Rebecca Symons

University of Washington Seattle, Seattle, WA, United States

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Publications (7)28 Total impact

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    ABSTRACT: Objective: Our goal was to perform a comparative effectiveness study of intravenous (IV)-only versus IV + enteral contrast in computed tomographic (CT) scans performed for patients undergoing appendectomy across a diverse group of hospitals. Background: Small randomized trials from tertiary centers suggest that en- teral contrast does not improve diagnostic performance of CT for suspected appendicitis, but generalizability has not been demonstrated. Eliminating en- teral contrast may improve efficiency, patient comfort, and safety. Methods: We analyzed data for adult patients who underwent nonelective appendectomy at 56 hospitals over a 2-year period. Data were obtained directly from patient charts by trained abstractors. Multivariate logistic regression was utilized to adjust for potential confounding. The main outcome measure was concordance between final radiology interpretation and final pathology report. Results: A total of 9047 adults underwent appendectomy and 8089 (89.4%) underwent CT, 54.1% of these with IV contrast only and 28.5% with IV + enteral contrast. Pathology findings correlated with radiographic findings in 90.0% of patients who received IV + enteral contrast and 90.4% of patients scanned with IV contrast alone. Hospitals were categorized as rural or ur- ban and by their teaching status. Regardless of hospital type, there was no difference in concordance between IV-only and IV + enteral contrast. After adjusting for age, sex, comorbid conditions, weight, hospital type, and perfo- ration, odds ratio of concordance for IV + enteral contrast versus IV contrast alone was 0.95 (95% CI: 0.72–1.25). Conclusions: Enteral contrast does not improve CT evaluation of appendicitis in patients undergoing appendectomy. These broadly generalizable results from a diverse group of hospitals suggest that enteral contrast can be eliminated in CT scans for suspected appendicitis.
    Annals of Surgery 07/2014; 260(2):311-316. · 6.33 Impact Factor
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    ABSTRACT: This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Preoperative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.
    The American surgeon 12/2012; 78(12):1336-44. · 0.92 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (ie, death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from the 4th quarter of 2005 through 4th quarter of 2010. Of the 9,705 patients undergoing elective colorectal operations (mean age 60.6 ± 15.6 years; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 4th quarter of 2005 to 41.6% in 4th quarter of 2010 (trend during study period, p < 0.001). After adjustment (for age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size, and urban vs rural location), the risk of transfusions (odds ratio [OR] = 0.52; 95% CI, 0.39-0.7), wound infections (OR = 0.45; 95% CI, 0.34-0.61), and composite of adverse events (OR = 0.58; 95% CI, 0.43-0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a substantial increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, an 80.4% increase) and, in particular, the number of resections for noncancer diagnoses and right-sided pathology. The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery.
    Journal of the American College of Surgeons 04/2012; 214(6):909-18.e1. · 4.50 Impact Factor
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    ABSTRACT: To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. Observational, prospectively designed cohort study. Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.
    Archives of surgery (Chicago, Ill.: 1960) 04/2012; 147(4):345-51. · 4.32 Impact Factor
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    ABSTRACT: To determine the effectiveness of pharmacologic prophylaxis in preventing clinically relevant venous thromboembolic (VTE) events and deaths after surgery. The Surgical Care Improvement Project recommends that VTE pharmacologic prophylaxis be given within 24 hours of the operation. The bulk of evidence supporting this recommendation uses radiographic end points. The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement initiative with data linked to hospital admission/discharge and vital status records. We compared the rates of death, clinically relevant VTE, and a composite adverse event (CAE) in the 90 days after elective, colon/rectal resections, based on receipt of pharmacologic prophylaxis (within 24 hours of surgery) at 36 Surgical Care and Outcomes Assessment Program hospitals (2005-2009). Of 4,195 (mean age 61.1 ± 15.6 years; 54.1% women) patients, 56.5% received pharmacologic prophylaxis. Ninety-day death (2.5% vs 1.6%; p = 0.03), VTE (1.8% vs 1.1%; p = 0.04), and CAE (4.2% vs 2.5%; p = .002) were lower in those who received pharmacologic prophylaxis. After adjustment for patient and procedure characteristics, the odds were 36% lower for CAE (odds ratio = 0.64; 95% CI, 0.44-0.93) with pharmacologic prophylaxis. In any given quarter, hospitals where patients more often received pharmacologic prophylaxis (highest tertile of use) had the lowest rates of CAE (2.3% vs 3.6%; p = 0.05) compared with hospitals in the lowest tertile. Using clinical end points, this study demonstrates the effectiveness of VTE pharmacologic prophylaxis in patients having elective colorectal surgery. Hospitals that used pharmacologic prophylaxis more often had the lowest rates of adverse events.
