41 results on '"Katherine E. Cain"'
Search Results
2. Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery
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Jolyn S. Taylor, Maria D. Iniesta, Andres Zorrilla-Vaca, Katherine E. Cain, Javier D. Lasala, Gabriel E. Mena, Larissa A. Meyer, and Pedro T. Ramirez
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Obstetrics and Gynecology - Published
- 2023
3. 2030. Risk Factors for Recurrent Percutaneous Nephrostomy Tube Infections in Patients with Gynecological Malignancies
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Ariel D Szvalb, Claire A Marten, Katherine E Cain, Jolyn Taylor, Steven Y Huang, and George M Viola
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Infectious Diseases ,Oncology - Abstract
Background Percutaneous nephrostomy tube infections (PCNIs) are complex, affect quality of life, necessitate implant exchanges, and increase health care costs. Here, we analyzed risk factors for recurrent PCNIs in patients treated with our standardized institutional algorithm. Methods At our institution, we prospectively evaluated consecutive patients with gynecological malignancies who developed PCNIs between July 2019 to September 2021. All patients were treated using our institutional algorithm for PCNI, which consists of obtaining blood cultures plus urine analyses and cultures from each percutaneous nephrostomy tube (PCN); utilizing ultrasound or abdominal pelvic computed tomography scans to rule out obstructive hydronephrosis, pyelonephritis, or renal abscess; exchanging the PCN once patients are receiving concordant antimicrobial therapy; and having patients complete an adequate course of targeted antimicrobials. Thereafter, patients were followed up until reinfection, routine PCN exchange at 3 months, being lost to follow-up, or death. Results We treated 100 patients. Their median age was 54 years; 53% were White. The most common malignancies were cervical (61%), ovarian (23%), and endometrial (13%), with 60% being metastatic. To analyze the risk factors for developing a recurrent PCNI, patients were placed in 3 different groups: those reinfected with the same organism (19%), reinfected with a different organism (17%), and not reinfected (64%). Overall, there were no differences among the patient groups regarding demographics, comorbidities, clinical presentation, infection timing, PCN exchange (Table 1) or microorganisms encountered (Table 2). However, patients with prior radiation therapy or pelvic fistulas (urinary-vaginal-rectal or their permutations) had higher rates for developing a recurrent PCNIs with the same organism (P< .002). Conclusion Patients with prior radiation therapy and underlying pelvic fistulas have an increased risk for reinfection with the same pathogen. Therefore, further studies should be performed to mitigate this increased risk of recurrent infections with more frequent PCN exchanges or, more invasive procedure such as ureteral embolization, sclerosis, or ligation to dissociate the upper and lower urinary tracts. Disclosures All Authors: No reported disclosures.
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- 2022
4. Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway
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Juan P. Cata, Katherine E. Cain, Micah Vaughn, Gabriel E. Mena, Andres Zorrilla-Vaca, Pedro T. Ramirez, Larissa A. Meyer, Sarah P. Huepenbecker, Maria D. Iniesta, and Javier Lasala
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medicine.medical_specialty ,urologic and male genital diseases ,Article ,Gynecologic Surgical Procedures ,Postoperative Complications ,medicine ,Humans ,Rifle ,Enhanced recovery after surgery ,Aged ,business.industry ,Incidence ,Incidence (epidemiology) ,Acute kidney injury ,Obstetrics and Gynecology ,Perioperative ,Acute Kidney Injury ,Middle Aged ,medicine.disease ,female genital diseases and pregnancy complications ,Surgery ,Blood pressure ,Oncology ,Cohort ,Propensity score matching ,Female ,Enhanced Recovery After Surgery ,business - Abstract
OBJECTIVE: To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS: We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher’s Exact, and Wilcoxon rank-sum tests were used. RESULTS: Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p=.004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p5 minutes (41.7% vs 30.7%, p
- Published
- 2021
5. EPV259/#288 Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic oncology surgery: a 5-year single center experience
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Pedro T. Ramirez, Maria D. Iniesta, Andres Zorrilla-Vaca, Tina Suki, Larissa A. Meyer, J Garcia-Lopez, J Hayek, Gabriel E. Mena, Javier Lasala, and Katherine E. Cain
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medicine.medical_specialty ,Enhanced recovery ,business.industry ,Medicine ,Gynecologic oncology ,business ,Single Center ,Surgery - Published
- 2021
6. Patient characteristics and opioid use prior to discharge after open gynecologic surgery in an enhanced recovery after surgery (ERAS) program
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Ashley Siverand, Amalia Sanchez-Migallon, Javier Lasala, Tina Suki, Katherine E. Cain, Maria D. Iniesta, Larissa A. Meyer, Pedro T. Ramirez, Simone P.L. Veum, and R. Tyler Hillman
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Adult ,0301 basic medicine ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Patient characteristics ,Logistic regression ,Perioperative Care ,White People ,Article ,Young Adult ,03 medical and health sciences ,Gynecologic Surgical Procedures ,0302 clinical medicine ,Humans ,Medicine ,Postoperative Period ,Single institution ,Enhanced recovery after surgery ,Aged ,Retrospective Studies ,Aged, 80 and over ,Pelvic exenteration ,business.industry ,Opioid use ,Smoking ,Age Factors ,Obstetrics and Gynecology ,Retrospective cohort study ,Length of Stay ,Middle Aged ,Patient Discharge ,Surgery ,Analgesics, Opioid ,030104 developmental biology ,Oncology ,Opioid ,030220 oncology & carcinogenesis ,business ,medicine.drug - Abstract
OBJECTIVE. To identify clinical and demographic characteristics associated with the absence of opioid usage on the day before discharge among patients undergoing open gynecologic surgery within an enhanced recovery after surgery (ERAS) program. METHODS. This was a single institution retrospective cohort study including all patients who underwent elective open gynecologic surgery as part of an ERAS program between November 1, 2014 and September 30, 2018 and who were discharged between post-operative day 2 and 7. Patients were excluded if they reported preexisting chronic opioid use or underwent total pelvic exenteration. Descriptive statistics were used and multivariable logistic regression was used to identify factors associated with the absence of opioid usage on the day before discharge, after adjustment for relevant covariates. RESULTS. A total of 971 were included with a median length of stay of 3 days, and of these 526 (54.2%) used opioids on day before discharge and 445 (45.8%) did not. Absence of opioid use on the day before discharge was associated with age (P < .001), race (P = .04), Charlson Co-morbidity Index (P < .001), marital status (P = .004), and smoking status (P = .002) by univariate analysis. In a multivariable model, older age (adjusted OR 1.04; 95% CI 1.02–1.06; P < .001), current smoker status (adjusted OR 0.42; 95% CI 0.20–0.81; P = .01), and white or Caucasian race (adjusted OR 0.59; 95% CI 0.38–0.91; P = .02) were significantly associated with the absence of opioid use on the day prior to discharge. CONCLUSIONS. Nearly half of patients undergoing open gynecologic surgery within an established ERAS program did not consume any opioids on day before discharge. Safe, evidence-based reductions in post-operative opioid prescribing may be feasible for a subset of gynecologic surgery patients.
