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OBJECTIVES Prior studies have associated morbidity following anatomic lung resection with prolonged postoperative length of stay; however, each complication's individual impact on length of stay as a continuous variable has not been studied. The purpose of this study was to determine the risk-adjusted increase in length of stay associated with each individual postoperative complications following anatomic lung resection. METHODS Patients who underwent anatomic lung resection cataloged in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program participant use file, 2005–2018, were targeted. The association between preoperative characteristics, postoperative complications and length of stay in days was tested. A negative binomial model adjusting for the effect of preoperative characteristics and 18 concurrent postoperative complications was used to generate incidence rate ratios. This model was fit to generate risk-adjusted increases in length of stay by complication. RESULTS Of 32 133 patients, 5065 patients (15.8%) experienced at least one post-operative complication. The most frequent complications were pneumonia (n  = 1829, 5.7%), the need for transfusion (n  = 1794, 5.6%) and unplanned reintubation (n  = 1064, 3.3%). The occurrence of each of the 18 individual complications was associated with significantly increased length of stay. This finding persisted after risk-adjustment, with the greatest risk-adjusted increases being associated with prolonged ventilation (+17.4 days), followed by septic shock (+17.2 days), acute renal failure (+16.5 days) and deep surgical site infection (+13.2 days). CONCLUSIONS All 18 postoperative complications studied following anatomic lung resection were associated with significant risk-adjusted increases in length of stay, ranging from an increase of 17.4 days with prolonged ventilation to 2.6 days following the need for transfusion. [ABSTRACT FROM AUTHOR]

Background: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low‐risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low‐risk versus higher‐risk patients before and after release of these guidelines. Methods: The ACS‐NSQIP database, 2005–2018, was separated into low‐risk versus higher‐risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low‐ and higher‐risk patients. A difference‐in‐differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. Results: Of 7,507,991 patients, 972,431 (13.0%) were defined as low‐risk and 6,535,560 (87.0%) higher‐risk. Use of any preoperative laboratory test declined in low‐risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%–91.9% in higher‐risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk‐adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76–0.78) in low‐risk versus 0.93 (0.92–0.94) in higher‐risk patients. In low‐risk patients, lack of any preoperative testing was not associated with worse outcomes. Conclusions: While a majority of low‐risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low‐risk patients. [ABSTRACT FROM AUTHOR]

The downstream effects on healthcare delivery during the initial wave of the COVID‐19 pandemic remain unclear. The purpose of this study was to determine how the healthcare environment surrounding the pandemic affected the oncologic care of patients diagnosed with esophageal cancer. This was a retrospective cohort study evaluating patients in the National Cancer Database (2019–2020). Patients with esophageal cancer diagnoses were divided into pre‐pandemic (2019) and pandemic (2020) groups. Patient demographics, cancer‐related variables, and treatment modalities were compared. Among 26,231 esophageal cancer patients, 14,024 patients (53.5%) were in the pre‐pandemic cohort and 12,207 (46.5%) were in the pandemic cohort. After controlling for demographics, patients diagnosed during the pandemic were more likely to have poorly differentiated tumors (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.08–1.42), pathologic T3 disease compared to T1 (OR 1.25, 95% CI 1.02–1.53), positive lymph nodes on pathology (OR 1.36, 95% CI 1.14–1.64), and to be pathologic stage IV (OR 1.51, 95% CI 1.29–1.76). After controlling for oncologic characteristics, patients diagnosed during the pandemic were more likely to require at least two courses of systemic therapy (OR 1.78, 95% CI 1.48–2.14) and to be offered palliative care (OR 1.13, 95% CI 1.04–1.22). While these patients were offered curative therapy at lower rates, this became non‐significant after risk‐adjustment (p =.15). The pandemic healthcare environment was associated with significantly increased risk‐adjusted rates of patients presenting with advanced esophageal cancer. While this led to significant differences in treatment, most of these differences became non‐significant after controlling for oncologic factors. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to compare postoperative complication rates and healthcare charges between patients who underwent coordinated versus staged breast surgery and bilateral salpingo-oophorectomy (BSO). Patients and Methods: The MarketScan administrative database was used to identify adult female patients with invasive breast cancer or BRCA1/BRCA2 mutations who underwent BSO and breast surgery (lumpectomy or mastectomy with or without reconstruction) between 2010 and 2015. Patients were assigned to the coordinated group if a breast operation and BSO were performed simultaneously or assigned to the staged group if BSO was performed separately. Primary outcomes were (1) incidence of 90-day postoperative complications and (2) 2-year aggregate perioperative healthcare charges. Fisher's exact tests, Wilcoxon rank-sum tests, and multivariable regression analyses were performed. Results: Of the 4228 patients who underwent breast surgery and BSO, 412 (9.7%) were in the coordinated group and 3816 (90.3%) were in the staged group. The coordinated group had a higher incidence of postoperative complications (24.0% vs. 17.7%, p < 0.01), higher risk-adjusted odds of postoperative complications [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.06–1.76, p = 0.02], and similar aggregate healthcare charges before (median charges: $106,500 vs. $101,555, p = 0.96) and after risk-adjustment [incidence rate ratio (IRR) 1.00, 95% CI 0.93–1.07; p = 0.95]. In a subgroup analysis, incidence of postoperative complications (12.9% for coordinated operations vs. 11.7% for staged operation, p = 0.73) was similar in patients whose breast operation was a lumpectomy. Conclusions: While costs were similar, coordinating breast surgery with BSO was associated with more complications in patients who underwent mastectomy, but not in patients who underwent lumpectomy. These data should inform shared decision-making in high-risk patients. [ABSTRACT FROM AUTHOR]

