Stuart R Lipsitz

Harvard Medical School, Boston, Massachusetts, United States

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Publications (535)2982.29 Total impact

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    ABSTRACT: Background: Addressing patient expectations is necessary to achieve high satisfaction. However, few data are available on nurses' perceptions and performance with respect to patient expectations and satisfaction. Objectives: This international multicenter study aimed to: (a) evaluate nurses' attitudes and performance with respect to patient satisfaction and expectations, and (b) identify predictors of nurses' inquiry of patients' satisfaction at the point of discharge. Methods: A questionnaire examining attitudes and performance toward patient satisfaction and expectations was developed and validated. Nurses at four academic hospitals in the United States, the United Kingdom, Israel, and Denmark were surveyed. Results: A total of 536 nurses participated in the study (response rate 85.3%). Nurses expressed positive attitudes toward activities related to patient satisfaction and expectations, endorsing the importance of talking with patients about their satisfaction status (91.6%) and their expectations (93.2%). More than half of the responders (51.8%) claimed to have responded to the status of patient satisfaction or dissatisfaction (Israel: 25%; United States: 54.9%; United Kingdom: 61.7%; Denmark: 69.9%; p < .001). However, only 12.1% stated that they routinely ask patients about their level of satisfaction, with nurses in the United States (18.3%) and Denmark (17.5%) more likely to ask compared to nurses in the United Kingdom (7.4%) and Israel (6.3%; p = .001). Adjusted logistic regression identified four significant predictors (p < .05) of nurses' inquiry about patients' satisfaction: "Responding to patient's satisfaction status" (OR: 3.1; 95% CI: 1.7-5.8); "Documenting patient's satisfaction status" (OR: 2.8; 95% CI: 1.6-5.1); "Asking routinely about expectations" (OR: 5.4; 95% CI: 3-9.7); and "Responded to expectations during the past month" (OR: 4.3; 95% CI: 1.9-9.4). Linking evidence to action: These findings warrant further investigation, potentially into the nurses' work environments or educational programs, to better understand why nurses' positive attitudes toward patient satisfaction and expectations do not result in actively asking patients about their satisfaction level and what should be done to improve nurses' performance. Healthcare organizations and policy makers should develop and support structured programs to address patient expectations and improve patient satisfaction during hospitalization.
    Full-text · Article · Feb 2016 · Worldviews on Evidence-Based Nursing

  • No preview · Article · Jan 2016 · JAMA The Journal of the American Medical Association
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    ABSTRACT: Introduction: Lack of health insurance limits access to preventive services, including cancer screening. We examined effects of Medicare eligibility on the appropriate use of cancer screening services in the United States. Methods: We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor and Surveillance System (analyzed in 2014). Univariable and logistic regression analyses were performed for participants aged 60-64 and 66-70 to examine effects of Medicare eligibility on prevalence of self-reported screening for colorectal, breast, and prostate cancers. Sub-analyses were performed among low-income (<$25,000 annual/household). Results: Medicare-eligible individuals were significantly more likely to undergo all examined preventive services (colorectal cancer OR: 1.90; 95%CI 1.79-2.04; prostate cancer OR: 1.29; 95%CI 1.17-1.43; breast cancer OR: 1.23; 95%CI 1.10-1.37) and the effect was most pronounced among low-income individuals (colorectal cancer OR: 2.04; 95%CI 1.8-2.32; prostate cancer OR: 1.39; 95%CI 1.12-1.72; breast cancer OR: 1.42, 95%CI 1.20-1.67). Access to a healthcare provider was the strongest independent predictor of undergoing appropriate screening, ranging from OR 2.73 (95% CI 2.20-3.39) for colorectal cancer screening in the low-income population to OR 4.79 (95% CI 3.95-5.81) for breast cancer screening in the overall cohort. The difference in screening prevalence was most pronounced when comparing Medicare-eligible participants to uninsured Medicare-ineligible participants (+33.2%). Conclusions: Medicare eligibility impacts the prevalence of cancer screening, likely as a result of increased access to primary care. Low-income individuals benefit most from Medicare eligibility. Expanded public insurance coverage to these individuals may improve access to preventive services.
