Bijan J Borah

Mayo Clinic - Rochester, Rochester, Minnesota, United States

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Publications (36)81.91 Total impact

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    ABSTRACT: The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001). The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.
    Female pelvic medicine & reconstructive surgery. 12/2014;
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    ABSTRACT: The Patient Assessment of Chronic Illness Care (PACIC) survey is a widely used instrument to assess the patient experience with healthcare delivery.
    Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 09/2014;
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    ABSTRACT: To assess long-term outcomes of magnetic resonance (MR)-guided focused ultrasound (US) treatments of uterine fibroids.
    Journal of vascular and interventional radiology: JVIR 07/2014; · 1.81 Impact Factor
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    ABSTRACT: Objective: To evaluate the cost-effectiveness of the following three treatments of uterine fibroids in a population of premenopausal women who wish to preserve their uteri: myomectomy, magnetic resonance-guided focused ultrasound (MRgFUS) and uterine artery embolization (UAE). Materials & methods: A decision analytic Markov model was constructed. Cost-effectiveness was calculated in terms of US$ per quality-adjusted life year (QALY) over 5 years. Two types of costs were calculated: direct costs only, and the sum of direct and indirect (productivity) costs. Women in the hypothetical cohort were assessed for treatment type eligibility, were treated based on eligibility, and experienced adequate or inadequate symptom relief. Additional treatment (myomectomy) occurred for inadequate symptom relief or recurrence. Sensitivity analysis was conducted to evaluate uncertainty in the model parameters. Results: In the base case, myomectomy, MRgFUS and UAE had the following combinations of mean cost and mean QALYs, respectively: US$15,459, 3.957; US$15,274, 3.953; and US$18,653, 3.943. When incorporating productivity costs, MRgFUS incurred a mean cost of US$21,232; myomectomy US$22,599; and UAE US$22,819. Using probabilistic sensitivity analysis (PSA) and excluding productivity costs, myomectomy was cost effective at almost every decision threshold. Using PSA and incorporating productivity costs, myomectomy was cost effective at decision thresholds above US$105,000/QALY; MRgFUS was cost effective between US$30,000 and US$105,000/QALY; and UAE was cost effective below US$30,000/QALY. Conclusion: Myomectomy, MRgFUS, and UAE were similarly effective in terms of QALYs gained. Depending on assumptions about costs and willingness to pay for additional QALYs, all three treatments can be deemed cost effective in a 5-year time frame.
    Journal of comparative effectiveness research. 05/2014;
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    ABSTRACT: Hospital surgical care is complex and subject to unwarranted variation.
    Annals of surgery. 05/2014;
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    ABSTRACT: The full-service US hospital has been described organizationally as a "solution shop," in which medical problems are assumed to be unstructured and to require expert physicians to determine each course of care. If universally applied, this model contributes to unwarranted variation in care, which leads to lower quality and higher costs. We purposely disrupted the adult cardiac surgical practice that we led at Mayo Clinic, in Rochester, Minnesota, by creating a "focused factory" model (characterized by a uniform approach to delivering a limited set of high-quality products) within the practice's solution shop. Key elements of implementing the new model were mapping the care process, segmenting the patient population, using information technology to communicate clearly defined expectations, and empowering nonphysician providers at the bedside. Using a set of criteria, we determined that the focused-factory model was appropriate for 67 percent of cardiac surgical patients. We found that implementation of the model reduced resource use, length-of-stay, and cost. Variation was markedly reduced, and outcomes were improved. Assigning patients to different care models increases care value and the predictability of care process, outcomes, and costs while preserving (in a lesser clinical footprint) the strengths of the solution shop. We conclude that creating a focused-factory model within a solution shop, by applying industrial engineering principles and health information technology tools and changing the model of work, is very effective in both improving quality and reducing costs.