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- 2019
7. A practical guide for the safe implementation of early phase drug development and immunotherapy program in gynecologic oncology practice
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Robert L. Coleman, Emily Hinchcliff, Jeffry Cutrera, Cynae Johnson, Shannon N. Westin, Marlana Klinger, Aaron Shafer, Jaime Anderson, Katherine E. Cain, Sara E. Sharafi, Anil K. Sood, Pamela T. Soliman, Valerie F Villanueva, Karen H. Lu, Michael Frumovitz, Andrea S. Dickens, and Amir A. Jazaeri
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medicine.medical_specialty ,Genital Neoplasms, Female ,medicine.medical_treatment ,Gynecologic oncology ,Immunotherapy, Adoptive ,Article ,03 medical and health sciences ,Antineoplastic Agents, Immunological ,0302 clinical medicine ,Humans ,Medicine ,Molecular Targeted Therapy ,Intensive care medicine ,business.industry ,INVESTIGATIONAL AGENTS ,Obstetrics and Gynecology ,Cancer ,Immunotherapy ,medicine.disease ,Immune therapy ,Clinical trial ,Oncology ,Drug development ,030220 oncology & carcinogenesis ,Female ,business ,Early phase ,030215 immunology - Abstract
The success of targeted and immune therapies in other malignancies has led to an exponential increase in the number of active and pending clinical trials using these therapeutic approaches in patients with gynecologic cancers. These novel investigational agents are associated with unique and potentially life-threatening toxicities and many require special multidisciplinary logistical considerations. The objective of this review is to describe a practical approach for the safe implementation of targeted and immune therapies in academic gynecologic oncology practices based on our experience at M.D. Anderson Cancer Center.
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- 2018
8. Comparison of out-of-pocket cost between apixaban and enoxaparin for extended-duration venous thromboembolism prophylaxis in gynecologic oncology patients
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Katherine E. Cain, Jolyn S. Taylor, Ross F. Harrison, Claire A. Marten, and Nicole D. Fleming
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medicine.medical_specialty ,business.industry ,medicine.drug_class ,Obstetrics and Gynecology ,Low molecular weight heparin ,Pharmacy ,Retrospective cohort study ,Gynecologic oncology ,Oncology ,Specialty pharmacy ,Emergency medicine ,medicine ,Apixaban ,Prior authorization ,Medical prescription ,business ,medicine.drug - Abstract
Objectives: To compare out-of-pocket cost between apixaban and enoxaparin for prevention of postoperative venous thromboembolism (VTE) in gynecologic oncology patients. Current guidelines recommend low molecular weight heparin for thromboprophylaxis following gynecologic cancer surgery, but new evidence suggests that oral apixaban may provide another safe and effective alternative. Recent publications have suggested apixaban more cost-effective, however these data do not evaluate out-of-pocket cost. Methods: This retrospective study was approved by the institutional QIAB. Patients undergoing open surgery for gynecologic malignancy qualified for this study. Test claims for apixaban 2.5 mg by mouth twice daily and enoxaparin 40 mg subcutaneously daily for 28 days were submitted for each patient prior to surgery. Patient copays, number of patients requiring prior authorization, and number of patients without prescription insurance were collected. Results: A total of 86 consecutive patients had test claims sent for both apixaban and enoxaparin thromboprophylaxis between July 2020 and October 2020. The average patient out-of-pocket cost to complete 28 days of apixaban prophylaxis was $73.95 (median $42.84, range $0-448.45). The average patient cost to complete 28 days of enoxaparin prophylaxis was $38.08 (median $10, range $0-260.91). Partial fills were allowed for 4 of 5 enoxaparin prescriptions that required prior authorization. A total of 5 apixaban prescriptions (5.8%) required prior authorization for full 28 days. A total of 5 patients (5.8 %) did not have prescription insurance. Cash price for enoxaparin was nearly double the cash price of apixaban. A total 6 patients’ (7 %) insurance was not contracted with our pharmacy. A single patient (1.2%) required enoxaparin via specialty pharmacy. A total of 2 patients (2.3 %) were enrolled in the institution's financial assistance per the institution. Download : Download high-res image (65KB) Download : Download full-size image Conclusions: Patients prescribed extended-duration venous thromboembolism prophylaxis may face higher out-of-pocket costs with apixaban than with enoxaparin. Prior authorizations can often take 48 to 72 hours for approval. Sending test claims prior to surgery can help identify prescriptions that will need prior authorizations so prescriptions can be sent earlier to avoid discharge delays and patient nonadherence. There may not be a one size fits all solution and individualized patient care should be considered. Future research areas should evaluate patient adherence with a twice daily oral pill vs a once daily injection.
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- 2021
9. Longitudinal patient-reported outcomes and restrictive opioid prescribing after minimally invasive gynecologic surgery
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R. Tyler Hillman, Xin Shelley Wang, Qiuling Shi, Tina Suki, Larissa A. Meyer, Pedro T. Ramirez, Katherine E. Cain, Javier Lasala, Loretta A. Williams, Maria D. Iniesta, Tsun Chen, Gabriel E. Mena, and Jolyn S. Taylor
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Adult ,medicine.medical_specialty ,medicine.medical_treatment ,Aftercare ,Malignancy ,Opioid prescribing ,Article ,Gynecologic Surgical Procedures ,Statistical significance ,medicine ,Humans ,Minimally Invasive Surgical Procedures ,Longitudinal Studies ,Patient Reported Outcome Measures ,Practice Patterns, Physicians' ,Aged ,Retrospective Studies ,Aged, 80 and over ,Pain, Postoperative ,Hysterectomy ,business.industry ,Significant difference ,Obstetrics and Gynecology ,Middle Aged ,medicine.disease ,Quality Improvement ,Surgery ,Analgesics, Opioid ,Oncology ,Cohort ,Morphine ,Female ,business ,Oxycodone ,medicine.drug - Abstract
ObjectiveTo determine post-discharge patient-reported symptoms before and after implementation of restrictive opioid prescribing among women undergoing minimally invasive gynecologic surgery.MethodsWe compared clinical outcomes and symptom burden among a cohort of 389 women undergoing minimally invasive gynecologic surgery at a single institution before and after implementation of a restrictive opioid prescribing quality improvement initiative in July 2018. Post-discharge symptom burdens were collected up to 42 days after discharge using the MD Anderson Symptom Inventory and analyzed using linear mixed effects models.ResultsThe majority of women included in this study were white non-smokers and the median age was 55 (range 23–83). Most women underwent hysterectomy (64%), had surgery for malignancy (71%), and were discharged from the hospital on the day of surgery (65%). Women in the restrictive opioid prescribing group had a median reduction in morphine equivalent dose prescribed at discharge of 83%, corresponding to a median reduction in 25 tablets of 5 mg oxycodone per person. There was no difference between opioid prescribing groups in either the rate of refill requests (P=1) or hospital re-admission (P=1) up to 30 days after discharge. After adjustment for co-variates, there was no statistically significant difference in post-discharge symptom burden including patient-reported pain (P=0.08), sleep (P=0.30), walking interference (P=0.64), activity interference (P=0.12), or affective interference (P=0.67). There was a trend toward less reported constiptation in the restrictive opioid prescribing group that did not reach statistical significance (P=0.05).ConclusionWe found that restrictive post-operative opioid prescribing was not associated with differences in longitudinal symptom burden among women undergoing minimally invasive gynecologic surgery. These results provide the most comprehensive picture to date of post-operative symptom recovery under different opioid prescribing approaches, lending additional support for existing recommendations to reduce opioid prescribing following gynecologic surgery.
