401 results on '"Martin A. Makary"'
Search Results
2. Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study
- Author
-
Chen Dun, David P. Stonko, Sanuja Bose, Alana C. Keegan, Katherine M. McDermott, Kranti C. Rumalla, James H. Black, Corey A. Kalbaugh, Martin A. Makary, and Caitlin W. Hicks
- Subjects
claudication ,Medicare ,peripheral vascular interventions ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Previous cross‐sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. Methods and Results We conducted a retrospective analysis using 100% Medicare fee‐for‐service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilization and Medicare‐allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office‐based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare‐allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. Conclusions The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office‐based laboratory settings, non‐White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value‐based care for the treatment of claudication.
- Published
- 2024
- Full Text
- View/download PDF
3. The 10th anniversary of patient safety in surgery
- Author
-
Philip F. Stahel, Wade R. Smith, Ernest E. Moore, Philip S. Mehler, Sebastian Weckbach, Fernando J. Kim, Nathan Butler, Hans-Christoph Pape, Ted J. Clarke, Martin A. Makary, and Pierre-Alain Clavien
- Subjects
Patient safety in surgery ,Journal ,Publication metrics ,Medical errors ,Disclosure ,Reporting ,Surgery ,RD1-811 - Published
- 2017
- Full Text
- View/download PDF
4. Surgeons’ views on preoperative medical evaluation: a qualitative study
- Author
-
Kevin R. Riggs, Zackary D. Berger, Martin A. Makary, Eric B. Bass, and Geetanjali Chander
- Subjects
Preoperative care ,Risk assessment ,Medical overuse ,Surgery ,RD1-811 - Abstract
Abstract Background There is substantial variation in the practice of preoperative medical evaluation (PME) and limited evidence for its benefit, which raises concerns about overuse. Surgeons have a unique role in this multidisciplinary practice. The objective of this qualitative study was to explore surgeons’ practices and their beliefs about PME. Methods We conducted of semi-structured interviews with 18 surgeons in Baltimore, Maryland. Surgeons were purposively sampled to maximize diversity in terms of practice type (academic vs. private practice), surgical specialty, gender, and experience level. General topics included surgeons’ current PME practices, perceived benefits and harms of PME, the surgical risk assessment, and potential improvements and barriers to change. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes, which are presented as assertions. Transcripts were re-analyzed to identify supporting and opposing instances of each assertion. Results A total of 15 themes emerged. There was wide variation in surgeons’ described PME practices. Surgeons believed that PME improves surgical outcomes, but not all patients benefit. Surgeons were cognizant of the financial cost of the current system and the potential inconvenience that additional tests and office visits pose to patients. Surgeons believed that PME has minimal to no risk and that a normal PME is reassuring to them and patients. Surgeons were confident in their ability to assess surgical risk, and risk assessment by non-surgeons rarely affected their surgical decision-making. Hospital and anesthesiology requirements were a major driver of surgeons’ PME practices. Surgeons did not receive much training on PME but perceived their practices to be similar to their colleagues. Surgeons believed that PME provides malpractice protection, welcomed standardization, and perceived there to be inadequate evidence to significantly change their current practice. Conclusions Views of surgeons should be considered in future research on and reforms to the PME process.
- Published
- 2017
- Full Text
- View/download PDF
5. A novel approach for selecting combination clinical markers of pathology applied to a large retrospective cohort of surgically resected pancreatic cysts.
- Author
-
David L. Masica, Marco Dal Molin, Christopher L. Wolfgang, Tyler M. Tomita, Mohammad R. Ostovaneh, Amanda Blackford, Robert A. Moran, Joanna K. Law, Thomas Barkley, Michael Goggins, Marcia Irene Canto, Meredith E. Pittman, James R. Eshleman, Syed Z. Ali, Elliot K. Fishman, Ihab R. Kamel, Siva P. Raman, Atif K. Zaheer, Nita Ahuja, Martin A. Makary, Matthew J. Weiss, Kenzo Hirose, John L. Cameron, Neda Rezaee, Jin He, Young Joon Ahn, Wenchuan Wu, Yuxuan Wang, Simeon Springer, Luis L. Diaz Jr., Nickolas Papadopoulos, Ralph H. Hruban, Kenneth W. Kinzler, Bert Vogelstein, Rachel Karchin, and Anne Marie Lennon
- Published
- 2017
- Full Text
- View/download PDF
6. Medicare Beneficiaries In Disadvantaged Neighborhoods Increased Telemedicine Use During The COVID-19 Pandemic
- Author
-
Sanuja Bose, Chen Dun, George Q. Zhang, Christi Walsh, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Health Policy - Published
- 2022
7. Endophthalmitis Rates among Medicare Beneficiaries Undergoing Cataract Surgery between 2011 and 2019
- Author
-
Fasika A. Woreta, Divya Srikumaran, Peiqi Wang, Sidra Zafar, Oliver D. Schein, Martin A. Makary, and Chen Dun
- Subjects
medicine.medical_specialty ,genetic structures ,business.industry ,medicine.medical_treatment ,Patient risk ,Incidence (epidemiology) ,Medicare beneficiary ,Cataract surgery ,medicine.disease ,Logistic regression ,eye diseases ,Surgery ,Ophthalmology ,Endophthalmitis ,Patient age ,medicine ,sense organs ,Diagnosis code ,business - Abstract
Purpose To determine national incidence and risk factors associated with developing endophthalmitis after cataract surgery in the United States. Design Retrospective, cross-sectional analysis. Participants Medicare beneficiaries aged ≥65 years undergoing cataract surgery between 2011 and 2019. Methods Medicare claims were used to identify all patients who underwent ≥1 cataract surgery between 2011 and 2019. Endophthalmitis cases within 90 days of the cataract surgery were identified using diagnostic codes. Patients with a history of endophthalmitis 12 months before their cataract surgery procedure were excluded. Annual and aggregate 9-year incidences were determined for all cataract surgeries and for stand-alone cataract procedures. A stepwise multivariable logistic regression model using generalized estimating equations was used to evaluate factors associated with occurrence of postoperative endophthalmitis. Main Outcome Measures The 90-day postoperative endophthalmitis rate and patient risk factors associated with onset of endophthalmitis after cataract surgery. Results A total of 14 396 438 cataract surgeries were performed among Medicare beneficiaries between 2011 and 2019. The overall 90-day postoperative endophthalmitis rate was 1.36 per 1000 cataract surgeries for all cataract procedures and 1.30 per 1000 cataract surgeries for stand-alone cataract procedures. A decreasing trend was noted for postoperative endophthalmitis rates during the 9-year study period. On multivariable analysis, the risk of endophthalmitis after cataract surgery was increased for cases performed among those aged ≥75 years versus those aged Conclusions The overall 90-day postoperative endophthalmitis rate after cataract surgery was 1.36 per 1000 cataract surgeries between 2011 and 2019. Patient age, gender, race, and CCI were associated with risk of endophthalmitis.
- Published
- 2022
8. Low-value Peripheral Vascular Interventions are Becoming Increasingly Prevalent in the Treatment of Claudication
- Author
-
Chen Dun, David P. Stonko, Sanuja Bose, Alana Keegan, Katherine M. McDermott, James H. Black, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2023
9. Infrapopliteal Peripheral Vascular Interventions for Claudication Are Associated With Poor Long-term Outcomes Regardless of Anatomical and Disease Severity
- Author
-
Sanuja Bose, Chen Dun, Alana C. Keegan, Katherine M. McDermott, David P. Stonko, James H. Black, Jesse A. Columbo, Michael S. Conte, Sarah A. Deery, Philip P. Goodney, Jessica P. Simons, Jeffrey J. Siracuse, Karen Woo, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2023
10. Laparoscopic versus Open Pancreatoduodenectomy in Patients with Periampullary Tumors: A Systematic Review and Meta-analysis
- Author
-
Shahab Aldin Sattari, Ali Reza Sattari, Martin A. Makary, Chen Hu, and Jin He
- Subjects
Surgery - Abstract
To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors.LPD has gained attention; however, its safety and efficacy versus OPD remain debatable.We searched PubMed, and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade≥Ⅲ complications, and 90-day mortality. Secondary outcomes were blood loss (BL) (ml), blood transfusion (BT), duration of operation (minute), readmission, reoperation, comprehensive complication index (CCI) score, bile leak, gastro- or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection (SSI), intraabdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data were calculated using the random-effect model. The GRADE approach was used for grading the level of evidence.Four RCTs yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that two approaches were similar, except in the LPD group, the LOS tended to be shorter (MD=-2.54 [-5.17, 0.09], P=0.06), LOS in ICU was shorter (MD=-1[-1.8, -0.2], P=0.01), duration of operation was longer (MD=75.16[23.29, 127.03], P=0.005), BL was lower (MD=-115.40[-152.13, -78.68], P0.00001), BT was lower (OR=0.66[0.47, 0.92], P=0.01), and SSI was lower (OR=0.35[0.12, 0.96], P=0.04). The overall certainty of the evidence was moderate.Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD.
