Biomedical subjects
Publications and source records attributed to Clifford Y Ko.
In order to successfully meet the CMS Age-Friendly Hospital Measure (AFHM) requirements, hospitals will need to adapt clinical workflows to facilitate increased interdisciplinary collaboration. We present five key principles for hospitals to consider to meet the CMS AFHM requirements.
BACKGROUND: Colorectal cancer is the second most common cancer type among new cancer diagnoses in the United States. Attention to the quality of surgical care for colorectal cancer is of particular importance given the increasing numbers of colorectal cancer resections performed in the aging population. A National Cancer Institute-sponsored consensus panel produced guidelines for colorectal cancer surgery in 2000. We have updated and extended that work by using a formal process to identify and rate quality indicators as valid for care during the preoperative, intraoperative, and postoperative periods. METHODS: Using a modification of the RAND/UCLA Appropriateness Methodology, we carried out structured interviews with leaders in the field of colorectal cancer surgery and systematic reviews of the literature to identify candidate quality indicators addressing perioperative care for patients undergoing surgery for colorectal cancer. A panel of 14 colorectal surgeons, general surgeons, and surgical oncologists then evaluated and formally rated the indicators using the modified Delphi method to identify valid indicators. RESULTS: A total of 142 candidate indicators were identified in six broad domains: privileging (which addresses surgical credentials), preoperative evaluation, patient-provider discussions, medication use, intraoperative care, and postoperative management. The expert panel rated 92 indicators as valid. These indicators address all domains of perioperative care for patients undergoing surgery for colorectal cancer. CONCLUSIONS: The RAND/UCLA Appropriateness Methodology can be used to identify and rate indicators of high-quality perioperative care for patients undergoing surgery for colorectal cancer. The indicators can be used as quality performance measures and for quality-improvement programs.
INTRODUCTION: Deep venous thrombosis (DVT) prophylaxis is particularly important for surgical oncologists given the high rate of DVT in patients with malignancy. Additionally, DVT prophylaxis may soon be implemented by some payers as a "pay for performance" quality measure. This is a systematic review of randomized controlled trial (RCT) evidence for DVT prophylaxis in cancer patients undergoing surgery. We examine overall rates of DVT, the efficacy of high versus low-dose heparin prophylaxis, and the rate of bleeding complications. METHODS: The Medline database was searched for English language RCTs using key words DVT, venous thromboembolism, prophylaxis, and general surgery. Inclusion criteria were RCTs evaluating surgical oncology patients. RESULTS: Fifty-five RCTs studied DVT prophylaxis in surgery (nonorthopedic) patients. Twenty-six RCTs evaluated 7,639 cancer patients. The overall DVT rate was 12.7% for pharmacologic prophylaxis and 35.2% for controls. High-dose low-molecular weight heparin (LMWH) was more effective than low dose, lowering the DVT rate from 14.5% to 7.9% (P < 0.01). Heparin decreased the rate of proximal DVTs. Bleeding complications requiring discontinuation of prophylaxis occurred in 3% of the patients. There was no difference between LMWH and unfractionated heparin in efficacy, DVT location, or bleeding complications. CONCLUSION: Using RCT data, this study demonstrates a greatly reduced DVT rate with pharmacologic prophylaxis in cancer patients, and higher doses appear more effective. Complication rates are low and should not prevent the use of prophylaxis in most patients. Finally, we found no difference between LMWH and unfractionated heparin in these RCTs. These results highlight the importance of routine pharmacologic prophylaxis in surgical patients with malignancy.
CONTEXT: Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. OBJECTIVE: To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. MAIN OUTCOME MEASURES: Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. RESULTS: A total of 719,608 patients received 1 of the 10 operations. Overall, nonwhites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81). CONCLUSIONS: There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.
