Biomedical subjects

Orit Even-Shoshan

Publications and source records attributed to Orit Even-Shoshan.

5 recordsLinked to original sources

PubMed2006

Variation in chemotherapy utilization in ovarian cancer: the relative contribution of geography.

OBJECTIVE: This study investigates geographic variation in chemotherapy utilization for ovarian cancer in both absolute and relative terms and examines area characteristics associated with this variation. DATA SOURCES: Surveillance, Epidemiology, and End Results (SEER) Medicare data from 1990 to 2001 for Medicare patients over 65 with a diagnosis of ovarian cancer between 1990 and 1999. Chemotherapy within a year of diagnosis was identified by Medicare billing codes. The hospital referral region (HRR) represents the geographic unit of analysis. STUDY DESIGN: A logit model predicting the probability of receiving chemotherapy by each of the 39 HRRs. Control variables included medical characteristics (patient age, stage, year of diagnosis, and comorbidities) and socioeconomic characteristics (race, income, and education). The variation among HRRs was tested by the chi2 statistic, and the relative contribution was measured by the omega statistic. HHR market characteristic are then used to explain HRR-level variation. PRINCIPAL FINDINGS: The average chemotherapy rate was 56.6 percent, with a range by HRR from 33 percent to 67 percent. There were large and significant differences in chemotherapy use between HRRs, reflected by a chi2 for HRR of 146 (df = 38, p < .001). HRR-level variation in chemotherapy use can be partially explained by higher chemotherapy rates in HRRs with a higher percentage of hospitals with oncology services. However, an omega analysis indicates that, by about 15 to one, the variation between patients in use of chemotherapy reflects variations in patient characteristics rather than unexplained variation among HRRs. CONCLUSIONS: While absolute levels of chemotherapy variation between geographic areas are large and statistically significant, this analysis suggests that the role of geography in determining who gets chemotherapy is small relative to individual medical characteristics. Nevertheless, while variation by medical characteristics can be medically justified, the same cannot be said for geographic variation. Our finding that density of oncology hospitals predicts chemotherapy use suggests that provider supply is positively correlated with geographic variation.

Aged↗

PubMed2005

Changes in prognosis after the first postoperative complication.

BACKGROUND: Postoperative complications are common in the Medicare population, yet no study has formally quantified the change in prognosis that occurs after a broad range of first complications. OBJECTIVE: We sought to estimate the relative severity of 24 first postoperative complications. RESEARCH DESIGN: We undertook a multivariate matched, population-based, case-control study of death after surgery in a sample of 1362 Pennsylvania Medicare patients. SUBJECTS: Cases (681 deaths) were selected randomly using claims from 1995-1996. Models were developed to scan all Pennsylvania claims, looking for similar controls that did not die. MEASURES: Charts were abstracted, complications identified, and models were constructed to estimate the odds of dying after any 1 of 24 first postoperative complications. RESULTS: The odds of dying within 60 days increased 3.4-fold (95% confidence interval [CI] 2.5-4.7) in patients with complications as compared with those without complications. A first complication of respiratory compromise was associated with a 7.2-fold increase in the odds of dying (95% CI 4.5-11.6). The first complications of pneumonia or congestive heart failure were associated with, respectively, 5-fold (95% CI 2.1-12.1) and 5.1-fold (2.3-11.1) increases in odds of dying as compared with no complication. CONCLUSIONS: First complications after surgery, even seemingly mild ones, may radically alter the patient's risk of death. First complications often begin the cascade of complications that end in death. Caregivers should consider the first complication as a timely signal of a changed clinical situation demanding a reevaluation of the patient's care. Researchers may use these estimates to determine the relative severity of a broad range of first or early complications.

Aged↗

PubMed2005

Preoperative antibiotics and mortality in the elderly.