Introduction: Receiving a new breast cancer diagnosis can cause anxiety and distress, which can lead to psychologic morbidity, decreased treatment adherence, and worse clinical outcomes. Understanding sources of distress is crucial in providing comprehensive care. This study aims to evaluate the relationship between delays in breast cancer diagnosis and patient-reported distress. Secondary outcomes include assessing patient characteristics associated with delay. Methods: Newly diagnosed breast cancer patients who completed a distress screening tool at their initial evaluation at an academic institution between 2014 and 2019 were retrospectively evaluated. The tool captured distress levels in the emotional, social, health, and practical domains with scores of "high distress" defined by current clinical practice guidelines. Delay from mammogram to biopsy, whether diagnostic or screening mammogram, was defined as >30 days. Result: 745 newly diagnosed breast cancer patients met inclusion criteria. Median time from abnormal mammogram to core biopsy was 12 days, and 11% of patients experienced a delay in diagnosis. The non-delayed group had higher emotional (p = 0.04) and health (p = 0.03) distress than the delayed group. No statistically significant differences in social distress were found between groups. Additionally, patients with higher practical distress had longer time interval between mammogram and surgical intervention compared to those with lower practical distress. Older age, diagnoses of invasive lobular carcinoma or ductal carcinoma in situ, and clinical anatomic stages 0-I were associated with diagnostic delay. Conclusion: Patients with higher emotional or health-related distress were more likely to have timely diagnoses of breast cancer, suggesting that patients with higher distress may seek healthcare interventions more promptly. Improved understanding of sources of distress will permit early intervention regarding the devastating impact of breast cancer diagnosis. [ABSTRACT FROM AUTHOR]

Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran's Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2–6 days) vs. 7 days (6–9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61–104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations. Methods: Using the 2005–2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations. Results: A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25–75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I–II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations. Conclusion: In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients. [ABSTRACT FROM AUTHOR]

Background: Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality. Methods: We calculated associations between comorbidities, complications, and 30-day mortality using the 2012–2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality. Results: 5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths. Conclusion: The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality. [ABSTRACT FROM AUTHOR]