BACKGROUND: Most literature available on rare colorectal cancer (CRC) is from case series reports. This population-based evaluation is the first comprehensive look at four rare histologic types of CRC, allowing comparisons with the more common adenocarcinoma for clinical and pathological features and survival rates. MATERIALS AND METHODS: All patients diagnosed with carcinoid (n=2,565), malignant lymphoma (n=955), non-carcinoid neuroendocrine (n=455), squamous cell (n=437), and adenocarcinoma (n=164,638) in SEER cancer database (1991-2000) were analyzed. Evaluation of age-adjusted incidence rate, stage at presentation, and 5-year relative survival were determined for each histologic subtype. RESULTS: All rare histologic subtypes had younger mean age than adenocarcinomas (70 years; p<0.05). Lymphoma was more common in males (65.1%; P<0.01). Incidence rates in 2000 per million were: carcinoid 10.6, lymphoma 3.5, neuroendocrine 2.0, squamous 1.9, and adenocarcinoma 496.3. The annual percent change in incidence for each rare tumor increased significantly during the 10 years (range: 3.1-9.4%, p<0.05), except squamous cell carcinoma (5.9%, p>0.05). Squamous (93.4%) and carcinoid (73.7%) tumors occurred more often in the rectum; lymphoma (79.0%), neuroendocrine (70.8%), and adenocarcinoma (70.1%) occurred more often in the colon (P<0.01). Carcinoids presented at earlier stage (localized/regional, 90.5%) more often than adenocarcinoma (80.6%; p<0.01), but squamous cell (82.1%; p=0.50), lymphoma(70.6%; p<0.01), and neuroendocrine (37.8%; p<0.01) presented at earlier stage similarly or less often than adenocarcinoma. Relative 5-year survival rate was highest for carcinoid (91.3%), and lowest for neuroendocrine tumors (21.4%). CONCLUSION: This study provides the first population-based analysis of the epidemiology, tumor characteristics, and survival rates for rare CRC.
BACKGROUND: Small bowel obstruction (SBO) is a common reason for surgical consultation, but little is known about the natural history of SBO. We performed a population-based analysis to evaluate SBO frequency, type of operation, and longterm outcomes. STUDY DESIGN: Using the California Inpatient File, we identified all patients admitted in 1997 with a diagnosis of SBO. Patients were excluded if they had a diagnosis of bowel obstruction in the previous 6 years (1991 to 1996). Of the remaining cohort, the natural history of SBO over the subsequent 5 years (1998 to 2002) was analyzed. Index hospitalization outcomes (eg, surgical versus nonsurgical management, length of stay, in-hospital mortality), and longterm outcomes, including SBO readmissions and 1-year mortality, were evaluated. RESULTS: We identified 32,583 patients with an index admission for SBO in 1997; 24% had surgery during the index admission. The distribution of surgical procedures was: 38% lysis of adhesions, 38% hernia repair, 18% small bowel resection with lysis of adhesions, and 6% small bowel resection with hernia repair. Patients who underwent operations during index admission had longer lengths of stay, lower mortality, fewer SBO readmissions, and longer time to readmission than patients treated nonsurgically. Regardless of treatment during the index admission, 81% of surviving patients had no additional SBO readmissions over the subsequent 5 years. CONCLUSIONS: Most of the 32,583 patients requiring admission for index SBO in 1997 were treated nonsurgically, and few of these patients were readmitted. This is the first longitudinal population-based analysis of SBO evaluating surgical versus nonsurgical management and outcomes, including mortality and readmissions.
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The growth of new knowledge continues to advance the surgical disciplines, and several types of literature reviews attempt to consolidate this expansion of information. Meta-analysis is one such method that integrates findings on the same subject from different studies. Within surgery, there is a wealth of literature on a given topic, which needs to be considered collectively. As such, meta-analyses have been performed to address issues like the use of bowel preparation for colorectal surgery and comparisons of outcomes for laparoscopic vs open surgical approaches. A basic understanding of the groundwork required for meta-analysis is fundamental toward interpreting and critiquing its results. This review provides an overview of the principles, application, and limitations of meta-analysis in the context of surgery.