    Journal of the American College of Surgeons 08/2011; 213(5):596-603, 603.e1. · 4.50 Impact Factor
  • Todd R Vogel, Rebecca Symons, David R Flum
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    ABSTRACT: The reported rate of abdominal aortic graft infections (AGIs) is low, but its incidence and associated factors have not been evaluated on a population level. We hypothesized that AGI occurs more often in patients with periprocedural nosocomial infections and less often after endovascular aneurysm repair (EVAR). A retrospective cohort study was done of all patients undergoing abdominal aortic aneurysm (AAA) repair (1987-2005) in Washington State by using the Comprehensive Hospital Abstract Reporting System (CHARS) data. Nosocomial infection was defined as one or more of pneumonia, urinary tract infections, blood stream septicemia, or surgical site infection at the index admission. Readmissions and reintervention for graft infections defined AGIs excluding the diagnostic code of renal failure or those who appeared to have dialysis grafts. Between 1987 and 2005, 13,902 patients (mean age, 71.3 +/- 8.8 years; 90.8% men) underwent AAA repair (12,626 open, 1276 EVAR). The cumulative rate of AGIs in the cohort was 0.44%. The 2-year rate of AGI was 0.19% among open vs 0.16% in EVAR (P = .75) and 0.2% in both elective and nonelective patients. Open procedures had greater rates of perioperative pneumonia (11.1% vs 2.4%, P < .001), blood stream septicemia (1.6% vs 0.7%, P < .01), and surgical site infection (.5% vs 0%, P < .012) compared with EVAR. When individually analyzed, blood stream septicemia (.93% vs 18%, P = .014) and surgical site infection (1.61% vs 0.19%, P = .01) were significantly associated with AGIs. The median time to AGI was 3.0 years, and AGI presented sooner (< or =1.4 years) if nosocomial infection occurred at the index admission. This risk of developing AGI after open repair was highest in the first postoperative year (32% of all AGI occurred in year 1). In an adjusted model, blood stream septicemia was significantly associated with AGI (odds ratio, 4.2; 95% confidence interval, 1.5-11.8) The incidence of AGI was low, presented most commonly in the first postoperative year, and was similar among patients undergoing open AAA repair and EAVR. Patients with nosocomial infection had an earlier onset of AGI. The 2-year rate of AGI was significantly higher in patients who had blood stream septicemia and surgical site infection in the periprocedural hospitalization. These data may be helpful in directing surveillance programs for AIG.
    Journal of Vascular Surgery 02/2008; 47(2):264-9. · 2.88 Impact Factor
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    ABSTRACT: The use of noninvasive and invasive diagnostic tests improves the accuracy of mediastinal staging for lung cancer. It is unknown how frequently multimodality mediastinal staging is used, or whether its use is associated with better health outcomes. A cohort study was conducted using Surveillance, Epidemiology, and End Results-Medicare data (1998-2005). Patients were categorized as having undergone single (computed tomography [CT] only), bi- (CT and positron emission tomography or CT and invasive staging), or tri-modality (CT, positron emission tomography, and invasive staging) staging. Among 43,912 subjects, 77%, 21%, and 2% received single, bi-, and tri-modality staging, respectively. The use of single modality staging decreased over time from 90% in 1998 to 67% in 2002 (p-trend <0.001), whereas the use of bi- and tri-modality staging increased from 10% to 30% and 0.4% to 5%, respectively. After adjustment for differences in patient characteristics, the use of a greater number of staging modalities was associated with a lower risk of death (bi- versus single modality: hazard ratio [HR] 0.58, 99% confidence interval [CI] 0.56-0.60; tri- versus single modality: HR 0.49, 99% CI 0.45-0.54; tri- versus bi-modality: HR 0.85, 99% CI 0.77-0.93). These associations were maintained even after excluding stage IV patients or adjustment for stage. The use of multimodality mediastinal staging increased over time and was associated with better survival. Stage migration and unmeasured patient and provider characteristics may have affected the magnitude of these associations. Cancer treatment guidelines should emphasize the potential relationship between staging procedures and outcomes, and health care policy should encourage adherence to staging guidelines.
    Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 01/2008; 4(3):355-63. · 4.55 Impact Factor