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News Article | May 23, 2017
Site: www.eurekalert.org

Boston, MA-- Unintentional injury is the leading cause of pediatric death in the U.S. and motor vehicle crashes (MVCs) are the most common cause of injury. A new paper published in the Journal of Pediatrics by researchers at Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital (BWH) and UT Southwestern Medical Center in Dallas, is the first to examine state-level factors contributing to variation in pediatric mortality in motor vehicle crashes and to identify trends across states. On average across all states, researchers found that 20 percent of children involved in a fatal crash were unrestrained or inappropriately restrained at the time of the crash. Thirteen percent were inappropriately seated in the front seat, and nearly 9 percent of drivers transporting a child passenger were under the influence of alcohol. The study's authors estimate that a 10 percent absolute improvement in child restraint use--decreasing the average number of unrestrained or inappropriately restrained children from 20 percent to 10 percent nationally--would avert approximately 232 pediatric deaths per year, or more than 1,100 over five years. These findings highlight the importance of child restraint use and reinforce guidelines on child restraints published by the American Academy of Pediatrics (AAP) in 2011. "In order to prevent children from being killed in motor vehicle crashes, we must understand the effects of state-level regulations, their implementation and enforcement," said Lindsey Wolf, MD, MPH, general surgery resident at BWH, research fellow at CSPH and lead author of the study. "Since laws governing child traffic safety are made at the state level, we formulated a study design that would produce state-by-state geographic results, which could easily be utilized by policy makers aiming to reduce pediatric mortality and save children's lives in their states." The authors found substantial state-level variation, and concluded overall that the percentage of children who were unrestrained or inappropriately restrained was a leading predictor of mortality. The percentage of children involved in a fatal crash who were unrestrained or inappropriately restrained varied from 2 percent in New Hampshire to 38 percent in Mississippi. Crashes were most likely to occur on state highways (35 percent) and on roads classified as rural by the Federal Highway Authority (62 percent). Characteristics of the crashes also varied: the percentage of those that occurred on a rural road varied from 17 percent in Massachusetts and Rhode Island to 100 percent in Maine and Vermont; the percentage of those that occurred on state highways varied from 11 percent in Iowa to 84 percent in Hawaii; and the percentage of those that occurred on a road with a speed limit 65 to 80 miles per hour varied from 0 percent in Hawaii, Maine, and Rhode Island to 80 percent in Wyoming. The number of fatal crashes over 2010-2014 ranged from 18 in Rhode Island to 2,017 in Texas, while the number of deaths ranged from 3 in Rhode Island to 346 in Texas. Age-adjusted, mean MVC-related pediatric mortality per 100,000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi. The percentage of children that died of those involved in a fatal crash varied from 8 percent in New Hampshire to 30 percent in Nebraska. The first-of-its-kind analysis included data from 18,116 children, ages 15 and younger, riding in a passenger vehicle involved in a fatal crash occurring from 2010-2014, as reported in the Fatality Analysis Reporting System (FARS) dataset. FARS is a nationwide census providing publicly-available data on fatalities associated with MVCs, compiled from various documents in each state, including police accident reports, death certificates, state vehicle registration files, medical examiner reports, state driver licensing files, state highway department data, emergency medical service reports and vital statistics. These data were used in conjunction with annual U.S. Census data to create population size estimates by age, state and region, and the percentage of households with a vehicle, in examining two outcomes: state-based, age-adjusted, mean MVC-related pediatric mortality per 100,000 children; and percentage of children involved in a fatal crash who died ("fatal crashes" were defined as crashes that occurred on a public road and resulted in at least one death, adult or pediatric, within 30 days). Both of these outcomes were calculated by region (Midwest, Northeast, South, West) and nationally. An extensive list of factors potentially affecting MVC-related pediatric mortality were examined, including restraint use, road type, vehicle type, speed limit, red light camera policy and more. In order to understand the effects of individual factors on the desired outcomes, the study's authors leveraged an ecological study design, first employing multivariable linear regression to identify state characteristics associated with each outcome. "The American Academy of Pediatrics has issued clear guidelines regarding child restraints and other factors in order to save children's lives in the event of motor vehicle crashes, and many states have implemented them in part, but no state has implemented them fully," said Faisal Qureshi, MD, MBA, associate professor of surgery at UT Southwestern Medical Center, and senior author of the study. "The significant state-level variation evident in our findings emphasizes the need for close collaboration between the injury prevention community and those enacting and enforcing legislation, and suggests the potential for a federal intervention in the area of child traffic safety." The authors note that further research is required to understand how factors like vehicle type, roadway characteristics, speed limits, and red light camera use may contribute to the overall risk of death. This work was supported by the American College of Surgeons Resident Research Scholarship to Lindsey L. Wolf, MD. Elena Losina, PhD is supported by a grant from the U.S. National Institute of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (K24AR057827-02). The study sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit for publication. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript. A portion of this work was presented as an oral presentation at the American Academy of Pediatrics National Conference & Exhibition in San Francisco, October 21-25, 2016. The Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital was established in 2005 as a joint program of Harvard Medical School and the Harvard T. H. Chan School of Public Health. Its mission is to advance the science of surgical care delivery by studying effectiveness, quality, equity, and value at the population level, and developing surgeon-scientists committed to excellence in these areas. CSPH works with a diverse set of collaborators, including academic institutions, non-profit and for-profit organizations nationally and internationally, in order to eliminate disparities and foster patient-centered care through policy and practice. Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $600 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.