HYPOTHESIS: Major bleeding complications from pharmacologic deep venous thrombosis (DVT) prophylaxis are infrequent. DESIGN: Systematic review of the MEDLINE database from 1965 to August 2005, using the terms DVT, prophylaxis, general surgery, and heparin. SETTING AND PATIENTS: Randomized controlled trials evaluating pharmacologic DVT prophylaxis in patients undergoing general surgery. MAIN OUTCOME MEASURES: Eight complication categories: injection site bruising, wound hematoma, drain site bleeding, hematuria, gastrointestinal tract bleeding, retroperitoneal bleeding, discontinuation of prophylaxis, and subsequent operation. RESULTS: Fifty-two randomized controlled trials studied DVT prophylaxis; 33 randomized controlled trials with 33 813 patients undergoing general surgery evaluated pharmacologic prophylaxis and quantified bleeding complications. Of the minor complications, injection site bruising (6.9%), wound hematoma (5.7%), drain site bleeding (2.0%), and hematuria (1.6%) were most common. Major bleeding complications, such as gastrointestinal tract (0.2%) or retroperitoneal (<0.1%) bleeding, were infrequent. Discontinuation of prophylaxis occurred in 2.0% of patients and subsequent operation in less than 1% of patients. When analyzed by high- vs low-dose unfractionated heparin, the lower dose had a smaller rate of discontinuation of prophylaxis (P = .02) and subsequent operation (P = .06). CONCLUSIONS: Knowledge of bleeding complication rates is important for surgeons because DVT prophylaxis may soon be implemented by Medicare as a quality measure. This level 1 evidence report shows that bleeding complications requiring a change in care occur less than 3% of the time and seem reduced with lower-dose prophylaxis. Given these findings, most patients undergoing general surgery could receive pharmacologic prophylaxis safely.
INTRODUCTION: To improve colorectal cancer outcomes, appropriate adjuvant therapy (chemotherapy, radiation therapy) should be given. Numerous studies have demonstrated underuse of adjuvant therapy in colorectal cancer. The current study examines variables associated with underuse of adjuvant therapy. METHODS: Three population-based databases were linked: California Cancer Registry, California Patient Discharge Database, 2000 Census. All colorectal cancer patients diagnosed from 1994 to 2001 were studied. Patient characteristics (age, gender, race/ethnicity, comorbidities, payer, diagnosis year, socioeconomic status) were used in five multivariate regression analyses to predict receipt of chemotherapy for Stage III colon cancer, and receipt of chemotherapy and radiation therapy for Stages II, III rectal cancer. RESULTS: The overall cohort was 18,649 Stage III colon cancer and Stages II, III rectal cancer patients. Mean age was 68.9 years, 50 percent male, 74 percent non-Hispanic white, 6 percent black, 11 percent Hispanic, 9 percent Asian, and 65 percent had no significant comorbid disease. Receipt of chemotherapy was 48 percent for Stage III colon cancer, 48 percent for Stage II rectal cancer, and 66 percent for Stage III rectal cancer. Receipt of radiation therapy was 52 percent for Stage II rectal cancer and 66 percent for Stage III rectal cancer. In all five models, low socioeconomic status predicted underuse of chemotherapy or radiation therapy (P < 0.016). Race/ethnicity was not statistically associated with underuse in any of the models. CONCLUSIONS: Most literature identifies race/ethnicity as the reason for disparate receipt of adjuvant therapy in colorectal cancer. Using a more robust database of three population-based sources, our analysis demonstrates that socioeconomic status is a more important predictor of (in)appropriate care than race/ethnicity. Explicit measures to improve care to the poor with colorectal cancer are needed.
PURPOSE: As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. METHODS: We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. RESULTS: A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9-0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89-0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. CONCLUSIONS: The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process.