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- 2020
10. Enhanced recovery for obese patients undergoing gynecologic cancer surgery
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Ross F. Harrison, Katherine E. Cain, Javier Lasala, Gabriel E. Mena, Larissa A. Meyer, Maria D. Iniesta, Pedro T. Ramirez, Ashley Siverand, and Brandelyn Pitcher
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medicine.medical_specialty ,Uterine Cervical Neoplasms ,Patient Readmission ,Article ,Body Mass Index ,Primary outcome ,Postoperative Complications ,Enhanced recovery ,Gynecologic cancer ,medicine ,Humans ,Obesity ,Aged ,Retrospective Studies ,Ovarian Neoplasms ,business.industry ,Obstetrics and Gynecology ,Cancer ,Length of Stay ,Middle Aged ,medicine.disease ,Surgery ,Analgesics, Opioid ,Oncology ,Female ,Complication ,business ,Enhanced Recovery After Surgery ,Cohort study ,Abdominal surgery - Abstract
ObjectiveTo compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery.MethodsWe performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance.ResultsAfter matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48–66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, pConclusionsNeither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.
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- 2020
11. Rate of venous thromboembolism in gynecologic patients on an ERAS pathway
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Maria Iniesta-Donate, Javier Lasala, Jolyn S. Taylor, Larissa A. Meyer, Katherine E. Cain, Pedro T. Ramirez, Andres S. Zorilla Vaca, and Gabriel E. Mena
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Cancer Research ,medicine.medical_specialty ,Oncology ,business.industry ,medicine ,Care pathway ,business ,Complication ,Venous thromboembolism ,Enhanced recovery after surgery ,Surgery - Abstract
214 Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.
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- 2021
12. 373 Outcomes of obese patients undergoing gynecologic surgery on an enhanced recovery after surgery (ERAS) program
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Larissa A. Meyer, Katherine E. Cain, Brandelyn Pitcher, Javier Lasala, Ross F. Harrison, Ashley Siverand, Pedro T. Ramirez, and Iniesta
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medicine.medical_specialty ,business.industry ,Open surgery ,nutritional and metabolic diseases ,Perioperative ,Overweight ,medicine.disease ,Obesity ,Surgery ,Blood loss ,medicine ,Operative time ,medicine.symptom ,business ,Enhanced recovery after surgery ,Body mass index - Abstract
Objectives To compare perioperative outcomes of obese vs. non-obese patients undergoing gynecologic surgery on an ERAS program. Methods We retrospectively reviewed patients undergoing open surgery 11/2014–11/2018. Patients were classified into three categories based on body mass index (BMI) and obesity class:: normal/overweight [BMI 18.0–29.9 kg/m2], class I [BMI 30.0–34.9 kg/m2], class II [BMI 35.0–39.9 kg/m2], and class III or greater [BMI ≥40.0 kg/m2]. Obese patients were matched to non-obese patients by age, procedure date, and surgical indication. Standard statistical methods were utilized. Primary outcome was postoperative length of stay [LOS]. Results After matching, 696 patients were included in the analysis [normal/overweight, n=348; class I, n=163 class II, n=88; class III or greater, n=97]. All groups had a median postoperative LOS of 3 days. Obese patients had longer procedure times [median OR time: 218 min vs. 192.5 min, p Conclusions Even after longer operative time and greater blood loss, obese ERAS patients had comparable compliance, perioperative complications, and length of stay to non-obese patients.
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- 2019
13. 52 Impact of ERAS program implementation in gynecologic surgery on healthcare costs
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Pedro T. Ramirez, Alexis B. Guzman, Larissa A. Meyer, Andrea Rodriguez-Restrepo, Ross F. Harrison, Javier Lasala, Iniesta, Katherine E. Cain, Y. Li, and Brandelyn Pitcher
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Surgical team ,medicine.medical_specialty ,Primary outcome ,business.industry ,Health care ,Invasive surgery ,Cohort ,medicine ,Pharmacy ,Healthcare service ,business ,Resource utilization ,Surgery - Abstract
Objectives To evaluate differences in hospital charges and healthcare service utilization for gynecologic surgery patients managed before and after ERAS implementation. Methods We retrospectively reviewed women undergoing open gynecologic surgery before and after ERAS implementation. Consecutive patients from 5/2014–10/2014 and 11/2014–11/2015 comprised the pre-ERAS and ERAS cohorts, respectively. Patients were excluded if they had a multidisciplinary surgical team or underwent minimally invasive surgery. All technical and professional charges were ascertained for healthcare services from procedure date until postoperative day 30. Adjuvant treatment charges were excluded. Charges were categorized by the type of clinical service provided. The primary outcome was the difference in total charges between the two groups. Results A total of 271 patients were included with 58 and 213 patients in the pre-ERAS and ERAS cohort, respectively. 70,177 technical charges and 6,775 professional charges were identified and classified. The median hospital charge decreased 15.6% from the pre-ERAS to ERAS groups [95% CI 0–39%; p=0.008]. ERAS patients had lower charges for laboratory services [20% decrease; 95% CI 0–39%; p=0.04], pharmacy services [30% decrease; 95% CI 14–41%; p Conclusions Hospital charges and healthcare service utilization were lower for ERAS patients compared with patients receiving conventional perioperative care. ERAS may be considered high value as it provides improved outcomes while lowering resource utilization.
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- 2019
14. A prospective randomized trial comparing liposomal bupivacaine vs standard bupivacaine wound infiltration in open gynecologic surgery on an enhanced recovery pathway
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Javier Lasala, Maria D. Iniesta, Pedro T. Ramirez, Qiuling Shi, Camila Corzo, Xin Shelly Wang, Mark F. Munsell, Katherine E. Cain, Gabriel E. Mena, Brandelyn Pitcher, and Larissa A. Meyer
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Adult ,medicine.medical_specialty ,Exploratory laparotomy ,medicine.medical_treatment ,law.invention ,Young Adult ,03 medical and health sciences ,Gynecologic Surgical Procedures ,0302 clinical medicine ,Randomized controlled trial ,law ,Laparotomy ,medicine ,Humans ,Single-Blind Method ,Prospective Studies ,030212 general & internal medicine ,Anesthetics, Local ,Syringe ,Aged ,Pain Measurement ,Aged, 80 and over ,Bupivacaine ,Pain, Postoperative ,Wound Healing ,030219 obstetrics & reproductive medicine ,business.industry ,Obstetrics and Gynecology ,Middle Aged ,Liposomal Bupivacaine ,Surgery ,Treatment Outcome ,Opioid ,Liposomes ,Morphine ,Female ,business ,medicine.drug - Abstract
Background Value in healthcare is reflected by patient-centered outcomes of care per health dollar expended. Although liposomal bupivacaine is more expensive, it has been shown to provide prolonged analgesia (up to 72 hours). Objective This study aimed to evaluate whether the addition of liposomal bupivacaine to standard bupivacaine could decrease opioid intake and improve pain control after laparotomy for gynecologic surgery compared with standard bupivacaine alone in an enhanced recovery after surgery pathway. Study Design A prospective randomized controlled single-blinded trial of wound infiltration with liposomal bupivacaine plus 0.25% bupivacaine (study arm) vs 0.25% bupivacaine (control arm) was performed at a National Cancer Institute–designated tertiary referral cancer center. Participants were patients aged ≥18 years undergoing exploratory laparotomy for a gynecologic indication. All patients were treated on an enhanced recovery pathway including local wound infiltration before closure. In this study, 266 mg of liposomal bupivacaine (free base; equal to 300 mg bupivacaine HCL)+150 mg of bupivacaine mixed in the same syringe was used in the study arm, and 150 mg of bupivacaine was used in the control arm. The primary outcome was the proportion of patients who were opioid-free within 48 hours after surgery. Secondary outcomes included number of opioid-free days from postoperative day 0 to postoperative day 3, days to first opioid administration, morphine equivalent daily dose, and patient-reported outcomes collected with the MD Anderson Symptom Inventory. The MD Anderson Symptom Inventory was administered as a preoperative baseline, daily while hospitalized, and at least weekly for 8 weeks after discharge. All outcomes were prespecified before data collection. Results In this study, 102 patients were evaluated. Among them, 16.7% of patients in the study arm received no opioids up to 48 hours compared with 14.8% in the control arm (P=.99). There were no significant differences in the amount of intraoperative opioids administered or days to first opioid use. There was no significant difference between the 2 arms in median cumulative morphine equivalent daily dose (21.3 [study arm] vs 33.8 [control arm]; P=.36) or between the groups in morphine equivalent daily dose per individual day. There were no significant differences in patient-reported pain or interference with walking between the 2 arms or other patient-reported outcomes. Conclusion Within an enhanced recovery after surgery pathway, adding liposomal bupivacaine to 0.25% bupivacaine wound infiltration did not decrease the proportion of patients who were opioid-free within 48 hours after surgery, did not decrease opioid intake, or did not improve patient’s self-reported pain and functional recovery compared with standard bupivacaine.