    Health Affairs 05/2014; 33(5):746-55. · 4.64 Impact Factor
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    ABSTRACT: IMPORTANCE Cigarette smoking adds an estimated $100 billion in annual incremental direct health care costs nationwide. Cigarette smoking increases complication risk in surgical patients, but the potential effects of smoking status on perioperative health care costs are unclear. OBJECTIVE To test the hypothesis that current and former smoking at the time of admission for inpatient surgery, compared with never smoking, are independently associated with higher incremental health care costs for the surgical episode and the first year after hospital discharge. DESIGN, SETTING, AND PARTICIPANTS This population-based, propensity-matched cohort study, with cohort membership based on smoking status (current smokers, former smokers, and never smokers) was performed at Mayo Clinic in Rochester (a tertiary care center) and included patients at least 18 years old who lived in Olmsted County, Minnesota, for at least 1 year before and after the index surgery. EXPOSURE Undergoing an inpatient surgical procedure at Mayo Clinic hospitals between April 1, 2008, and December 31, 2009. MAIN OUTCOMES AND MEASURES Total costs during the index surgical episode and 1 year after hospital discharge, with the latter standardized as costs per month. Costs were measured using the Olmsted County Healthcare Expenditure and Utilization Database, a claims-based database including information on medical resource use, associated charges, and estimated economic costs for patients receiving care at the 2 medical groups (Mayo Clinic and Olmsted Medical Center) that provide most medical services within Olmsted County, Minnesota. RESULTS Propensity matching resulted in 678 matched pairs in the current vs never smoker grouping and 945 pairs in the former vs never smoker grouping. Compared with never smokers, adjusted costs for the index hospitalization did not differ significantly for current or former smokers. However, the adjusted costs in the year after hospitalization were significantly higher for current and former smokers based on regression analysis (predicted monthly difference of $400 [95% CI, $131-$669] and $273 [95% CI, $56-$490] for current and former smokers, respectively). CONCLUSIONS AND RELEVANCE Compared with never smokers, health care costs during the first year after hospital discharge for an inpatient surgical procedure are higher in both former and current smokers, although the cost of the index hospitalization is not affected by smoking status.
    JAMA surgery. 03/2014;
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    ABSTRACT: To compare the costs of vaginal and abdominal hysterectomy with robotically assisted hysterectomy. We identified all cases of robotically assisted hysterectomy, with or without bilateral salpingo-oophorectomy, treated at the Mayo Clinic (Rochester, Minnesota) from January 1, 2007, through December 31, 2009. Cases were propensity score-matched (one-to-one) to cases of vaginal and abdominal hysterectomy, selected randomly from January 1, 2004, through December 31, 2006 (before acquisition of the robotic surgical system). All billed costs were abstracted through the sixth postoperative week from the Olmsted County Healthcare Expenditure and Utilization Database and compared between cohorts with a generalized linear modeling framework. Predicted costs were estimated with the recycled predictions method. Costs of operative complications also were estimated. The total number of abdominal hysterectomies collected for comparison was 234 and the total number of vaginal hysterectomies was 212. Predicted mean cost of robotically assisted hysterectomy was $2,253 more than that of vaginal hysterectomy ($13,619 compared with $11,366; P<.001), although costs of complications were not significantly different. The predicted mean costs of robotically assisted compared with abdominal hysterectomy were similar ($14,679 compared with $15,588; P=.35). The costs of complications were not significantly different. Overall, vaginal hysterectomy was less costly than robotically assisted hysterectomy. Abdominal hysterectomy and robotically assisted hysterectomy had similar costs. LEVEL OF EVIDENCE:: II.
