Author Interviews, Brigham & Women's - Harvard, Johns Hopkins, Race/Ethnic Diversity, Surgical Research / 29.01.2016
Only 1 in 3 Surgeons Perceive Racial Disparities in Health Care
MedicalResearch.com Interview with:
Adil H. Haider, MD, MPH
Kessler Director for the Center for Surgery and Public Health
Brigham and Women's Hospital Harvard Medical School,
and the Harvard T.H. Chan School of Public Health
Deputy Editor of JAMA Surgery
Medical Research: What is the background for this study?
Dr. Haider: Racial/Ethnic disparities have been identified in multiple surgical fields. They are thought to be caused by a complex interplay of patient-, provider-, and systems-level factors. As healthcare professionals, providers play a key role in the care and outcomes that patients experience. However, despite published research about the existence of disparities, it remains unknown the extent to which surgeons perceive that racial/ethnic disparities exist.
Medical Research: What are the main findings?
Dr. Haider: In a pilot study designed to assess the extent to which US surgeons report awareness of racial/ethnic disparities, only 36.6% agreed that racial/ethnic disparities exist in healthcare. Even fewer, 11.6% acknowledged that disparities were present in their hospital or clinic, and a mere 4.7% reported disparities in their personal practice.
Adil H. Haider, MD, MPH
Kessler Director for the Center for Surgery and Public Health
Brigham and Women's Hospital Harvard Medical School,
and the Harvard T.H. Chan School of Public Health
Deputy Editor of JAMA Surgery
Medical Research: What is the background for this study?
Dr. Haider: Racial/Ethnic disparities have been identified in multiple surgical fields. They are thought to be caused by a complex interplay of patient-, provider-, and systems-level factors. As healthcare professionals, providers play a key role in the care and outcomes that patients experience. However, despite published research about the existence of disparities, it remains unknown the extent to which surgeons perceive that racial/ethnic disparities exist.
Medical Research: What are the main findings?
Dr. Haider: In a pilot study designed to assess the extent to which US surgeons report awareness of racial/ethnic disparities, only 36.6% agreed that racial/ethnic disparities exist in healthcare. Even fewer, 11.6% acknowledged that disparities were present in their hospital or clinic, and a mere 4.7% reported disparities in their personal practice.
Dr. Rachael Callcut[/caption]
MedicalResearch.com Interview with:
Dr. Rachael Callcut M.D., M.S.P.H
Dr. Jeffrey Silber[/caption]
Jeffrey H. Silber, M.D., Ph.D.
The Nancy Abramson Wolfson Professor of Health Services Research
Professor of Pediatrics and Anesthesiology & Critical Care, The University of Pennsylvania Perelman School of Medicine
Professor of Health Care Management
The Wharton School
Director, Center for Outcomes Research
The Children's Hospital of Philadelphia
Philadelphia, PA 19104
Medical Research: What is the background for this study?
Response: We wanted to test whether hospitals with better nursing work environments displayed better outcomes and value than those with worse nursing environments, and to determine whether these results depended on how sick patients were when first admitted to the hospital.
Medical Research: What are the main findings?
Response: Hospitals with better nursing work environments (defined by Magnet status), and staffing that was above average (a nurse-to-bed ratio greater than or equal to 1), had lower mortality than those hospitals with worse nursing environments and below average staffing levels. The mortality rate in Medicare patients undergoing general surgery was 4.8% in the hospitals with the better nursing environments versus 5.8% in those hospitals with worse nursing environments. Furthermore, cost per patient was similar. We found that better nursing environments were also associated with lower need to use the Intensive Care Unit. The greatest mortality benefit occurred in patients in the highest risk groups.
Dr. Daniel McIsaac[/caption]
Dr. Daniel I McIsaac, MD, MPH, FRCPC
Assistant Professor of Anesthesiology
Department of Anesthesiology
The Ottawa Hospital, Civic Campus
Ottawa, ON
Medical Research: What is the background for this study?
Dr. McIsaac: Older age is a well-known risk factor for adverse outcomes after surgery, however, many older patients have positive surgical outcomes. Frailty is a syndrome that encompasses the negative health attributes and comorbidities that accumulate across the lifespan, and is a strong discriminating factor between high- and low-risk older surgical patients. By definition, frail patients are “sicker” than non-frail patients, so their higher rates of morbidity and mortality after surgery aren’t surprising. However, frailty increases in prevalence with increasing age, so as our population ages we expect to see more frail people presenting for surgery. Our goal was to evaluate the impact of frailty on postoperative mortality at a population-level, and over the first year after surgery to provide insights that aren’t available in the current literature, which largely consists of single center studies limited to in-hospital and 30-day outcome windows.