News Article | May 25, 2017
Site: www.sciencedaily.com

Unintentional injury is the leading cause of pediatric death in the U.S. and motor vehicle crashes (MVCs) are the most common cause of injury. A new paper published in the Journal of Pediatrics by researchers at Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital (BWH) and UT Southwestern Medical Center in Dallas, is the first to examine state-level factors contributing to variation in pediatric mortality in motor vehicle crashes and to identify trends across states. On average across all states, researchers found that 20 percent of children involved in a fatal crash were unrestrained or inappropriately restrained at the time of the crash. Thirteen percent were inappropriately seated in the front seat, and nearly 9 percent of drivers transporting a child passenger were under the influence of alcohol. The study's authors estimate that a 10 percent absolute improvement in child restraint use -- decreasing the average number of unrestrained or inappropriately restrained children from 20 percent to 10 percent nationally -- would avert approximately 232 pediatric deaths per year, or more than 1,100 over five years. These findings highlight the importance of child restraint use and reinforce guidelines on child restraints published by the American Academy of Pediatrics (AAP) in 2011. "In order to prevent children from being killed in motor vehicle crashes, we must understand the effects of state-level regulations, their implementation and enforcement," said Lindsey Wolf, MD, MPH, general surgery resident at BWH, research fellow at CSPH and lead author of the study. "Since laws governing child traffic safety are made at the state level, we formulated a study design that would produce state-by-state geographic results, which could easily be utilized by policy makers aiming to reduce pediatric mortality and save children's lives in their states." The authors found substantial state-level variation, and concluded overall that the percentage of children who were unrestrained or inappropriately restrained was a leading predictor of mortality. The percentage of children involved in a fatal crash who were unrestrained or inappropriately restrained varied from 2 percent in New Hampshire to 38 percent in Mississippi. Crashes were most likely to occur on state highways (35 percent) and on roads classified as rural by the Federal Highway Authority (62 percent). Characteristics of the crashes also varied: the percentage of those that occurred on a rural road varied from 17 percent in Massachusetts and Rhode Island to 100 percent in Maine and Vermont; the percentage of those that occurred on state highways varied from 11 percent in Iowa to 84 percent in Hawaii; and the percentage of those that occurred on a road with a speed limit 65 to 80 miles per hour varied from 0 percent in Hawaii, Maine, and Rhode Island to 80 percent in Wyoming. The number of fatal crashes over 2010-2014 ranged from 18 in Rhode Island to 2,017 in Texas, while the number of deaths ranged from 3 in Rhode Island to 346 in Texas. Age-adjusted, mean MVC-related pediatric mortality per 100,000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi. The percentage of children that died of those involved in a fatal crash varied from 8 percent in New Hampshire to 30 percent in Nebraska. The first-of-its-kind analysis included data from 18,116 children, ages 15 and younger, riding in a passenger vehicle involved in a fatal crash occurring from 2010-2014, as reported in the Fatality Analysis Reporting System (FARS) dataset. FARS is a nationwide census providing publicly-available data on fatalities associated with MVCs, compiled from various documents in each state, including police accident reports, death certificates, state vehicle registration files, medical examiner reports, state driver licensing files, state highway department data, emergency medical service reports and vital statistics. These data were used in conjunction with annual U.S. Census data to create population size estimates by age, state and region, and the percentage of households with a vehicle, in examining two outcomes: state-based, age-adjusted, mean MVC-related pediatric mortality per 100,000 children; and percentage of children involved in a fatal crash who died ("fatal crashes" were defined as crashes that occurred on a public road and resulted in at least one death, adult or pediatric, within 30 days). Both of these outcomes were calculated by region (Midwest, Northeast, South, West) and nationally. An extensive list of factors potentially affecting MVC-related pediatric mortality were examined, including restraint use, road type, vehicle type, speed limit, red light camera policy and more. In order to understand the effects of individual factors on the desired outcomes, the study's authors leveraged an ecological study design, first employing multivariable linear regression to identify state characteristics associated with each outcome. "The American Academy of Pediatrics has issued clear guidelines regarding child restraints and other factors in order to save children's lives in the event of motor vehicle crashes, and many states have implemented them in part, but no state has implemented them fully," said Faisal Qureshi, MD, MBA, associate professor of surgery at UT Southwestern Medical Center, and senior author of the study. "The significant state-level variation evident in our findings emphasizes the need for close collaboration between the injury prevention community and those enacting and enforcing legislation, and suggests the potential for a federal intervention in the area of child traffic safety." The authors note that further research is required to understand how factors like vehicle type, roadway characteristics, speed limits, and red light camera use may contribute to the overall risk of death.