- Published
- 2021
15. What Is the Real Rate of Surgical Site Infection?
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Kathleen M. Schmeler, Deepthi James, Linda Graviss, Thomas A. Aloia, Keith N. Myers, Shital Vachhani, K. Potts, Claire A. Marten, Charles F Levenback, Diane C. Bodurka, Larissa A. Meyer, Jolyn S. Taylor, Lynn M. Cloutier, Cheryl Hubbs, Anne K. Park, Alpa M. Nick, Tara N. Tatum, Katherine E. Cain, Shauna Fenton, Kathy M. Ware, and Jennifer K. Burzawa
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medicine.medical_specialty ,Databases, Factual ,MEDLINE ,030501 epidemiology ,Special Series: Quality Care Symposium ,03 medical and health sciences ,Government Agencies ,0302 clinical medicine ,Chart review ,Health care ,Surgical site ,medicine ,Humans ,Surgical Wound Infection ,Quality of Health Care ,Oncology (nursing) ,business.industry ,Extramural ,Health Policy ,United States ,Surgery ,Acs nsqip ,Oncology ,030220 oncology & carcinogenesis ,Inclusion and exclusion criteria ,Emergency medicine ,0305 other medical science ,business ,Surgical site infection - Abstract
Purpose: Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. Methods: We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher’s exact test. Results: Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). Conclusion: There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.
- Published
- 2016
16. Lack of utility of the Khorana score for predicting VTE in advanced ovarian cancer
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Anil K. Sood, Robert L. Coleman, Nicole D. Fleming, Shannon N. Westin, Bryan Fellman, Kathleen M. Schmeler, Jolyn S. Taylor, G.Z. Dal Molin, Vahid Afshar-Kharghan, and Katherine E. Cain
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Oncology ,medicine.medical_specialty ,Advanced ovarian cancer ,business.industry ,Internal medicine ,medicine ,Obstetrics and Gynecology ,business - Published
- 2020
17. Impact of implementation of an enhanced recovery program in gynecologic surgery on healthcare costs
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Javier Lasala, Brandelyn Pitcher, Larissa A. Meyer, Ross F. Harrison, Andrea Rodriguez-Restrepo, Alexis B. Guzman, Pedro T. Ramirez, Yao Li, Katherine E. Cain, and Maria D. Iniesta
- Subjects
Adult ,medicine.medical_specialty ,Adolescent ,Pharmacy ,Article ,Cohort Studies ,Young Adult ,03 medical and health sciences ,Gynecologic Surgical Procedures ,0302 clinical medicine ,Enhanced recovery ,Health care ,medicine ,Humans ,030212 general & internal medicine ,Aged ,Retrospective Studies ,Aged, 80 and over ,Surgical team ,030219 obstetrics & reproductive medicine ,business.industry ,Obstetrics and Gynecology ,Retrospective cohort study ,Health Care Costs ,Clinical Laboratory Services ,Length of Stay ,Middle Aged ,Hospital Charges ,Confidence interval ,Surgery ,Cohort ,Female ,Enhanced Recovery After Surgery ,Pharmacy Service, Hospital ,business ,Abdominal surgery - Abstract
Enhanced recovery programs have been associated with improved outcomes after gynecologic surgery. There are limited data on the effect of enhanced recovery programs on healthcare costs or healthcare service use.The purpose of this study was to evaluate differences in hospital charges for women who undergo surgery for a suspected gynecologic cancer that is managed in an enhanced recovery program as compared with conventional perioperative care.We performed a retrospective cohort study of women who underwent open abdominal surgery for a suspected gynecologic cancer before and after the implementation of an enhanced recovery after surgery program. Consecutive patients from May to October 2014 and from November 2014 to November 2015 comprised the conventional perioperative care (before enhanced recovery after surgery) and enhanced recovery after surgery cohorts, respectively. Patients were excluded if they underwent surgery with a multidisciplinary surgical team or minimally invasive surgery. All technical and professional charges were ascertained for all healthcare services from the day of surgery until postoperative day 30. Charges for adjuvant treatment were excluded. Charges were classified according to the type of clinical service provided. The primary outcome was the difference in total hospital charges between the pre-enhanced recovery after surgery and the enhanced recovery after surgery groups. Secondary outcomes were between group differences in hospital charges within clinical service categories.A total of 271 patients were included in the analysis (58 patients in the pre-enhanced recovery after surgery and 213 patients in the enhanced recovery after surgery cohort). A total of 70,177 technical charges and 6775 professional charges were identified and classified. The median hospital charge for a patient decreased 15.6% in the enhanced recovery after surgery group compared with the pre-enhanced recovery after surgery group (95% confidence interval, 5-24.5%; P=.008). Patients in the enhanced recovery after surgery group also had lower charges for laboratory services (20% lower; 95% confidence interval, 0--39%; P=.04), pharmacy services (30% lower; 95% confidence interval, 14--41%; P.001), room and board (25% lower; 95% confidence interval, 20--47%; P=.005), and material goods (64% lower; 95% confidence interval, 44--81%; P.001). No differences in charges were observed for perioperative services, diagnostic procedures, emergency department care, transfusion-related services, interventional radiology procedures, physical/occupational therapy, outpatient care, or other services.Hospital charges and healthcare service use were lower for enhanced recovery patients compared with patients who received conventional perioperative care after open surgery for a suspected gynecologic cancer. Enhanced recovery programs may be considered to be high value in healthcare because they provide improved outcomes while lowering resource use.