Dr. Jenny Löfgren[/caption]
MedicalResearch.com Interview with:
Dr. Jenny Löfgren
Surgery and Perioperative Sciences
Faculty of Medicine,
University Hospital of Umeå
Umeå Sweden
Medical Research: What is the background for this study? What are the main findings?
Response: There are an estimated 220 million groin hernia patients in the World. 20 million are operated on annually making it one of the worlds most commonly performed surgeries. The surgical repair rate in low income settings is very low. Also, the quality of the surgery is lower than in high income settings. The superior technique that uses a synthetic mesh to reinforce the abdominal wall at the site of the hernia is not affordable due to the high cost of that mesh. Mosquito mesh, which is very similar to the expensive mesh, is already used in several settings but its safety and effectiveness had not previously been investigated in a randomized trial of sufficient size with follow up for as long as one year.
Medical Research: What are the main findings?
Response: The most important finding of the study is that it was not able to detect any differences in terms of safety, effectiveness and patient satisfaction when outcomes in the group receiving the low-cost (mosquito) mesh with the group receiving a commonly used commercial mesh. The study also shows that high quality surgery, on par with standards in high income settings, can be provided for an underserved population in rural Uganda, at an affordable cost. Finally, the study shows that it is possible to conduct high quality surgical (clinical) research with high follow up rates also in settings such as rural Uganda. This should encourage us and others to conduct other trials in the future.
Dr. Aaron Dawes[/caption]
MedicalResearch.com Interview with:
Aaron J. Dawes, MD
Fellow, VA/RWJF Clinical Scholars Program
Division of Health Services Research
University of California Los Angeles
Los Angeles, CA 90024
Medical Research: What is the background for this study? What are the main findings?
Dr. Dawes: We reviewed the published literature to answer three basic questions about bariatric surgery and mental health conditions.
First, how common are mental health conditions among patients being referred for or undergoing bariatric surgery?
Dr. Sam Most[/caption]
MedicalResearch.com Interview with:
Sam P. Most, M.D., F.A.C.S.
Professor, Departments of Otolaryngology-Head & Neck Surgery and Surgery (Division of Plastic Surgery, by courtesy)
Chief, Division of Facial Plastic & Reconstructive Surgery
Stanford University School of Medicine
Stanford, CA
Medical Research: What is the background for this study? What are the main findings?
Dr. Most: Insurance companies often require patients to try a 6 or more week treatment with nasal steroids prior to allowing nasal surgery to proceed. This is true even in cases of physician-documented severe or extreme anatomic nasal obstruction that we know will not respond to medical therapy. We sought to examine this from a cost and quality-of-life perspective.
We found that while the up-front cost of surgery is obviously much higher than medical therapy, when viewed from an effect on improvement of quality of life (or lack thereof, in the case of medical therapy), the surgical therapy became more cost effective as years passed by.
Dr. Jason Lee[/caption]
MedicalResearch.com Interview with:
Jason B. Lee MD
Professor , Clinical Vice Chair
Department of Dermatology and Cutaneous Biology
Director, Jefferson Dermatopathology Center
Thomas Jefferson University
Philadelphia, Pennsylvania
Medical Research: What is the background for this study? What are the main findings?
Dr. Lee: When initially described, Clark et al. suggested that dysplastic nevi were intermediate lesions that lie biologically on a spectrum between benign and malignant. As such, they were to be histologically graded as mild, moderate, and severe (or a combination thereof), with mild presumably closer to benign and severe closer to malignant. In this paradigm, adopted by most dermatologists, these nevi are routinely excised based on histologic grading and margin status. Recent outcomes of follow-up and excision studies of dysplastic nevi suggest that they are over treated as there have been very low rates of melanoma on re-excision.
An alternative approach considers dysplastic or eponymously Clark nevi as common acquired nevi, typically in fair skin individuals, and rejects the entire notion that they are intermediate lesions as there exists no formal proof of their intermediate status. This approach omits grading and margin status entirely, providing the clinician an explicit recommendation for excision only for those cases of diagnostic uncertainty. In this study, excision recommendation rate of dysplastic/Clark nevi was determined along with analysis of excision outcomes in a laboratory where non-grading histologic diagnostic approach to these nevi has been adopted.