    No preview · Article · Jan 2016 · Preventive Medicine
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    ABSTRACT: Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.
    No preview · Article · Dec 2015
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    ABSTRACT: Objectives To identify factors associated with mortality in older adults 30, 180, and 365days after emergency major abdominal surgery. DesignA retrospective study linked to Medicare claims from 2000 to 2010. SettingHealth and Retirement Study (HRS). ParticipantsMedicare beneficiaries aged 65.5 enrolled in the HRS from 2000 to 2010 with at least one urgent or emergency major abdominal surgery and a core interview from the HRS within 3years before surgery. MeasurementsSurvival analysis was used to describe all-cause mortality 30, 180, and 365days after surgery. Complementary log-log regression was used to identify participant characteristics and postoperative events associated with poorer survival. ResultsFour hundred individuals had one of the urgent or emergency surgeries of interest, 24% of whom were aged 85 and older, 50% had coronary artery disease, 48% had cancer, 33% had congestive heart failure, and 37% experienced a postoperative complication. Postoperative mortality was 20% at 30days, 31% at 180days, and 34% at 365days. Of those aged 85 and older, 50% were dead 1year after surgery. After multivariate adjustment including postoperative complications, dementia (hazard ratio (HR)=2.02, 95% confidence interval (CI)=1.24-3.31), hospitalization within 6months before surgery (HR=1.63, 95% CI=1.12-2.28), and complications (HR=3.45, 95% CI=2.32-5.13) were independently associated with worse 1-year survival. Conclusion Overall mortality is high in many older adults up to 1year after undergoing emergency major abdominal surgery. The occurrence of a complication is the clinical factor most strongly associated with worse survival.
    No preview · Article · Dec 2015 · Journal of the American Geriatrics Society
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    ABSTRACT: Background: Accurate risk estimation is essential when benchmarking surgical outcomes for reimbursement and engaging in shared decision-making. The greater complexity of emergency surgery patients may bias outcome comparisons between elective and emergency cases. Objective: To test whether an established risk modelling tool, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) predicts mortality comparably for emergency and elective cases. Methods: From the ACS-NSQIP 2011-2012 patient user files, we selected core emergency surgical cases also common to elective scenarios (gastrointestinal, vascular, and hepato-biliary-pancreatic). After matching strategy for Common Procedure Terminology (CPT) and year, we compared the accuracy of ACS-NSQIP predicted mortality probabilities using the observed-to-expected ratio (O:E), c-statistic, and Brier score. Results: In all, 56,942 emergency and 136,311 elective patients were identified as having a common CPT and year. Using a 1:1 matched sample of 37,154 emergency and elective patients, the O:E ratios generated by ACS-NSQIP models differ significantly between the emergency [O:E = 1.031; 95% confidence interval (CI) = 1.028-1.033] and elective populations (O:E = 0.79; 95% CI = 0.77-0.80, P < 0.0001) and the c-statistics differed significantly (emergency c-statistic = 0.927; 95% CI = 0.921-0.932 and elective c-statistic = 0.887; 95% CI = 0.861-0.912, P = 0.003). The Brier score, tested across a range of mortality rates, did not differ significantly for samples with mortality rates of 6.5% and 9% (eg, emergency Brier score = 0.058; 95% CI = 0.048-0.069 versus elective Brier score = 0.057; 95% CI = 0.044-0.07, P = 0.87, among 2217 patients with 6.5% mortality). When the mortality rate was low (1.7%), Brier scores differed significantly (emergency 0.034; 95% CI = 0.027-0.041 versus elective 0.016; 95% CI = 0.009-0.023, P value for difference 0.0005). Conclusion: ACS-NSQIP risk estimates used for benchmarking and shared decision-making appear to differ between emergency and elective populations.