    Obstetrics and Gynecology 01/2014; · 4.80 Impact Factor
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    ABSTRACT: To compare one-year all-cause and uterine fibroid (UF)-related direct costs in patients treated with one of the following three uterine-sparing procedures: magnetic resonance-guided focused ultrasound (MRgFUS), uterine artery embolization (UAE) and myomectomy. This retrospective observational cohort study used healthcare claims for several million individuals with healthcare coverage from employers in the MarketScan Database for the period 2003-2010. UF patients aged 25-54 on their first UF procedure (index) date with 366-day baseline experience, 366-day follow-up period, continuous health plan enrollment during baseline and follow-up, and absence of any baseline UF procedures were included in the final sample. Cost outcomes were measured by allowed charges (sum of insurer-paid and patient-paid amounts). UF-related cost was defined as difference in mean cost between study cohorts and propensity-score-matched control cohorts without UF. Multivariate adjustment of cost outcomes was conducted using generalized linear models. The study sample comprised 14,426 patients (MRgFUS = 14; UAE = 4,092; myomectomy = 10,320) with a higher percent of older patients in MRgFUS cohort (71% vs. 50% vs. 12% in age-group 45-54, P < 0.001). Adjusted all-cause mean cost was lowest for MRgFUS ($19,763; 95% CI: $10,425-$38,694) followed by myomectomy ($20,407; 95% CI: $19,483-$21,381) and UAE ($25,019; 95% CI: $23,738-$26,376) but without statistical significance. Adjusted UF-related costs were also not significantly different between the three procedures. Adjusted all-cause and UF-related costs at one year were not significantly different between patients undergoing MRgFUS, myomectomy and UAE.
    Journal of therapeutic ultrasound. 01/2014; 2:7.
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    ABSTRACT: Propensity score (PS) methods have proliferated in recent years in observational studies in general and in observational comparative effectiveness research (CER) in particular. PS methods are an important set of tools for estimating treatment effects in observational studies, enabling adjustment for measured confounders in an easy-to-understand and transparent way. This article demonstrates how PS methods have been used to address specific CER questions from 2001 through to 2012 by identifying six impactful studies from this period. This article also discusses areas for improvement, including data infrastructure, and a unified set of guidelines in terms of PS implementation and reporting, which will boost confidence in evidence generated through observational CER using PS methods.
    Journal of comparative effectiveness research. 11/2013;
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    ABSTRACT: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses. We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect. Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001). Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes.
    Mayo Clinic Proceedings 10/2013; 88(10):1075-1084. · 5.79 Impact Factor
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    ABSTRACT: Abstract Background: Uterine fibroids have a disproportionate impact on African-American women. There are, however, no data to compare racial differences in symptoms, quality of life, effect on employment, and information-seeking behavior for this disease. Methods: An online survey was conducted by Harris Interactive between December 1, 2011 and January 16, 2012. Participants were U.S. women aged 29-59 with symptomatic uterine fibroids. African-American women were oversampled to allow statistical comparison of this high-risk group. Bivariate comparison of continuous and categorical measures was based on the t-test and the Chi-squared test, respectively. Multivariable adjustment of risk ratios was based on log binomial regression. Results: The survey was completed by 268 African-American and 573 white women. There were no differences between groups in education, employment status, or overall health status. African-American women were significantly more likely to have severe or very severe symptoms, including heavy or prolonged menses (RR=1.51, 95% CI 1.05-2.18) and anemia (RR=2.73, 95% CI 1.47-5.09). They also more often reported that fibroids interfered with physical activities (RR=1.67, 95% CI 1.20-2.32) and relationships (RR=2.27, 95% CI 1.23-4.22) and were more likely to miss days from work (RR=1.77, 95% CI 1.20-2.61). African-American women were more likely to consult friends and family (36 vs. 22%, P=0.004) and health brochures (32 vs. 18%, P<0.001) for health information. Concerns for future fertility (RR=2.65, 95% CI 1.93-3.63) and pregnancy (RR=2.89, 95% CI 2.11-3.97) following fibroid treatments were key concerns for black women. Conclusions: African-American women have more severe symptoms, unique concerns, and different information-seeking behavior for fibroids.
