Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

Background: The local treatment of extremity sarcomas usually is predicated on a decision between limb salvage and amputation. The manner in which surgical options are presented in the context of shared decision-making may influence this decision. In a population of "simulated" patients-survey respondents presented with a mock clinical vignette and then asked to choose between treatments-we assessed cognitive bias by deliberate alteration of the subjective presentation of the same objective information.

Stress Urinary Incontinence Surgery in Washington State Before and After Introduction of the Mesh Midurethral Sling.

Objectives: Mesh midurethral slings (MUSs) are safe, effective treatments for female stress urinary incontinence (SUI), but many companies have ceased production because of controversies surrounding transvaginal mesh. To determine if introduction of MUS has increased the complication rate associated with SUI surgery, we compared women undergoing SUI surgery in the MUS era to those who had surgery prior its introduction.

Methods: This was a retrospective cohort study of a statewide hospital discharge database.

Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washington State Hospitals.

Objective: Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013).

Effectiveness of a Medical vs Revascularization Intervention for Intermittent Leg Claudication Based on Patient-Reported Outcomes.

Importance: Intermittent claudication (IC) is the most common presentation of infrainguinal peripheral artery disease. Both medical and revascularization interventions for IC aim to increase walking comfort and distance, but there is inconclusive evidence of the comparative benefit of revascularization given the possible risk of limb loss.

Objective: To compare the effectiveness of a medical (walking program, smoking cessation counseling, and medications) vs revascularization (endovascular or surgical) intervention for IC in the community, focusing on outcomes of greatest importance to patients.

Outpatient Rehabilitation for Medicaid-Insured Children Hospitalized With Traumatic Brain Injury.

Objectives: To describe the prevalence of postdischarge outpatient rehabilitation among Medicaid-insured children hospitalized with a traumatic brain injury (TBI) and to identify factors associated with receipt of services.

Methods: Retrospective cohort of children <21 years, hospitalized for a TBI between 2007 and 2012, from a national Medicaid claims database. Outcome measures were receipt of outpatient rehabilitation (physical, occupational, or speech therapies or physician visits to a rehabilitation provider) 1 and 3 years after discharge.

Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes.

Objective: To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort.

Background: Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM).

Methods: Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010-2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State.

Enteral contrast in the computed tomography diagnosis of appendicitis: comparative effectiveness in a prospective surgical cohort.

Objective: Our goal was to perform a comparative effectiveness study of intravenous (IV)-only versus IV + enteral contrast in computed tomographic (CT) scans performed for patients undergoing appendectomy across a diverse group of hospitals.

Background: Small randomized trials from tertiary centers suggest that enteral contrast does not improve diagnostic performance of CT for suspected appendicitis, but generalizability has not been demonstrated. Eliminating enteral contrast may improve efficiency, patient comfort, and safety.

Neoadjuvant chemotherapy in the Medicare cohort with advanced ovarian cancer.

Objective: The value of neoadjuvant chemotherapy (NAC) for the treatment of advanced ovarian cancer has yet to be determined. While NAC may facilitate and simplify complete cytoreduction and reduce the risk of surgery, the delay of surgery related to NAC needs to be balanced against any potential benefit.

Methods: Surveillance, Epidemiology and End-Results (SEER) data linked to Medicare claims were used to identify 6844 women with treated stage III/IV epithelial ovarian cancer (1995-2005).

Diagnostic imaging and biopsy use among elderly medicare beneficiaries with hepatocellular carcinoma.

Purpose: Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general community.

Thirty-day mortality after primary cytoreductive surgery for advanced ovarian cancer in the elderly.

Objective: To identify factors associated with increased 30-day mortality after advanced ovarian cancer debulking among elderly women.

Methods: A database linking Medicare records with the Surveillance, Epidemiology, and End Results (SEER) data was used to identify a cohort of 5,475 women aged 65 and older who had primary debulking surgery for stage III or IV epithelial ovarian cancer (diagnosed 1995-2005). Women were stratified by acuity of hospital admission.

Trends in treatment of advanced epithelial ovarian cancer in the Medicare population.

Objective: Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy.

Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards.

Background: The Leapfrog Group established a minimum hospital case volume of 13 for esophageal resection in a response to known improved outcomes in larger volume centers. The aim of this study was to evaluate variation in short-term outcomes among hospitals that met the Leapfrog volume criteria.

Methods: Using the Washington State Comprehensive Hospital Abstract Reporting System, a retrospective cohort design evaluated all patients (≥18 years) undergoing esophageal resection for any diagnosis since the introduction of Leapfrog standards (2000 to 2007).

A critical evaluation of the impact of Leapfrog's evidence-based hospital referral.

Background: Evidence-based hospital referral (EBHR) is a Leapfrog group quality metric based primarily on hospital procedural volume. It has yet to be determined if EBHR has led to regionalized surgical care and whether it has improved patient outcomes.

Study Design: We conducted a before and after cohort study of 13,157 adults (1994 to 2007) who underwent pancreatic or esophageal resection or abdominal aortic aneurysm (AAA) repair in Washington State.

Trends in the utilization and impact of radiofrequency ablation for hepatocellular carcinoma.

Background: The incidence of hepatocellular carcinoma (HCC) is rising and radiofrequency ablation (RFA) appears to be increasingly used. The nationwide use and impact of RFA have not been well characterized.

