Data, Data Everywhere: But Not a Drop to Analyze

Heena Santry, M.D., M.S. will discuss the challenges she faced as a researcher in converting two decades worth of trauma registry data into usable form for analysis. Dr. Santry is Assistant Professor of Surgery and Quantitative Health Sciences where she also serves as Director of Trauma Outcomes Research and Quality Assessment. She is also a UMass Clinical Research Scholar funded through the CTSA

2010 K12 Awardees: Overview of Research Projects

Two UMCCTS Clinical Research Scholars (K awardees) describe their research projects and professional growth as junior faculty: - Sarah Cutrona on Electronic Transmission of Health Information across Networks - Heena Santry on Career Development for an Academic Acute Care Surgeon and Acute Care Surgery Practice Patterns: A Tale of Two Complexitie

Does Aeromedical Transport Increase Anything Else Besides The Cost Of Care For Trauma Patients?

INTRODUCTION: Unlike many other interventions for trauma, the utilization of transport services are directly impacted by environmental factors such as geography and weather. The previous literature on aeromedical transport for trauma patients has not accounted for the variability in patient selection based on these factors. Furthermore, travel distances for aeromedical transport are rarely accounted for when trying to address this controversial topic. We undertook this study to determine whether helicopter transport imparted a survival benefit. METHODS: Our institution’s trauma registry was queried from January 1, 2000 to December 31, 2010 for adult patients (≥15yrs of age) transported directly from the scene of injury to our level one trauma center in central New England. Cohorts were designated ‘AIR’ if transported by helicopter and ‘GROUND’ if by ground EMS vehicles. A multivariable logistic regression model for mortality was constructed. In order to account for the travel time a patient would have been subject to if transported by ground, we included a co-variate for network bands in our model. Network bands were generated by 5-min increments, using Maptitude geographic information systems software that measure predicted time of travel based on available roadways and traffic patterns, as shown in figure 1. RESULTS: There were 3,615 patients who met inclusion criteria on these days. 1,281 (35%) were assigned to the AIR cohort and 2,334 (65%) were assigned to the GROUND cohort. Multivariable analyses of mortality showed that neither mode of transport nor the distance traveled were independent predictors of mortality. However, intubation status, presence of abnormal systolic blood pressure at the time of presentation to the trauma center, age, ISS, AIS and RTS were all independent predictors of mortality. CONCLUSION: There was no survival benefit for patients transported by helicopter in this study

Not Just Full of Hot Air: Hyperbaric Oxygen Therapy Increases Survival in Cases of Necrotizing Soft Tissue Infections

INTRODUCTION: The utility of hyperbaric oxygen therapy (HBOT) in the treatment for necrotizing soft tissue infections (NSTI) has not been proven. Previous studies have been subject to significant selection bias since HBOT is not universally available at all medical centers and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities. METHODS: We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (N=14). Cases of NSTI were identified by ICD-9 diagnosis codes, which included Fournier’s gangrene (608.83), necrotizing fascitis (728.86), and gas gangrene (040.0). HBOT treatment status was identified by the presence (HBOT) or absence (CONTROL) of ICD-9 procedure code (93.95). We then risk stratified and matched our cohort by UHC’s validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression. RESULTS: There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Risk stratified univariate outcomes are summarized in the table. There was no difference between HBOT and CONTROL groups in hospital length of stay (LOS), direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p CONCLUSION: At HBOT capable centers, receiving HBOT was associated with a significant survival benefit. HBOT in conjunction with current practices for the treatment of NSTI can be both a cost effective and life saving therapy

Gastrointestinal Perforations: Examining the Overlooked Unintentional Consequences of Our Nation’s Epidemic of Antibiotic Exposure