Background: Formal surgical risk assessment tools have been developed to predict risk of adverse postoperative patient outcomes. Such tools accurately predict common postoperative complications, inform patients and providers of likely perioperative outcomes, guide decision making, and improve patient care. However, these are underutilized. We studied the attitudes towards and techniques of how surgeons preoperatively assess risk. Methods: Surgeons at a large academic tertiary referral hospital and affiliate community hospitals were emailed a 16-question survey via REDCap (Research Electronic Data Capture) between 8/2019-6/2020. Reminder emails were sent once weekly for three weeks. All completed surveys by surgical residents and attendings were included; incomplete surveys were excluded. Surveys were analyzed using descriptive statistics (frequency distributions and percentages for categorical variables, means, and standard deviations for continuous variables), and Fisher's exact test and unpaired t-tests comparing responses by surgical attendings vs. residents. Results: A total of 108 surgical faculty, 95 surgical residents, and 58 affiliate surgeons were emailed the survey. Overall response rates were 50.0% for faculty surgeons, 47.4% for residents, and 36.2% for affiliate surgeons. Only 20.8% of surgeons used risk calculators most or all of the time. Attending surgeons were more likely to use prior experience and current literature while residents used risk calculators more frequently. Risk assessment tools were more likely to be used when predicting major complications and death in older patients with significant risk factors. Greatest barriers for use of risk assessment tools included time, inaccessibility, and trust in accuracy. Conclusions: A small percentage of surgeons use surgical risk calculators as part of their routine practice. Time, inaccessibility, and trust in accuracy were the most significant barriers to use. [ABSTRACT FROM AUTHOR]

Background: Breast-conserving therapy (BCT) offers oncologic outcomes similar to those of mastectomy, yet many patients, when provided the option, choose mastectomy. This study aimed to evaluate the relationship between patient-reported distress and surgical decisions and to determine factors predictive of choosing BCT versus mastectomy. Methods: Patients with newly diagnosed breast cancer deemed candidates for BCT who completed a distress screen at their initial visit to an academic institution between 2016 and 2019 were retrospectively reviewed. This screening tool captures distress in emotional, social, health, and practical domains on a scale of 0 to 10. The distress scores were compared against surgical decisions using nonparametric Wilcoxon rank-sum tests. Patient factors associated with surgical choice were analyzed using chi-square, Fisher's exact, and Student's t tests. A two-sided p value lower than 0.05 was considered significant. Results: Of 506 patients deemed eligible for BCT, 430 (85%) chose BCT and 76 (15%) pursued mastectomy. The distress levels did not differ significantly between the surgical options. The patients who underwent mastectomy were on the average younger (50.7 vs 60.4 years; p < 0.0001), presented with palpable masses (p < 0.0001), had stage 0, 2, or 3 versus stage 1 disease (p < 0.0001), sought consultation for second opinions (19.7% vs 8.6%; p = 0.0032), received neoadjuvant chemotherapy (31.6% vs 16.3%; p = 0.0016), or had deleterious gene mutations (21.1% vs 5.1%; p < 0.0001). Conclusions: Distress was not associated with the pursuit of surgical treatment. Rather, younger age, search for a second opinion, and a palpable mass present at presentation were associated with more aggressive surgical decisions. Understanding factors that influence surgical decision-making is critical in guiding informed decisions that reflect patient values. [ABSTRACT FROM AUTHOR]

Introduction: Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is utilized as a life‐saving procedure and bridge to myocardial recovery for patients in refractory cardiogenic shock. Despite technical advancements, VA‐ECMO retains high mortality. This study aims to identify the clinical predictors of in‐hospital mortality after VA‐ECMO to improve risk stratification for this tenuous patient population. Methods: The REgistry for Cardiogenic Shock: Utility and Efficacy of Device Therapy database is a multicenter, observational registry of ECMO patients. From 2013 to 2018, 789 patients underwent VA‐ECMO. Bivariate analysis was performed on more than 300 variables regarding their association with in‐hospital mortality. Logistic regression analyses were performed with variables chosen based upon clinical and statistical significance in the bivariate analysis. Tests were considered significant at a two‐sided P <.05. Results: Although 63.5% patients were successfully weaned from VA‐ECMO, in‐hospital mortality was 57.9%. Nonsurvivors were older (P <.0001), had higher body mass index (P =.01), higher rates of hypertension (P =.02), coronary artery disease (P =.02), chronic obstructive pulmonary disease (P =.02), chronic liver disease (P =.008), percutaneous coronary intervention (P =.02), and surgical revascularization (P =.02). Multivariate predictors for in‐hospital mortality include older age (odds ratio [OR], 1.019; P =.007), cardiac arrest (OR, 2.76; P =.006), chronic liver disease (OR, 8.87; P =.04), elevated total bilirubin (OR, 1.093; P <.0001), and the presence of a left ventricular vent (OR, 2.018; P =.03). Pre‐ECMO sinus rhythm was protective (OR, 0.374; P =.006). Conclusions: In a large study of recent VA‐ECMO patients, in‐hospital mortality remains significant, but acceptable given the severe pathology manifested in this population. Identification of pre‐ECMO predictors of mortality helps stratify high‐risk patients when deciding on ECMO placement, prolonged support, and prognosis. [ABSTRACT FROM AUTHOR]