- Published
- 2020
18. Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes
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Qiuling Shi, Xin Shelley Wang, Javier Lasala, Pedro T. Ramirez, Mark F. Munsell, Katherine E. Cain, Maria D. Iniesta, Alpa M. Nick, Karen H. Lu, and Larissa A. Meyer
- Subjects
Adult ,medicine.medical_specialty ,Quality management ,Adolescent ,Opioid consumption ,Genital Neoplasms, Female ,Treatment outcome ,Perioperative Care ,Article ,03 medical and health sciences ,0302 clinical medicine ,Gynecologic Surgical Procedures ,Postoperative Complications ,medicine ,Humans ,030212 general & internal medicine ,Patient Reported Outcome Measures ,Postoperative Period ,Enhanced recovery after surgery ,Fatigue ,Aged ,Pain Measurement ,Aged, 80 and over ,Pain, Postoperative ,Extramural ,business.industry ,Opioid use ,Obstetrics and Gynecology ,Perioperative ,Length of Stay ,Middle Aged ,Physical Functional Performance ,Quality Improvement ,Analgesics, Opioid ,Treatment Outcome ,030220 oncology & carcinogenesis ,Perioperative care ,Emergency medicine ,Female ,business - Abstract
OBJECTIVE: To investigate the effect of an enhanced recovery after surgery (ERAS) program on perioperative outcomes with an emphasis on opioid consumption and patient-reported outcomes in the immediate and extended postoperative period. METHODS: We initiated our ERAS program as part of a quality improvement initiative in November 2014. We compared clinical outcomes among a cohort of 607 women undergoing open gynecologic surgery before or after implementation of ERAS. For 293 patients, patient reported outcomes were compared using the MD Anderson Symptom Inventory-Ovarian Cancer (MDASI-OC). RESULTS: Median age was 58 years (18–85). Median length of stay decreased by 25% for patients in the ERAS pathway, (p
- Published
- 2018
19. Improved Compliance With Venous Thromboembolism Pharmacologic Prophylaxis for Patients With Gynecologic Malignancies Hospitalized for Nonsurgical Indications Did Not Reduce Venous Thromboembolism Incidence
- Author
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Lauren S. Prescott, Lisa M. Kidin, Mark F. Munsell, David J. Cleveland, Ginger L. Wilson, Pedro T. Ramirez, Kathleen M. Schmeler, Charles F Levenback, Michael H. Kroll, Rebecca L. Downs, Alma Yvette DeJesus, and Katherine E. Cain
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Adult ,medicine.medical_specialty ,Genital Neoplasms, Female ,Population ,MEDLINE ,Article ,Cohort Studies ,Young Adult ,Patient safety ,Risk Factors ,medicine ,Humans ,Young adult ,Intensive care medicine ,education ,Contraindication ,Aged ,Neoplasm Staging ,Aged, 80 and over ,education.field_of_study ,business.industry ,Incidence ,Incidence (epidemiology) ,Anticoagulants ,Obstetrics and Gynecology ,Venous Thromboembolism ,Middle Aged ,Prognosis ,Quality Improvement ,Texas ,Hospitalization ,Oncology ,Practice Guidelines as Topic ,Cohort ,Patient Compliance ,Female ,Guideline Adherence ,business ,Follow-Up Studies ,Cohort study - Abstract
ObjectiveNational guidelines recommend prophylactic anticoagulation for all hospitalized patients with cancer to prevent hospital-acquired venous thromboembolism (VTE). However, adherence to these evidence-based recommended practice patterns remains low. We performed a quality improvement (QI) project to increase VTE pharmacologic prophylaxis rates among patients with gynecologic malignancies hospitalized for nonsurgical indications and evaluated the resulting effect on rates of development of VTE.Materials and MethodsIn June 2011, departmental VTE practice guidelines were implemented for patients with gynecologic malignancies who were hospitalized for nonsurgical indications. A standardized VTE prophylaxis module was added to the admission electronic order sets. Outcome measures included number of admissions receiving VTE pharmacologic prophylaxis within 24 hours of admission; and number of potentially preventable hospital-acquired VTEs diagnosed within 30 and 90 days of discharge. Outcomes were compared between a preguideline implementation cohort (n = 99), a postguideline implementation cohort (n = 127), and a sustainability cohort assessed 2 years after implementation (n = 109). Patients were excluded if upon admission they had a VTE, were considered low risk for VTE, or had a documented contraindication to pharmacologic prophylaxis.ResultsAdministration of pharmacologic prophylaxis within 24 hours of admission increased from 20.8% to 88.2% immediately following the implementation of guidelines, but declined to 71.8% in our sustainability cohort (P < 0.001). There was no difference in VTE incidence among the 3 cohorts [n = 2 (4.2%) vs n = 3 (3.9%) vs n = 3 (4.2%), respectively; P = 1.00].ConclusionsOur QI project improved pharmacologic VTE prophylaxis rates. A small decrease in prophylaxis during the subsequent 2 years suggests a need for continued surveillance to optimize QI initiatives. Despite increased adherence to guidelines, VTE rates did not decline in this high-risk population.
- Published
- 2015
20. Is oral acetaminophen comparable to intravenous acetaminophen when used as a premedication in an ERAS pathway?
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Camila Corzo, Maria D. Iniesta, Bryan Fellman, Ashley Siverand, Pedro T. Ramirez, Javier Lasala, Tina Suki, Larissa A. Meyer, and Katherine E. Cain
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Nutrition and Dietetics ,business.industry ,Endocrinology, Diabetes and Metabolism ,Anesthesia ,medicine ,Intravenous acetaminophen ,Premedication ,business ,Acetaminophen ,medicine.drug - Published
- 2018
21. Adoption of an enhanced recovery program leads to decreased opioid use and associated patient-reported opioid related adverse symptoms
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Qiuling Shi, Pedro T. Ramirez, Camila Corzo, Katherine E. Cain, Larissa A. Meyer, Javier Lasala, Terri Earles, Melinda Harris, Xin S. Wang, and Maria D. Iniesta
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Nutrition and Dietetics ,Enhanced recovery ,Opioid ,business.industry ,Endocrinology, Diabetes and Metabolism ,Opioid use ,Anesthesia ,medicine ,business ,medicine.drug - Published
- 2018
22. An initiative to improve mortality index in gynecologic oncology
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Jennifer F. Miller, Roshonda Finch, Jolyn S. Taylor, Van Nguyen, Karen L. Brown, Katherine E. Cain, Tricia K. Blanco, Corrine C. Byrd, Charles F Levenback, Karen H. Lu, Anita Holloway, Edith K. Ballard, Donna Fleming, Anne Park, Kathleen M. Schmeler, Arletta Smith, and Claire A. Marten
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Cancer Research ,medicine.medical_specialty ,Oncology ,Mortality index ,business.industry ,Emergency medicine ,Medicine ,Metric (unit) ,Gynecologic oncology ,business - Abstract
256 Background: The mortality index (MI) is a quality metric that measures the ratio of actual mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on patient risks and comorbidities. A MI of < 1.0 represents that fewer patients die while admitted to the hospital than expected. Methods: We formed a multidisciplinary team that included Gynecologic Oncology (GO), Health Information Management, Clinical Informatics, Revenue Operations, Coding and Institutional Compliance experts. Our aim was to decrease the GO MI by 10% within a year. Quality Improvement Assessment Board approval was obtained. GO clinical providers were educated on proper documentation of patient comorbidities and severity of illness. Audits of the documentation were performed by the multidisciplinary team. GO patients perceived at high-risk of inpatient mortality were identified for additional review. All GO inpatient deaths were reviewed at the monthly GO Morbidity and Mortality conference and opportunities for avoidance of inpatient death were discussed. Plan-Do-Study-Act (PDSA) cycles were repeated with adjustments made to the review and education processes. Baseline (BL) 8/2017-7/2018 and interim post-intervention (PI) 11/2018-2/2019 outcomes were compared using the Mann Whitney U test. Results: The BL median number of inpatient deaths per month was 2 (range 0-7), with a median expected mortality of 2.96 (range 1.46-5.11), and a median MI of 0.84 (range 0-1.37). The PI median number of inpatient deaths per month was 2.5 (range 2-5), with a median expected mortality of 4.24 (range 3.77-5.06), and a median MI of 0.56 (range 0.53-1.27). The number of inpatient deaths per month was similar between groups (2 vs 2.5; p = 0.49) but the expected mortality increased from to 2.96 to 4.24 (p = 0.03). MI decreased by 33% between BL and PI (0.84 vs 0.56). Conclusions: Inpatient mortality is an important quality metric. Accurate measurement of expected mortality is critical and requires proper documentation. This can be improved through education, review and frequent assessment by PDSA cycles. Our preliminary results show improvement in accurate documentation and measurement of expected mortality resulting in a decrease in MI.