Objective: More than 266 million courses of antibiotics are dispensed to outpatients annually in the US, with the rising elderly population consuming a substantial number of antibiotics. At least 30% of these antibiotics prescribed are unnecessary. Alterations in gut microbiome are known to cause stomach and small intestine (SSI) perforations. However, the impact of antibiotic exposure outcomes of SSI perforations among the elderly has not been studied. We examined the relationship between antibiotic exposure, as a proxy for microbiome modulation, and SSI perforation outcomes in a nationwide sample of elderly patients. Methods: A 5% random sample of Medicare beneficiaries (2009-2011) was queried to identify patients with SSI perforations. Previous outpatient antibiotic exposure (0-30, 31-60, 61-90 days prior to admission) was assessed. Clinical characteristics were compared between no previous antibiotic exposure (NPA) and previous antibiotic exposure (PA) patients. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay and 30-day readmission. Univariate and multivariable regression analyses were performed. Results: Overall, 401 patients ≥ 65 years had SSI perforations (68.3% with NPA and 31.7 % with PA). Mean age (± SD) was 80 years (± 8). Overall in-hospital mortality was 13%. There was a significant difference in the rates of mortality (12% in NPA vs. 18 % in 0-30 days PA, 17% 31-60 days PA, and 8% 61-90 days PA, P= 0.002). After adjustment of other factors, a trend toward increased in-hospital mortality was observed among patients in 0-30 days PA (odds ratio [OR] 2.0, 95% confidence interval [CI] (0.9, 4.7) and was significantly associated with ICU admission (OR 4.3, 95% CI (1.8, 10.2). Conclusion: Recent antibiotic use increases illness severity and may increase mortality among elderly patients with SSI perforations. Exposure to antibiotics, one of the most modifiable determinants of microbiota, should be minimized in the outpatient setting

The Effect of Oral Antibiotics on the Development of Community Acquired Clostridium Difficile Colitis in Medicare Beneficiaries

Clostridium difficile infection (CDI) is increasingly prevalent among community dwelling Americans. Older Americans are particularly vulnerable to community-acquired Clostridium difficile (CACD), in part to increasing use of antibiotics. We studied the association between outpatient antibiotics and CACD among Medicare beneficiaries. Case-control study utilizing a 5% sample of Medicare beneficiaries (2009-2011). Patients with CACD severe enough to warrant hospitalization were identified by a primary diagnosis code for CDI and no exposure to a healthcare environment within 90-days of admission. 1,514 CACD cases were matched to ten controls each on birth year and sex. Potential controls with exposure to healthcare environment were excluded. Outpatient oral antibiotic exposure was classified into three groups: ≤30 days, 31-60 days, or 61-90 days prior to case subject’s index admission. Metronidazole and Vancomycin were excluded because they are used to treat CDI. Multivariable models were utilized to determine the independent effect of antibiotics on the development of CACD while controlling for several patient associated characteristics. Cases of CACD had more outpatient antibiotic exposure in each time period examined: ≤30 days = 40.0% vs 8.4%; 31-60 = 10.7% vs 5.0%; and 61-90 = 5.5% vs 4.4% (all p-values \u3c 0.05). Subjects exposed to antibiotics ≤30 days prior to admission had a markedly higher risk of being admitted with CACD compared with those not exposed (OR 8.09, 95% CI 7.13, 9.19). Similarly, subjects taking antibiotics 31-60 days and 61-90 days prior to admission had increased risk of CDI admission (OR 3.65, 95% CI 3.02, 4.41) and (OR 2.06, 95% CI 1.61, 2.63) respectively. Recent exposure to outpatient oral antibiotics increases the risk of CACD among community dwelling elderly with the risk persisting as long as 90 days after exposure. Inappropriate antibiotic usage must be minimized and older Americans who require outpatient antibiotic treatment may warrant close observation for signs of CDI

Utilization and Outcomes of Patients with Colorectal Cancer Liver Metastases in the Medicare Population

Aggressive treatment of colorectal liver metastases (CRLM) after colectomy is increasing in the last two decades with reports of improved survival. Multiple treatment options are available for CRLM but their use and utility remains unknown. Methods: Using SEER-Medicare linked database (1991-2005), we identified 7131 patients who had undergone colectomy with CRLM. Demographic, clinical and tumor factors were examined as determinants of therapy. Treatment options consisted of surgery (resection, ablation) or chemotherapy. Univariate and multivariate analyses were performed to determine predictors of overall survival after colectomy. Results:635 patients (8.9%) underwent liver directed surgery defined as either a liver resection (n=495), ablation (n=216) or both (n=76) for CRLM. 322 patients (51%) were female and 313 (49%) were male. 147 patients (23%) were SES 1, 230 patients (36%) were SES 2, and 258 (41%) were SES 3. There was a survival advantage to receiving liver surgery or chemotherapy in selected patients with CRLM (p Conclusion: In the Medicare population, patients with CRLM who receive potentially curative therapy such as resection, ablation or chemotherapy experience a substantial survival advantage; despite this only 8.9% of patients received directed therapy for their metastasis. Barriers to treatment and its underutilization must be identified to improve survival in patients diagnosed with CRLM after colectomy