Background: Receiving a new breast cancer (BC) diagnosis can cause significant patient anxiety, which is amplified by delays in diagnosis. There is a lack of defined time periods for delays in the workup of BC. This study aims to evaluate national variations in timing from first abnormal mammogram to first biopsy and to determine independent predictors of delay in diagnosis. Patients and Methods: Data were derived from SEER–Medicare linked claims database from 2007 to 2013. Time intervals from abnormal mammogram, either screening or diagnostic, to biopsy were assessed. The fourth quartile for timing from first mammogram to first biopsy was utilized to define delay in diagnosis. Multivariate analyses were used to evaluate the association between clinicopathologic variables and delays in diagnosis. Results: We analyzed 53,758 patients with stage 0–II BC who underwent upfront surgery. Significant variations in timing of care were identified, with mean times from mammogram to biopsy, surgeon visit, and breast surgery of 23.3, 31.6, and 52.6 days, respectively. Over the study period, there was a decrease in delays from mammogram to biopsy. Non-White race, Northeast location, and earlier stage disease were found to be independent predictors of delays in the diagnosis of BC (p < 0.0001). Conclusions: The study demonstrates significant variations in time to diagnostic biopsy. More efficient processes of care to address these delays should be implemented, and further studies are needed to determine whether improved efficiency decreases patient anxiety. The large variations in time to diagnosis speak to the need for consensus guidelines to establish a standard of care. [ABSTRACT FROM AUTHOR]

Background: Risk assessment is essential to informed decision making in surgery. Preoperative use of the Surgical Risk Preoperative Assessment System (SURPAS) providing individualized risk assessment, may enhance informed consent. We assessed patient and provider perceptions of SURPAS as a risk assessment tool. Methods: A convergent mixed-methods study assessed SURPAS's trial implementation, concurrently collecting quantitative and qualitative data, separately analyzing it, and integrating the results. Patients and providers were surveyed and interviewed on their opinion of how SURPAS impacted the preoperative encounter. Relationships between patient risk and patient and provider assessment of SURPAS were examined. Results: A total of 197 patients were provided their SURPAS postoperative risk estimates in nine surgeon's clinics. Of the total patients, 98.8% reported they understood their surgical risks very or quite well after exposure to SURPAS; 92.7% reported SURPAS was very helpful or helpful. Providers shared that 83.4% of the time they reported SURPAS was very or somewhat helpful; 44.7% of the time the providers reported it changed their interaction with the patient and this change was beneficial 94.3% of the time. As patient risk increased, providers reported that SURPAS was increasingly helpful (p < 0.0001). Conclusions: Patients and providers reported the use of SURPAS helpful and informative during the preoperative risk assessment of patients, thus improving the surgical decision making process. Patients thought that SURPAS was helpful regardless of their risk level, whereas providers thought that SURPAS was more helpful in higher risk patients. [ABSTRACT FROM AUTHOR]

