against poor performers.  This approach allows us to separate transplant center’s response to the threat of CMS sanctions from any changes in behavior that are driven by information about quality of care they are currently providing. 

Results: 69 centers were flagged or notified of underperformance for kidney transplant and 43 for liver transplant at least once during the study period.  Simply receiving information about performance was not related to statistically significant changes in volume for either the low-performing organ or other programs within a transplant center.  However, programs flagged for poor performance in the COP period reduced volume for the flagged organ (54 fewer transplants per year after the second kidney flag, p < 0.01; 18 fewer transplants after the second liver flag, p < 0.10).  Transplant centers also reduced lung transplant volume following flags for both kidney (-12, p < 0.10 for first flag, -14, p < 0.01 for second flag) and liver transplant (-20, p < 0.05 for first flag, -5.3 for second flag).

Conclusion:  Transplant centers respond to the threat of CMS sanctions by reducing transplant volume for organ programs with and without potential quality programs.  Reduced access to transplant across organ types may be an unintended consequence of CMS efforts to improve the quality of transplant care. 

 

16.01 The Role of Breast MRI in Ductal Carcinoma in situ: Has it Improved Clinical Outcomes?

Posted on December 22, 2014

L. S. Sparber1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Deptarment Of Surgery,Livingston, NJ, USA 2Saint George’s University,School Of Medicine,St. George’s, , Grenada 3New Jersey Medical School,Rutgers University – Department Of Surgery,Newark, NJ, USA

Introduction: For over three decades, screening mammography has played a central role in the early detection of in situ breast tumors in the United States.  More recently, breast magnetic resonance imaging (MRI) has emerged as a potentially more sensitive imaging modality than traditional mammography, but whether its use should be limited to adjunct screening for those at high risk or be universally utilized remains controversial.  While breast MRI undoubtedly detects subtler breast abnormalities, it is unclear whether this has resulted in an improvement in treatment decisions for patients with Ductal Carcinoma in situ (DCIS).

Methods: A comprehensive search for all published clinical studies on the use of MRI and its impact on DCIS management (2010-2014) was conducted using PubMed and Google Scholar.  The search focused on the value of MRI to guide treatment strategies, including mastectomy rates, re-excision rates and the overall benefit of this added imaging modality.  Keywords searched included: “breast MRI”, “mastectomy”, “DCIS”, “Ductal Carcinoma in situ”, and “surgical planning” in all possible combinations.

Results:  Six studies involving 3,296 patients have been published (Table 1). Pilewskie et al (2014) reported the largest study involving 2,321 DCIS patients (596 DCIS patients in MRI group; 1,725 patients in non-MRI group).  Within this group, 904 DCIS patients underwent radiation therapy [RT]; and 1,391 patients did not.  In the non-RT subgroup there was no association with the performance of an MRI and lower loco regional recurrence rates (p = 0.28). Three additional studies analyzed the impact of MRI on DCIS mastectomy rates, with Allen et al reporting no significant difference in mastectomy rates if an MRI was performed (p = .62). In contrast, Itakura et al reported increased mastectomy rates in patients undergoing preoperative MRI (p < .001). Re-excision rates were investigated in three studies, and preoperative performance of an MRI did not statistically impact these rates favorably or negatively. Pilewskie et al, demonstrated that breast conserving surgery was more successful in the non-MRI group (p = .06), whereas Allen et al and Kropcho et al found the results to not be statistically significant (p = .41 and p = .414, respectively). Across all studies, preoperative MRI was judged not routinely beneficial in DCIS patients.    

Conclusion: Breast MRI is associated with an increased sensitivity compared to other breast imaging technologies; however, it does not appear to improve clinical outcomes in patients with DCIS when added to conventional breast assessment.  Moreover, routine breast MRI in DCIS may contribute to an increase in unnecessary mastectomies.

 

16.02 Effects of drinking hydrogen-rich water on muscle fatigue caused by acute exercise in athletes

Posted on December 22, 2014

A. Nakao1, J. Kotani1, K. Kohama1, T. Nishimura1, T. Yamada1, S. Miyakawa2  1Hyogo College Of Medicine,Emergency, Disaster And Critical Care Medicine,Nishinomiya, HYOGO, Japan 2University Of Tsukuba,Doctoral Program In Sports Medicine,Tsukuba, IBARAKI, Japan

Introduction: Muscle contraction during short intervals of intense exercise causes oxidative stress, which can play a role in the development of overtraining symptoms, including increased fatigue, resulting in muscle microinjury or inflammation. Recently it has been said that hydrogen can function as antioxidant, so we investigated the effect of hydrogen-rich water (HW) on oxidative stress and muscle fatigue in response to acute exercise.

Methods: Ten male soccer players aged 20.9 ± 1.3 years old were subjected to exercise tests and blood sampling. Each subject was examined twice in a crossover double-blind manner; they were given either HW or placebo water (PW) for one week intervals. Subjects were requested to use a cycle ergometer at a 75 % maximal oxygen uptake (VO2) for 30 min, followed by measurement of peak torque and muscle activity throughout 100 repetitions of maximal isokinetic knee extension. Oxidative stress markers and creatine kinase in the peripheral blood were sequentially measured.

Results:Although acute exercise resulted in an increase in blood lactate levels in the subjects given PW, oral intake of HW prevented an elevation of blood lactate during heavy exercise. Peak torque of PW significantly decreased during maximal isokinetic knee extension, suggesting muscle fatigue, but peak torque of HW didn’t decrease at early phase. There was no significant change in blood oxidative injury markers (d-ROMs and BAP) or creatine kinease after exercise.

Conclusion:Adequate hydration with hydrogen-rich water pre-exercise reduced blood lactate levels and improved exercise-induced decline of muscle function. Although further studies to elucidate the exact mechanisms and the benefits are needed to be confirmed in larger series of studies, these preliminary results may suggest that HW may be suitable hydration for athletes.

 

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