- Published
- 2022
11. Commercial Negotiated Prices for CMS-specified Shoppable Radiology Services in U.S. Hospitals
- Author
-
Ge Bai, John Jiang, and Martin A. Makary
- Subjects
Economic Competition ,Cost Control ,Radiology Department, Hospital ,Negotiating ,business.industry ,Humans ,Medicine ,Radiology, Nuclear Medicine and imaging ,Accounting ,business ,Centers for Medicare and Medicaid Services, U.S ,United States - Published
- 2022
12. Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia
- Author
-
Rebecca Sorber, Chen Dun, Qingwen Kawaji, Christopher J. Abularrage, James H. Black, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2023
13. University-age vaccine mandates: reply to Lam and Nichols
- Author
-
Tracy Beth Høeg, Allison Krug, Stefan Baral, Euzebiusz Jamrozik, Salmaan Keshavjee, Trudo Lemmens, Vinay Prasad, Martin A Makary, and Kevin Bardosh
- Subjects
Issues, ethics and legal aspects ,Health (social science) ,Arts and Humanities (miscellaneous) ,Health Policy - Published
- 2023
14. Clinical Protection During the First Omicron Wave in Unvaccinated, Convalescent US Adults-Reply
- Author
-
Jennifer L. Alejo, Martin A. Makary, and Dorry L. Segev
- Subjects
General Medicine - Published
- 2022
15. Practice Patterns Surrounding the Use of Tibial Interventions for Claudication in the Medicare Population
- Author
-
Sanuja Bose, Chen Dun, Rebecca Sorber, David P. Stonko, Alex J. Solomon, James H. Black, Ying-Wei Lum, Michael S. Conte, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Abstract
There have been no data to support the use of tibial interventions in the treatment of claudication to date. We aimed to characterize the practice patterns surrounding tibial peripheral vascular interventions (PVI) in patients with claudication in the United States.Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients undergoing an index PVI for claudication. Patients who had any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and a multivariable hierarchical logistic regression were used to assess patient and physician characteristics associated with the use of tibial PVI for claudication.Of 59,930 Medicare patients who underwent index PVI for claudication between 2017 and 2019, 16,594 (27.7%) received a tibial PVI (38.5% isolated tibial PVI and 61.5% tibial PVI with concomitant femoropopliteal PVI). Of 1,542 physicians included in the analysis, the median physician-level tibial PVI rate was 20.0% (IQR 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR] 1.23), increasing age (aOR1.30-1.96), Black race (aOR 1.47), Hispanic ethnicity (aOR 1.86), diabetes (aOR 1.36), no history of hypertension (aOR 1.12), and never-smoking (aOR 1.64; all, P0.05). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR 2.97), practice location in the West (aOR 1.75), high-volume PVI practice (aOR 1.87), majority practice in an ASC/OBL setting (aOR 2.37), and physician specialty; vascular surgeons had significantly lower odds of performing tibial PVI compared to radiologists (aOR 2.98) and cardiologists (aOR 1.67; all, P0.05). Average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs. quartile 1-3: $12,023.96 vs. $692.31 per patient, P0.001).Tibial PVI for claudication are performed more commonly by non-vascular surgeons, in high-volume practices, and in high-reimbursement settings. This reveals a critical need to reevaluate the indications, education, and reimbursement policies surrounding these procedures.
- Published
- 2022
16. Research Letter: Incidence of SARS-CoV-2 infection among unvaccinated US adults during the Omicron wave
- Author
-
Jennifer L. Alejo, Teresa PY Chiang, Jonathan Mitchell, Aura T. Abedon, Alexa A. Jefferis, William Werbel, Allan B. Massie, Martin A. Makary, and Dorry L. Segev
- Abstract
As of 4/20/2022, approximately 23% of the eligible US population was unvaccinated. We studied COVID-19 infections during the Omicron (B.1.1.529) wave in unvaccinated US adults, stratified by pre-Omicron antibody levels. Anti-spike serologic testing was performed prior to the Omicron wave in the United States (9/23/21-11/5/21) and participants were surveilled to determine incident COVID-19. Only 12% of those who entered the wave with antibodies reported a test-confirmed COVID-19 infection, compared to 35% of those without antibodies prior to the Omicron wave. Effectiveness of these anti-RBD antibodies in this unvaccinated population was 67%. Among people with antibodies, titer did not appear to be associated with risk of test-confirmed Omicron infection.
- Published
- 2022
17. Vaccine-Induced Intratumoral Lymphoid Aggregates Correlate with Survival Following Treatment with a Neoadjuvant and Adjuvant Vaccine in Patients with Resectable Pancreatic Adenocarcinoma
- Author
-
Jessica Hoare, Katrina Purtell, Elizabeth A. Sugar, Raka Bhattacharya, Arsen Osipov, Daniel A. Laheru, Katherine M. Bever, Rose Parkinson, Beth Onner, Matthew J. Weiss, Jin He, Ding Ding, Qingfeng Zhu, Elizabeth M. Jaffee, Guanglan Mo, Elizabeth D. Thompson, Amy Hacker-Prietz, Victoria M. Kim, Martin A. Makary, Hongyan Cai, Barish H. Edil, Richard D. Schulick, Robert A. Anders, John L. Cameron, Joseph M. Herman, Lindsey Manos, Nilofer S. Azad, Christopher L. Wolfgang, Dung T. Le, Dwayne L. Thomas, Jennifer N. Durham, Kevin C. Soares, Carol Judkins, Alex B. Blair, Ana De Jesus-Acosta, Sara Solt, and Lei Zheng
- Subjects
Male ,0301 basic medicine ,Oncology ,Cancer Research ,medicine.medical_specialty ,Cyclophosphamide ,medicine.medical_treatment ,Cancer Vaccines ,Article ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Clinical endpoint ,Humans ,Lymphocytes ,Adjuvants, Vaccine ,Antineoplastic Agents, Alkylating ,Aged ,business.industry ,Immunotherapy ,Middle Aged ,Prognosis ,medicine.disease ,GVAX ,Neoadjuvant Therapy ,Vaccine therapy ,Pancreatic Neoplasms ,Survival Rate ,Clinical trial ,030104 developmental biology ,030220 oncology & carcinogenesis ,Feasibility Studies ,Adenocarcinoma ,Female ,business ,Adjuvant ,Carcinoma, Pancreatic Ductal ,Follow-Up Studies ,medicine.drug - Abstract
Purpose: Immunotherapy is currently ineffective for nearly all pancreatic ductal adenocarcinomas (PDAC), largely due to its tumor microenvironment (TME) that lacks antigen-experienced T effector cells (Teff). Vaccine-based immunotherapies are known to activate antigen-specific Teffs in the peripheral blood. To evaluate the effect of vaccine therapy on the PDAC TME, we designed a neoadjuvant and adjuvant clinical trial of an irradiated, GM-CSF-secreting, allogeneic PDAC vaccine (GVAX). Patients and Methods: Eighty-seven eligible patients with resectable PDAC were randomly assigned (1:1:1) to receive GVAX alone or in combination with two forms of low-dose cyclophosphamide. Resected tumors following neoadjuvant immunotherapy were assessed for the formation of tertiary lymphoid aggregates (TLA) in response to treatment. The clinical endpoints are disease-free survival (DFS) and overall survival (OS). Results: The neoadjuvant treatment with GVAX either alone or with two forms of low-dose cyclophosphamide is safe and feasible without adversely increasing the surgical complication rate. Patients in Arm A who received neoadjuvant and adjuvant GVAX alone had a trend toward longer median OS (35.0 months) than that (24.8 months) in the historical controls who received adjuvant GVAX alone. However, Arm C, who received low-dose oral cyclophosphamide in addition to GVAX, had a significantly shorter DFS than Arm A. When comparing patients with OS > 24 months to those with OS < 15 months, longer OS was found to be associated with higher density of intratumoral TLA. Conclusions: It is safe and feasible to use a neoadjuvant immunotherapy approach for PDACs to evaluate early biologic responses. In-depth analysis of TLAs is warranted in future neoadjuvant immunotherapy clinical trials.
- Published
- 2021
18. Sleep disorders and the development of Alzheimer's disease among <scp>U.S. Medicare</scp> beneficiaries
- Author
-
Christi Walsh, Nadia M. Chu, Chen Dun, Mara McAdams-DeMarco, Martin A. Makary, and Farah Hashim
- Subjects
Aged, 80 and over ,Male ,Sleep Wake Disorders ,Gerontology ,business.industry ,MEDLINE ,Medicare beneficiary ,Disease ,Medicare ,Sleep in non-human animals ,Article ,United States ,Causality ,Alzheimer Disease ,Case-Control Studies ,Humans ,Medicine ,Female ,Geriatrics and Gerontology ,business ,Aged - Published
- 2021
19. Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care
- Author
-
Peiqi Wang, Mehran Habibi, Katerina Kaczmarski, Susan Hutfless, David M. Euhus, Martin A. Makary, Julie R. Lange, Lisa K. Jacobs, Richard C. Gilmore, and Melissa Camp
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,Breast surgery ,medicine.medical_treatment ,Retrospective cohort study ,Guideline ,Odds ratio ,medicine.disease ,Confidence interval ,Breast cancer ,Oncology ,Surgical oncology ,Biopsy ,Medicine ,Surgery ,Radiology ,business - Abstract
Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery. We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern. We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29–2.73), in the South (OR 1.84, 95% CI 1.20–2.84) or West region (OR 1.78, 95% CI 1.11–2.86), > 20 years in practice (OR 1.52, 95% CI 1.09–2.11), and low breast cancer surgery volume (
- Published
- 2021
20. Perioperative Outcomes of Robotic Pancreaticoduodenectomy: a Propensity-Matched Analysis to Open and Laparoscopic Pancreaticoduodenectomy
- Author
-
John L. Cameron, Joseph R. Habib, Elisabetta Sereni, William R. Burns, Ding Ding, Christopher L. Wolfgang, Richard A. Burkhart, A. Floortje van Oosten, Ahmer Irfan, Benedict Kinny-Köster, Jin He, Vincent P. Groot, Michael J. Wright, Ryan K. Schmocker, I. Quintus Molenaar, and Martin A. Makary
- Subjects
medicine.medical_specialty ,Gastric emptying ,business.industry ,Incidence (epidemiology) ,medicine.medical_treatment ,Gastroenterology ,Perioperative ,030230 surgery ,Pancreaticoduodenectomy ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,030220 oncology & carcinogenesis ,Propensity score matching ,Cohort ,Medicine ,Robotic surgery ,business ,Laparoscopic pancreaticoduodenectomy - Abstract
Robotic pancreaticoduodenectomy is slowly gaining acceptance within pancreatic surgery. Advantages have been demonstrated for robotic surgery in other fields, but robust data for pancreaticoduodenectomy is limited. The aim of this study was to compare the short-term outcomes of robotic pancreaticoduodenectomy (RPD) to open pancreaticoduodenectomy (OPD) and laparoscopic pancreaticoduodenectomy (LPD). Patients who underwent a pancreaticoduodenectomy between January 2011 and July 2019 at the Johns Hopkins Hospital were included in this retrospective propensity-matched analysis. The RPD cohort was matched to patients who underwent OPD in a 1:2 fashion and LPD in a 1:1 fashion. Short-term outcomes were analyzed for all three cohorts. In total, 1644 patients were included, of which 96 (5.8%) underwent RPD, 131 (8.0%) LPD, and 1417 (86.2%) OPD. RPD was associated with a decreased incidence of delayed gastric emptying (9.4%) compared to OPD (23.5%; P = 0.006). The median estimated blood loss was significantly less in the RPD cohort (RPD vs OPD, 150 vs 487 mL; P < 0.001, RPD vs LPD, 125 vs 300 mL; P < 0.001). Compared to OPD, the robotic approach was associated with a shorter median length of stay (median 8 vs 9 days; P = 0.014) and a decrease in wound complications (4.2% vs 16.7%; P = 0.002). The incidence of other postoperative complications was comparable between RPD and OPD, and RPD and LPD. In the hands of experienced surgeons, RPD may have a modest yet statistically significant reduction in estimated blood loss, postoperative length of stay, wound complications, and delayed gastric emptying comparing to OPD in similar patients.