    No preview · Article · Dec 2015 · Annals of Surgery
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    ABSTRACT: Importance Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes.Objectives To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.Design, Setting, and Participants Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region.Exposures Cesarean delivery rate.Main Outcomes and Measures The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births).Results The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, −10.1; 95% CI, −16.8 to −3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5; P < .001), respectively (adjusted for total health expenditure per capita, population, percent of urban population, fertility rate, and region). Higher cesarean delivery rates were not correlated with maternal or neonatal mortality at a country level. A sensitivity analysis including only 76 countries with the highest-quality cesarean delivery rate information had a similar result: cesarean delivery rates greater than 6.9 to 20.1 per 100 live births were inversely correlated with the maternal mortality ratio (slope coefficient, −21.3; 95% CI, −32.2 to −10.5, P < .001). Cesarean delivery rates of 12.6 to 24.0 per 100 live births were inversely correlated with neonatal mortality (slope coefficient, −1.4; 95% CI, −2.3 to −0.4; P = .004).Conclusions and Relevance National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.
    No preview · Article · Dec 2015 · JAMA The Journal of the American Medical Association
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    ABSTRACT: Importance There is extensive evidence suggesting that black men with localized prostate cancer (PCa) have worse cancer-specific mortality compared with their non-Hispanic white counterparts.Objective To evaluate racial disparities in the use, quality of care, and outcomes of radical prostatectomy (RP) in elderly men (≥65 years) with nonmetastatic PCa.Design, Setting, and Participants This retrospective analysis of outcomes stratified according to race (black vs non-Hispanic white) included 2020 elderly black patients (7.6%) and 24 462 elderly non-Hispanic white patients (92.4%) with localized PCa who underwent RP within the first year of PCa diagnosis in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 1992 and 2009. The study was performed in 2014.Main Outcomes and Measures Process of care (ie, time to treatment, lymph node dissection), as well as outcome measures (ie, complications, emergency department visits, readmissions, PCa-specific and all-cause mortality, costs) were evaluated using Cox proportional hazards regression. Multivariable conditional logistic regression and quantile regression were used to study the association of racial disparities with process of care and outcome measures.Results The proportion of black patients with localized prostate cancer who underwent RP within 90 days was 59.4% vs 69.5% of non-Hispanic white patients (P < .001). In quantile regression of the top 50% of patients, blacks had a 7-day treatment delay compared with non-Hispanic whites. (P < .001). Black patients were less likely to undergo lymph node dissection (odds ratio [OR], 0.76 [95% CI, 0.66-0.80]; P < .001) but had higher odds of postoperative visits to the emergency department (within 30 days: OR, 1.48 [95% CI, 1.18-1.86]); after 30 days or more (OR, 1.45 [95% CI, 1.19-1.76]) and readmissions (within 30 days: OR, 1.28 [95% CI, 1.02-1.61]); ≥30 days (OR, 1.27 [95% CI, 1.07-1.51]) compared with non-Hispanic whites. The surgical treatment of black patients was associated with a higher incremental annual cost (the top 50% of blacks spent $1185.50 (95% CI , $804.85-1 $1566.10; P < .001) more than the top 50% of non-Hispanic whites). There was no difference in PCa-specific mortality (P = .16) or all-cause mortality (P = .64) between black and non-Hispanic white men.Conclusions and Relevance Blacks treated with RP for localized PCa are more likely to experience adverse events and incur higher costs compared with non-Hispanic white men; however, this does not translate into a difference in PCa-specific or all-cause mortality.
    No preview · Article · Oct 2015
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    ABSTRACT: Introduction: Much teaching to surgical residents takes place in the operating room (OR). The explicit content of what is taught in the OR, however, has not previously been described. This study investigated the content of what is taught in the OR, specifically during laparoscopic cholecystectomies (LCs), for which a cognitive task analysis (CTA), explicitly delineating individual steps, was available in the literature. Methods: A checklist of necessary technical and decision-making steps to be executed during performance of LCs, anchored in the previously published CTA, was developed. A convenience sample of LCs was identified over a 12-month period from February 2011 to February 2012. Using the checklist, a trained observer recorded explicit teaching that occurred regarding these steps during each observed case. All observations were tallied and analyzed. Results: In all, 51 LCs were observed; 14 surgery attendings and 33 residents participated in the observed cases. Of 1042 observable teaching points, only 560 (53.7%) were observed during the study period. As a proportion of all observable steps, technical steps were observed more frequently, 377 (67.3%), than decision-making steps, 183 (32.7%). Also when focusing on technical and decision-making steps alone, technical steps were taught more frequently (60.9% vs 43.3%). Conclusions: Only approximately half of all possible observable teaching steps were explicitly taught during LCs in this study. Technical steps were more frequently taught than decision-making steps. These findings may have important implications: a better understanding of the content of intraoperative teaching would allow educators to steer residents' preoperative preparation, modulate intraoperative instruction by members of the surgical faculty, and guide residents to the most appropriate teaching venues.