News Article | April 24, 2017
Site: www.futurity.org

Patients are far more willing to disclose their sexual orientation to health care providers than those providers believe, new research suggests. More than three-quarters of hospital emergency room doctors and nurses thought patients would refuse to discuss their sexual orientation, while only 10.3 percent of patients said they would balk at the question, the study shows. Closing that disclosure gap, the investigators say, has the potential to improve the care of lesbian, gay, and bisexual patients, a population with historically poorer overall health and less access to health care and insurance than the straight population. About 8 million American adults identify as lesbian, gay, or bisexual, according to government estimates. The research, published in JAMA Internal Medicine, is part of the EQUALITY Study, a collaboration among researchers at the Johns Hopkins University School of Medicine, Brigham and Women’s Hospital, and Harvard Medical School. “Unlike racial/ethnic and age data, information about sexual orientation and gender identity has not been collected routinely in health care settings, which limits the ability of researchers and clinicians to determine the unique needs of the lesbian, gay and bisexual communities,” says Brandyn Lau, assistant professor of surgery at Johns Hopkins and the study’s senior author. “Health care providers haven’t collected these data, at least in part due to fear of offending patients, but this study shows that most patients actually would not be offended,” he says. Researchers aren’t taking to LGB teens of color The study focused on emergency departments, which get more than 130 million patient visits annually in the United States. EDs are the source of nearly half of US inpatient hospital admissions and the primary point of entry for uninsured and underinsured patients. The research team first interviewed 53 adult patients and 26 health care professionals from three community hospitals and two academic medical centers. Although clinicians recognized the importance of knowing a patient’s sexual orientation when medically relevant, most patients believed that sexual orientation was always relevant. Many felt health care professionals needed to know sexual orientation not just to enable them to provide relevant care, but also to help them recognize the lesbian, gay, and bisexual population. “Our patients are telling us,” says lead author Adil Haider, director of the Center for Surgery and Public Health at Brigham and Women’s Hospital, “that routinely asking all patients who come to the ED about this information creates a sense of normalcy toward people of all sexual orientations and signals that each patient is equally welcome here, including the 3 to 10 percent of Americans who identify as lesbian, gay, or bisexual.” Being rude to your doctor makes them mess up The second phase of the research was an online survey of 1,516 potential adult patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses). Just under 78 percent of the clinicians said patients would refuse to provide their sexual orientation if asked, but only 10.3 percent of patients said they would decline. Specifically, only about 10 percent of straight patients, 4.8 percent of lesbians, 12 percent of gay men, and 16.4 percent of bisexual patients said they would refuse to answer a question in the ED about sexual orientation. “We need to make collecting sexual orientation information a regular part of our practice, similar to how other demographic information such as age and race is collected,” Lau says. “Because I don’t think providers will start consistently collecting these data on their own, clinics and hospitals need to mandate it.” The Patient-Centered Outcomes Research Institute funded the work. Source: Johns Hopkins University The post Doctors don’t think we’ll answer this identity question appeared first on Futurity.