Introduction: The Surgical Risk Preoperative Assessment System is a parsimonious, universal surgical risk calculator integrated into our local electronic health record. We determined how many of its eight preoperative risk predictor variables could be automatically obtained from the electronic health record. This has implications for the usability and adoption of Surgical Risk Preoperative Assessment System, serving as an example of use of electronic health record data for populating clinical decision support tools. Methods: We quantified the availability and accuracy in the electronic health record of the eight Surgical Risk Preoperative Assessment System predictor variables (patient age, American Society of Anesthesiology physical status classification, functional health status, sepsis, work Relative Value Unit, in-/outpatient operation, surgeon specialty, emergency status) at the patient's preoperative encounter of 5205 patients entered into the American College of Surgeons National Surgical Quality Improvement Program. Accuracy was determined by comparing the electronic health record data to the same patient's National Surgical Quality Improvement Program data, used as the "gold standard." Acceptable accuracy was defined as a Kappa statistic or Pearson correlation coefficient ≥0.8 when comparing electronic health record and National Surgical Quality Improvement Program data. Acceptable availability was defined as presence of the variable in the electronic health record at the preoperative encounter ≥95% of the time. Results: Of the eight predictor variables, six had acceptable accuracy. Only preoperative sepsis and functional health status had Kappa statistics <0.8. However, only patient age and surgeon specialty were ≥95% available in the electronic health record at the preoperative visit. Conclusions: Processes need to be developed to populate more of the Surgical Risk Preoperative Assessment System preoperative predictor variables in the patient's electronic health record prior to the preoperative visit to lessen the burden on the busy surgeon and encourage more widespread use of Surgical Risk Preoperative Assessment System. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: There is limited data linking demographic determinants to clinical outcomes in facial trauma, particularly when comparing regional to national datasets; these are the aims of the present study.Study Design: Retrospective chart review.Methods: A 10-year, retrospective single-institutional chart review was undertaken at Children's Hospital Colorado (CHC) to characterize a pediatric population with facial fractures. A comparative analysis between the CHC and National Trauma Data Bank (NTDB) datasets was also conducted.Results: In the CHC dataset, increased hospital stay was positively predicted by bilateral mandible fracture, skull, intracranial, spine, thoracic, abdominal, and limb injuries. Predictors of increased intensive-care unit (ICU) stay included skull, spine, and limb injuries. The CHC cohort had younger subjects, more females, fewer African Americans, and more Hispanics than the NTDB dataset. They were more likely to be injured by nonviolent activities than by altercations. Divergent facial and associated injuries between the datasets were found. Multivariate models showed longer length of hospital stay for the CHC group (P = .0085), but the NTDB group had higher ICU admission (P = .04) and longer lengths of ICU stay (P = .007).Conclusion: The demographic disparities (age, ethnicity, mechanism of injury, and injury type) resulted in divergent injury patterns and likely influenced clinical outcomes.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objectives: Our objectives were to: (1) delineate factors associated with surgery at <1 year and (2) determine if early intervention was associated with increased risk of readmission. Methods: We conducted a retrospective review of children age 0-18 years with a diagnosis of UPJ obstruction who underwent pyeloplasty from 1/1/1999 to 9/1/2009 using the PHIS database. Data collected included patient factors (race, gender, insurance type, APR-DRG severity of illness) and hospital factors (annual case volume, census region, academic status). Outcomes assessed were: age at surgery and hospital readmission within 1 year of surgery. Data were analyzed using logistic regression and Cox PH for multivariate analyses. Results: 4499 children met study criteria. Minority race (OR 1.55), male gender (OR 1.49), public insurance (OR 1.37), high severity of illness (OR 3.60), Southern region (OR 1.44), and low hospital volume (OR 1.37) were significant predictors of early surgery ( p < 0.05). Only early surgery (HR 2.42; 95 % CI 1.67-3.49 2.42) was associated with increased risk of readmission. Conclusions: In children with UPJ obstruction, age at surgery is associated with patient demographic and hospital factors. Early surgery is associated with higher rates of readmission, suggesting that variations in age at surgery may be associated with significant differences in outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings. OBJECTIVE: To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. RESEARCH DESIGN AND PARTICIPANTS: Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes. MAIN MEASURES: Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. KEY RESULTS: One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients ( P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients ( P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. CONCLUSIONS: Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership. [ABSTRACT FROM AUTHOR]