    No preview · Article · Oct 2015 · Journal of Surgical Education
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    ABSTRACT: Objectives To examine the prevalence of cervical spine fractures after falls in older Americans, to show changes in recent years, and to compare 12-month outcomes between individuals with cervical and hip fracture after falls.DesignRetrospective study of Medicare data from 2007 to 2011.SettingAcute care hospitals.ParticipantsIndividuals aged 65 and older with cervical or hip fracture after a fall.MeasurementsCervical fracture rate, 12-month mortality, and readmission rate after injury.ResultsRates of cervical fracture increased from 4.6 per 10,000 in 2007 to 5.3 per 10,000 in 2011; rates of hip fracture decreased from 77.3 per 10,000 in 2007 to 63.5 per 10,000 in 2011. Participants with cervical fracture with and without spinal cord injury (SCI) were more likely than those with hip fracture to receive treatment at large hospitals (59.4% and 54.1% vs 28.1%, P < .001), teaching hospitals (49.3% and 40.0% vs 13.4%, P < .001), and regional trauma centers (46.3% and 38.5% vs 13.0%, P < .001). Participants with cervical fracture without (24.7%) and with SCI (41.7%) had greater risk-adjusted mortality at 1 year than those with hip fracture (22.7%) (P < .001). By 1 year, 73.4% of participants with cervical fracture with and 59.5% without SCI and 59.3% of those with hip fracture had died or were readmitted to the hospital (P < .001).Conclusion Cervical spinal fractures occur in one of every 2,000 Medicare beneficiaries annually and appear to be increasing over time. Participants with cervical fracture had greater mortality than those with hip fracture. Given the increasing prevalence and the poor outcomes in this population, hospitals need to develop processes to improve care for these vulnerable individuals.
    No preview · Article · Oct 2015 · Journal of the American Geriatrics Society
  • S Emani · D.Y. Ting · M Healey · S.R. Lipsitz · H Ramelson · V Suric · D.W. Bates
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    ABSTRACT: Background: A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS. Objectives: Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers. Methods: A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program. Results: Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001). Conclusions: Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.
    No preview · Article · Oct 2015 · Applied Clinical Informatics
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    ABSTRACT: Introduction Ensuring that patients receive care that is consistent with their goals and values is a critical component of high-quality care. This article describes the protocol for a cluster randomised controlled trial of a multicomponent, structured communication intervention. Methods and analysis Patients with advanced, incurable cancer and life expectancy of <12 months will participate together with their surrogate. Clinicians are enrolled and randomised either to usual care or the intervention. The Serious Illness Care Program is a multicomponent, structured communication intervention designed to identify patients, train clinicians to use a structured guide for advanced care planning discussion with patients, ‘trigger’ clinicians to have conversations, prepare patients and families for the conversation, and document outcomes of the discussion in a structured format in the electronic medical record. Clinician satisfaction with the intervention, confidence and attitudes will be assessed before and after the intervention. Self-report data will be collected from patients and surrogates approximately every 2 months up to 2 years or until the patient's death; patient medical records will be examined at the close of the study. Analyses will examine the impact of the intervention on the patient receipt of goal-concordant care, and peacefulness at the end of life. Secondary outcomes include patient anxiety, depression, quality of life, therapeutic alliance, quality of communication, and quality of dying and death. Key process measures include frequency, timing and quality of documented conversations. Ethics and dissemination This study was approved by the Dana-Farber Cancer Institute Institutional Review Board. Results will be reported in peer-reviewed publications and conference presentations. Trial registration number Protocol identifier NCT01786811; Pre-results.