This study reports the relationship between hospital surgical volume and outcomes after total knee arthroplasty. Discharge data from 1991 to 2001 were obtained from California's Office of Statewide Health Planning and Development and linked to California death records. Multivariate logistic regression models were performed to examine the association between hospital volume and complications. The models were adjusted for patient age, sex, race/ethnicity, insurance type, Charlson comorbidity index, hospital type and size, year of surgery, and whether patients underwent bilateral procedures. A total of 222684 primary total knee arthroplasties were identified during the study period. Patients treated at low volume hospitals had a higher likelihood in the 90 days after discharge of death (rate 0.55% vs 0.49%, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.14-1.98, P = .004), and readmission for infection (1.13% vs 0.65%, OR 1.60, 95% CI 1.21-2.12, P = .001), pulmonary embolism (0.48% vs 0.39%, OR 1.45, 95% CI 1.07-1.97, P = .016), and thrombophlebitis (0.49% vs 0.28%, OR 2.12, 95% CI 1.47-3.05, P </= .001). This study confirms the relationship of lower hospital volumes to a higher OR for complications after total knee arthroplasty.
This study attempts to identify the optimal follow-up period to report short-term complication rates after primary total knee arthroplasty. Discharge data from 1991 through 2001 was obtained from California and linked to state death records. Rates of mortality, infection, and pulmonary embolism were determined at 30-day intervals for up to 1 year postoperatively. An analysis of 222,684 primary total knee arthroplasties was performed. The peak rate and a large proportion of the complications that occurred during the first year after surgery were seen within the initial 30-day postoperative period. Regression analyses demonstrated that the patient and hospital characteristics predictive of outcome differed when comparing the results at 1 year postoperatively to shorter-term follow-up periods. The findings of this study indicate that 30- and 60-day follow-up periods provide an adequate accounting for adverse events related to mortality, infection, and pulmonary embolism. However, the regression results highlight the continued importance of reporting long-term outcomes.
OBJECTIVE: The purpose of this study was to determine the 30-day and 365-day mortality for the repair of thoracoabdominal aortic aneurysms (TAA), when stratified by age, in the general population. These data provide clinicians with information more applicable to an individual patient than mortality figures from a single institutional series. METHODS: Data were obtained from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1991 to 2002. These data were linked to the state death certificate file, allowing for continued information on the status of the patients after hospital discharge. All patients undergoing elective and ruptured TAA repair as coded by International Classification of Diseases, 9th Clinical Modification (ICD-9, CM) in California were identified. Patients aged <50 or >90 years old were excluded. We determined 30- and 365-day mortality and stratified our findings by decade of patient age (eg, 50 to 59). Demographics of elective and ruptured cases were also compared. RESULTS: We identified 1010 patients (797 elective, 213 ruptured) who underwent TAA repair. Mean patient ages were 70.0 (elective) and 72.1 years (ruptured). Men comprised 62% of elective and 68% of ruptured aneurysm patients, and 80% (elective) and 74% (ruptured) were white. Overall elective patient mortality was 19% at 30 days and 31% at 365 days. There was a steep increase in mortality with increasing age, such that elective 365-day mortality increased from about 18% for patients 50 to 59 years old to 40% for patients 80 to 89 years old. The elective case 31-day to 365-day mortality ranged from 7.8% for the youngest patients to 13.5%. Mortality for ruptured cases was 48.4% at 30 days and 61.5% at 365 days, and these rates also increased with age. CONCLUSIONS: Our observed 30-day mortality for TAA repairs is consistent with previous reports; however, mortality at 1 year demonstrates a significant risk beyond the initial perioperative period, and this risk increases with age. These data reflect surgical mortality for TAA repair in the general population and may provide more useful data for surgeons and patients contemplating TAA surgery.