- Published
- 2019
23. Effect of anesthesia technique on intra-operative and post-operative morphine equivalent daily dose (MEDD) in open gynecologic surgery in an enhanced recovery after surgery (ERAS) pathway
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Juan P. Cata, B. Pitcher, Javier Lasala, Katherine E. Cain, M. Iniesta-Donate, Ashley Siverand, Gabriel E. Mena, Tina Suki, Pedro T. Ramirez, and Larissa A. Meyer
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medicine.medical_specialty ,Nutrition and Dietetics ,Intra operative ,business.industry ,Endocrinology, Diabetes and Metabolism ,Anesthesia ,Morphine ,Medicine ,Post operative ,business ,Enhanced recovery after surgery ,Surgery ,medicine.drug - Published
- 2019
24. Integration of a standardized diabetic management protocol into an ERAS program
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K. Stewart, Jolyn S. Taylor, Katherine E. Cain, Javier Lasala, Pedro T. Ramirez, L. McGrew, Melinda Harris, C. Hubbs, J. Dottino, Deepthi James, C. Siebel, Larissa A. Meyer, A. Enbaya, C. Best, M. Iniesta-Donate, S. Thosani, Shital Vachhani, Terri Earles, K.M. Schmeler, and S. Sahai
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Protocol (science) ,medicine.medical_specialty ,Nutrition and Dietetics ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,Medical physics ,business - Published
- 2019
25. Patient cost associated with filling a prescription for extended-duration venous thromboembolism (VTE) prophylaxis following surgery for gynecologic cancer
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Pedro T. Ramirez, Kathleen M. Schmeler, Charles F Levenback, Katherine E. Cain, Oliver Max, and Ginger Langley
- Subjects
Adult ,medicine.medical_specialty ,Genital Neoplasms, Female ,Cost-Benefit Analysis ,Pharmacy ,Vte prophylaxis ,Insurance Coverage ,Young Adult ,Gynecologic Surgical Procedures ,Gynecologic cancer ,Hospital discharge ,Humans ,Medicine ,Prior authorization ,Enoxaparin ,Medical prescription ,Aged ,Aged, 80 and over ,business.industry ,Prescription Fees ,Anticoagulants ,Obstetrics and Gynecology ,Health Care Costs ,Venous Thromboembolism ,Middle Aged ,United States ,Surgery ,Oncology ,Female ,Health Expenditures ,business ,Venous thromboembolism ,Abdominal surgery - Abstract
Objective The primary purpose of this study was to determine the average patient cost for filling a prescription for extended-duration enoxaparin prophylaxis. Methods Women who underwent major abdominal/pelvic surgery for histologically confirmed gynecologic malignancy were included. Patients who underwent minimally invasive surgery, had benign disease or were on treatment for existing VTE were excluded. Pharmacy resource specialists electronically submitted test prescriptions to verify enoxaparin coverage in the outpatient setting prior to hospital discharge. Patient co-pay information collected included: the number of patients requiring prescription insurance prior authorization, those qualifying for the Lovenox Patient Assistance Program® (PAP) and insurance status. Results Three hundred and sixty-four patients were discharged with extended-duration enoxaparin prophylaxis for 28days between October 2009 and May 2011. The average patient cost to complete 28days of enoxaparin prophylaxis was $62 (median $21, range $0–1210). Prior authorization was required for 32 patients (10%). Two patients (0.6%) qualified for the Lovenox Patient Assistance Program®. A decrease in the average patient cost from $71 to $52 (median $30 to $10) was observed after generic enoxaparin approval in July 2011. Conclusion Our results show that at least 90% of patients filled their prescription of extended-duration enoxaparin prophylaxis after major abdominal surgery for cancer regardless of cost.
- Published
- 2012
26. Use of pregabalin for preemptive analgesia in an enhanced recovery after surgery program
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Maria D. Iniesta, Camila Corzo, Katherine E. Cain, Larissa A. Meyer, Javier Lasala, Nhi Hoang, Pedro T. Ramirez, and Brandelyn Pitcher
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Cancer Research ,business.industry ,Pregabalin ,Hydromorphone ,Regimen ,Oncology ,Opioid ,Anesthesia ,medicine ,Celecoxib ,Morphine ,Tramadol ,business ,Oxycodone ,medicine.drug - Abstract
265 Background: A key component of any Enhanced Recovery After Surgery (ERAS) program is standardized multimodal analgesia to minimize opioid use. Our program utilizes acetaminophen, nonsteroidal anti-inflammatory agents and gabapentanoids perioperatively. The primary aim of our study was to evaluate pregabalin use after surgery and impact on total morphine equivalent daily dose (MEDD). Methods: Data was collected retrospectively on consecutive ERAS patients who underwent open gynecologic surgery from 3/4/2016 through 2/22/2018. We excluded any patient identified as a chronic opioid user. Standard preoperative medications included 300 mg tramadol ER, 75 mg pregabalin, and 400 mg celecoxib per institutional guidelines. Standard postoperative pain regimen included scheduled oral acetaminophen, ibuprofen and pregabalin unless contraindicated with rescue oral oxycodone and IV hydromorphone as needed. Pregabalin was ordered 75 mg twice daily for 4 doses. Recommended exceptions to pregabalin included hypersensitivity or age greater than 65 years. Median and range were calculated to summarize continuous variables. Spearman’s rank was used to test the correlation between post-operative pregabalin dose and MEDD. Results: A total of 533 patients were included for analysis. Twelve patients were excluded for chronic opioid use. 38% of patients received all four post-operative pregabalin doses (207/533). 32.8% of patients received no pregabalin (175/533). The fourth dose was the most common missed dose (274/533, 51.4%). The top reasons dose 4 was missed included not being ordered (58.8%) and patient already discharged (12.4%). There were 202 patients older than 65 years, the majority of these patients received no post-operative pregabalin (123/202, 60.9%). There was no difference in the amount of MEDD between those who received all pregabalin doses compared to those who received none (90.75 mg [4-663.5 mg] vs 82.5 mg [4-634.5 mg]; p = 0.269). Conclusions: Pregabalin for preemptive analgesia in an ERAS program does not decrease MEDD.
- Published
- 2018
27. Surgical Universal euGlycemic Attainment during Recovery (SUGAR) Initiative
- Author
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Christine Siebel, Ahmed Enbaya, Larissa A. Meyer, Kathleen M. Schmeler, Terri Earles, Sonali Thosani, Deepthi James, Conor Best, Cheryl Hubbs, Shital Vachhani, Leon McGrew, Katherine E. Cain, Sunil K. Sahai, Javier Lasala, Melinda Harris, Joseph A. Dottino, Maria D. Iniesta, Jolyn S. Taylor, Pedro T. Ramirez, and Katherine Stewart
- Subjects
Cancer Research ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Insulin ,Pharmacy ,Gynecologic oncology ,Oncology ,Anesthesiology ,Laparotomy ,Emergency medicine ,Surgical site ,Health care ,Medicine ,business ,Surgical incision - Abstract
252 Background: Surgical site infections (SSI) are infections of the surgical incision or organ space within 30 days of surgery and are associated with increased morbidity, mortality and healthcare expenditures. Diabetic patients undergoing laparotomy are at high risk. Prior studies have shown SSI reduction by avoiding hyperglycemia. The aim of our Quality Improvement (QI) initiative is to reduce the SSI rate among diabetic patients undergoing laparotomy by 40% within 2 years compared to the baseline (2/2015-8/2017) rate of 16%. Methods: We formed a multi-disciplinary QI team including physicians, nurses and advanced care providers from Gynecologic Oncology, Pharmacy, Nutrition, Endocrinology, Internal Medicine and Anesthesiology. The intervention began 2/2018 in our main center and 5 satellite sites including: screening gynecologic cancer patients undergoing laparotomy with hemoglobin A1C, intra-operative glucose monitoring with goal of < 180mg/dL, creation and use of a standardized basal-bolus insulin order set for post-operative care, and endocrine and nutritional consultation. The following variables were assessed: age, race, ethnicity, BMI, cancer type, comorbidities, smoking status, surgical procedure, receipt of antibiotic prophylaxis, hemoglobin A1C, post-operative glucose values, intervention compliance, intra-operative complications, post-operative complications including SSI, hospital readmissions, reoperation and mortality. Results: Since 2/2018, 39 gynecologic cancer patients have undergone laparotomy. Overall compliance with HgA1c screening is 64% (25/39), which has improved from 42% in 2/2018 to 70% in 3/2018 and 83% in 4/2018. Causes of non-compliance included unplanned conversion to laparotomy and need for additional education. Five of 39 (13%) patients were diabetic, including one newly diagnosed through this initiative. The post-intervention diabetic SSI rate is 0% (0/5) with all post-intervention glucose values < 180mg/dL. There have been no safety adverse events resulting in patient harm. Conclusions: Implementing a QI initiative to standardize management of diabetic patients undergoing surgery is both safe and feasible. Effectiveness data will continue to be collected.