- Published
- 2020
21. Postoperative Complications in Medicare Beneficiaries Following Endothelial Keratoplasty Surgery
- Author
-
Fasika A. Woreta, Divya Srikumaran, Peiqi Wang, Zara Ghous, Kanza Aziz, Martin A. Makary, and Sidra Zafar
- Subjects
Choroid Hemorrhage ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Population ,Visual Acuity ,Glaucoma ,Corneal Diseases ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Endophthalmitis ,Glaucoma surgery ,Humans ,Medicine ,Cumulative incidence ,education ,Corneal transplantation ,Aged ,Retrospective Studies ,030304 developmental biology ,Aged, 80 and over ,0303 health sciences ,education.field_of_study ,business.industry ,Corneal Edema ,Endothelium, Corneal ,Fuchs' Endothelial Dystrophy ,Graft Survival ,Retinal Detachment ,Retinal detachment ,Retrospective cohort study ,medicine.disease ,United States ,eye diseases ,Surgery ,Ophthalmology ,030221 ophthalmology & optometry ,Female ,Medicare Part B ,sense organs ,business ,Follow-Up Studies - Abstract
Purpose To determine national-level incidence rates of major postoperative complications following endothelial keratoplasty (EK) procedures and to stratify these rates based on EK indications over an 8-year period using Medicare claims data. Design Retrospective, cohort study. Methods Setting: population-based; study population: Medicare beneficiaries aged ≥65 years who underwent EK procedures; main outcome measurements: 1) occurrence of major postoperative complications (i.e., endophthalmitis, choroidal hemorrhage, infectious keratitis, cystoid macular edema [CME], retinal detachment [RD], or RD surgery) following EK surgery; 2) time-to-event analysis for glaucoma surgery; and 3) occurrence of graft complications. Results A total of 94,829 EK procedures (n = 71,040 unique patients) were included in the analysis. Of the total, 29% of patients had pre-existing glaucoma. The overall 90-day cumulative incidence of postoperative endophthalmitis and choroidal hemorrhage following EK was 0.03% and 0.05%, respectively. The overall 1-year cumulative rates of RD or RD surgery, infectious keratitis, and CME were 1.0%, 0.8%, and 4.1%, respectively. Approximately 7.6%, 12.2%, and 13.8% of all eyes in this study needed glaucoma surgery at 1-, 5-, and 8-years of follow-up, respectively. The probability of glaucoma surgery among patients with pre-existing glaucoma was 29% vs. 8% among those without pre-existing glaucoma at 8 years. The cumulative probabilities of developing any graft complications were 13%, 23.2%, and 27.1% at 1, 5, and 8 years, respectively, of follow-up. On average, patients undergoing EK procedures for a prior failed graft had the highest rate of complications, whereas those with Fuchs' corneal endothelial dystrophy had the lowest. Conclusions The incidence of major postoperative complications including endophthalmitis, retinal detachment, and choroidal hemorrhage following EK procedures is low. A high proportion of eyes undergoing EK eventually require glaucoma surgery and experience graft-related complications. Postoperative outcomes are typically worse for patients undergoing EK for prior failed grafts than for those undergoing EK for Fuchs' corneal endothelial dystrophy.
- Published
- 2020
22. Predictors of Receiving Keratoplasty for Fuchs' Endothelial Corneal Dystrophy among Medicare Beneficiaries
- Author
-
Nicolas J. Heckenlaible, Chen Dun, Christina Prescott, Allen O. Eghrari, Fasika Woreta, Martin A. Makary, and Divya Srikumaran
- Subjects
Male ,Fuchs' Endothelial Dystrophy ,Endothelium, Corneal ,Visual Acuity ,Medicare ,United States ,Corneal Transplantation ,Ophthalmology ,Humans ,Female ,Keratoplasty, Penetrating ,Descemet Stripping Endothelial Keratoplasty ,Aged ,Retrospective Studies - Abstract
To identify factors associated with receipt of endothelial keratoplasty (EK) and penetrating keratoplasty (PK) in patients with Fuchs' endothelial corneal dystrophy (FECD).Retrospective cohort study.Medicare beneficiaries 65 years of age or older with a FECD diagnosis between 2011 and 2019.The 100% Medicare fee-for-service administrative claims database was queried for treatment-naïve FECD patients. A multivariate logistic regression model including age, race and ethnicity, sex, geography, ocular comorbidities and surgeries, Charlson comorbidity index (CCI), and socioeconomic status was used to identify factors associated with receipt of EK and PK. Kaplan-Meier survival analyses were used to determine the rate of EK after cataract or complex or other anterior segment surgery.Factors associated with receipt of an EK or PK, plus rate of EK after cataract or complex or other anterior segment surgery.Of 719 066 beneficiaries identified, 31 372 (4.4%) received an EK and 2426 (0.3%) received a PK. In a multivariate analysis, female sex decreased likelihood of both EK and PK (adjusted odds ratio 0.83 [95% confidence interval 0.81-0.85] and 0.84 [0.78-0.92], respectively), while Western residence (1.33 [1.29-1.38]; 1.25 [1.11-1.42]) compared to Southern and history of complex or other anterior segment surgery (1.62 [1.54-1.70]; 5.52 [4.97-6.12]) increased the likelihood of both. Compared to Whites, the likelihood of EK was decreased for Black (0.76 [0.72-0.80]), Asian or Pacific Islander (0.54 [0.48-0.61]), and Hispanic or Latino (0.62 [0.55-0.70]) race and ethnicity, while for the same groups likelihood of PK was increased (for Black 1.32 [1.14-1.53]; Asian/Pacific Islander 1.46 [1.13-1.89]; and Hispanic/Latino 1.62 [1.25-2.11]). Following cataract or complex/other anterior segment surgery, rates of EK were 1.3% and 3.3% at 1 year and 2.3% and 5.6% at 8 years, respectively.In a multivariate analysis, women beneficiaries are less likely to receive EK or PK for FECD compared with men, whereas non-White beneficiaries are less likely to receive EK and more likely to receive PK compared with White beneficiaries.
- Published
- 2022
23. Pancreatic volume does not correlate with histologic fibrosis in adult patients with recurrent acute and chronic pancreatitis
- Author
-
Ihab R. Kamel, Rita R. Kalyani, Daniel S. Warren, Michaël Noë, Jin He, Rifat Mannan, Erica Hall, Vikesh K. Singh, Michael Goggins, Elham Afghani, Mahya Faghih, Zhaoli Sun, Atif Zaheer, Christi Walsh, Martin A. Makary, Niraj M. Desai, and Ralph H. Hruban
- Subjects
Adult ,Male ,medicine.medical_specialty ,Endocrinology, Diabetes and Metabolism ,medicine.medical_treatment ,Islets of Langerhans Transplantation ,Recurrent acute pancreatitis ,Recurrent acute ,Gastroenterology ,03 medical and health sciences ,Pancreatectomy ,0302 clinical medicine ,Atrophy ,Recurrence ,Fibrosis ,Pancreatitis, Chronic ,Internal medicine ,medicine ,Humans ,Pancreas ,Hepatology ,Adult patients ,business.industry ,Middle Aged ,medicine.disease ,Autotransplantation ,medicine.anatomical_structure ,Pancreatitis ,030220 oncology & carcinogenesis ,Acute Disease ,Female ,030211 gastroenterology & hepatology ,Tomography, X-Ray Computed ,business ,Negative Results - Abstract
Reduced pancreatic volume, often referred to as atrophy, is a commonly reported imaging feature of chronic pancreatitis (CP). This study evaluated whether there is an association between pancreatic volume and fibrosis, the criterion standard of CP, in patients undergoing total pancreatectomy with islet autotransplantation (TPIAT) for recurrent acute pancreatitis (RAP) and CP.All adult patients who underwent TPIAT between 2010 and 2019 were categorized into 3 groups: RAP, definite CP and indeterminate CP. Pancreatic volume was calculated by summing up the areas from each thin section of the pancreas on 3D CT imaging. Excisional biopsies of the pancreatic head as well as body/tail region were obtained at the time of TPIAT. Two different fibrosis scores were used for histologic assessment.A total of 16, 29 and 15 patients underwent TPIAT for RAP, definite CP and indeterminate CP, respectively. The mean pancreatic volumes for patients with RAP, definite CP and indeterminate CP were 65.7 ± 28.5 cc, 54.9 ± 22.9 cc and 61.8 ± 23.6 cc, respectively (p = 0.3). The mean fibrosis scores were significantly higher in patients with definite CP compared to RAP (p 0.001) and indeterminate CP (p 0.001). Pancreatic volume was not associated with either fibrosis score after adjusting for age, gender, duration of disease, BMI and diabetes in the multivariable analysis.While the fibrosis scores were higher in definite CP compared to both RAP and indeterminate CP, there was no correlation between pancreatic volume and fibrosis. This suggests that atrophy alone cannot be used to diagnose CP.