    Journal of Women's Health 09/2013; · 1.90 Impact Factor
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    ABSTRACT: To investigate the effects of enhanced recovery (a multimodal perioperative care enhancement protocol) in patients undergoing gynecologic surgery. Consecutive patients managed under an enhanced recovery pathway and undergoing cytoreduction, surgical staging, or pelvic organ prolapse surgery between June 20, 2011, and December 20, 2011, were compared with consecutive historical controls (March to December 2010) matched by procedure. Wilcoxon rank-sum, χ, and Fisher's exact tests were used for comparisons. Direct medical costs incurred in the first 30 days were obtained from the Olmsted County Healthcare Expenditure and Utilization Database and standardized to 2011 Medicare dollars. A total of 241 enhanced recovery women in the case group (81 cytoreduction, 84 staging, and 76 vaginal surgery) were compared with women in the control groups. In the cytoreductive group, patient-controlled anesthesia use decreased from 98.7% to 33.3% and overall opioid use decreased by 80% in the first 48 hours with no change in pain scores. Enhanced recovery resulted in a 4-day reduction in hospital stay with stable readmission rates (25.9% of women in the case group compared with 17.9% of women in the control group) and 30-day cost savings of more than $7,600 per patient (18.8% reduction). No differences were observed in rate (63% compared with 71.8%) or severity of postoperative complications (grade 3 or more: 21% compared with 20.5%). Similar, albeit less dramatic, improvements were observed in the other two cohorts. Ninety-five percent of patients rated satisfaction with perioperative care as excellent or very good. Implementation of enhanced recovery was associated with acceptable pain management with reduced opioids, reduced length of stay with stable readmission and morbidity rates, good patient satisfaction, and substantial cost reductions. : II.
    Obstetrics and Gynecology 08/2013; 122(2 Pt 1):319-28. · 4.80 Impact Factor
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    ABSTRACT: To characterize the impact of uterine leiomyomas (fibroids) in a racially diverse sample of women in the United States. A total of 968 women (573 White, 268 African-American, 127 other races) aged 29-59 with self-reported symptomatic uterine leiomyomas participated in a national survey. We assessed diagnosis, information seeking, attitudes about fertility, impact on work, and treatment preferences. Frequencies and percentages were summarized. Chi-square test was used to compare age groups. Women waited an average of 3.6 years before seeking treatment for leiomyomas, and 41% saw two or more healthcare providers for diagnosis. Almost a third of employed respondents (28%) reported missing work due to leiomyoma symptoms, and 24% felt that their symptoms prevented them from reaching their career potential. Women expressed desire for treatments that do not involve invasive surgery (79%), preserve the uterus (51%), and preserve fertility (43% of women under 40). Uterine leiomyomas cause significant morbidity. When considering treatment, women are most concerned about surgical options, especially women under 40 who want to preserve fertility.
    American journal of obstetrics and gynecology 07/2013; · 3.28 Impact Factor
  • Bijan J Borah, Anirban Basu
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    ABSTRACT: The quantile regression (QR) framework provides a pragmatic approach in understanding the differential impacts of covariates along the distribution of an outcome. However, the QR framework that has pervaded the applied economics literature is based on the conditional quantile regression method. It is used to assess the impact of a covariate on a quantile of the outcome conditional on specific values of other covariates. In most cases, conditional quantile regression may generate results that are often not generalizable or interpretable in a policy or population context. In contrast, the unconditional quantile regression method provides more interpretable results as it marginalizes the effect over the distributions of other covariates in the model. In this paper, the differences between these two regression frameworks are highlighted, both conceptually and econometrically. Additionally, using real-world claims data from a large US health insurer, alternative QR frameworks are implemented to assess the differential impacts of covariates along the distribution of medication adherence among elderly patients with Alzheimer's disease. Copyright © 2013 John Wiley & Sons, Ltd.