- Published
- 2018
28. Is recovery really 'enhanced' through enhanced recovery programs? An analysis of patient-reported perioperative symptom burden before and after implementation of an enhanced recovery pathway for gynecologic surgery
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Javier Lasala, Katherine E. Cain, Pedro T. Ramirez, Alpa M. Nick, Karen H. Lu, Larissa A. Meyer, Qiuling Shi, Xin Shelley Wang, Maria D. Iniesta, and Terri Earles
- Subjects
medicine.medical_specialty ,030219 obstetrics & reproductive medicine ,business.industry ,Symptom burden ,Obstetrics and Gynecology ,Perioperative ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Oncology ,Enhanced recovery ,030220 oncology & carcinogenesis ,Medicine ,business - Published
- 2016
29. Implementation of an Enhanced Surgical Recovery Programme (ESRP) gynaecologic oncology: How much did intra-operative opioid administration decrease in first year post implementation?
- Author
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Juan P. Cata, Katherine E. Cain, Ifeyinwa Ifeanyi, Jagtar Singh Heir, Alpa M. Nick, Javier Lasala, Vijaya Gottumukkala, Gloria Salvo, Maria D. Iniesta, Pedro T. Ramirez, Larissa A. Meyer, Gabriel E. Mena, and Mark F. Munsell
- Subjects
medicine.medical_specialty ,Nutrition and Dietetics ,Intra operative ,business.industry ,Post implementation ,Endocrinology, Diabetes and Metabolism ,General surgery ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Opioid ,Surgical recovery ,030220 oncology & carcinogenesis ,Medicine ,030211 gastroenterology & hepatology ,business ,Administration (government) ,medicine.drug - Published
- 2016
30. Decreased postoperative opioid consumption following implementation of enhanced recovery pathway after gynecologic surgery
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P.T. Ramirez, Terri Earles, Maria D. Iniesta, Mark F. Munsell, Javier Lasala, Katherine E. Cain, L.A. Meyer, and Alpa M. Nick
- Subjects
medicine.medical_specialty ,Oncology ,Enhanced recovery ,Opioid consumption ,business.industry ,Anesthesia ,Obstetrics and Gynecology ,Medicine ,business ,Surgery - Published
- 2016
31. Decreased intraoperative opioid consumption following institution of enhanced recovery program in open gynecologic surgery
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Piotr Kwater, T. Moon Calderon, January Y. Tsai, Juan P. Cata, J. Singh, Mark F. Munsell, Alpa M. Nick, Katherine E. Cain, Javier Lasala, Ifeyinwa Ifeanyi, Maria D. Iniesta, Pedro T. Ramirez, Larissa A. Meyer, Gabriel E. Mena, and Shital Vachhani
- Subjects
medicine.medical_specialty ,Oncology ,Enhanced recovery ,Opioid consumption ,business.industry ,Anesthesia ,medicine ,Obstetrics and Gynecology ,business ,Surgery - Published
- 2016
32. Antimicrobial prophylaxis in the DISINFECT initiative: Decreasing the incidence of surgical INFECTions in gynecologic oncology
- Author
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Jennifer K. Burzawa, Jolyn S. Taylor, Katherine E. Cain, Shital Vachhani, Deepthi James, K. Potts, Charles F Levenback, Claire A. Marten, Kathleen M. Schmeler, and Mark F. Munsell
- Subjects
medicine.medical_specialty ,Oncology ,business.industry ,Incidence (epidemiology) ,medicine ,Obstetrics and Gynecology ,Gynecologic oncology ,Intensive care medicine ,Antimicrobial ,business ,Surgical Infections - Published
- 2016
33. Implementation of an enhanced recovery program at a tertiary cancer center
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Katherine E. Cain, Pedro T. Ramirez, Terri Earles, Larissa A. Meyer, Melinda Harris, Karen H. Lu, Alpa M. Nick, Javier Lasala, Maria D. Iniesta, and Mark F. Munsell
- Subjects
medicine.medical_specialty ,Oncology ,Enhanced recovery ,business.industry ,Emergency medicine ,medicine ,Obstetrics and Gynecology ,Cancer ,Center (algebra and category theory) ,medicine.disease ,business - Published
- 2016
34. Impact of an Enhanced Surgical Recovery Programme (ESRP) on postoperative renal function: Is euvolemia ideal for all or only a select few?
- Author
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Javier Lasala, Alpa M. Nick, Pedro T. Ramirez, Vijaya Gottumukkala, Larissa A. Meyer, Maria D. Iniesta, Mark F. Munsell, Gloria Salvo, Juan P. Cata, Katherine E. Cain, Gabriel E. Mena, Ifeyinwa Ifeanyi, and Jagtar Singh Heir
- Subjects
medicine.medical_specialty ,Pathology ,Nutrition and Dietetics ,Ideal (set theory) ,Surgical recovery ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,Renal function ,business ,Surgery - Published
- 2016
35. Implementation of an Enhanced Surgical Recovery Programme (ESRP) in gynaecologic oncology: Has the development of a preoperative order set improved compliance for preventive analgesia and deep venous thromboembolic (DVT) prophylaxis?
- Author
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Ifeyinwa Ifeanyi, Juan P. Cata, Jagtar Singh Heir, Gabriel E. Mena, Javier Lasala, Katherine E. Cain, Maria D. Iniesta, Pedro T. Ramirez, Vijaya Gottumukkala, Mark F. Munsell, Alpa M. Nick, Gloria Salvo, and Larissa A. Meyer
- Subjects
Compliance (physiology) ,medicine.medical_specialty ,Nutrition and Dietetics ,Surgical recovery ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,Physical therapy ,Dvt prophylaxis ,Intensive care medicine ,business ,Preventive analgesia ,Order set - Published
- 2016
36. Bowel surgery in an Enhanced Surgical Recovery Programme (ESRP) for gynaecologic surgery: Is recovery still enhanced or do we need to take a step back?