- Published
- 2020
24. Implications of Consumerism in Health Care
- Author
-
Adam B. Cohen, Simon C. Mathews, and Martin A. Makary
- Subjects
medicine.medical_specialty ,Hepatology ,business.industry ,Consumerism ,Gastroenterology ,MEDLINE ,medicine.disease ,Inflammatory bowel disease ,Family medicine ,Health care ,medicine ,Humans ,Health Facilities ,business ,Delivery of Health Care - Published
- 2020
25. COVID-19 Vaccine Boosters for Young Adults: A Risk-Benefit Assessment and Five Ethical Arguments against Mandates at Universities
- Author
-
Kevin Bardosh, Allison Krug, Euzebiusz Jamrozik, Trudo Lemmens, Salmaan Keshavjee, Vinay Prasad, Martin A. Makary, Stefan Baral, and Tracy Beth Høeg
- Published
- 2022
26. Billing of cataract surgery as complex versus routine for Medicare beneficiaries
- Author
-
Fasika A. Woreta, Divya Srikumaran, Sidra Zafar, Oliver D. Schein, Jennifer E. Thorne, Peiqi Wang, and Martin A. Makary
- Subjects
Male ,Pediatrics ,medicine.medical_specialty ,genetic structures ,Referral ,Cross-sectional study ,Cost-Benefit Analysis ,medicine.medical_treatment ,MEDLINE ,Cataract Extraction ,Medicare ,Odds ,03 medical and health sciences ,0302 clinical medicine ,Odds Ratio ,Humans ,Medicine ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Retrospective cohort study ,Health Care Costs ,Odds ratio ,Middle Aged ,Cataract surgery ,United States ,eye diseases ,Sensory Systems ,Confidence interval ,Ophthalmology ,Cross-Sectional Studies ,030221 ophthalmology & optometry ,Female ,Surgery ,business ,030217 neurology & neurosurgery - Abstract
Purpose To estimate ophthalmologist-level variation in cataract surgery billing and evaluate patient and ophthalmologist characteristics associated with complex cataract surgery coding. Setting Cross-sectional study. Design Retrospective case series. Methods Medicare beneficiaries aged 65 years or older who had cataract surgery between January 1, 2016, and December 31, 2017, were included. Billing of cataract surgery as complex versus routine and patient and physician characteristics associated with billing of cataract surgery as complex were evaluated. Results An estimated 3.5 million cataract procedures were performed on Medicare beneficiaries in 2016 and 2017. Men (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.75-1.82), patients 75 years or older (versus those aged 65 to 74 years: OR, 1.35; 95% CI, 1.33-1.36), and racial minorities (blacks versus whites: OR, 1.80; 95% CI, 1.75-1.85) had increased odds of having cataract surgery coded as complex. The mean rate of coding for complex cataract surgery by individual surgeons (n = 10 075) in the United States was 11.2%, with significant variation. A high-risk clinical diagnosis code was associated with 40.0% of complex cataract surgeries. Adjusted for patient characteristics, ophthalmologists who graduated from medical school within the past 10 years (OR, 1.35; 95% CI, 1.22-1.49) were more likely to code for complex cataract surgery. Higher volume ophthalmologists were less likely to code for complex cataract surgery than low-volume ophthalmologists. Conclusions There was marked variation among ophthalmologists in the use of complex cataract surgery. Some variability might represent inaccurate coding and was not entirely based on differences in referral patterns for more complex patients.
- Published
- 2019
27. Evaluation of a Physician Peer-Benchmarking Intervention for Practice Variability and Costs for Endovenous Thermal Ablation
- Author
-
David P. Stonko, Chen Dun, Christi Walsh, Marlin Schul, John Blebea, Edward M. Boyle, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Adult ,Male ,Time Factors ,Research ,Correction ,General Medicine ,Middle Aged ,Quality Improvement ,Varicose Veins ,Benchmarking ,Online Only ,Venous Insufficiency ,Catheter Ablation ,Humans ,Surgery ,Female ,Prospective Studies ,Other ,health care economics and organizations ,Original Investigation ,Aged - Abstract
This quality improvement study uses Medicare claims data to evaluate the association of a peer-benchmarking intervention with physician variability in the use of endovenous thermal ablation (EVTA) and related costs., Key Points Question Is provision of individualized peer-benchmarking data on performance of endovenous thermal ablation (EVTA) associated with changes in physicians’ practice patterns or costs? Findings In this quality improvement study of 1558 physicians who performed at least 11 EVTAs for a total of 188 976 Medicare patients and were given a performance report of their EVTA use compared with their peers, a significant reduction in the number of EVTAs per patient was found after receipt of the reports, resulting in savings of $6.3 million to Medicare per year. Meaning In this quality improvement study, peer benchmarking was associated with a change in practice patterns of EVTA-performing physicians and with substantial Medicare savings., Importance The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database. Objective To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings. Design, Setting, and Participants This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment. Intervention A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018. Main Outcomes and Measures The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention. Results A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P
- Published
- 2021
28. NIH Funding of COVID-19 Research in 2020: a Cross Sectional Study
- Author
-
Logesvar Balaguru, Chen Dun, Andrea Meyer, Sanuri Hennayake, Christi M. Walsh, Christopher Kung, Brittany Cary, Frank Migliarese, Tinglong Dai, Ge Bai, Kathleen Sutcliffe, and Martin A. Makary
- Abstract
ObjectiveThis study aims to characterize and evaluate the NIH’s grant allocation pattern of COVID-19 research.DesignCross sectional studySettingCOVID-19 NIH RePORTER Dataset was used to identify COVID-19 relevant grants.Participants1,108 grants allocated to COVID-19 research.Main Outcomes and MeasuresThe primary outcome was to determine the number of grants and funding amount the NIH allocated for COVID-19 by research type and clinical/scientific area. The secondary outcome was to calculate the time from the funding opportunity announcement to the award notice date.ResultsThe NIH awarded a total of 56,169 grants in 2020, of which 2.0% (n=1,108) were allocated for COVID-19 research. The NIH had a $42 billion budget that year, of which 5.3% ($2.2 billion) was allocated to COVID-19 research. The most common clinical/scientific areas were social determinants of health (n=278, 8.5% of COVID-19 funding), immunology (n=211, 25.8%), and pharmaceutical interventions research (n=208, 47.6%). There were 104 grants studying COVID-19 non-pharmaceutical interventions, of which 2 grants studied the efficacy of face masks and 6 studied the efficacy of social distancing. Of the 83 COVID-19 funded grants on transmission, 5 were awarded to study airborne transmission of COVID-19, and 2 grants on transmission of COVID-19 in schools. The average time from the funding opportunity announcement to the award notice date was 151 days (SD: ±57.9).ConclusionIn the first year of the pandemic, the NIH diverted a small fraction of its budget to COVID-19 research. Future health emergencies will require research funding to pivot in a timely fashion and funding levels to be proportional to the anticipated burden of disease in the population.
- Published
- 2021
29. Use of Intravascular Ultrasound During First-Time Femoropopliteal Peripheral Vascular Interventions Among Medicare Beneficiaries()
- Author
-
Martin A. Makary, Caitlin W. Hicks, Sarah E. Deery, James H. Black, Chen Dun, Christopher J. Abularrage, and Earl Goldsborough
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Psychological intervention ,Logistic regression ,Medicare ,Article ,Atherectomy ,Angioplasty ,Internal medicine ,Intravascular ultrasound ,Medicine ,Humans ,Popliteal Artery ,cardiovascular diseases ,Ultrasonography, Interventional ,Aged ,Aged, 80 and over ,Peripheral Vascular Diseases ,medicine.diagnostic_test ,business.industry ,Medicare beneficiary ,General Medicine ,United States ,Peripheral ,Femoral Artery ,surgical procedures, operative ,Cardiology ,Surgery ,Female ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Claudication - Abstract
Objectives Intravascular ultrasound (IVUS) may be a useful adjunct to lower extremity peripheral vascular interventions (PVI) in certain clinical scenarios. We aimed to identify patient- and physician-level characteristics associated with the use of IVUS during first-time femoropopliteal PVI. Methods We included all Medicare beneficiaries undergoing elective femoropopliteal PVI for claudication or chronic limb-threatening ischemia between 01/01/2019 and 12/31/2019. We excluded patients with prior open or endovascular femoropopliteal intervention and all physicians performing ≤ 10 PVI during the study period. We calculated the proportion of patients who had IVUS performed as part of their index PVI for each physician. Hierarchical logistic regression was used to evaluate patient- and physician-level factors associated with use of IVUS. Results We identified 58,552 patients who underwent index femoropopliteal PVI, of whom 11,394 (19%) received IVUS. A total of 1,628 physicians performed >10 procedures during the study period, with IVUS utilization ranging from 0% to 100%. After hierarchical regression, claudication (vs. chronic limb-threatening ischemia: OR 1.23, 95% CI 1.11-1.36), stenting (vs. angioplasty alone: OR 1.57, 1.33-1.86) and atherectomy (vs. angioplasty alone: OR 2.09, 1.83-2.39) were associated with higher odds of IVUS utilization. Higher-volume providers (tertile 3 vs. tertile 1: OR 3.78, 2.43-5.90) and those with high rates of service provided in an office-based laboratory (tertile 3 vs. tertile 1: OR 10.72, 6.78-19.93) were more likely to utilize IVUS. Radiologists (OR 11.23, 5.96-21.17) and cardiologists (OR 1.97, 1.32-2.93) used IVUS more frequently than vascular surgeons. Conclusions Wide variability exists in the use of IVUS for first-time femoropopliteal PVI. The association of IVUS with claudication, atherectomy, and office-based laboratories raises concern about its potential overuse by some physicians.
- Published
- 2021
30. Tibial Interventions for Claudication Are Performed Often, but Not Often by Vascular Surgeons
- Author
-
Sanuja Bose, Chen Dun, Rebecca A. Sorber, David P. Stonko, Christopher J. Abularrage, James H. Black, Ying Wei Lum, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2022
31. Early Peripheral Vascular Interventions for Claudication in High Reimbursement Settings Are Associated With Higher Rates of Late Intervention and Progression to Chronic Limb-threatening Ischemia
- Author
-
Rebecca A. Sorber, Chen Dun, Qingwen Kawaji, Christopher J. Abularrage, James H. Black, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2022
32. Trends in Hospital Lawsuits Filed Against Patients for Unpaid Bills Following Published Research About This Activity
- Author
-
William E. Bruhn, Martin A. Makary, Michael J Boctor, Christi Walsh, Farah Hashim, Chen Dun, Ge Bai, and Joseph Giuseppe R. Paturzo
- Subjects
Warrant ,Adult ,Male ,medicine.medical_specialty ,media_common.quotation_subject ,Wage ,Media coverage ,Rate ratio ,Debt ,Medicine ,Humans ,Research article ,Mass Media ,Hospital Costs ,health care economics and organizations ,media_common ,Public awareness ,Aged ,Original Investigation ,Aged, 80 and over ,business.industry ,Virginia ,General Medicine ,Middle Aged ,Financial Management, Hospital ,Intervention (law) ,Cross-Sectional Studies ,Family medicine ,Legislation, Hospital ,Female ,business ,Forecasting - Abstract
Importance Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice. Objective To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills. Design, Setting, and Participants This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020). Exposures Publication of a research article and subsequent media coverage. Main Outcomes and Measures The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis. Results A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period. Conclusions and Relevance The findings of this study suggest that research leading to public awareness can shift hospital billing practices.