A study that surveyed a national sample of emergency department health care providers and adult patients suggests that patients are substantially more willing to disclose their sexual orientation than health care workers believe. In a report on the study, published in JAMA Internal Medicine on April 24, the researchers found that nearly 80 percent of health care professionals believed patients would refuse to provide sexual orientation information, while only 10.3 percent of patients reported they would refuse. Closing that disclosure gap, the investigators say, has the potential to improve the care of lesbian, gay and bisexual patients, a population with historically poorer overall health and less access to health care and insurance compared to the straight population. An estimated 8 million American adults identify as lesbian, gay or bisexual, according to government sources. The new research, part of the EQUALITY Study, is a collaborative effort among researchers at the Johns Hopkins University School of Medicine, Brigham and Women's Hospital and Harvard Medical School. "Unlike racial/ethnic and age data, information about sexual orientation and gender identity has not been collected routinely in health care settings, which limits the ability of researchers and clinicians to determine the unique needs of the lesbian, gay and bisexual communities," says Brandyn Lau, M.P.H., C.P.H., assistant professor of surgery at the Johns Hopkins University School of Medicine and the report's senior author. "Health care providers haven't collected these data, at least in part due to fear of offending patients, but this study shows that most patients actually would not be offended," he says. For the study, which the researchers believe is the first to compare patients' and clinicians' views about routine collection of sexual identity data, the scientists focused on emergency departments (EDs), which see more than 130 million visits annually in the U.S. EDs are the source of nearly half of inpatient hospital admissions in the U.S. and the primary point of entry for uninsured and underinsured patients, making them ideal locations for collecting sexual orientation information. In the study's first phase, the research team recruited 53 adult patients and 26 health care professionals from three community hospitals and two academic medical centers for qualitative interviews that lasted an average of one hour. The interviews took place between August 2014 and January 2015, and one of two researchers had a guided conversation with each participant about sexual orientation collection in the ED, barriers and facilitators to collection, and preferred methods of collection. The interviews revealed that although clinicians recognized the importance of disclosure of sexual orientation when medically relevant, most patients believed that sexual orientation was always relevant. Similarly, many patients stated that sexual orientation was something health care professionals needed to know, not only for the sake of patients' health care, but also for recognizing and normalizing the lesbian, gay and bisexual population. "Our patients are telling us that routinely asking all patients who come to the ED about this information creates a sense of normalcy toward people of all sexual orientations and signals that each patient is equally welcome here, including the three to 10 percent of Americans who identify as lesbian, gay or bisexual," says Adil Haider, M.D., M.P.H., Kessler Director of the Center for Surgery and Public Health at Brigham and Women's Hospital and the paper's first author. In the next phase of the study, the research team conducted an online survey using a nationally representative sample from GfK's KnowledgePanel and GfK's Physician Consulting Network. GfK is a marketing research company with survey tools tailored to a variety of interests. Surveys were sent to 1,516 potential adult patients (244 lesbian, 289 gay, 179 bisexual and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) between March and April 2015. The 53-question survey for patients and 45-question survey for health care professionals consisted of multiple-choice responses, Likert scale choices (agree/strongly agree, neutral, and disagree/strongly disagree) and open-ended questions. 333 (77.8 percent) of all surveyed clinicians said patients would refuse to provide their sexual orientation if asked, but only 154 patients (10.3 percent) reported they would refuse to do so, indicating a significant discrepancy between what physicians and patients believe, the researchers said. In the population-weighted results, 143 straight patients (10.1 percent of the total), one lesbian (4.8 percent), three gay (12.0 percent) and five bisexual (16.4 percent) patients would refuse to share their sexual orientation in the ED. Bisexual patients were almost twice as likely to refuse to provide their sexual orientation as were straight patients. Both patients and clinicians indicated nonverbal self-report as the preferred method of sexual orientation information collection. "We need to make collecting sexual orientation information a regular part of our practice, similar to how other demographic information such as age and race is collected, and because I don't think providers will start consistently collecting these data on their own, clinics and hospitals need to mandate it," says Lau. As a next step, the research team will test different approaches to data collection, also as part of the EQUALITY Study. Other authors on this paper include Lisa M. Kodadek, Claire Snyder, Laura Vail, Danielle German and Susan Peterson of the Johns Hopkins University; Eric B. Schneider, Rachel R. Adler and Anju Ranjit of Harvard Medical School; Maya Torain of Duke University School of Medicine; Ryan Y. Shields of Yale School of Medicine; and Jeremiah D. Schuur of Brigham & Women's Hospital. This study was funded by PCORI (contract AD-1306-03980). Brandyn Lau is supported by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant contract CE-12-11-4489 from the Patient Centered Outcomes Research Institute (PCORI) and grant 1R01HS024547 from the Agency for Healthcare Research and Quality.