The excision recommendation rate, representing the diagnostic uncertainty rate, was 11.1%. Out of 80% of the cases returned for excision, only 2.0% of the cases were interpreted as melanoma on excision; all were in situ or thin melanomas. This excision rate is much lower than in prior reports, which vary from 22-52%, while still capturing melanomas within this subset of lesions.
Dr. Mary Hawn[/caption]
MedicalResearch.com Interview with:
Dr. Mary Hawn MD MPH
Chair, Department of Surgery
Stanford School of Medicine
Stanford, California
Medical Research: What is the background for this study? What are the main findings?
Dr. Hawn: Patients with known coronary artery disease are at higher risk for adverse cardiac events in the peri-operative period. Revascularization with coronary stents does not appear to mitigate this risk and in fact, may elevate the risk if surgery is in the early post-stent period. Drug eluting stents pose a particular dilemma as these patients require 12 months of dual anti platelet therapy to prevent stent thrombosis, thus elective surgery is recommended to be delayed during this period. In contrast, bare metal stents with early epithilialization are not at the same risk for stent thrombosis with anti platelet cessation. In our retrospective cohort study, however, we observed that stent type was not a major driver of adverse events in the early post-stent period and that underlying cardiac disease and acuity of the surgery explained most of the risk. We undertook this study to determine the influence of the underlying indication for the stent procedure on surgical outcomes over time following the stent.
Dr. Trinh[/caption]
MedicalResearch.com Interview with:
Quoc-Dien Trinh MD
Assistant Professor, Harvard Medical School
Brigham and Williams Hospital
Medical Research: What is the background for this study? What are the main findings?
Dr. Trinh: Among elderly Medicare beneficiaries with metastatic prostate cancer, surgical castration is associated with lower risks of any fractures, peripheral arterial disease, and cardiac-related complications compared to medical castration using GnRH agonists.
Dr. Leigh Peterson[/caption]
MedicalResearch.com Interview with:
Leigh A. Peterson, PhD, MHS
Post-doctoral fellow
Department of Surgery - Bayview
Johns Hopkins School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Dr. Peterson: From our previous study published in Obesity Surgery earlier this year, we knew that vitamin D deficiency and insufficiency was very common in our bariatric surgery candidates (71.4% < 20 ng/ml and 92.9% < 30 ng/ml). We wanted to explore the effect of this deficiency on adverse outcomes after bariatric surgery such as wound healing, infection, and extended hospital stay.
We turned to the Nationwide Inpatient Sample to answer this question, as it would contain enough surgeries to detect changes in even less frequent outcomes such as wound infection. But blood concentration of vitamin D is not available, so we used a traditional method to estimate group vitamin D status with season and geography. 
Dr. Vitiello[/caption]
MedicalResearch.com Interview with:
Gerardo Vitiello, MD
Emory University School of Medicine
Emory Transplant Center
NYU Langone Medical Center
Department of Surgery
Medical Research: What is the background for this study? What are the main findings?
Dr. Vitiello: Screening for prostate cancer with prostate specific antigen (PSA) levels is highly controversial, as it is a non-specific marker for prostate cancer. A PSA level may be elevated in a variety of disease processes (not only prostate cancer), and even in the general population, the benefit of early intervention for prostate cancer is unclear. In contrast, end stage renal disease (ESRD), where patients no longer have renal function and require dialysis, is a major health problem with a huge impact on a patient’s quality of life. The only cure for ESRD is kidney transplantation, which has been shown to have an enormous health and quality of life benefit for transplant recipients. Transplant centers have rigorously screened candidates for potential malignancy prior to transplantation to ensure that there are no contraindications to receiving a transplant. For the first time, we demonstrate that screening for prostate cancer in kidney transplant candidates is not beneficial, and may actually be harmful, since it delays time to transplant and reduces a patient’s chance of receiving a transplant without an apparent benefit on patient survival.
Dr. Najib Rahman[/caption]
MedicalResearch.com Interview with:
Dr Najib Rahman D Phil MSc MRCP
Consultant and Senior Lecturer
Lead for Pleural Diseases
Oxford Centre for Respiratory Medicine
Clinical Director, Oxford Respiratory Trials Unit
Tutor in Clinical Medicine
University College, Oxford
Medical Research: What is the background for this study?