- Published
- 2021
33. Index atherectomy peripheral vascular interventions performed for claudication are associated with more reinterventions than nonatherectomy interventions
- Author
-
Qingwen Kawaji, Chen Dun, Christi Walsh, Rebecca A. Sorber, David P. Stonko, Christopher J. Abularrage, James H. Black, Bruce A. Perler, Martin A. Makary, and Caitlin W. Hicks
- Subjects
Male ,Atherectomy ,Time Factors ,Intermittent Claudication ,Medicare ,United States ,Peripheral Arterial Disease ,Treatment Outcome ,Risk Factors ,Humans ,Surgery ,Cardiology and Cardiovascular Medicine ,Aged ,Retrospective Studies - Abstract
Despite limited evidence supporting atherectomy alone over stenting/angioplasty as the index peripheral vascular intervention (PVI), the use of atherectomy has rapidly increased in recent years. We previously identified a wide distribution of atherectomy practice patterns among US physicians. The aim of this study was to investigate the association of index atherectomy with reintervention.We used 100% Medicare fee-for-service claims to identify all beneficiaries who underwent elective first-time femoropopliteal PVI for claudication between January 1, 2019, and December 31, 2019. Subsequent PVI reinterventions were examined through June 30, 2021. Kaplan-Meier curves were used to compare rates of PVI reinterventions for patients who received index atherectomy versus nonatherectomy procedures. Reintervention rates were also described for physicians by their overall atherectomy use (by quartile). A hierarchical Cox proportional hazard model was used to evaluate patient and physician-level characteristics associated with reinterventions.A total of 15,246 patients underwent an index PVI for claudication in 2019, of which 59.7% were atherectomy. After a median of 603 days (interquartile range, 77-784 days) of follow-up, 41.2% of patients underwent a PVI reintervention, including 48.9% of patients who underwent index atherectomy versus 29.8% of patients who underwent index nonatherectomy (P .001). Patients treated by high physician users of atherectomy (quartile 4) received more reinterventions than patients treated by standard physician users (quartiles 1-3) (56.8% vs 39.6%; P .001). After adjustment, patient factors association with PVI reintervention included receipt of index atherectomy (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 1.21-1.46), Black race (vs White; aHR; 1.18; 95% CI, 1.03-1.34), diabetes (aHR, 1.13; 95% CI, 1.07-1.21), and urban residence (aHR, 1.11; 95% CI, 1.01-1.22). Physician factors associated with reintervention included male sex (aHR, 1.52; 95% CI, 1.12-2.04), high-volume PVI practices (aHR, 1.23; 95% CI, 1.10-1.37), and physicians with a high use of index atherectomy (aHR, 1.49; 95% CI, 1.27-1.74). Vascular surgeons had a lower risk of PVI reintervention than cardiologists (vs vascular; aHR, 1.22; 95% CI, 1.09-1.38), radiologists (aHR, 1.55; 95% CI, 1.31-1.83), and other specialties (aHR, 1.59; 95% CI, 1.20-2.11). The location of services delivered was not associated with reintervention (P.05).The use of atherectomy as an index PVI for claudication is associated with higher PVI reintervention rates compared with nonatherectomy procedures. Similarly, high physician users of atherectomy perform more PVI reinterventions than their peers. The appropriateness of using atherectomy for initial treatment of claudication needs critical reevaluation.
- Published
- 2022
34. Index Atherectomy Peripheral Vascular Interventions Performed for Claudication Are Associated With More Reinterventions Than Nonatherectomy Procedures
- Author
-
Qingwen Kawaji, Chen Dun, Christi Walsh, David P. Stonko, Christopher J. Abularrage, James H. Black, Bruce Alan Perler, Martin A. Makary, and Caitlin Hicks
- Subjects
Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2022
35. Microbial Contamination, Infection, and Antimicrobial Use During Total Pancreatectomy With Islet Autotransplantation
- Author
-
Vikesh K. Singh, Rachel Kruer, Rita R. Kalyani, Martin A. Makary, Erica Hall, Michael J. Trisler, Laura A. Hatfield, Andrew S. Jarrell, Mahya Faghih, and Christi Walsh
- Subjects
Adult ,Male ,endocrine system ,medicine.medical_specialty ,endocrine system diseases ,Total pancreatectomy ,Endocrinology, Diabetes and Metabolism ,medicine.medical_treatment ,Islets of Langerhans Transplantation ,Transplantation, Autologous ,Gastroenterology ,Islets of Langerhans ,03 medical and health sciences ,Pancreatectomy ,Postoperative Complications ,0302 clinical medicine ,Endocrinology ,Pancreatitis, Chronic ,Internal medicine ,Internal Medicine ,Humans ,Medicine ,Retrospective Studies ,geography ,geography.geographical_feature_category ,Hepatology ,business.industry ,Bacterial Infections ,Length of Stay ,Middle Aged ,Antimicrobial ,Islet ,medicine.disease ,Autotransplantation ,Abdominal Pain ,Anti-Bacterial Agents ,Transplantation ,Treatment Outcome ,Antimicrobial use ,030220 oncology & carcinogenesis ,Pancreatitis ,Female ,030211 gastroenterology & hepatology ,business - Abstract
Total pancreatectomy with islet autotransplantation can relieve pain associated with chronic pancreatitis while preserving islet function. Islet preparations are often contaminated by enteric flora. We assessed the impact of contaminated islet preparations on the prevalence of postoperative infection.Electronic health records for patients who underwent total pancreatectomy with islet autotransplantation from August 1, 2011, to November 15, 2017 were retrospectively reviewed to compare the prevalence of postoperative infection in patients with a positive islet culture and islet culture negative patients.Sixty-one patients were included. Twenty-nine patients (47.5%) had a positive islet culture, and 23 (79.3%) of these patients received antimicrobial prophylaxis. The prevalence of postoperative infection did not differ between the islet culture positive and islet culture negative groups (41% vs 34%, P = 0.57). No infections occurred in the 6 islet culture positive patients who did not receive prophylaxis. No difference in intensive care unit or hospital length of stay or in 30-day or 90-day readmission rates were observed.Despite the common use of postoperative systemic antimicrobials, we observed no difference in the prevalence of postoperative infection, length of stay, or hospital readmission in patients receiving a contaminated islet preparation. If prophylactic antimicrobials are used, the duration should be minimized.
- Published
- 2019
36. Surgical Resection of 78 Pancreatic Solid Pseudopapillary Tumors: a 30-Year Single Institutional Experience
- Author
-
Michael J. Wright, Tyler Saunders, Martin A. Makary, Jun Yu, Richard A. Burkhart, Matthew J. Weiss, Ammar A. Javed, Yayun Zhu, John L. Cameron, Jin He, and Christopher L. Wolfgang
- Subjects
Adult ,Surgical resection ,medicine.medical_specialty ,Pancreatic disease ,Nodal disease ,Pancreaticoduodenectomy ,Metastasis ,Young Adult ,03 medical and health sciences ,Pancreatectomy ,0302 clinical medicine ,Surgical oncology ,medicine ,Humans ,Pancreas ,Retrospective Studies ,Tumor size ,business.industry ,Gastroenterology ,Middle Aged ,medicine.disease ,Surgery ,Pancreatic Neoplasms ,Treatment Outcome ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Female ,030211 gastroenterology & hepatology ,Neoplasm Recurrence, Local ,business ,Distal pancreatectomy - Abstract
Solid pseudopapillary tumors (SPTs) are rare, benign tumors of the pancreas that present as heterogeneous masses. We sought to evaluate the short- and long-term outcomes of surgical resected SPTs. Patients managed via initial surveillance were compared to those who underwent upfront resection. A prospectively maintained institutional database was used to identify patients who underwent surgical resection for a SPT between 1988 and 2018. Data on clinicopathological features and outcomes were collected and analyzed. Seventy-eight patients underwent surgical resection for SPT during the study period. The mean age was 34.0 ± 14.6 years and a majority were female (N = 67, 85.9%) and white (N = 46, 58.9%). Thirty patients (37.9%) were diagnosed incidentally. Imaging-based presumed diagnosis was SPT in 49 patients (62.8%). A majority were located in the body or tail of the pancreas (N = 47, 60.3%), and 48 patients (61.5%) underwent a distal pancreatectomy. The median tumor size was 4.0 cm (IQR, 3.0–6.0), nodal disease was present in three patients (3.9%), and R0 resection was performed in all patients. No difference was observed in clinicopathological features and outcomes between patients who were initially managed via surveillance and those who underwent upfront resection. None of the patients under surveillance had nodal disease or metastasis at the time of resection; however, one of them developed recurrence of disease 95.1 months after resection. At a median follow-up of 36.1 months (IQR, 8.1–62.1), 77 (%) patients were alive and one patient (1.3%) had a recurrence of disease at 95.1 months after resection and subsequently died due to disease. SPTs are rare pancreatic tumors that are diagnosed most frequently in young females. While a majority are benign and have an indolent course, malignant behavior has been observed. Surgical resection can result in exceptional outcomes.