Study Design: We performed an historical cohort study of US patients 18 years old and older, with a diagnosis of HCC (n = 22,103) using the national Surveillance, Epidemiology, and End Results (SEER) limited-use database (1998 to 2005).

Impact of advancing age on abdominal surgical outcomes.

Objective: To describe the population-level risk of adverse outcomes among older adults undergoing common abdominal surgical procedures.

Design: Retrospective, population-based cohort study.

Setting: Washington State hospital discharge database.

Health care utilization among surgically treated Medicare beneficiaries with lung cancer.

Background: Markers of increased health care utilization are surrogates for adverse events, and one such metric--prolonged length of stay greater than 14 days (PLOS)--was recently endorsed as a provider-level performance measure.

Methods: This is a cohort study (1992 through 2002) aimed to describe increased health care utilization among 21,067 operated lung cancer patients using the Surveillance, Epidemiology, and End-Results-Medicare database. Increased utilization was defined by PLOS, discharge to an institutional care facility (ICF), or readmission within 30 days.

Risk tolerance and bile duct injury: surgeon characteristics, risk-taking preference, and common bile duct injuries.

Background: Little is known about surgeon characteristics associated with common bile duct injury (CBDI) during laparoscopic cholecystectomy (LC). Risk-taking preferences can influence physician behavior and practice. We evaluated self-reported differences in characteristics and risk-taking preference among surgeons with and without a reported history of CBDI.

Safety and efficacy of video-assisted versus conventional lung resection for lung cancer.

Objective: We sought to evaluate the use of video-assisted thoracoscopy among patients with lung cancer and its safety and effectiveness relative to conventional resection.

Methods: A cohort study (1994-2002) was conducted by using the Surveillance, Epidemiology, and End-Results Medicare database. Video-assisted thoracoscopy and conventional resection were hypothesized to be equivalent in terms of risks of death.

Surgeon specialty and long-term survival after pulmonary resection for lung cancer.

Background: Long-term outcomes and processes of care in patients undergoing pulmonary resection for lung cancer may vary by surgeon type. Associations between surgeon specialty and processes of care and long-term survival have not been described.

Methods: A cohort study (1992 through 2002, follow-up through 2005) was conducted using Surveillance, Epidemiology, and End-Results-Medicare data.

The significance of discharge to skilled care after abdominopelvic surgery in older adults.

Content: Older adults frequently undergo abdominopelvic surgical operations, yet the risk and significance of postoperative discharge disposition has not been well characterized.

Objective: To describe the population-level risk of discharge to institutional care facilities and its impact on survival among older patients who undergo common abdominopelvic surgical procedures.

Design, Setting, And Participants: A retrospective, population-based cohort study, using the Washington State hospital discharge database for 89,405 adults aged 65 and older who underwent common abdominopelvic procedures (cholecystectomy, colectomy, hysterectomy/oophorectomy, and prostatectomy) between 1987 and 2004.

Surgeon knowledge, behavior, and opinions regarding intraoperative cholangiography.

Background: The risk of common bile duct injury during laparoscopic cholecystectomy (LC) is 50% to 70% lower when an intraoperative cholangiogram (IOC) is used, and this effect is exaggerated among less experienced surgeons. Routine IOC is not universal, and barriers to its use, including surgeon knowledge, behavior, and attitudes, should be understood in developing quality-improvement interventions aimed at increasing IOC use.

Study Design: There were 4,100 general surgeons randomly selected from the American College of Surgeons who were mailed a survey about IOC.

Multi-modality mediastinal staging for lung cancer among medicare beneficiaries.

Introduction: The use of noninvasive and invasive diagnostic tests improves the accuracy of mediastinal staging for lung cancer. It is unknown how frequently multimodality mediastinal staging is used, or whether its use is associated with better health outcomes.

Methods: A cohort study was conducted using Surveillance, Epidemiology, and End Results-Medicare data (1998-2005).

Racial disparities among patients with lung cancer who were recommended operative therapy.

Hypothesis: Health care system and provider biases and differences in patient characteristics are thought to be prevailing factors underlying racial disparities. The influence of these factors on the receipt of care would likely be mitigated among patients who are recommended optimal therapy. We hypothesized that there would be no significant evidence of racial disparities among patients with early-stage lung cancer who are recommended surgical therapy.

Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program.

Objective: To evaluate negative appendectomy (NA) and the relationship of NA and computed tomography (CT) and/or ultrasound (US). SUMMARY BACKGROUND INFORMATION: NA may be influenced by the use and accuracy of preoperative CT/US. The Surgical Care and Outcomes Assessment Program (SCOAP) gathers chart-abstracted process of care data (such as CT/US accuracy) for general surgical procedures (including appendectomy) at most Washington State hospitals.

Trends in the operative management and outcomes of T4 lung cancer.

Background: This study describes temporal trends and variables in the operative management and outcomes of patients with T4 lung tumors in the general community.

Methods: Surveillance, Epidemiology, and End-Results-Medicare data were used for a cohort study (1992 to 2002) of patients with stage IIIB lung cancer defined by T4 tumors. Patient characteristics, tumor size, nodal status, use of staging modalities, extent of resection, multi-modality therapy, and provider volume were examined.