OBJECTIVE: The purpose of this study was to determine the in-hospital, 30-day, and 365-day mortality for the open repair of abdominal aortic aneurysms (AAAs), when stratified by age, in the general population. Age stratification could provide clinicians with information more applicable to an individual patient than overall mortality figures. METHODS: In a retrospective analysis, data were obtained from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1995 to 1999. Out-of-hospital mortality was determined via linkage to the state death registry. All patients undergoing AAA repair as coded by International Classification of Diseases, 9th Revision (ICD-9) procedure code 38.44 and diagnosis codes 441.4 (intact) and 441.3/441.5 (ruptured) in California were identified. Patients <50 years of age were excluded. We determined in-hospital, 30-day, and 365-day mortality, and stratified our findings by patient age. Multivariate logistic regression was used to determine predictors of mortality in the intact and ruptured AAA cohorts. RESULTS: We identified 12,406 patients (9,778 intact, 2,628 ruptured). Mean patient age was 72.4 +/- 7.2 years (intact) and 73.9 +/- 8.2 (ruptured). Men comprised 80.9% of patients, and 90.8% of patients were white. Overall, intact AAA patient mortality was 3.8% in-hospital, 4% at 30 days, and 8.5% at 365 days. There was a steep increase in mortality with increasing age, such that 365-day mortality increased from 2.9% for patients 51 to 60 years old to 15% for patients 81 to 90 years old. Mortality from day 31 to 365 was greater than both in-hospital and 30-day mortality for all but the youngest intact AAA patients. Perioperative (in-hospital and 30-day) mortality for ruptured cases was 45%, and mortality at 1 year was 54%. CONCLUSIONS: There is continued mortality after the open repair of AAAs during postoperative days 31 to 365 that, for many patients, is greater than the perioperative death rate. This mortality increases dramatically with age for both intact and ruptured AAA repair.
The causes of colorectal carcinoma are multifactorial. Numerous lines of epidemiologic evidence support the role of dietary factors, with strong associations revealed for folate and calcium, more equivocal evidence exists for dietary antioxidants. Lifestyle factors such as physical activity, alcohol in-take, and tobacco use are also positively correlated with the risk of colorectal carcinoma. Health services research examines epidemiologic issues,clinical evidence regarding prevention and treatment, patient preferences,and other factors with the goal of improving the quality of care. Observations based on epidemiologic studies and health services research will in the future provide the basis for reducing personal and social burdens caused by colorectal carcinoma.
OBJECTIVE: To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships. DESIGN: Nationwide survey using a simple random sample. SETTING: One hundred and twenty-one allopathic 4-year medical schools in the United States. PARTICIPANTS: A total of 2,250 fourth-year medical students. MEASUREMENTS AND MAIN RESULTS: In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6). CONCLUSION: Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.
OBJECTIVE: To present the design and methods of a multisite study of health-related quality of life (HR-QOL) in veterans living with ostomies. RESEARCH DESIGN AND METHODS: Veterans from Tucson, Indianapolis, and Los Angeles VA Medical Centers were surveyed using the validated City of Hope ostomy-specific tool (mCOH-QOL-Ostomy) and the SF-36V. Cases (ostomates) had a major gastrointestinal procedure that required an intestinal stoma, while controls had similar procedures for which an ostomy was not required. Ostomy subjects were recruited for four focus groups in each of two sites divided by ostomy type (colostomy versus ileostomy) and overall mCOH-QOL-Ostomy HR-QOL score (highest versus lowest quartile). The focus groups further evaluated barriers, concerns, and adaptation methods and skills. MAIN OUTCOME MEASURES: This report presents recruitment results, reliability of survey instruments, and demographic characteristics of the sample. RESULTS: The overall response (i.e., recruitment) rate across all sites was 48% and by site was 53%, 57%, and 37%, respectively (p < 0.001). Internal consistency reliability estimates indicated that both instruments remain reliable in this population (Cronbach's alpha for HR-QOL domains/scales: 0.71-0.96). Cases and controls were similar in demographic characteristics. Proportions of minority subjects matched projections from the site patient populations. Subjects with ostomies had significantly longer time since surgery than controls (p < 0.001). Focus groups were comprised of two to six subjects per group and demonstrated racial diversity at the Los Angeles site. CONCLUSIONS: The unique design of our study of VA patients with ostomies is an illustration of a successful mixed methods approach to HR-QOL research. We collected meaningful quantitative and qualitative data that will be used in the development of new approaches to care that will lead to improved functioning and well-being in persons living with ostomies. Subsequent reports will provide the results of this research project.