    Health Economics 04/2013; · 2.23 Impact Factor
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    ABSTRACT: BACKGROUND & AIMS: Central obesity could increase risk for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) by mechanical and/or metabolic mechanisms, such as hyperinsulinemia. We performed an epidemiologic study to determine if there whether prior type 2 diabetes mellitus (DM2) is associated with BE. METHODS: We performed a population-based case-control study using the General Practice Research Database (GPRD), a United Kingdom primary care database that contains information from more than 8 million subjects, to identify cases of BE (using previously validated codes; n=14,245) and matched controls without BE (by age, sex, enrollment date, duration of follow up, and practice region, by incidence density sampling; n=70,361). We assessed the association of a prior diagnosis of DM2 with BE, using conditional univariate and multivariable regression analysis. Confounders assessed included smoking, obesity measured by BMI, and gastroesophageal reflux disease (GERD). RESULTS: BE cases were more likely than controls to have smoked (52.4% vs 49.9%), have a higher mean BMI (27.2 vs 26.9), and a higher prevalence of DM2 than controls (5.8% vs 5.3%). On multivariable analysis, DM2 was associated with a 49% increase in the risk of BE, independent of other known risk factors (odds ratio, 1.49; 95% confidence interval, 1.16-1.91). This association was stronger in women than men. Results remained stable with sensitivity analyses. CONCLUSIONS: In a large population based case-control study, DM2 was a risk factor for BE, independent of obesity (as measured by BMI) and other risk factors (smoking and GERD). These data suggest that metabolic pathways related to DM2 should be explored in BE pathogenesis and esophageal carcinogenesis.
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 04/2013; · 5.64 Impact Factor
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    ABSTRACT: OBJECTIVE: Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI). METHODS: Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated. RESULTS: Among 1,369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5,447 median increase in 30-day cost. CONCLUSIONS: Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.
    Gynecologic Oncology 04/2013; · 3.93 Impact Factor
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    ABSTRACT: Magnetic resonance-guided focused ultrasound (MRgFUS) is a relatively new minimally invasive treatment, approved by the US Food and Drug Administration in 2004 for treatments of symptomatic uterine leiomyomas (fibroids). The purpose of this work is to present retrospective cohort analysis of women that underwent commercial MRgFUS treatment between 2005 and 2009 at a single center, to identify baseline patient characteristics that predict successful MRgFUS fibroid treatment. Identifying these clinical predictors of MRgFUS would be helpful to clinicians choosing the optimal patient for this treatment modality. One hundred thirty women with symptomatic uterine leiomyomas who underwent MRgFUS were followed up with a mean length of follow up of 17.4 ± 10.3 months. The main outcome measure of the follow-up was to identify patients who required additional fibroid treatment due to continued fibroid symptoms. Additionally, patient medical history and radiological findings obtained prior to MRgFUS were reviewed, and statistical analysis was performed to identify factors associated with reduced risk of having additional fibroid treatment. Twenty-nine patients (22.3%) underwent additional fibroid treatment due to continued or recurrent fibroid symptoms during the follow up. Cumulative incidence of additional fibroid treatment was 9.7%, 29.3%, and 44.7% at 1, 2, and 3 years following MRgFUS, respectively. In multivariable Cox proportional hazard regression analyses, older age (hazard ratio (HR) 0.54 per 5-year increase in age, 95% confidence interval 0.39 to 0.76, p < 0.001), greater number of fibroids (HR 0.19 for more than three vs. one fibroid, 95% CI 0.05 to 0.67, p = 0.033), and greater fibroid volume (HR 0.70 per doubling in volume, 95% CI 0.51 to 0.96, p = 0.025) were significantly associated with less risk of having additional fibroid treatment. Older age at treatment and having multiple fibroids with larger volume are associated with a lower risk of additional intervention following MRgFUS treatment for uterine fibroids.
    Journal of therapeutic ultrasound. 01/2013; 1:15.