    Full-text · Article · Oct 2015 · BMJ Open

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Purpose: Long-term survivors of Hodgkin's lymphoma (HL) treated with mediastinal radiotherapy often have multiple subclinical cardiac abnormalities, possibly including restrictive cardiomyopathy. The clinical importance of these abnormalities has not been established, but they may eventually reduce quality of life. We sought to confirm an earlier cross-sectional correlation between maximum oxygen consumption (VO2max) and the physical component score (PCS) of the SF-36 quality of life instrument completed years later. Methods: We created a cohort of 21 survivors of HL in childhood or adolescence who had participated in both of two independent studies: a study of multiple cardiac measures in 48 survivors at a median of 14.3. years after diagnosis and a study performed about 5. years later of 511 survivors who completed the SF-36. We assessed the correlation between VO2max and left ventricular fractional shortening (LVFS) measured during the first study with PCS measured during the second. Results: Median PCS was 10.0 points lower (55.2 to 45.2) in the second study. The correlation between VO2max and PCS at a median of 5. years later was r = 0.50 (P = 0.021): that between LVFS in the first study and PCS in the second was r = -0.50 (P = 0.021). Conclusions: In HL survivors treated with mediastinal radiotherapy, VO2max appears to be associated with future quality of life. Measures of LVFS are clearly not sufficient to address whether decreased quality of life in these survivors is associated with cardiac impairment Larger longitudinal studies are necessary to determine how much V02max explains future quality of life.
    No preview · Article · Oct 2015 · Progress in Pediatric Cardiology

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Background: The importance of leadership is recognized in surgery, but the specific impact of leadership style on team behavior is not well understood. In other industries, leadership is a well-characterized construct. One dominant theory proposes that transactional (task-focused) leaders achieve minimum standards and transformational (team-oriented) leaders inspire performance beyond expectations. Study design: We videorecorded 5 surgeons performing complex operations. Each surgeon was scored on the Multifactor Leadership Questionnaire, a validated method for scoring transformational and transactional leadership style, by an organizational psychologist and a surgeon researcher. Independent coders assessed surgeons' leadership behaviors according to the Surgical Leadership Inventory and team behaviors (information sharing, cooperative, and voice behaviors). All coders were blinded. Leadership style (Multifactor Leadership Questionnaire) was correlated with surgeon behavior (Surgical Leadership Inventory) and team behavior using Poisson regression, controlling for time and the total number of behaviors, respectively. Results: All surgeons scored similarly on transactional leadership (range 2.38 to 2.69), but varied more widely on transformational leadership (range 1.98 to 3.60). Each 1-point increase in transformational score corresponded to 3 times more information-sharing behaviors (p < 0.0001) and 5.4 times more voice behaviors (p = 0.0005) among the team. With each 1-point increase in transformational score, leaders displayed 10 times more supportive behaviors (p < 0.0001) and displayed poor behaviors 12.5 times less frequently (p < 0.0001). Excerpts of representative dialogue are included for illustration. Conclusions: We provide a framework for evaluating surgeons' leadership and its impact on team performance in the operating room. As in other fields, our data suggest that transformational leadership is associated with improved team behavior. Surgeon leadership development, therefore, has the potential to improve the efficiency and safety of operative care.
    Full-text · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery. We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic. A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81. The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population. Epidemiologic/prognostic study, level III; therapeutic study, level IV.
    No preview · Article · Sep 2015
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    ABSTRACT: For complex surveys with a binary outcome, logistic regression is widely used to model the outcome as a function of covariates. Complex survey sampling designs are typically stratified cluster samples, but consistent and asymptotically unbiased estimates of the logistic regression parameters can be obtained using weighted estimating equations (WEEs) under the naive assumption that subjects within a cluster are independent. Despite the relatively large samples typical of many complex surveys, with rare outcomes, many interaction terms, or analysis of subgroups, the logistic regression parameters estimates from WEE can be markedly biased, just as with independent samples. In this paper, we propose bias-corrected WEEs for complex survey data. The proposed method is motivated by a study of postoperative complications in laparoscopic cystectomy, using data from the 2009 United States' Nationwide Inpatient Sample complex survey of hospitals. © The Author(s) 2015.