- Published
- 2019
37. Main Duct Dilatation Is the Best Predictor of High-grade Dysplasia or Invasion in Intraductal Papillary Mucinous Neoplasms of the Pancreas
- Author
-
Ding Ding, Lindsey Manos, Neda Rezaee, Richard A. Burkhart, Martin A. Makary, John L. Cameron, Chunhui Yuan, Urban Arnelo, Marco Del Chiaro, Nicola Orsini, Ross Beckman, Jin He, Zeeshan Ateeb, Lingdi Yin, Georgios A. Margonis, Matthew J. Weiss, Jun Yu, Roberto Valente, and Christopher L. Wolfgang
- Subjects
Adult ,Male ,medicine.medical_specialty ,endocrine system diseases ,Pancreatic Intraductal Neoplasms ,Malignancy ,Main duct ,03 medical and health sciences ,0302 clinical medicine ,Pancreatic cancer ,medicine ,Humans ,Neoplasm Invasiveness ,In patient ,Pancreatic resection ,Aged ,Retrospective Studies ,Aged, 80 and over ,High grade dysplasia ,business.industry ,Background data ,Pancreatic Ducts ,Middle Aged ,Prognosis ,medicine.disease ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Female ,030211 gastroenterology & hepatology ,Surgery ,Radiology ,Neoplasm Grading ,Pancreas ,business ,Dilatation, Pathologic - Abstract
The purpose of this study is to determine preoperative factors that are predictive of malignancy in patients undergoing pancreatic resection for intraductal papillary mucinous neoplasms (IPMN).IPMN of the pancreas may be precursor lesions to pancreatic cancer (PC) and represent a target for early diagnosis or prevention. While there has been much effort to define preoperative risk factors for malignant pathology, guidelines are ever-changing and controversy remains surrounding which patients would benefit most from resection.We performed a retrospective analysis of 901 consecutive patients obtained from two tertiary referral centers who underwent pancreatic resection for histologically proven IPMN between 2004 and 2017. Collected data included patient demographic characteristics, preoperative symptoms, radiological findings, and laboratory data.Main pancreatic duct (MPD) dilatation was the only variable that was significantly associated with increased probability of malignancy (defined high-dysplasia or invasion) on both univariate and multivariate analysis. Even middle-range MPD dilatation from 5 mm to 9.9 mm (n = 286) was associated with increased odds of HG-IPMN (OR = 2.74; 95% CI = 1.80-4.16) and invasion (OR = 4.42; 95% CI = 2.55-7.66). MPD dilatation10 mm (n = 150) had even greater odds of HG-IPMN (OR = 6.57; 95% CI = 3.94-10.98) and invasion (OR = 15.07; 95% CI = 8.21-27.65). A cutoff of 5 to 7 mm MPD diameter was determined to be the best predictor to discriminate between malignant and benign lesions.In agreement with current IPMN management guidelines, we found MPD dilatation, even low levels from 5 mm to 9.9 mm, to be the single best predictor of HG-IPMN or invasion, highlighting the critical role that MPD plays in the selection of surgical candidates.
- Published
- 2019
38. Association Between Board Certification, Maintenance of Certification, and Surgical Complications in the United States
- Author
-
David W. Price, Martin A. Makary, Tim Xu, Ambar Mehta, and Angela Park
- Subjects
medicine.medical_specialty ,Certification ,Credentialing ,01 natural sciences ,Decile ,Maintenance of Certification ,03 medical and health sciences ,Patient safety ,Postoperative Complications ,0302 clinical medicine ,Humans ,Medicine ,030212 general & internal medicine ,0101 mathematics ,Quality of Health Care ,Surgeons ,business.industry ,Health Policy ,General surgery ,010102 general mathematics ,Retraining ,Odds ratio ,United States ,Surgical Procedures, Operative ,Orthopedic surgery ,Board certification ,business - Abstract
Physician credentialing processes aim to improve patient safety and quality, but little research has examined their direct relationship with surgical outcomes. Using national Medicare claims for 2009 to 2013, the authors studied the association between board certification and completion of Maintenance of Certification (MOC) requirements and surgeon rates of complications for 8 elective procedures. Exemplar surgeons were defined as those in the lowest decile of complication rates, and outlier surgeons were those in the highest decile. The analysis included 1.9 million procedures performed by 14 598 surgeons (64% orthopedics, 17% general surgery, 11% urology, 7% neurosurgery). Board-certified surgeons were less likely to be outliers (odds ratio 0.79 [0.66-0.94]). However, completion of MOC was not associated with differences in complication rates in orthopedic surgery or urology. Incorporating additional assessment methods into MOC, such as video evaluation of technical skills, retraining on state-of-the-art care, and peer review, may facilitate further improvements in surgical quality.
- Published
- 2019
39. A Peer Data Benchmarking Intervention to Reduce Opioid Overprescribing: A Randomized Controlled Trial
- Author
-
Chen Dun, Heidi N. Overton, Christi M. Walsh, Sanuri Hennayake, Peiqi Wang, Christine Fahim, Mark C. Bicket, and Martin A. Makary
- Subjects
General Medicine - Abstract
Background Driving physician behavior change has been an elusive goal for quality improvement efforts aimed at reducing low-value care. We proposed the use of “nudge” interventions at the surgeon level in order to reduce post-surgical opioid overprescribing in accordance with consensus guidelines. Methods We used 2017 Medicare data to identify outlier surgeons. A peer data benchmarking report that showed each surgeon the average number of opioid tablets they prescribed for an open inguinal hernia repair procedure from January 1, 2017 to December 31, 2017. We conducted a 1:1 randomized controlled trial providing outlier surgeons a report of their opioid prescribing patterns for a standard operation compared to the national average and prescribing guidelines. Results There were 489 surgeons randomized to the intervention, of which 180 (36.8%) had data in the post-intervention period. Data was available for 87 surgeons in the intervention group and 93 surgeons in the control group. 97.7% of surgeons in the intervention group reduced their opioid prescribing pattern compared to 95.7% in the control group. Surgeons who received the data benchmarking report intervention prescribed 14.3% less opioids than surgeons in the control group (10.54 (SD 5.34) vs. 12.30 (SD 6.02), P = .04). The intervention was associated with a 1.83 lower mean number of opioid tablets prescribed per patient in the multivariable linear regression model after controlling for other factors (Intervention group vs. control group 95% CI [−3.61, −.04], P = .04). Discussion The implementation of a peer data benchmarking intervention can drive physician behavior change towards high-value care.
- Published
- 2022
40. Inpatient COVID‐19 outcomes in solid organ transplant recipients compared to non‐solid organ transplant patients: A retrospective cohort
- Author
-
Willa Cochran, Brian T. Garibaldi, Seema Mehta Steinke, Darin Ostrander, Allan B. Massie, Kieren A. Marr, Pali D. Shah, Robin K. Avery, Daniel C. Brennan, Afrah S Sait, Nitipong Permpalung, Dorry L. Segev, Jacqueline Garonzik-Wang, Teresa Po Yu Chiang, and Martin A. Makary
- Subjects
medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,medicine.medical_treatment ,030230 surgery ,03 medical and health sciences ,0302 clinical medicine ,Disease severity ,Internal medicine ,Diabetes mellitus ,medicine ,Illness severity ,Humans ,Immunology and Allergy ,Pharmacology (medical) ,Pandemics ,Retrospective Studies ,Inpatients ,Transplantation ,business.industry ,SARS-CoV-2 ,COVID-19 ,Retrospective cohort study ,Immunosuppression ,Organ Transplantation ,medicine.disease ,Transplant Recipients ,business ,Solid organ transplantation - Abstract
Immunosuppression and comorbidities might place solid organ transplant (SOT) recipients at higher risk from COVID-19, as suggested by recent case series. We compared 45 SOT vs. 2427 non-SOT patients who were admitted with COVID-19 to our health-care system (March 1, 2020 - August 21, 2020), evaluating hospital length-of-stay and inpatient mortality using competing-risks regression. We compared trajectories of WHO COVID-19 severity scale using mixed-effects ordinal logistic regression, adjusting for severity score at admission. SOT and non-SOT patients had comparable age, sex, and race, but SOT recipients were more likely to have diabetes (60% vs. 34%, p < .001), hypertension (69% vs. 44%, p = .001), HIV (7% vs. 1.4%, p = .024), and peripheral vascular disorders (19% vs. 8%, p = .018). There were no statistically significant differences between SOT and non-SOT in maximum illness severity score (p = .13), length-of-stay (sHR: 0.9 1.11.4 , p = .5), or mortality (sHR: 0.1 0.41.6 , p = .19), although the severity score on admission was slightly lower for SOT (median [IQR] 3 [3, 4]) than for non-SOT (median [IQR] 4 [3-4]) (p = .042) Despite a higher risk profile, SOT recipients had a faster decline in disease severity over time (OR = 0.76 0.810.86 , p < .001) compared with non-SOT patients. These findings have implications for transplant decision-making during the COVID-19 pandemic, and insights about the impact of SARS-CoV-2 on immunosuppressed patients.
- Published
- 2021
- Full Text
- View/download PDF
41. The Commissions Paid to Brokers for Fully Insured Health Insurance Plans
- Author
-
Heidi N. Overton, Angela Park, Yang Wang, Martin A. Makary, Ge Bai, and William E. Bruhn
- Subjects
Finance ,Insurance, Health ,business.industry ,Salaries and Fringe Benefits ,Health Policy ,Pharmacy ,Sample (statistics) ,Plan (drawing) ,Commission ,Purchasing ,United States ,Health Benefit Plans, Employee ,Transparency (graphic) ,Health care ,Health insurance ,Humans ,business ,Delivery of Health Care - Abstract
Insurance agents and brokers play an important role in facilitating the contracting of fully insured health insurance and pharmacy benefit plans for U.S. employers. They are primarily compensated with a commission charged back to the plan. Using a national sample that covered 11.7 million employees enrolled in 33,689 health plans in 2017, we found that a plan’s commission (median: $178) was positively associated with a plan’s premium (coefficient: 0.01 for the full sample and 0.03 for small plans, p < .001) after controlling for the number of enrollees. The commission-to-premium ratio was greater for smaller plans and plans offered by nonmajor insurance companies, and varied by geographic region. Policy makers should consider improving transparency of the commission to facilitate employers making efficient broker contracting and plan purchasing decisions. The fee-based brokerage model has the potential to help employers and workers contain health care spending.
- Published
- 2020
42. Prevalence and Durability of SARS-CoV-2 Antibodies Among Unvaccinated US Adults by History of COVID-19
- Author
-
Jennifer L. Alejo, Jonathan Mitchell, Amy Chang, Teresa P. Y. Chiang, Allan B. Massie, Dorry L. Segev, and Martin A. Makary
- Subjects
Research Letter ,General Medicine - Abstract
This study uses serologic testing to characterize natural immunity and the long-term durability of SARS-CoV-2 antibodies among unvaccinated US adults by history of COVID-19 infection.