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    ABSTRACT: BACKGROUND: Value-based purchasing (VBP) program that links Medicare payments to quality of care will become effective from 2013. It is unclear whether specific hospital characteristics are associated with a hospital's VBP score, and consequently incentive payments.The objective of the study was to assess the association of hospital characteristics with (i) the mean VBP score, and (ii) specific percentiles of the VBP score distribution. The secondary objective was to quantify the associations of hospital characteristics on the VBP score components: clinical process of care (CPC) and patient satisfaction. METHODS: Observational analysis that used data from three sources: Medicare Hospital Compare Database, American Hospital Association 2010 Annual Survey and Medicare Impact File. The final study sample included 2491 U.S. acute care hospitals eligible for the VBP program. The association of hospital characteristics with the mean VBP score and specific VBP score percentiles were assessed by ordinary least square (OLS) regression and quantile regression (QR), respectively. RESULTS: VBP score had substantial variations, with mean score of 30 and 60 in the first and fourth quartiles of the VBP score distribution. For-profit status (vs. non-profit), smaller bed size (vs. 100--199 beds), East South Central region (vs. New England region) and the report of specific CPC measures (discharge instructions, timely provision of antibiotics and beta blockers, and serum glucose controls in cardiac surgery patients) were positively associated with mean VBP scores (p<0.01 in all). Total number of CPC measures reported, bed size of 400--499 (vs. 100--199 beds), a few geographic regions (Mid-Atlantic, West North Central, Mountain and Pacific) compared to the New England region were negatively associated with mean VBP score (p<0.01 in all). Disproportionate share index, proportion of Medicare and Medicaid days to total inpatient days had significant (p<0.01) but small effects. QR results indicate evidence of differential effects of some of the hospital characteristics across low-, medium- and high-quality providers. CONCLUSIONS: Although hospitals serving the poor and the elderly are more likely to score lower under the VBP program, the correlation appears small. Profit status, geographic regions, number and type of CPC measures reported explain the most variation among scores.
    BMC Health Services Research 12/2012; 12(1):464. · 1.77 Impact Factor
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    ABSTRACT: : To identify patient characteristics and perioperative factors predictive of 30-day morbidity and cost in patients with endometrial carcinoma. : Data of consecutive patients treated with hysterectomy for endometrial carcinoma between 1999 and 2008 were collected prospectively. Thirty predictors were chosen from more than 130 collected based on anticipated clinical relevance and prevalence (more than 3%). Complications were graded per the Accordion Classification. Multivariable models were developed using stepwise and backward variable selection methods. Thirty-day cost analyses were expressed in 2010 Medicare dollars. : Of 1,369 patients, significant predictors (P<.01) of grade 2 and higher morbidity included American Society of Anesthesiologists physical status classification system class higher than 2 (odds ratio [OR] 2.1), preoperative white blood count (OR 2.1 per doubling), history of deep vein thrombosis (OR 2.1), pelvic and para-aortic lymphadenectomy (OR 2.3 compared with no lymphadenectomy), laparotomy (OR 2.8 compared with minimally invasive surgery), myometrial invasion more than 50% (OR 2.4), operating time (OR 1.9 per doubling), and grade 4 surgical complexity (OR 2.7 compared with grade 1). After controlling for patient factors in a multivariable model, laparotomy, pelvic, and para-aortic lymphadenectomy were associated with significant increases in cost compared with the use of minimally invasive surgery or hysterectomy alone. : This analysis identifies patient and perioperative care factors predictive of 30-day morbidity and cost. These data are useful for preoperative counseling, for defining equitable reimbursement and factors critical for risk-adjustment when comparing outcomes, and for identifying areas for quality improvement in patients with endometrial carcinoma. Given the marked increases in morbidity and cost associated with laparotomy and lymphadenectomy, minimally invasive surgery and selective lymphadenectomy should be standard treatment for patients with endometrial carcinoma. : II.
    Obstetrics and Gynecology 12/2012; 120(6):1419-27. · 4.80 Impact Factor

Publication Stats

209 Citations
81.91 Total Impact Points

Institutions

  • 2011–2014
    • Mayo Clinic - Rochester
      • Department of Radiology
      Rochester, Minnesota, United States
    • Mayo Foundation for Medical Education and Research
      Rochester, Michigan, United States