Yale Center for Analytical science

New Haven, CT, United States

Yale Center for Analytical science

New Haven, CT, United States
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Ghogawala Z.,Lahey Hospital and Medical Center | Dziura J.,Clinical Translational Science Institute | Butler W.E.,Massachusetts General Hospital | Dai F.,Boston All in Massachusetts | And 10 more authors.
New England Journal of Medicine | Year: 2016

BACKGROUND The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. METHODS In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression- Alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years. RESULTS A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P = 0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompressionalone group at 3 years and at 4 years (P = 0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P = 0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P = 0.05). CONCLUSIONS Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.). © 2016 Massachusetts Medical Society.

Sullivan M.C.,Yale University | Yeo H.,Sloan Kettering Cancer Center | Roman S.A.,Duke University | Ciarleglio M.M.,Yale Center for Analytical science | And 3 more authors.
Journal of the American College of Surgeons | Year: 2013

Background: Voluntary resident attrition remains problematic despite recent changes in postgraduate general surgery training, including reduction of work hours. Study Design: We conducted a prospective study of all postgraduate year (PGY)-1 and -2 trainees on the 2008 American Board of Surgery resident roster (ABS-RR) who completed the National Study of Expectations and Attitudes of Residents in Surgery (NEARS) survey after the American Board of Surgery In-Training Examination (ABSITE) in 2008 or 2009. Results: Among 2,222 PGY-1 and -2 residents on the 2008 ABS-RR, 2,033 completed the NEARS survey in 2008 or 2009 (91.5%). The only demographic or programmatic variables associated with voluntary attrition on univariate analysis were PGY-1 status (9.4% risk vs 4.5% risk for PGY-2, p < 0.001) and program location (p = 0.03). Response differences (p < 0.01) were noted in 23 survey items. In multivariate modeling, PGY-2 status was protective against voluntary attrition (p < 0.001, hazard ratio [HR] 0.41), while programs located outside of the South (Northeast: p = 0.006, HR 2.39; Midwest: p = 0.01, HR 2.37; West: p = 0.10, HR 1.76) were associated with higher attrition. The attrition group more frequently reported that they had considered leaving training (p < 0.001, HR 2.59), that the personal cost of training was too great (p < 0.001, HR 2.89), that they were dissatisfied with their operative experience (p = 0.002, HR 1.89), and that they were not committed to completing their training (p < 0.001, HR 3.96). Using the estimated regression coefficient for each variable in the multivariate models, we calculated a risk score for individual residents; these scores were used to construct covariate-adjusted survivorship functions. Conclusions: Resident attitudes, PGY-1 status, and program location are most frequently associated with voluntary attrition. Our risk score calculation represents a novel potential tool for programs to quantify deficiencies in the training experience of residents, and develop targeted strategies to limit disaffection and improve resident retention. © 2013 by the American College of Surgeons.

Chen Y.,Wenzhou Medical College | Li F.-Y.,Yale Center for Analytical science | Lin X.,Wenzhou Medical College | Chen J.,Wenzhou Medical College | And 2 more authors.
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2013

Objective Compare changes in pelvic organ prolapse (POP) from 36-38 weeks of gestation to 1 year postpartum after unlaboured cesarean delivery(UCD)and trial of labour (TOL). Design Prospective observational cohort study. Setting Wenzhou Third People's Hospital, Wenzhou, Zhejiang, China. Population Nulliparous women undergoing UCD or TOL. Methods Pelvic organ prolapse was assessed at 36-38 weeks of gestation, then at 6 weeks, 6 months and 1 year postpartum, using the Pelvic Organ Prolapse Quantification (POPQ) system. Main outcome measures Postpartum POP status in UCD and TOL determined by POPQ measurements over time. Results Points Aa (Ba) determined the final stage assignment in most cases. Stage II POP was present in 35% and 37% of women in UCD and TOL at 36-38 weeks of gestation. After delivery, the likelihood of stage II POP declined during the first year postpartum in the whole cohort. The TOL group was much less likely to recover from stage II POP compared with the UCD group (odds ratio 0.04, 95% confidence interval 0.01-0.18) after adjustment for POP status at 36-38 weeks of gestation, age, first-trimester body mass index, newborn birthweight, educational level, gravidity and smoking status. With the exception of age, education and gravidity, these covariates were also independent predictors of postpartum POP. Conclusion Factors unique to labour and delivery lead to sustained pelvic floor relaxation postpartum. Pelvic organ prolapse at 36-38 weeks of gestation, and higher first-trimester body mass index also appear to predict long-term POP. Further investigation into mechanisms leading to persistent or progressive POP after TOL are warranted. In addition, caution is needed in generalising the findings due to the single-centre design. © 2013 RCOG.

