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Portland, OR, United States

Wiler J.L.,Aurora University | Asplin B.R.,Fairview Health Services | Granovsky M.,Fort Washington Hospital | Moorhead J.,Oregon Health science Center | And 2 more authors.
Annals of Emergency Medicine | Year: 2012

Optimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting. © 2011 American College of Emergency Physicians. Source

Reece T.B.,University of Colorado at Denver | Welke K.F.,Oregon Health science Center | O'Brien S.,Duke Clinical Research Institute | Grau-Sepulveda M.V.,Duke Clinical Research Institute | And 2 more authors.
Annals of Thoracic Surgery | Year: 2014

Background Although questionable durability has tempered enthusiasm for the Ross procedure in the last decade, the perioperative risks of the Ross procedure relative to conventional aortic valve replacement are not well described. The goal of this study is to describe both the perioperative outcomes and utilization trends of the Ross procedure in adults in The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Methods The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to review all Ross procedures performed between 1994 and 2010. The utilization of the procedure in the database was assessed. Then the preoperative comorbidities, patient demographics, and risk factors were reviewed, as were intraoperative and perioperative outcomes. Results Of 648,541 aortic valve replacements during the study period, 3,054 (0.47%) were identified as Ross procedures. Utilization of the procedures as a percent of total aortic valve replacements peaked in 1998 at 1.2%, followed by a steady decline to 0.09% by 2010. More than a quarter of all Ross operations were performed at six sites. Using propensity-matching analyses, Ross patients experienced significantly more perioperative complications including reexploration (9.4% versus 5.8%; p < 0.01), renal failure (2.6% versus 0.8%; p < 0.001), and operative mortality (2.7% versus 0.9%; p = 0.001). Conclusions These data suggest that the Ross procedure is associated with greater perioperative morbidity and mortality risks compared with conventional aortic valve replacement. Recognition of these risks along with durability concerns have resulted in a dramatic decline in the number of Ross procedures performed in North America in the last decade. © 2014 by The Society of Thoracic Surgeons. Source

Liang M.K.,University of Texas Health Science Center at Houston | Goodenough C.J.,University of Texas Health Science Center at Houston | Martindale R.G.,Oregon Health science Center | Roth J.S.,University of Kentucky | Kao L.S.,University of Texas Health Science Center at Houston
Surgical Infections | Year: 2015

Background: Previously, we reported that the Ventral Hernia Risk Score (VHRS) was more accurate in a Veterans Affairs (VA) population in predicting surgical site infection (SSI) after open ventral hernia repair (VHR) compared with other models such as the Ventral Hernia Working Group (VHWG) model. The VHRS was developed using single-center data and stratifies SSI risk into five groups based on concomitant hernia repair, skin flaps created, American Society of Anesthesiologists (ASA) score ≥3, body mass index ≥40 kg/m2, and incision class 4. The purpose of this study was to validate the VHRS for other hospitals. Methods: A prospective database of all open VHRs performed at three institutions from 2009-2011 was utilized. All 436 patients with a follow-up of at least 1 mo were included. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized. Each patient was assigned a VHRS, VHWG, and CDC incision classification. Receiver-operating characteristic curves were used to assess predictive accuracy, and the areas under the curve (AUCs) were compared for the three risk-stratification systems. Results: The median follow-up was 20 mos (range 1-49 mos). During this time, 111 patients (25.5%) developed a SSI. The AUC of the VHRS (0.73; 95% confidence interval [CI] 0.67-0.78) was greater than that of the VHWG (0.66; 95% CI 0.60-0.72; p<0.01) and the CDC incision class (0.68; 95% CI 0.61-0.74; p<0.05). Conclusions: The VHRS provides a novel, internally and externally validated score for a patient's likelihood of developing a SSI after open VHR. Elevating skin flaps, ASA score ≥3, concomitant procedures, morbid obesity, and incision class all independently predicted SSI. It remains to be determined if pre-operative patient selection and risk reduction, surgical techniques, and post-operative management can improve outcomes in the highest-risk patients. The VHRS provides a starting point for key stakeholders to discuss the management of ventral hernias. © 2015 Mary Ann Liebert, Inc. Source

Holihan J.L.,University of Texas Health Science Center at Houston | Alawadi Z.,University of Texas Health Science Center at Houston | Martindale R.G.,Oregon Health science Center | Roth J.S.,University of Kentucky | And 4 more authors.
Journal of the American College of Surgeons | Year: 2015

Background Ventral hernia repairs are one of the most common procedures performed by the general surgeon. They are also among the most complex procedures performed. We hypothesized that with each surgical failure, subsequent ventral hernia repair becomes more complicated and morbid. Study Design We assessed a multicenter database of patients who underwent an elective ventral hernia repair from 2000 to 2012 with at least 6 months of follow-up and elective repairs. Patients were evaluated by the number of previous ventral hernia repairs they had: primary ventral hernia repair (PVHR), first time incisional hernia repair (IHR1), second time incisional hernia repair (IHR2), or third time or greater incisional hernia repair (IHR3). The main outcomes measured were abdominal reoperation, operative duration, surgical site infection (SSI), and hernia recurrence. Complications were assessed and compared between the 4 groups. Time to recurrence was estimated using the Kaplan-Meier curve method by study cohort (PVHR, IHR1, IHR2, IHR3). Results A total of 794 patients were assessed; of these, 481 (60.6%) had PVHR, 207 (26.1%) had IHR1, 78 (9.8%) had IHR2, and 28 (3.5%) had IHR3. Patients with multiple repairs were more likely to undergo subsequent reoperation, have a longer operative duration, develop SSI, and have a recurrence. At 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias have recurred. The highest recurrence rates are seen in IHR3, with 73% recurring. Conclusions Previous ventral hernia repair increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair. Furthermore, long-term outcomes for ventral hernia repair are poor. Future studies should focus on hernia prevention and improving long-term outcomes after hernia repair. © 2015 American College of Surgeons. Source

Khan A.,Oregon Health science Center | Morgenthaler T.I.,Center for Sleep Medicine | Ramar K.,Center for Sleep Medicine
Journal of Clinical Sleep Medicine | Year: 2014

Introduction: The effect of isolated unilateral or bilateral diaphragmatic dysfunction (DD), in the absence of a generalized neuromuscular disorder, on sleep disordered breathing (SDB) is not well understood. The type of positive airway pressure (PAP) device needed to treat SDB in patients with isolated DD is also not well established. Methods: We retrospectively analyzed data on patients with isolated unilateral or bilateral DD who were referred for polysomnography (PSG) for clinical symptoms or abnormal oximetry between 1994 and 2006. Results: We found 66 patients who met criteria, of whom 74.2% were males with an average age of 58.8 ± 10.9 years. 56 had isolated unilateral DD, and 10 had isolated bilateral DD. All had significant SDB with an apnea-hypopnea index (AHI) of 26.6 ± 28.4. There were no significant differences in PSG measures, arterial blood gas analysis, pulmonary function tests, or echocardiographic data, except for lower maximal inspiratory pressure in patients with bilateral DD compared to unilateral DD (40.2% ± 17.8% vs. 57.7% ± 20.5%, p = 0.02). Control of SDB with continuous PAP (CPAP) was possible in only 37.9% of patients with the rest requiring bilevel PAP (BPAP). Patients with isolated bilateral DD and SDB were 6.8 times more likely to fail CPAP than those with unilateral DD (p = 0.03). Conclusions: Most patients with isolated DD failed CPAP and required BPAP. Patients with bilateral DD were more likely to require BPAP than those with unilateral DD. Patients with isolated DD should be considered for in-lab titration to determine adequacy of therapy. Source

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