Zogg C.K.,Center for Surgery and Public Health
Journal of Oncology | Year: 2014

Exemplified by cancer cells' preference for glycolysis, for example, the Warburg effect, altered metabolism in tumorigenesis has emerged as an important aspect of cancer in the past 10-20 years. Whether due to changes in regulatory tumor suppressors/oncogenes or by acting as metabolic oncogenes themselves, enzymes involved in the complex network of metabolic pathways are being studied to understand their role and assess their utility as therapeutic targets. Conversion of glycolytic intermediate 3-phosphoglycerate into phosphohydroxypyruvate by the enzyme phosphoglycerate dehydrogenase (PHGDH) - a rate-limiting step in the conversion of 3-phosphoglycerate to serine - represents one such mechanism. Forgotten since classic animal studies in the 1980s, the role of PHGDH as a potential therapeutic target and putative metabolic oncogene has recently reemerged following publication of two prominent papers near-simultaneously in 2011. Since that time, numerous studies and a host of metabolic explanations have been put forward in an attempt to understand the results observed. In this paper, I review the historic progression of our understanding of the role of PHGDH in cancer from the early work by Snell through its reemergence and rise to prominence, culminating in an assessment of subsequent work and what it means for the future of PHGDH. © 2014 Cheryl K. Zogg.


Nguyen P.L.,Dana-Farber Cancer Institute | Je Y.,Harvard University | Schutz F.A.B.,Harvard University | Hoffman K.E.,University of Houston | And 4 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Whether androgen deprivation therapy (ADT) causes excess cardiovascular deaths in men with prostate cancer is highly controversial and was the subject of a joint statement by multiple medical societies and a US Food and Drug Administration safety warning. Objective: To perform a systematic review and meta-analysis of randomized trials to determine whether ADT is associated with cardiovascular mortality, prostate cancer-specific mortality (PCSM), and all-cause mortality in men with unfavorable-risk, nonmetastatic prostate cancer. Data Sources: A search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for relevant randomized controlled trials in English between January 1, 1966, and April 11, 2011. Study Selection: Inclusion required nonmetastatic disease, intervention group with gonadotropin-releasing hormone agonist-based ADT, control group with no immediate ADT, complete information on cardiovascular deaths, and median follow-up of more than 1 year. Data Extraction: Extraction was by 2 independent reviewers. Summary incidence, relative risk (RR), and CIs were calculated using random-effects or fixed-effects models. Results: Among 4141 patients from 8 randomized trials, cardiovascular death in patients receiving ADT vs control was not significantly different (255/2200 vs 252/ 1941 events; incidence, 11.0%; 95% CI, 8.3%-14.5%; vs 11.2%; 95% CI, 8.3%- 15.0%; RR, 0.93; 95% CI, 0.79-1.10; P=.41). ADT was not associated with excess cardiovascular death in trials of at least 3 years (long duration) of ADT (11.5%; 95% CI, 8.1%-16.0%; vs 11.5%; 95% CI, 7.5%-17.3%; RR, 0.91; 95% CI, 0.75-1.10; P=.34) or in trials of 6 months or less (short duration) of ADT (10.5%; 95% CI, 6.3%- 17.0%; vs 10.3%; 95% CI, 8.2%-13.0%; RR, 1.00; 95% CI, 0.73-1.37; P=.99). Among 4805 patients from 11 trials with overall death data, ADT was associated with lower PCSM (443/2527 vs 552/2278 events; 13.5%; 95% CI, 8.8%-20.3%; vs 22.1%; 95% CI, 15.1%-31.1%; RR, 0.69; 95% CI, 0.56-0.84; P≲λτ∀.001) and lower all-cause mortality (1140/2527 vs 1213/2278 events; 37.7%; 95% CI, 27.3%-49.4%; vs 44.4%; 95% CI, 32.5%-57.0%; RR, 0.86; 95% CI, 0.80-0.93; P≲λτ∀. 001). Conclusion: In a pooled analysis of randomized trials in unfavorable-risk prostate cancer, ADT use was not associated with an increased risk of cardiovascular death but was associated with a lower risk of PCSM and all-cause mortality. ©2011 American Medical Association. All rights reserved.