Feinstein A.J.,Yale University | Ciarleglio M.M.,Yale Center for Analytical science | Cong X.,Yale Center for Analytical science | Otremba M.D.,Yale University | Judson B.L.,Yale University
Laryngoscope | Year: 2013

Objectives/Hypothesis Assess the demographic, clinical, and pathologic features of patients with parotid gland lymphoma and their prognostic importance using US population-based data. Study Design Retrospective cohort study. Methods Patients were selected from the Surveillance, Epidemiology, and End Results program database between the years of 1973 and 2008, and individual characteristics were compared using univariate and multivariate Cox proportional hazards models. Kaplan-Meier survival curves were constructed and log-rank tests were performed. Results We identified 2,140 patients with primary parotid gland lymphoma. Hodgkin lymphoma was found in 3.5% of patients. More common were non-Hodgkin lymphoma subtypes: marginal zone B-cell lymphoma, follicular lymphoma, and diffuse large B cell lymphoma accounted for 27.9%, 25.8%, and 23.7% of cases, respectively. Survival was decreased with patient age over 50 years, increasing stage, male gender, non-Hodgkin histology, and status other than married. Of the patients, 72.0% received some form of surgery, and 136 patients had facial nerve sacrifice during parotidectomy. Conclusions Non-Hodgkin lymphoma is the predominant type of lymphoma seen in the parotid gland. Patient and histologic features determine survival, and surgery is often performed. Facial nerve sacrifice, which is contraindicated given the systemic nature of lymphoma and the role of chemotherapy and radiation in its treatment, is reported in 6.4% of patients with parotid gland lymphoma. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Aslanian H.R.,Yale University | Shieh F.K.,Yale University | Chan F.W.,Yale University | Ciarleglio M.M.,Yale Center for Analytical science | And 4 more authors.
American Journal of Gastroenterology | Year: 2013

OBJECTIVES:To determine whether a second observer during colonoscopy increases adenoma detection.METHODS:Consecutive patients undergoing screening colonoscopy were prospectively randomized to routine colonoscopy or physician and nurse observation during withdrawal.RESULTS:Of 502 patients, 249 were randomized to routine colonoscopy, and 253 to physician plus nurse observation during withdrawal. A total of 592 polyps were detected, 40 identified by the endoscopy nurse only. With nurse observation, 1.32 polyps and 0.82 adenomas were found per colonoscopy, vs. 1.03 polyps and 0.64 adenomas in the routine group, demonstrating a 1.29-fold and a 1.28-fold increase in the average number of polyps and of adenomas detected, respectively. The overall adenoma detection rate (ADR) was 44.1%, with trends toward increased ADR and all-polyp detection rate with nurse observation.CONCLUSIONS:Nurse observation during colonoscopy resulted in an increase in the number of polyps and adenomas found per colonoscopy, along with a trend toward improved overall ADR and all-polyp detection rate. © 2013 by the American College of Gastroenterology.

Bizzarro M.J.,Yale University | Li F.Y.,Yale Center for Analytical science | Katz K.,Yale Center for Analytical science | Shabanova V.,Yale Center for Analytical science | And 2 more authors.
Journal of Perinatology | Year: 2014

Objective: To reduce exposure to hyperoxia and its associated morbidities in preterm neonates. Study Design: A multidisciplinary group was established to evaluate oxygen exposure in our neonatal intensive care unit. Infants were assigned target saturation ranges and signal extraction technology implemented to temporally quantify achievement of these ranges. The outcomes bronchopulmonary dysplasia/death, retinopathy of prematurity (ROP)/death, severe ROP and ROP requiring surgery were compared in a pre- versus post-intervention evaluation using multivariate analyses. Result: A total of 304 very low birth weight pre-initiative infants were compared with 396 post-initiative infants. Multivariate analyses revealed decreased odds of severe ROP (adjusted odds ratio (OR): 0.41; 95% confidence interval (CI): 0.24-0.72) and ROP requiring surgery (adjusted OR 0.31; 95% CI: 0.17-0.59) post-initiative. No differences in death were observed. Conclusion: Significant reductions in severe ROP and ROP requiring surgery were observed after staff education and implementation of new technology to quantify success in achieving targeted saturations and reinforce principles and practices. © 2014 Nature America, Inc. All rights reserved.

Schonberger R.B.,Yale University | Dutton R.P.,Anesthesia Quality Institute | Dai F.,Yale University | Dai F.,Yale Center for Analytical science
Anesthesia and Analgesia | Year: 2016