- Published
- 2022
43. A Machine Learning Study of 534,023 Medicare Beneficiaries with COVID-19: Implications for Personalized Risk Prediction
- Author
-
Martin A. Makary, Timothy A. Lash, Christi Walsh, Dorry L. Segev, Joseph Paturzo, Sunjae Bae, Eric Toner, Chen Dun, Farah Hashim, and Amesh A. Adalja
- Subjects
Coronavirus disease 2019 (COVID-19) ,business.industry ,Diabetes mellitus ,medicine ,Medicare beneficiary ,Risk of death ,Disease ,medicine.disease ,Logistic regression ,business ,Random effects model ,Kidney disease ,Demography - Abstract
BackgroundGlobal demand for a COVID-19 vaccine will exceed the initial limited supply. Identifying individuals at highest risk of COVID-19 death may help allocation prioritization efforts. Personalized risk prediction that uses a broad range of comorbidities requires a cohort size larger than that reported in prior studies.MethodsMedicare claims data was used to identify patients age 65 years or older with diagnosis of COVID-19 between April 1, 2020 and August 31, 2020. Demographic characteristics, chronic medical conditions, and other patient risk factors that existed before the advent of COVID-19 were identified. A random forest model was used to empirically explore factors associated with COVID-19 death. The independent impact of factors identified were quantified using multivariate logistic regression with random effects.ResultsWe identified 534,023 COVID-19 patients of whom 38,066 had an inpatient death. Demographic characteristics associated with COVID-19 death included advanced age (85 years or older: aOR: 2.07; 95% CI, 1.99-2.16), male sex (aOR, 1.88; 95% CI, 1.82-1.94), and non-white race (Hispanic: aOR, 1.74; 95% CI, 1.66-1.83). Leading comorbidities associated with COVID-19 mortality included sickle cell disease (aOR, 1.73; 95% CI, 1.21-2.47), chronic kidney disease (aOR, 1.32; 95% CI, 1.29-1.36), leukemias and lymphomas (aOR, 1.22; 95% CI, 1.14-1.30), heart failure (aOR, 1.19; 95% CI, 1.16-1.22), and diabetes (aOR, 1.18; 95% CI, 1.15-1.22).ConclusionsWe created a personalized risk prediction calculator to identify candidates for early vaccine and therapeutics allocation (www.predictcovidrisk.com). These findings may be used to protect those at greatest risk of death from COVID-19.
- Published
- 2020
44. Risk Factors for Repeat Keratoplasty after Endothelial Keratoplasty in the Medicare Population
- Author
-
Peiqi Wang, Martin A. Makary, Kanza Aziz, Sidra Zafar, Fasika A. Woreta, and Divya Srikumaran
- Subjects
Male ,Reoperation ,medicine.medical_specialty ,medicine.medical_treatment ,Population ,Comorbidity ,Kaplan-Meier Estimate ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Asian People ,Risk Factors ,Glaucoma surgery ,Medicine ,Humans ,education ,030304 developmental biology ,Aged ,Probability ,Proportional Hazards Models ,Retrospective Studies ,Aged, 80 and over ,0303 health sciences ,education.field_of_study ,business.industry ,Proportional hazards model ,Hazard ratio ,Retrospective cohort study ,Glaucoma ,Confidence interval ,United States ,Surgery ,Black or African American ,Ophthalmology ,Cohort ,030221 ophthalmology & optometry ,Female ,business ,Descemet Stripping Endothelial Keratoplasty ,Cohort study - Abstract
Purpose To evaluate long-term rates of repeated keratoplasty after endothelial keratoplasty (EK), and to explore risk factors associated with graft failure. Design Retrospective, cohort study. Methods Population-based using 2010-2019 Medicare carrier claims. Study population: Medicare beneficiaries aged ≥65 years who underwent endothelial keratoplasty (EK) procedures. Main outcome measures were 1) occurrence of repeated keratoplasty for the overall cohort as well as stratified by clinical indication, and 2), risk factors associated with repeated keratoplasty. The probability of undergoing repeated keratoplasty for different indications was estimated using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards regression model was constructed to determine patient and physician factors associated with the risk of repeated keratoplasty. Results A total of 94,829 Medicare EK procedures (N = 71,040 unique patients) were included in the analysis. Over the study period, 11,013 of 94,829 EK procedures were followed by repeated keratoplasty. The overall probability of receiving a repeated keratoplasty was 6.1% at 6 months, 7.6% at 1 year, 14.3% at 5 years and 16.9% at 8 years. The probability of repeated keratoplasty was highest for procedures performed for prior failed grafts: 10.2% at 1 year, 29.9% at 8 years. Whereas 6.4% and 11.4% of grafts performed for Fuchs' endothelial dystrophy (FED) required repeated keratoplasty at 1 and 8 years of follow-up, respectively. For bullous keratoplasty and/or corneal edema, 8.6% and 22% of grafts underwent repeated keratoplasty at 1 and 8 years, respectively. In a multivariate analysis, patient factors associated with increased risk of repeated keratoplasty were black (hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.20-1.38) or Asians (HR: 1.26; 95% CI: 1.10-1.45) having a glaucoma diagnosis (HR: 1.53; 95% CI: 1.46-1.60), prior glaucoma surgery (HR: 1.26; 95% CI: 1.18-1.35), and concurrent glaucoma surgery (HR: 1.31; 95% CI: 1.20-1.44). Surgeons with higher EK volumes had a decreased risk of repeated keratoplasty. Physicians who graduated medical school >30 years previously had increased risk of repeated keratoplasty compared to those who graduated within 10 years (HR: 1.16; 95% CI: 1.10-1.23). Conclusions Blacks or Asians, comorbid glaucoma, concurrent or prior glaucoma surgery, and lower volumes of surgery are associated with increased risk of repeated keratoplasty. Racial disparities identified in this study warrant further investigation.
- Published
- 2020
45. Physician Practice Variability in the Use of Extended-Fraction Radiation Therapy for Bone Metastases: Are We Choosing Wisely?
- Author
-
Nina N. Sanford, David H. Johnson, Ramy Sedhom, Peiqi Wang, Amol Narang, Robert C. Miller, Mark R. Waddle, Sara R. Alcorn, Martin A. Makary, Arjun Gupta, and Fumiko Chino
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Bone Neoplasms ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Intervention (counseling) ,Physicians ,medicine ,Humans ,Fraction (mathematics) ,030212 general & internal medicine ,Aged ,Retrospective Studies ,Oncology (nursing) ,business.industry ,Health Policy ,United States ,Radiation therapy ,Oncology ,030220 oncology & carcinogenesis ,Female ,Radiology ,Dose Fractionation, Radiation ,business - Abstract
PURPOSE: Routine use of extended-fraction (> 10 fractions) radiation therapy (RT) for palliation of bone metastases is recognized as a low-value intervention by the American Society for Radiation Oncology. We examined contemporary practice patterns of, and physician characteristics associated with extended-fraction RT use. MATERIALS AND METHODS: We conducted a retrospective cohort study using Medicare fee-for-service data. We included patients who underwent 2- or 3-dimensional external-beam RT for bone metastases between January 1, 2016, and December 31, 2018. Physicians treating > 10 patients over the study period were analyzed for their individual practice. Hierarchic logistic regression modeling was used to identify patient- and physician-level factors associated with extended-fraction RT use. RESULTS: A total of 12,221 patients (median age, 75.6 years; 40.9% women, 87.6% white) were included. The rate of extended-fraction RT was 23.4%. A total of 1,432 physicians treated any patient. Among the 382 physicians treating > 10 patients, 127 (33.2%) used extended-fraction RT > 30% (consensus threshold). Physician factors associated with decreased odds of extended-fraction RT were years since medical school graduation (≤ 10 years and 11-20 years v ≥ 31 years: adjusted odds ratio [aOR], 0.32 [95% CI, 0.20 to 0.51] and 0.64 [95% CI, 0.44 to 0.93]) and practicing in the Northeast or Midwest versus the South (aOR, 0.36 [95% CI, 0.22 to 0.58] and 0.48 [95% CI, 0.31 to 0.74]). Physicians treating > 20 patients ( v 11-14 patients) over the study period had increased odds of delivering extended-fraction RT (aOR, 1.53 [95% CI, 1.10 to 2.12]). CONCLUSION: In this study, almost one fourth of patients received extended-fraction RT, and one third of physicians had an extended-fraction RT use rate of > 30%. Personalized feedback of performance data, clinical pathways and peer review, and updated reimbursement models are potential mechanisms to address this low-value care.
- Published
- 2020
46. Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care
- Author
-
Richard C, Gilmore, Peiqi, Wang, Katerina, Kaczmarski, Susan, Hutfless, David M, Euhus, Lisa K, Jacobs, Mehran, Habibi, Julie, Lange, Melissa, Camp, and Martin A, Makary
- Subjects
Humans ,Breast Neoplasms ,Female ,Biopsy, Large-Core Needle ,Breast ,Medicare ,United States ,Aged ,Retrospective Studies - Abstract
Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery.We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern.We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29-2.73), in the South (OR 1.84, 95% CI 1.20-2.84) or West region (OR 1.78, 95% CI 1.11-2.86), 20 years in practice (OR 1.52, 95% CI 1.09-2.11), and low breast cancer surgery volume ( 30 cases in the study period; OR 4.03, 95% CI 2.75-5.90).Marked variation exists in whether a breast core biopsy is performed prior to initial breast surgery, which may represent unnecessary surgery on individual patients. Providing surgeon-specific feedback on guideline compliance may reduce unwarranted variation.