OBJECTIVE AND BACKGROUND: It is generally thought that the use of preoperative antibiotics reduces the risk of postoperative infection, yet few studies have described the association between preoperative antibiotics and the risk of dying. The objective of this study was to determine whether preoperative antibiotics are associated with a reduced risk of death. METHODS: We performed a multivariate matched, population-based, case-control study of death following surgery on 1362 Pennsylvania Medicare patients between 65 and 85 years of age undergoing general and orthopedic surgery. Cases (681 deaths within 60 days from hospital admission) were randomly selected throughout Pennsylvania using claims from 1995 and 1996. Models were developed to scan Medicare claims, looking for controls who did not die and who were the closest matches to the previously selected cases based on preoperative characteristics. Cases and their controls were identified, and charts were abstracted to define antibiotic use and obtain baseline severity adjustment data. RESULTS: For general surgery, the odds of dying within 60 days were less than half in those treated with preoperative antibiotics within 2 hours of incision as compared with those without such treatment: (odds ratio = 0.44; 95% confidence interval, 0.32-0.60), P < 0.0001). For orthopedic surgery, no significant mortality reduction was observed (OR = 0.85; 95% confidence interval, 0.54-1.32; P < 0.464). INTERPRETATION: Preoperative antibiotics are associated with a substantially lower 60-day mortality rate in elderly patients undergoing general surgery. In patients who appear to be comparable, the risk of death was half as large among those who received preoperative antibiotics.

Age Factors↗

PubMed2003

Length of stay, conditional length of stay, and prolonged stay in pediatric asthma.

OBJECTIVE: To understand differences in length of stay for asthma patients between New York State and Pennsylvania across children's and general hospitals in order to better guide policy. DATA SOURCES/STUDY SETTING: All pediatric admissions for asthma in the states of Pennsylvania and New York using claims data obtained from each state for the years 1996-1998, n = 38,310. STUDY DESIGN: A retrospective cohort design to model length of stay (LOS), the probability of prolonged stay, conditional length of stay (CLOS or the LOS after stay is prolonged), and the probability of readmission, controlling for patient factors, state, location and hospital type. ANALYTIC METHODS: Logit models were used to estimate the probability of prolonged stay and readmission. The LOS and the CLOS were estimated with Cox regression. Model variables included comorbidities, income, race, distance from hospital, and insurance type. Prolonged stay was based on a Hollander-Proschan "New-Worse-Than-Used" test, corresponding to a three-day stay. PRINCIPAL FINDINGS: The LOS was longer in New York than Pennsylvania, and the probabilities of prolonged stay and readmission were much higher in New York than Pennsylvania. However, once an admission was prolonged, there were no differences in CLOS between states (when readmissions were not added to the LOS calculation). In both states, children's hospitals and general hospitals had similar adjusted LOS. CONCLUSIONS: Management of asthma appears more efficient in Pennsylvania than New York: Less severe patients are discharged faster in Pennsylvania than New York; once discharged, patients are less likely to be readmitted in Pennsylvania than New York. However, once a stay is prolonged, there is little difference between New York and Pennsylvania, suggesting medical care for severely ill patients is similar across states. Differences between children's and general hospitals were small as compared to differences between states. We conclude that policy initiatives in New York, and other states, should focus their efforts on improving the care provided to less severe patients in order to help reduce overall length of stay.

Adolescent↗

PubMed2002

Anesthesiologist board certification and patient outcomes.

BACKGROUND: Board certification is often used as a surrogate indicator of provider competence, although few outcome studies have demonstrated its validity. The aim of this study was to compare the outcomes of patients who underwent surgical procedures under the care of an anesthesiologist with or without board certification. METHODS: Medicare claims records for 144,883 patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991 and 1994 were used to determine provider-specific outcome rates adjusted to account for patient severity and case mix, and hospital characteristics. Outcomes of 8,894 cases involving midcareer anesthesiologists, 11-25 yr from medical school graduation, who lacked board certification were compared with all other cases. Midcareer anesthesiologist cases were studied because this group had sufficient time to become certified during an era when obtaining certification was already considered important, and consequently had the highest rate of board certification. Mortality within 30 days of admission and the failure-to-rescue rate (defined as the rate of death after an in-hospital complication) were the two primary outcome measures. RESULTS: Adjusted odds ratios for death and failure to rescue were greater when care was delivered by noncertified midcareer anesthesiologists (death = 1.13 [95% confidence interval, 1.00, 1.26], P < 0.04; failure to rescue = 1.13 [95% confidence interval, 1.01, 1.27], P < 0.04). Adjusting for international medical school graduates did not change these results. CONCLUSIONS: When anesthesiology board certification is very common, as in midcareer practitioners, the lack of board certification is associated with worse outcomes. However, the poor outcomes associated with noncertified providers may be a result of the hospitals at which they practice and not necessarily their manner of practice.

Adult↗