BACKGROUND: Modifications in physician billing patterns have been shown to occur in response to payer incentives, but the phenomenon remains largely unexplored in billing for anesthesia services. Within the field of anesthesiology, Medicare's policy not to provide additional reimbursement for higher ASA physical status scores contrasts with the practices of most private payers, and this pattern of reimbursement introduces a change in billing incentives once patients attain Medicare eligibility. We hypothesized that, coincident with the onset of widespread Medicare eligibility at age 65 years, a discontinuity in reported ASA physical status scores would be observed after controlling for the underlying trend of increasing ASA physical status scores with age. This phenomenon would manifest as a pattern of upcoding of ASA physical status scores for patients younger than 65 years that would become less common in patients age 65 years and older. METHODS: Using data on age, sex, ASA physical status scores, and type of surgery from the National Anesthesia Clinical Outcomes Registry, we used a quasi-experimental regression discontinuity design to analyze whether there was evidence for a discontinuity in reported ASA physical status scores occurring at age 65 years for the nondeferrable anesthesia services accompanying hip, femur, or lower leg fracture repair. RESULTS: A total of 49,850 records were analyzed. In models designed to detect regression discontinuity at 65 years of age, neither the binary variable "age ≥ 65" nor the interaction term of age × age ≥ 65 was a statistically significant predictor of the outcome of ASA physical status score. The statistical inference was unchanged when ASA physical status scores were reclassified as a binary outcome (I-II vs III-V) and when different bandwidths around age 65 years were used. To test the validity of our study design for detecting regression discontinuity, simulations of the occurrence of deliberate upcoding of ASA physical status scores demonstrated the ability to detect deliberate upcoding occurring at rates exceeding 2% of eligible cases of patients younger than 65 years. CONCLUSIONS: We found no evidence for a significant discontinuity in the pattern of ASA physical status scores coincident with Medicare eligibility at age 65 years for the nondeferrable conditions of hip, femur, or lower leg fracture repair. Our data do not support the presence of fraudulent ASA physical status scoring among National Anesthesia Clinical Outcomes Registry contributors. If deliberate upcoding of ASA physical status scores is present in our data, the behavior is either too rare or too insensitive to the removal of payer incentives at age 65 years to be evident in the present analysis. © 2015 International Anesthesia Research Society.

Alexander V.N.,Yale University | Northrup V.,Yale Center for Analytical science | Bizzarro M.J.,Yale University
Journal of Pediatrics | Year: 2011

Objective: To determine whether duration of antibiotic exposure is an independent risk factor for necrotizing enterocolitis (NEC). Study design: A retrospective, 2:1 control-case analysis was conducted comparing neonates with NEC to those without from 2000 through 2008. Control subjects were matched on gestational age, birth weight, and birth year. In each matched triad, demographic and risk factor data were collected from birth until the diagnosis of NEC in the case subject. Bivariate and multivariate analyses were used to assess associations between risk factors and NEC. Results: One hundred twenty-four cases of NEC were matched with 248 control subjects. Cases were less likely to have respiratory distress syndrome (P =.018) and more likely to reach full enteral feeding (P =.028) than control subjects. Cases were more likely to have culture-proven sepsis (P <.0001). Given the association between sepsis and antibiotic use, we tested for and found a significant interaction between the two variables (P =.001). When neonates with sepsis were removed from the cohort, the risk of NEC increased significantly with duration of antibiotic exposure. Exposure for >10 days resulted in a nearly threefold increase in the risk of developing NEC. Conclusions: Duration of antibiotic exposure is associated with an increased risk of NEC among neonates without prior sepsis. © 2011 Mosby Inc. All rights reserved.

Colacchio K.,Yale University | Deng Y.,Yale Center for Analytical science | Northrup V.,Yale Center for Analytical science | Bizzarro M.J.,Yale University
Journal of Perinatology | Year: 2012

Objective: The objective of this study is to compare complication rates between peripherally inserted central catheters (PICCs) and peripherally inserted non-central catheters (PINCCs) in the neonatal intensive care unit (NICU).Study Design: A retrospective, observational study was conducted. The PICCs were catheters whose tip terminated in the vena cavae, and PINCCs were defined as those whose tip fell short of this location. Complication rates were assessed using generalized estimating equations modeling.Result: A total of 91 PINCCs and 889 PICCs were placed in 750 neonates. In all, 44.0% of PINCCs had a major complication compared with 25.2% of PICCs (P=0.0001). The unadjusted (unadj.) complication rate among PINCCs was 51.7 per 1000 line days and 15.9 for PICCs (unadj. rate ratio: 3.25; 95% confidence interval (CI): 2.32, 4.55). After adjusting for multiple confounders, the risk remained significantly higher for PINCCs (adjusted odds ratio: 2.41; 95% CI: 1.33, 4.37).Conclusion: The rate of associated complications with the use of PINCCs in the NICU population is more than twice that of the PICCs. © 2012 Nature America, Inc.

Johnson K.M.,Yale University | Johnson B.K.,Yale Center for Analytical science
American Journal of Roentgenology | Year: 2014

OBJECTIVE. The purpose of this article is to present a visual conceptual framework for important statistical concepts in radiology, and to provide an online application to facilitate this visualization. CONCLUSION. Statistical measures such as sensitivity, specificity, and predictive values are ubiquitous in medical literature, yet thinking fluidly about these concepts is not always easy. The 2 x 2 diagram is a helpful guide. © American Roentgen Ray Society.

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