Dr. Rahman : Up to TIME1, the evidence base behind optimal pleurodesis for malignant pleural effusion in terms of tube size and analgesia was poor. Optimal pleurodesis in this context is one which is successful (i.e. the patient needs no further pleural interventions for that malignant effusion), but occurs with the minimum discomfort. This is particularly important as the treatment intent in malignant effusion pleurodesis is palliative.
This is the first adequately powered randomized trial to address two important issues in pleurodesis for malignant pleural effusion - that of whether NSAIDs reduce pleurodesis efficacy, and if smaller chest tubes (12F) are "as good as" larger chest tubes (24F) for pleurodesis success and in terms of pain.
Medical Research: What are the main findings?
Dr. Rahman : The main and somewhat surprising findings are that:
Dr. Jochen Reinöhl[/caption]
MedicalResearch.com Interview with:
Dr. Jochen Reinöhl
Consultant and Head of the ISAH team (intervention for structural and congenital cardiovascular diseases)
Department of Cardiology and Angiology I (Medical Director: Prof. Dr. Christoph Bode)
University Heart Center Freiburg ∙ Bad Krozingen
Medical Research: What is the background for this study? What are the main findings?
Dr. Reinöhl: Aortic valve stenosis is a medical condition with very high short-term mortality. Previously its only treatment – therefore the gold standard – consisted of surgical valve replacement. Since 2007 transcatheter aortic-valve replacement (TAVR) can be considered alternative. Its impact on clinical practice, however, is largely unknown.
TAVR numbers rose from 144 in 2007 to 9,147 in 2013, whereas surgical aortic-valve replacement procedures only marginally decreased from 8,622 to 7,048. For both groups in-hospital mortality, as well as, the incidence of stroke, bleeding and pacemaker implantation (but not acute kidney injury) decreased.
Dr. Minneci[/caption]
MedicalResearch.com Interview with:
Dr. Peter C. Minneci, M.D., MHSc
Center for Innovation in Pediatric Practice
Assistant Professor, Pediatric Surgery
The Ohio State's Wexner Medical Center
Medical Research: What is the background for this study? What are the main findings?
Dr. Minneci: Non-operative management of uncomplicated appendicitis has been shown to safe and effective studied in several international adult trials. To be a reasonable treatment alternative to urgent appendectomy, non-operative management of appendicitis in children must have a clinically acceptable success rate with minimal harm in patients that fail and subsequently undergo appendectomy. We performed a prospective single-institution patient choice trial allowing the families of children with acute uncomplicated appendicitis to choose between urgent appendectomy or non-operative management with antibiotics alone. We enrolled 102 patients, with 65 choosing surgery and 37 choosing non-operative management with antibiotics alone. Non-operative management had an in-hospital success rate of 94%, a 30-day success rate of 89%, and a 1-year success rate of 76%. Compared to the surgery group, patients managed non-operatively reported higher quality of life scores at 30 days and had significantly fewer disability days and lower costs, with no differences in the rates of complicated appendicitis or treatment-related complications at 1 year of follow-up. With this being said, there are some cases that I have read about where doctors have failed to diagnose patients for Appendicitis even after they have complained about having a number of the symptoms associated with it. Following this, some patients have even contacted companies like 
Dr. Chagpar[/caption]
MedicalResearch.com Interview with:
Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS
Associate Professor, Department of Surgery
Director, The Breast Center
Smilow Cancer Hospital at Yale-New Haven
Assistant Director -- Global Oncology
Yale Comprehensive Cancer Center
Yale University School of Medicine
Medical Research: What is the background for this study?
Dr. Chagpar: Up to 40% of women undergoing breast conserving surgery for breast cancer will have to return to the operating room due to positive margins (or cancer cells being found at the edge of what was removed at the initial surgery). We recently reported the results of a randomized controlled trial, published in the 
Dr. Grovaert[/caption]
MedicalResearch.com Interview with:
Johannes Govaert MD
Department of Surgery
Leiden University Medical Center
Leiden, The Netherlands
Medical Research: What is the background for this study?
Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined.
Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing.
Medical Research: What are the main findings?
Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction.
Dr. Soroush Zaghi[/caption]
MedicalResearch.com Interview with:
Soroush Zaghi, MD
Department of Head and Neck Surgery
David Geffen School of Medicine at UCLA
University of California, Los Angeles
MedicalResearch: What is the central message for clinicians and surgeons from your results?