Background Patients nearing the end of their lives face an array of difficult decisions. Objective This study was designed to assess the feasibility and acceptability of a decision aid (DA) designed for patients facing advanced or terminal illness. Design We conducted a pilot randomized clinical trial of Health Dialog's Looking Ahead: choices for medical care when you're seriously ill DA (booklet and DVD) applied to patients on a hospital-based palliative care (PC) service. Setting University of Colorado Hospital - December 2009 and May 2010. Participants All adult, English-speaking patients or their decision makers were potentially eligible. Patients were not approached if they were in isolation, did not speak English or if any provider felt that they were not appropriate because of issues such as family conflict or actively dying. Intervention All participants received a standard PC consultation. Participants in the intervention arm also received a copy of the DA. Measurements Primary outcomes included decision conflict and knowledge. Participants in the intervention arm also completed an acceptability questionnaire and qualitative exit interviews. Results Of the 239 patients or decision makers, 51(21%) enrolled in the trial. The DA had no significant effect on decision conflict or knowledge. Exit interviews indicated it was acceptable and empowering, although they wished they had access to the DA earlier. Conclusions While the DA was acceptable, feasibility was limited by late-life illness challenges. Future trials of this DA should be performed on patients earlier in their illness trajectory and should include additional outcome measures such as self-efficacy and confidence. [ABSTRACT FROM AUTHOR]

Background: There are no evidence-based recommendations for statin continuation or discontinuation near the end of life. However, some expert opinion recommends continuing statins prescribed for secondary versus primary prevention of cardiovascular disease. Objectives: Our aim was to explore statin prescribing patterns in a longitudinal cohort of individuals with life-limiting illness, and to evaluate differences in these patterns based on secondary versus primary prevention of cardiovascular disease. Design and setting: This study was a retrospective cohort analysis of 539 persons in an integrated, not-for-profit health maintenance organization (HMO) setting who were receiving statins at diagnosis of a cancer with 0% to 25% predicted 5-year survival. Of the cohort patients, 343 were taking statins for secondary prevention and 196 for primary prevention of cardiovascular disease. Measurements included number and timing of statin refills between diagnosis and date of death, disenrollment, or the end of the observation period. Results: Four hundred and ninety-six cohort members died within the observation period. Fifty-eight percent of the secondary prevention and 62% of the primary prevention group had at least one statin refill after diagnosis. There were no significant differences between groups for number of days between diagnosis and last refill, or between last refill and death. Two deaths were attributable to cardiovascular causes in each group. Conclusions: Our retrospective cohort analysis of persons with incident poor-prognosis cancer describes diminished, but persistent statin refills after diagnosis. Neither timing of statin discontinuation nor cardiovascular mortality differed by prescribing indication. There may be an opportunity to reevaluate medication burden in persons taking statins for primary prevention, and it is unclear whether continuing statins prescribed for secondary prevention affects cardiovascular outcomes. [ABSTRACT FROM AUTHOR]

The article presents information on a study conducted to investigate whether clinicians' explicit and implicit ethnic or racial bias is linked to the perceptions of black and Latino patients in established clinical relationships. In the Primary Care Assessment Survey, a telephone survey of 2,908 patients was conducted, that addressed their clinicians' interpersonal treatment, communication, and trust. The study found that levels of explicit bias were low among clinicians.

In young virgin Acheta domesticus females, the spiking response of the prothoracic L3 auditory interneuron discriminates between calling songs (CSs) with phonotactically attractive and unattractive syllable periods (SPs), which parallels phonotactic discrimination. Presentation of a CS with an originally attractive SP, but with the intensity modulated so as to minimize L3's selective response, results in a CS with little phonotactic attractiveness. Conversely, a CS with an originally unattractive SP becomes much more attractive when the CS is intensity modulated in ways that duplicate L3's selective response. L3's discriminatory response to CS SP deteriorates with age, in parallel with decreased phonotactic selectiveness (females, older than 14 days, typically are unselective for CS SPs). SP-selective processing, which was not apparent in these old L3s, is immediately restored by removing the contralateral ear. SP-specific information is resident in a network of neurons within the prothoracic ganglion that results in the SP selective responses of the L3 neuron in young females. Changes in the SP-selective responses of the L3 neuron are highly correlated with corresponding changes in the female's phonotactically selective behavior. [ABSTRACT FROM AUTHOR]