- Author
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Katherine E. Cain, Alpa M. Nick, Meyer A. Larissa, Terri Earles, Gabriel E. Mena, Maria D. Iniesta, Javier Lasala, Mark F. Munsell, Gloria Salvo, and Pedro T. Ramirez
- Subjects
medicine.medical_specialty ,Gynaecologic surgery ,Nutrition and Dietetics ,Surgical recovery ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,business ,Bowel surgery ,Surgery - Published
- 2016
37. A comprehensive evaluation of different risk-assessment models to predict 30-day postoperative complications in gynaecologic patients undergoing surgery under an Enhanced Surgical Recovery Programme (ESRP)
- Author
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Mark F. Munsell, Maria D. Iniesta, Javier Lasala, Katherine E. Cain, Terri Earles, Gloria Salvo, Larissa A. Meyer, Pedro T. Ramirez, and Alpa M. Nick
- Subjects
medicine.medical_specialty ,Nutrition and Dietetics ,Surgical recovery ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,business ,Risk assessment ,Surgery - Published
- 2016
38. Correlation of Body Mass Index (BMI) and perioperative outcomes in patients on an Enhanced Surgical Recovery Programme (ESRP): Are obese patients at a disadvantage or do all have the same benefit?
- Author
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Gloria Salvo, Katherine E. Cain, Gabriel E. Mena, Terri Earles, Javier Lasala, Pedro T. Ramirez, Alpa M. Nick, Mark F. Munsell, Maria D. Iniesta, and Larissa A. Meyer
- Subjects
Correlation ,medicine.medical_specialty ,Nutrition and Dietetics ,Surgical recovery ,business.industry ,Endocrinology, Diabetes and Metabolism ,medicine ,In patient ,Perioperative ,business ,Body mass index ,Disadvantage ,Surgery - Published
- 2016
39. What is the real rate of surgical-site infection?
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Kathy M. Ware, Linda Graviss, Thomas A. Aloia, Anne Park, Deepthi James, Jennifer K. Burzawa, Shauna Fenton, Kathleen M. Schmeler, Tara N. Tatum, Charles F Levenback, Katherine E. Cain, Jolyn S. Taylor, Shital Vachhani, Claire A. Marten, Lynn M. Cloutier, Diane C. Bodurka, Cheryl Hubbs, Alpa M. Nick, Larissa A. Meyer, and K. Potts
- Subjects
Cancer Research ,medicine.medical_specialty ,business.industry ,medicine.disease ,Acs nsqip ,Surgery ,Oncology ,Chart review ,Surgical site ,Health care ,Inclusion and exclusion criteria ,medicine ,Medical emergency ,business ,Surgical site infection - Abstract
171 Background: Surgical site infections (SSI) are associated with patient morbidity and increased healthcare costs. Although several national organizations monitor SSI including the University Health System Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), National Healthcare Safety Network (NHSN) and Agency for Healthcare Research and Quality (AHRQ), there is no standard reporting methodology. We compared SSI rates from these databases to our own chart review. Methods: We queried the UHC, NSQIP, NHSN and AHRQ databases from 7/2012-6/2014 for SSI following gynecologic surgery at our institution. UHC and AHRQ rely on ICD-9 coding while NSQIP and NHSN employ trained reviewers. Each organization uses different definitions, inclusion and exclusion criteria for SSI. NSQIP reviews 13-17% of cases at our institution while the other agencies include all cases. The rate of SSI was also obtained from chart review for 5/1/2014-6/30/2014 with SSI defined as an infection of the surgical incision or organ space requiring antibiotics. SSI was classified as superficial, deep or organ space (OS). The rates reported by the agencies were compared to the rate obtained by chart review using Fisher’s exact test. Results: The combined UHC/NSQIP/NHSN/AHRQ SSI rate was 5.1% (78/1,540) while the rate found by chart review was 12% (20/166) (p = 0.001). Overall SSI rates for the databases were: UHC 1.6%, NSQIP 8.8%, NHSN 2.9% and AHRQ < 1%. The combined database reported fewer superficial SSI compared to investigator chart review but did not differ significantly when reporting deep and OS: superficial 1.6% v 7.8% (p < 0.001), deep 2.1% v 1.2% (p = 0.57) and OS 2.9% v 3.6% (p = 0.26). The individual databases had wide variation in rate of superficial (UHC 0.7% NSQIP 1.2% NHSN 0.5% AHRQ 0%), deep (UHC 0.7% NSQIP 4.7% NHSN 1.3% AHRQ 0%) and OSI (UHC 0.03% NSQIP 4.4% NHSN 1.4% AHRQ < 1%). Only 19 cases (24.4%) were included in > 1 database. Only one case was included in three databases (1.3%) and no cases were included in all four. Conclusions: There is discordance among national reporting agencies tracking SSI and all agencies reported a different rate of SSI compared to chart review. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.
- Published
- 2016
40. Venous Thromboembolism (VTE) Rates Following the Implementation of Extended Duration Prophylaxis for Patients Undergoing Surgery for Gynecologic Malignancies
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Mark F. Munsell, Charles F Levenback, Robert L. Coleman, Pedro T. Ramirez, Ginger L. Wilson, Michael Frumovitz, Pamela T. Soliman, Alpa M. Nick, Michael H. Kroll, Kathleen M. Schmeler, and Katherine E. Cain
- Subjects
Adult ,medicine.medical_specialty ,Genital Neoplasms, Female ,medicine.medical_treatment ,Article ,Gynecologic surgical procedures ,Young Adult ,Gynecologic Surgical Procedures ,Laparotomy ,Gynecologic cancer ,Humans ,Medicine ,cardiovascular diseases ,Young adult ,Duration (project management) ,Aged ,Aged, 80 and over ,Extramural ,business.industry ,Incidence (epidemiology) ,Obstetrics and Gynecology ,Venous Thromboembolism ,General Medicine ,Heparin, Low-Molecular-Weight ,Middle Aged ,equipment and supplies ,Surgery ,Heparin.low molecular weight ,Oncology ,Practice Guidelines as Topic ,Female ,business ,Venous thromboembolism - Abstract
To compare the incidence of venous thromboembolism (VTE) before and after the implementation of standardized extended duration prophylaxis guidelines in women undergoing laparotomy for gynecologic cancer.In October 2009, departmental practice guidelines were implemented for VTE prevention. Patients undergoing laparotomy for gynecologic cancer were started on low molecular weight heparin (LMWH) within 24h of surgery and it was continued for a total of 28 days postoperatively. The incidence of VTE diagnosed within 30 and 90 days of surgery was determined and compared to a historic cohort of patients who underwent surgery prior to implementation of the guidelines.The incidence of VTE within 30 days of surgery decreased from 2.7% (8/300) to 0.6% (2/334) following implementation of VTE prevention guidelines (78% reduction, p=0.040). However, when the pre and post-guideline implementation groups were compared for the development of VTE within 90 days of surgery, there was no significant difference (11/300 (3.7%) vs. 10/334 (3.0%) respectively, p=0.619). The median time between surgery and VTE diagnosis was 12 days in the pre-guideline implementation group, compared with 57 days in the post-guideline implementation group (p=0.012).Patients receiving extended duration LMWH were found to have significantly lower rates of VTE within 30 days of surgery when compared with similar patients who did not receive extended duration LMWH. However, this effect was not sustained when the groups were compared for VTE diagnosis within 90 days of surgery. Additional study is needed to further reduce long-term VTE rates in this high-risk population.
- Published
- 2013
41. Patient costs associated with extended-duration venous thromboembolism (VTE) prophylaxis following surgery for gynecologic cancer
- Author
-
C. Levenback, Katherine E. Cain, O. Max, Ginger Langley, Kathleen M. Schmeler, and Pedro T. Ramirez
- Subjects
medicine.medical_specialty ,Oncology ,business.industry ,Gynecologic cancer ,medicine ,Obstetrics and Gynecology ,Vte prophylaxis ,Duration (project management) ,business ,Venous thromboembolism ,Surgery - Published
- 2012
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