- Published
- 2020
47. Blood Type as a Predictor of High-Grade Dysplasia and Associated Malignancy in Patients with Intraductal Papillary Mucinous Neoplasms
- Author
-
Martin A. Makary, Matthew J. Weiss, Laura D. Wood, Michael Goggins, John L. Cameron, Christopher L. Wolfgang, Katherine E. Poruk, James D. Griffin, and Jin He
- Subjects
Adult ,Male ,medicine.medical_specialty ,Adolescent ,endocrine system diseases ,Adenocarcinoma ,030230 surgery ,Malignancy ,Gastroenterology ,Article ,ABO Blood-Group System ,Young Adult ,03 medical and health sciences ,Pancreatectomy ,0302 clinical medicine ,Predictive Value of Tests ,Risk Factors ,ABO blood group system ,Pancreatic cancer ,Internal medicine ,medicine ,Humans ,Risk factor ,Aged ,Gastrointestinal Neoplasms ,Retrospective Studies ,Aged, 80 and over ,Blood type ,Hyperplasia ,Intraductal papillary mucinous neoplasm ,business.industry ,Pancreatic Ducts ,Middle Aged ,medicine.disease ,Dysplasia ,030220 oncology & carcinogenesis ,Female ,Surgery ,business - Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are precursor lesions to the development of pancreatic adenocarcinoma. We determined if non-O blood groups are more common in patients with IPMN and if blood group is a risk factor for progression to invasive pancreatic cancer among patients with IPMN. The medical records were reviewed of all patients undergoing resection of an IPMN at Johns Hopkins Hospital from June 1997 to August 2016. Potential risk factors of high-grade dysplasia and associated adenocarcinoma were identified through a multivariate logistic regression model. Seven hundred and seventy-seven patients underwent surgical resection of an IPMN in which preoperative blood type was known. Sixty-two percent of IPMN patients had non-O blood groups (vs. 57% in two large US reference cohorts, P = 0.002). The association between non-O blood group was significant for patients with IPMN with low- or intermediate-grade dysplasia (P
- Published
- 2018
48. Frequency and Predictors of Polypharmacy in US Medicare Patients: A Cross-Sectional Analysis at the Patient and Physician Levels
- Author
-
Christine Fahim, William E. Bruhn, Jennifer L. Carnahan, Angela Park, Michael I. Ellenbogen, Heidi N. Overton, Martin A. Makary, Peiqi Wang, Amy Linsky, and Seki A. Balogun
- Subjects
Male ,medicine.medical_specialty ,Drug-Related Side Effects and Adverse Reactions ,Cross-sectional study ,Comorbidity ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Pharmacotherapy ,Acquired immunodeficiency syndrome (AIDS) ,Diabetes mellitus ,Medicine ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Practice Patterns, Physicians' ,Adverse effect ,Aged ,Polypharmacy ,business.industry ,Primary care physician ,Middle Aged ,medicine.disease ,Prognosis ,Drug Utilization ,United States ,Cross-Sectional Studies ,Emergency medicine ,Female ,Geriatrics and Gerontology ,business ,030217 neurology & neurosurgery - Abstract
Polypharmacy in older patients increases the risk of medication-related adverse events and can be a marker of unnecessary care. The aim of this study was to describe the frequency of polypharmacy among patients 65 years of age or older and identify factors associated with the occurrence of patient-level and physician-level polypharmacy. We performed a cross-sectional analysis of 100% Medicare claims data from January 1, 2016 to December 31, 2016. All patients with continuous Medicare coverage (Parts A, B, and D) throughout 2016 who were 65 years of age or older and who were prescribed at least one medication for at least 30 days were included in the analysis. Each patient was attributed to the primary care physician who prescribed them the most medications. Physicians treating fewer than ten patients were excluded. We defined polypharmacy based on the highest number of concurrent medications at any point during the year. We used hierarchical linear regression to study patient- and physician-level characteristics associated with high prescribing rates. We identified 25,747,560 patients attributed to 147,879 primary care physicians. The patient-level mean [standard deviation (SD)] concurrent medication rate was 5.6 (3.3), and the physician-level mean (SD) was 5.6 (1.1). A total of 6108 physicians (4.1% of sample) had a mean concurrent number of medications greater than two SDs above the physician-level mean. At the patient level in the adjusted model, a history of HIV/AIDS, diabetes mellitus, solid organ transplant, and systolic heart failure were the comorbidities most strongly associated with polypharmacy. The relative difference in number of medications associated with these comorbidities were 1.89, 1.39, 1.32, and 1.06, respectively. At the physician level, increased time since medical school graduation and smaller practice size were associated with lower rates of polypharmacy. Patterns of high prescribing to older patients is common and measurable at the physician level. Addressing high outlier prescribers may represent an opportunity to reduce avoidable harm and excessive costs.
- Published
- 2019
49. Is a Pathological Complete Response Following Neoadjuvant Chemoradiation Associated With Prolonged Survival in Patients With Pancreatic Cancer?
- Author
-
Christopher L. Wolfgang, Lei Zheng, Ralph H. Hruban, Martin A. Makary, Vincent P. Groot, Kevin M. Waters, Daniel A. Laheru, Matthew J. Weiss, Justin Poling, John L. Cameron, Jin He, Alex B. Blair, Ammar A. Javed, Georgios Gemenetzis, Joseph M. Herman, and Richard A. Burkhart
- Subjects
Adult ,Male ,Oncology ,medicine.medical_specialty ,endocrine system diseases ,medicine.medical_treatment ,Leucovorin ,Antineoplastic Agents ,Irinotecan ,Radiosurgery ,Article ,03 medical and health sciences ,0302 clinical medicine ,Pancreatic cancer ,Internal medicine ,Antineoplastic Combined Chemotherapy Protocols ,medicine ,Carcinoma ,Humans ,Pathological ,Neoadjuvant therapy ,Survival analysis ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Retrospective cohort study ,Chemoradiotherapy, Adjuvant ,Chemoradiotherapy ,Middle Aged ,Prognosis ,medicine.disease ,Survival Analysis ,Neoadjuvant Therapy ,digestive system diseases ,Oxaliplatin ,Pancreatic Neoplasms ,Lymphatic Metastasis ,030220 oncology & carcinogenesis ,Pancreatectomy ,Female ,030211 gastroenterology & hepatology ,Surgery ,Fluorouracil ,business ,Carcinoma, Pancreatic Ductal ,Follow-Up Studies - Abstract
To describe the survival outcome of patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) who have a pathologic complete response (pCR) following neoadjuvant chemoradiation.Patients with BR/LA-PDAC are often treated with neoadjuvant chemoradiation in an attempt to downstage the tumor. Uncommonly, a pCR may result.A retrospective review of a prospectively maintained database was performed at a single institution. pCR was defined as no viable tumor identified in the pancreas or lymph nodes by pathology. A near complete response (nCR) was defined as a primary tumor less than 1 cm, without nodal metastasis. Overall survival (OS) and disease-free survival (DFS) were reported.One hundred eighty-six patients with BR/LA-PDAC underwent neoadjuvant chemoradiation and subsequent pancreatectomy. Nineteen patients (10%) had a pCR, 29 (16%) had an nCR, and the remaining 138 (74%) had a limited response. Median DFS was 26 months in patients with pCR, which was superior to nCR (12 months, P = 0.019) and limited response (12 months, P0.001). The median OS of nCR (27 months, P = 0.003) or limited response (26 months, P = 0.001) was less than that of pCR (more than 60 months). In multivariable analyses pCR was an independent prognostic factor for DFS (HR = 0.45; 0.22-0.93, P = 0.030) and OS (HR=0.41; 0.17-0.97, P = 0.044). Neoadjuvant FOLFIRINOX (HR=0.47; 0.26-0.87, P = 0.015) and negative lymph node status (HR=0.57; 0.36-0.90, P = 0.018) were also associated with improved survival.Patients with BR/LA-PDAC who had a pCR after neoadjuvant chemoradiation had a significantly prolonged survival compared with those who had nCR or a limited response.
- Published
- 2018
50. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA
- Author
-
Anthony N. Kalloo, Susan Hutfless, Martin A. Makary, Saowanee Ngamruengphong, Peiqi Wang, and Tim Xu
- Subjects
Male ,medicine.medical_specialty ,Colonoscopy ,Ambulatory Care Facilities ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Outpatients ,medicine ,Humans ,Mass Screening ,Mammography ,Endoscopy, Digestive System ,Early Detection of Cancer ,Gram-Positive Bacterial Infections ,Aged ,Retrospective Studies ,medicine.diagnostic_test ,Esophagogastroduodenoscopy ,business.industry ,Gastroenterology ,Bacterial Infections ,Emergency department ,Cystoscopy ,Middle Aged ,Ambulatory Surgical Procedure ,United States ,Surgery ,Prostate cancer screening ,Ambulatory Surgical Procedures ,Intestinal Perforation ,030220 oncology & carcinogenesis ,Ambulatory ,Female ,030211 gastroenterology & hepatology ,Gastrointestinal Hemorrhage ,Gram-Negative Bacterial Infections ,business - Abstract
ObjectiveOver 15 million colonoscopies and 7 million osophagogastroduodenoscopies (OGDs) are performed annually in the USA. We aimed to estimate the rates of infections after colonoscopy and OGD performed in ambulatory surgery centres (ASCs).DesignWe identified colonoscopy and OGD procedures performed at ASCs in 2014 all-payer claims data from six states in the USA. Screening mammography, prostate cancer screening, bronchoscopy and cystoscopy procedures were comparators. We tracked infection-related emergency department visits and unplanned in-patient admissions within 7 and 30 days after the procedures, examined infection sites and organisms and analysed predictors of infections. We investigated case-mix adjusted variation in infection rates by ASC.ResultsThe rates of postendoscopic infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy, 1.6 for non-screening colonoscopy and 3.0 for OGD; all higher than screening mammography (0.6) but lower than bronchoscopy (15.6) and cystoscopy (4.4) (p<0.0001). Predictors of postendoscopic infection included recent history of hospitalisation or endoscopic procedure; concurrence with another endoscopic procedure; low procedure volume or non-freestanding ASC; younger or older age; black or Native American race and male sex. Rates of 7-day postendoscopic infections varied widely by ASC, ranging from 0 to 115 per 1000 procedures for screening colonoscopy, 0 to 132 for non-screening colonoscopy and 0 to 62 for OGD.ConclusionWe found that postendoscopic infections are more common than previously thought and vary widely by facility. Although screening colonoscopy is not without risk, the risk is lower than diagnostic endoscopic procedures.
- Published
- 2018
Catalog
Discovery Service for Jio Institute Digital Library
For full access to our library's resources, please sign in.