Perry D.C.,University of Liverpool | Metcalfe D.,Center for Surgery and Public Health | Griffin X.L.,University of Oxford | Costa M.L.,University of Oxford
BMJ (Online) | Year: 2016

Objectives: To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities. Design: Observational cohort study using the National Hip Fracture Database (NHFD). Setting: All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland. Participants: Patients within the national database (all aged ≥60) who received operative treatment for a nonpathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015. Main outcom e measures: Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE). Results: 114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98). Conclusions: There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital. © BMJ Publishing Group Ltd 2016.


Sacks G.D.,Center for Surgery and Public Health | Hill C.,Harvard University | Rogers S.O.,Brigham and Women's Hospital
Journal of Trauma - Injury, Infection and Critical Care | Year: 2011

Background: Postacute care is an essential component of medical care aimed at returning trauma patients to their preinjury functional status. Rehabilitation services, skilled nursing facilities, and home care all play a role in facilitating the healing process. Access to such care may be limited based on insurance status, leaving the uninsured with limited resources to reach full recovery. We hypothesized that access to specialized postacute care is less available to patients who lack health insurance. Methods: A retrospective cohort of trauma patients in the National Trauma Databank from 2002 to 2006 was assessed to determine whether insurance status was a predictor of discharge to a specialized postacute care facility (rehabilitation, skilled nursing facilities, and home health). Using multivariate logistic regression, we assessed the likelihood of discharge to such facilities on the basis of insurance status, controlling for patient demographics and injury severity. Results: Adjusting for variation in age, race/ethicity, gender, and injury type and severity, uninsured patients had the lowest odds of being discharged to a skilled nursing facility (odds ratio [OR], 0.76; 95% confidence interval [CI] 0.73-0.80; p < 0.001), home health (OR, 0.51; 95% CI 0.49-0.53; p < 0.001), and rehabilitation (OR, 0.45; 95% CI 0.44-0.46; p < 0.001). Uninsured patients had the highest odds, however, of being discharged directly home (OR, 1.32; 95% CI 1.30-1.34; p < 0.001). Conclusion: Insurance status is an important predictor of hospital disposition and access to specialized posthospital care. Uninsured patients are less likely to have access to the full range of medical care available to ensure complete recovery from traumatic injuries. Copyright © 2011 by Lippincott Williams & Wilkins.


Billmeier S.E.,Brigham and Women's Hospital | Billmeier S.E.,Center for Surgery and Public Health | Ayanian J.Z.,Center for Surgery and Public Health | Ayanian J.Z.,Harvard University | And 6 more authors.
Journal of the National Cancer Institute | Year: 2011

Background Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections. Methods A population-and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests. Results One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P =. 004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P =. 02), more severe lung disease (P <. 001), and a history of stroke (P =. 049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P =. 02), non-fee-for-service compensation (P =. 008), and National Cancer Institute cancer center designation (P =. 006) were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P =. 003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI =-.1% to 9.2%, P =. 09). Postoperative complications did not differ by type of surgery (all P >. 05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P =. 05). Conclusions Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection. © 2011 The Author.


McClure R.S.,Brigham and Women's Hospital | Narayanasamy N.,Brigham and Women's Hospital | Wiegerinck E.,Brigham and Women's Hospital | Lipsitz S.,Center for Surgery and Public Health | And 5 more authors.
Annals of Thoracic Surgery | Year: 2010

Background: This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. Methods: From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 ± 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Results: Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. Conclusions: The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure. © 2010 The Society of Thoracic Surgeons.

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