Background: The Surgical Risk Preoperative Assessment System (SURPAS) is a parsimonious set of models providing accurate preoperative prediction of common adverse outcomes for individual patients. However, focus groups with surgeons and patients have developed a list of questions about and recommendations for how to further improve SURPAS's usability and usefulness. Eight issues were systematically evaluated to improve SURPAS. Methods: The eight issues were divided into three groups: concerns to be addressed through further analysis of the database; addition of features to the SURPAS tool; and the collection of additional outcomes. Standard multiple logistic regression analysis was performed using the 2005–2015 American College of Surgeons National Surgical Quality Improvement Participant Use File (ACS NSQIP PUF) to refine models: substitution of the preoperative sepsis variable with a procedure-related risk variable; testing of an indicator variable for multiple concurrent procedure codes in complex operations; and addition of outcomes to increase clinical applicability. Automated risk documentation in the electronic health record and a patient handout and supporting documentation were developed. Long term functional outcomes were considered. Results: Model discrimination and calibration improved when preoperative sepsis was replaced with a procedure-related risk variable. Addition of an indicator variable for multiple concurrent procedures did not significantly improve the models. Models were developed for a revised set of eleven adverse postoperative outcomes that separated bleeding/transfusion from the cardiac outcomes, UTI from the other infection outcomes, and added a predictive model for unplanned readmission. Automated documentation of risk assessment in the electronic health record, visual displays of risk for providers and patients and an "About" section describing the development of the tool were developed and implemented. Long term functional outcomes were considered to be beyond the scope of the current SURPAS tool. Conclusion: Refinements to SURPAS were successful in improving the accuracy of the models, while reducing manual entry to five of the eight variables. Adding a predictor variable to indicate a complex operation with multiple current procedure codes did not improve the accuracy of the models. We developed graphical displays of risk for providers and patients, including a take-home handout and automated documentation of risk in the electronic health record. These improvements should facilitate easier implementation of SURPAS. [ABSTRACT FROM AUTHOR]

Background: Risk assessment in surgery is essential to guide treatment decisions but is highly variable in practice. Providing formal preoperative risk assessment to surgical teams and patients may optimize understanding of risk. Implementation of the Surgical Risk Preoperative Assessment System (SURPAS), an innovative real time, universal, preoperative tool providing individualized risk assessment, may enhance informed consent and reduce adverse outcomes. To ensure optimal development and implementation of SURPAS we performed an in-depth pre-implementation evaluation of SURPAS at an academic tertiary referral center in Colorado. Methods: Four focus groups with 24 patients, three focus groups with 29 surgical providers and clinic administrators, and five individual interviews with administrative officials were conducted to elicit their perspectives about the development and implementation of SURPAS. Qualitative data collection and analyses, utilizing a Matrix Analysis approach were used to explore insights regarding SURPAS. Results: Participants were positive about SURPAS and provided suggestions to improve and address concerns regarding it. For healthcare personnel three major themes emerged: 1) The SURPAS tool - Important work especially for high risk patients, yet not a substitute for clinical judgment; 2) Benefits of SURPAS to the risk assessment process - Improves the processes, enhances patients' participation in shared decision-making process, and creates a permanent record; and 3) Facilitators and barriers of implementation of SURPAS - Easy to incorporate into clinical practice in spite of surgical providers' resistance to adoption of new technology. For patients three major themes emerged: 1) Past experience of preoperative risk assessment discussions – Patients were not made aware of possible complications that occurred; 2) The SURPAS tool - All patients liked SURPAS and believed having printed material would be useful to guide discussions and facilitate remembering conversations with the providers; and 3) Potential concerns with having risk assessment information – Patients were mixed in deciding to have an operation with high risks. Conclusions: Systematically capturing data from the beginning of the implementation process from key stakeholders (patients, surgical providers, clinical staff, and administrators) that includes adaptations to the tool and implementation process will help to inform pragmatic approaches for implementing the SURPAS tool in various settings, scaling-up, and sustaining it. [ABSTRACT FROM AUTHOR]