Acute Care Surgery Patterns in the Current Era: Results of a Qualitative Study

Introduction: Since Acute Care Surgery (ACS) was first conceptualized as a specialty a decade ago, ACS teams have been widely adopted. Little is known about the structure and function of these teams. Methods: We conducted 18 open-ended interviews with ACS leaders (1 interview/center representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] variations). Two independent reviewers analyzed transcribed interviews using an inductive approach to determine major themes in practice variation (NVivo qualitative analysis software). Results: All respondents described ACS as a specialty treating time sensitive surgical disease including trauma, emergency general surgery (EGS), and surgical critical care (SCC). 11/18 combined trauma and EGS into a single clinical team; 6/18 included elective general surgery. Emergency orthopedics, neurosurgery, and triage for all surgical services were rare (1/18 each). 11/18 had blocked OR time. All had a core group of trauma and SCC surgeons; 8/18 shared EGS due to volume, manpower, or competition for EGS call. Many (12/18) had formal morning signout rounds; few (2/18) had prospective EGS data registries. Streamlined access to EGS, evidence-based EGS protocols, and improved communication were considered strengths of ACS. ACS was described as the last great surgical service reinvigorated to provide timely, cost-effective EGS by experts in resuscitation and critical care and to attract young, talented, eager surgeons to trauma and SCC; however, there was concern that it might become the waste basket for everything that happens at inconvenient times. Conclusion: Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive

Contemporary Analysis of Malignancies in Women of Child-Bearing Age: An NSQIP Analysis

Background: Recent evidence suggests that cancer incidence among pregnant women is increasing. The pattern of malignancies in pregnant women and how these compare to their nonpregnant counterparts has not been explored. Here we describe the differences in the proportion of resected malignancies in this population. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify women aged 18-49 who underwent an operation for malignancy from 2007-2012. Age-adjusted distribution of specific surgical interventions for malignancy based on ICD-9 codes were compared among pregnant and non-pregnant women using logistic regression analysis. Results: 42,732 subjects with malignancies surgically treated during child-bearing age were identified. 0.33% (n=143) were pregnant. The most common tumors requiring resection were breast (51%), thyroid (17%), and colorectal (9%). The distribution for most cancers was similar between groups. The age-adjusted proportion was significantly increased in breast, major salivary gland and oropharyngeal malignancies (p\u3c0.05). The proportion of resected colorectal cancers was significantly lower in pregnant women (p\u3c0.05; Table 1). Conclusion: This study serves as the first comprehensive and contemporary overview of malignancies resected in women of childbearing age. This study demonstrates that the proportion of resections among pregnant women was significantly greater in breast, major salivary gland and oropharyngeal cancers and lower for colorectal cancers. While these data might represent true differences in cancer incidence, further work is necessary to demonstrate if these are true differences in incidence versus differences in detection and treatment of the pregnant patient

Endemic Gallbladder Cancer: Is There a Role for Prophylactic Cholecystectomy?

Background: Gallbladder cancer (GBC) is an often lethal malignancy with variable distribution. Incidence in the United States is low. However, in areas of Central/South America, Central Europe, Japan, and the Indian subcontinent, GBC is a major cause of cancer death. Cholecystectomy is safe and commonly performed worldwide. Thus, prophylactic cholecystectomy (PCCY) has been proposed in regions with endemic GBC. We developed a simple decision model to assist caregivers in determining the optimal strategy for managing GBC based on local incidence and technological capabilities. Methods: Rates of disease and outcomes were derived from a review of the literature. Using TreeAge-Pro software, a decision model was created to simulate expected health outcomes for populations with high GBC incidence, following 3 treatment strategies: no early intervention, one-time screening ultrasound (US), or PCCY. Lifetime cancer-specific survival was the outcome of interest. Sensitivity analyses were performed to determine threshold values. Results: Based on our model, populations where lifetime risk of GBC exceeds 0.4% may benefit from early intervention by US or PCCY. Two-way sensitivity analysis shows that over a relatively narrow range of disease incidence, US may be favored if sensitivity exceeds 50%. In many cases where lifetime risk exceeds 1%, PCCY may improve survival. Conclusions: GBC varies in incidence, but affects many individuals in some populations in the Americas. The lethality of GBC may justify aggressive public health intervention including screening or prophylactic cholecystectomy. Decision analysis models using best-available evidence may help determine the optimal treatment of individuals at risk for GBC