Dr. Zaghi: Multiple studies from different practitioners and institutions agree that Maxillomandibular Advancement (MMA) is a highly effective surgical option for patients with obstructive sleep apnea who cannot tolerate positive pressure therapy and have not found success with other surgical procedures.
Dr. Yao[/caption]
MedicalResearch.com Interview with:
Katharine Yao, MD
Director, Breast Surgical Program
NorthShore University HealthSystem
Illinois
Medical Research: What is the background for this study? What are the main findings?
Dr. Yao: A survey of breast surgeons was conducted to determine their knowledge level with contralateral breast cancer and how contralateral prophylactic mastectomy (CPM) affects survival. Of five knowledge questions, only 60% scored with high knowledge (4 or 5 questions correct) scores. Surgeons mostly scored low on contralateral cancer risks. Most surgeons correctly stated that 
Dr. Chunsheng Wang[/caption]
MedicalResearch.com Interview with:
Chunsheng Wang, MD
Department of Cardiovascular Surgery, Shanghai Cardiovascular Institution
and Zhongshan Hospital
Fudan University, Shanghai, China
Medical Research: What is the background for this study? What are the main findings?
Dr. Wang: Transcatheter aortic valve replacement (TAVR) has been widely used in high-risk patients for surgical aortic valve replacement. However, the majority of the TAVR devices were designed for aortic valve stenosis with significant valve calcification. For most of these devices, predominant aortic regurgitation remained to be a technological challenge because of questionable anchoring, which can result in a high incidence of valve migration and paravalvular leak. Consequently, the guidelines from the United States and the Europe suggest that candidates with predominant aortic regurgitation (>grade 3+) or noncalcified valve should not undergo 
Dr. Jason Gold[/caption]
MedicalResearch.com Interview with:
Jason S. Gold MD FACS
Chief of Surgical Oncology, VA Boston Healthcare System
Assistant Professor of Surgery, Harvard Medical School
Brigham and Women’s Hospital
Medical Research: What is the background for this study?
Dr. Gold: Pancreas cancer is a lethal disease. While advances in the best available care for pancreas cancer are desperately needed, improvements can be made in addressing disparities in care. This study aimed to evaluate associations of social and demographic variables with the utilization of surgical resection as well as with survival after surgical resection for early-stage pancreas cancer.
Medical Research: What are the main findings?
Dr. Gold: The main findings are the following:
1: We found that less than half of patients with early-stage pancreas cancer undergo resection in the United States. Interestingly, the rate of resection has not changed with time during the eight-year study period.
2. We also found significant disparities associated with the utilization of surgical resection for early-stage pancreas cancer in the United States. African American patients, Hispanic patients, single patients, and uninsured patients were significantly less likely to have their tumors removed. There were regional variations in the utilization of surgical resection as well. Patients in the Southeast were significantly less likely to have a pancreas resection for cancer compared to patients in the Northeast.
3. Among the patients who underwent surgical resection for early-stage pancreas cancer, we did not see significant independent associations with survival for most of the social and demographic variables analyzed. Surprisingly, however, patients from the Southeast had worse long-term survival after pancreas cancer resection compared to those in other regions of the United States even after adjusting for other variables.
Dr. Schlansky[/caption]
MedicalResearch.com Interview with:
Barry Schlansky, M.D., M.P.H
Assistant Professor of Medicine
Oregon Health & Science University
Medical Research: What are the main findings and significance of this study?
Dr. Schlansky: This study examines how obese patients fare before and after liver transplantation. Similar to other researchers, we found that obese patients do just as well as normal weight patients after liver transplantation. We were surprised, however, to find that very obese patients died more often while on the wait list before liver transplant.
Patrick Hardison before surgery (left) and in November 2015, nearly three months after the surgery.[/caption]
Mr. Hardison was referred to 
MedicalResearch.com Interview with:
Dr. Giuseppe Andò
University of Messina, Messina, Italy
Medical Research: What is the background for this study?
Dr. Andò: Patients’ preference for radial access for coronary angiography and percutaneous intervention is paralleled by an almost complete abolition of access-site bleeding. Given the deleterious impact of any clinically relevant bleeding event on short- and long-term outcomes, the use of radial access should translate into a reduction in net adverse events, especially in patients with high risk of bleeding such as those with an acute coronary syndrome. Nonetheless, studies conducted over the past decade by pioneers of