Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely ... more Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely rare occurrence with a high mortality. Abdominal aortic dissection can be associated with an abdominal aortic aneurysm (AAA) and the presence of an AAD with an AAA mandates surgical intervention because of a high rate of rupture. We present the case of a 53-year-old woman with a spontaneous AAD that extended retrograde into the thoracic aorta with a concomitant supraceliac intimal tear and an infrarenal AAA repaired electively with a hybrid approach using a supraceliac stent graft and an open infrarenal aortobiiliac graft. This hybrid approach provided an excellent outcome of this rare and complex vascular pathology.
In the traditional model of acute appendicitis, time is the major driver of disease progression; ... more In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. To evaluate whether there is an association between time and perforation after patients present to the hospital. Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital ...
There are increasing efforts towards improving the quality and safety of surgical care while decr... more There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.
In the traditional model of acute appendicitis, time is the major driver of disease progression; ... more In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. To evaluate whether there is an association between time and perforation after patients present to the hospital. Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital ...
Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used mo... more Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used more commonly to treat postoperative pain, but recent small studies have suggested that NSAIDs may impair anastomotic healing in the gastrointestinal tract. To evaluate the relationship between postoperative NSAID administration and anastomotic complications. Retrospective cohort study of 13 082 patients undergoing bariatric or colorectal surgery at 47 hospitals in Washington State from January 1, 2006, through December 31, 2010, using data from the Surgical Care and Outcomes Assessment Program linked to the Washington State Comprehensive Abstract Reporting System. NSAID administration beginning within 24 hours after surgery. We used multivariate logistic regression modeling to assess the risk for anastomotic complications (reoperation, rescue stoma, revision of an anastomosis, and percutaneous drainage of an abscess) through 90 days after bariatric and colorectal surgery involving anastom...
There are increasing efforts towards improving the quality and safety of surgical care while decr... more There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.
Learning health care systems apply the experiences of prior patients to inform care and help to g... more Learning health care systems apply the experiences of prior patients to inform care and help to guide decision making for current patients. These systems should help to deliver more effective, efficient, and appropriate care. Most examples of learning systems derive from integrated care delivery systems and examples of such systems in the community at large have been lacking. The comparative effectiveness research translation network (CERTAIN) is a learning system bringing together hospitals and outpatient clinics across Washington State. CERTAIN leverages existing medical record-based data collection taking place at nearly all statewide hospitals and links this data collection with patient-reported information about function and quality of life. We have described the components of the CERTAIN infrastructure, the elements of a pilot project evaluating treatments of claudication, and the opportunities and challenges of developing and implementing a "real world" learning system. Examples in the areas of vascular disease, spine care, gastrointestinal disease, and urology. Learning health care systems face many operational challenges but hold great promise for discovery and implementation of more effective clinical practices.
To describe the inaugural comparative effectiveness research (CER) cohort study of Washington Sta... more To describe the inaugural comparative effectiveness research (CER) cohort study of Washington State's Comparative Effectiveness Research Translation Network (CERTAIN), which compares invasive with noninvasive treatments for peripheral artery disease, and to focus on the patient centeredness of this cohort study by describing it within the context of a newly published conceptual framework for patient-centered outcomes research (PCOR). The peripheral artery disease study was selected because of clinician-identified uncertainty in treatment selection and differences in desired outcomes between patients and clinicians. Patient centeredness is achieved through the "Patient Voices Project," a CERTAIN initiative through which patient-reported outcome (PRO) instruments are administered for research and clinical purposes, and a study-specific patient advisory group where patients are meaningfully engaged throughout the life cycle of the study. A clinician-led research advisory panel follows in parallel. Primary outcomes are PRO instruments that measure function, health-related quality of life, and symptoms, the latter developed with input from the patients. Input from the patient advisory group led to revised retention procedures, which now focus on short-term (3-6 months) follow-up. The research advisory panel is piloting a point-of-care, patient assessment checklist, thereby returning study results to practice. The cohort study is aligned with the tenets of one of the new conceptual frameworks for conducting PCOR. The CERTAIN's inaugural cohort study may serve as a useful model for conducting PCOR and creating a learning health care network.
To study the association between diabetes status, perioperative hyperglycemia, and adverse events... more To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort. Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM). Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010-2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State. Among 40,836 patients (mean age, 54 years; 53.6% women), 19% had diabetes; 47% underwent a perioperative blood glucose (BG) test, and of those, 18% had BG ≥180 mg/dL. DM patients had a higher rate of adverse events (12% vs 9%, P < 0.001) than NDM patients. After adjustment, among NDM patients, those with hyperglycemia had an increased risk of adverse events compared with those with normal BG. Among NDM patients, there was a dose-response relationship between the level of BG and composite adverse events [odds ratio (OR), 1.3 for BG 125-180 (95% confidence interval (CI), 1.1-1.5); OR, 1.6 for BG ≥180 (95% CI, 1.3-2.1)]. Conversely, hyperglycemic DM patients did not have an increased risk of adverse events, including those with a BG 180 or more (OR, 0.8; 95% CI, 0.6-1.0). NDM patients were less likely to receive insulin at each BG level. For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia. Underlying this paradoxical effect may be the underuse of insulin, but also that hyperglycemia indicates higher levels of stress in NDM patients than in DM patients.
Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely ... more Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely rare occurrence with a high mortality. Abdominal aortic dissection can be associated with an abdominal aortic aneurysm (AAA) and the presence of an AAD with an AAA mandates surgical intervention because of a high rate of rupture. We present the case of a 53-year-old woman with a spontaneous AAD that extended retrograde into the thoracic aorta with a concomitant supraceliac intimal tear and an infrarenal AAA repaired electively with a hybrid approach using a supraceliac stent graft and an open infrarenal aortobiiliac graft. This hybrid approach provided an excellent outcome of this rare and complex vascular pathology.
In the traditional model of acute appendicitis, time is the major driver of disease progression; ... more In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. To evaluate whether there is an association between time and perforation after patients present to the hospital. Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital ...
There are increasing efforts towards improving the quality and safety of surgical care while decr... more There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.
In the traditional model of acute appendicitis, time is the major driver of disease progression; ... more In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. To evaluate whether there is an association between time and perforation after patients present to the hospital. Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital ...
Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used mo... more Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used more commonly to treat postoperative pain, but recent small studies have suggested that NSAIDs may impair anastomotic healing in the gastrointestinal tract. To evaluate the relationship between postoperative NSAID administration and anastomotic complications. Retrospective cohort study of 13 082 patients undergoing bariatric or colorectal surgery at 47 hospitals in Washington State from January 1, 2006, through December 31, 2010, using data from the Surgical Care and Outcomes Assessment Program linked to the Washington State Comprehensive Abstract Reporting System. NSAID administration beginning within 24 hours after surgery. We used multivariate logistic regression modeling to assess the risk for anastomotic complications (reoperation, rescue stoma, revision of an anastomosis, and percutaneous drainage of an abscess) through 90 days after bariatric and colorectal surgery involving anastom...
There are increasing efforts towards improving the quality and safety of surgical care while decr... more There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.
Learning health care systems apply the experiences of prior patients to inform care and help to g... more Learning health care systems apply the experiences of prior patients to inform care and help to guide decision making for current patients. These systems should help to deliver more effective, efficient, and appropriate care. Most examples of learning systems derive from integrated care delivery systems and examples of such systems in the community at large have been lacking. The comparative effectiveness research translation network (CERTAIN) is a learning system bringing together hospitals and outpatient clinics across Washington State. CERTAIN leverages existing medical record-based data collection taking place at nearly all statewide hospitals and links this data collection with patient-reported information about function and quality of life. We have described the components of the CERTAIN infrastructure, the elements of a pilot project evaluating treatments of claudication, and the opportunities and challenges of developing and implementing a "real world" learning system. Examples in the areas of vascular disease, spine care, gastrointestinal disease, and urology. Learning health care systems face many operational challenges but hold great promise for discovery and implementation of more effective clinical practices.
To describe the inaugural comparative effectiveness research (CER) cohort study of Washington Sta... more To describe the inaugural comparative effectiveness research (CER) cohort study of Washington State's Comparative Effectiveness Research Translation Network (CERTAIN), which compares invasive with noninvasive treatments for peripheral artery disease, and to focus on the patient centeredness of this cohort study by describing it within the context of a newly published conceptual framework for patient-centered outcomes research (PCOR). The peripheral artery disease study was selected because of clinician-identified uncertainty in treatment selection and differences in desired outcomes between patients and clinicians. Patient centeredness is achieved through the "Patient Voices Project," a CERTAIN initiative through which patient-reported outcome (PRO) instruments are administered for research and clinical purposes, and a study-specific patient advisory group where patients are meaningfully engaged throughout the life cycle of the study. A clinician-led research advisory panel follows in parallel. Primary outcomes are PRO instruments that measure function, health-related quality of life, and symptoms, the latter developed with input from the patients. Input from the patient advisory group led to revised retention procedures, which now focus on short-term (3-6 months) follow-up. The research advisory panel is piloting a point-of-care, patient assessment checklist, thereby returning study results to practice. The cohort study is aligned with the tenets of one of the new conceptual frameworks for conducting PCOR. The CERTAIN's inaugural cohort study may serve as a useful model for conducting PCOR and creating a learning health care network.
To study the association between diabetes status, perioperative hyperglycemia, and adverse events... more To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort. Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM). Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010-2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State. Among 40,836 patients (mean age, 54 years; 53.6% women), 19% had diabetes; 47% underwent a perioperative blood glucose (BG) test, and of those, 18% had BG ≥180 mg/dL. DM patients had a higher rate of adverse events (12% vs 9%, P < 0.001) than NDM patients. After adjustment, among NDM patients, those with hyperglycemia had an increased risk of adverse events compared with those with normal BG. Among NDM patients, there was a dose-response relationship between the level of BG and composite adverse events [odds ratio (OR), 1.3 for BG 125-180 (95% confidence interval (CI), 1.1-1.5); OR, 1.6 for BG ≥180 (95% CI, 1.3-2.1)]. Conversely, hyperglycemic DM patients did not have an increased risk of adverse events, including those with a BG 180 or more (OR, 0.8; 95% CI, 0.6-1.0). NDM patients were less likely to receive insulin at each BG level. For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia. Underlying this paradoxical effect may be the underuse of insulin, but also that hyperglycemia indicates higher levels of stress in NDM patients than in DM patients.
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