    No preview · Article · Aug 2015 · Statistical Methods in Medical Research
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    ABSTRACT: Medical organizations have increased interest in identifying and improving behaviors that threaten team performance and patient safety. Three hundred and sixty degree evaluations of surgeons were performed at 8 academically affiliated hospitals with a common Code of Excellence. We evaluate participant perceptions and make recommendations for future use. Three hundred and eighty-five surgeons in a variety of specialties underwent 360-degree evaluations, with a median of 29 reviewers each (interquartile range 23 to 36). Beginning 6 months after evaluation, surgeons, department heads, and reviewers completed follow-up surveys evaluating accuracy of feedback, willingness to participate in repeat evaluations, and behavior change. Survey response rate was 31% for surgeons (118 of 385), 59% for department heads (10 of 17), and 36% for reviewers (1,042 of 2,928). Eighty-seven percent of surgeons (95% CI, 75%-94%) agreed that reviewers provided accurate feedback. Similarly, 80% of department heads believed the feedback accurately reflected performance of surgeons within their department. Sixty percent of surgeon respondents (95% CI, 49%-75%) reported making changes to their practice based on feedback received. Seventy percent of reviewers (95% CI, 69%-74%) believed the evaluation process was valuable, with 82% (95% CI, 79%-84%) willing to participate in future 360-degree reviews. Thirty-two percent of reviewers (95% CI, 29%-35%) reported perceiving behavior change in surgeons. Three hundred and sixty degree evaluations can provide a practical, systematic, and subjectively accurate assessment of surgeon performance without undue reviewer burden. The process was found to result in beneficial behavior change, according to surgeons and their coworkers. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Jul 2015 · Journal of the American College of Surgeons

Publication Stats

18k Citations
2,982.29 Total Impact Points


  • 1990-2016
    • Harvard Medical School
      • • Department of Surgery
      • • Department of Medicine
      Boston, Massachusetts, United States
  • 2005-2015
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, Massachusetts, United States
    • New York University
      New York City, New York, United States
    • Creighton University
      Omaha, Nebraska, United States
    • University of South Florida St. Petersburg
      St. Petersburg, Florida, United States
  • 1994-2015
    • Harvard University
      • Department of Health Policy and Management
      Cambridge, Massachusetts, United States
  • 2014
    • The University of Chicago Medical Center
      • Section of Urology
      Chicago, Illinois, United States
  • 2010-2012
    • Beverly Hospital, Boston MA
      BVY, Massachusetts, United States
    • University of Miami Miller School of Medicine
      • Department of Pediatrics
      Miami, Florida, United States
  • 1990-2012
    • Dana-Farber Cancer Institute
      • • Lank Center for Genitourinary Oncology
      • • Department of Biostatistics and Computational Biology
      Boston, Massachusetts, United States
  • 2011
    • Cedars-Sinai Medical Center
      • Cedars Sinai Medical Center
      Los Ángeles, California, United States
  • 1999-2010
    • Medical University of South Carolina
      • • Department of Medicine
      • • Division of Biostatistics and Epidemiology
      Charleston, South Carolina, United States
  • 2009
    • CUNY Graduate Center
      New York, New York, United States
  • 2008-2009
    • Partners HealthCare
      Boston, Massachusetts, United States
  • 2007
    • Texas A&M University
      • Department of Statistics
      College Station, Texas, United States
  • 1999-2005
    • University of Rochester
      • Division of Pediatric Cardiology
      Rochester, New York, United States
  • 2003
    • University Center Rochester
      Рочестер, Minnesota, United States
  • 2002
    • University of North Carolina at Chapel Hill
      • Department of Biostatistics
      North Carolina, United States
    • Royal Perth Hospital
      Perth City, Western Australia, Australia
  • 1998
    • Fox Chase Cancer Center
      Filadelfia, Pennsylvania, United States
  • 1991-1998
    • Massachusetts Department of Public Health
      Boston, Massachusetts, United States
  • 1997
    • Montefiore Medical Center
      New York City, New York, United States
  • 1995
    • Albert Einstein College of Medicine
      • Department of Medicine
      New York City, NY, United States
  • 1993
    • Arizona State University
      Tempe, Arizona, United States