Isabel Boero

Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and... more Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011–2016). Multilevel, multivariable Fine‐Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1‐year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th–75th percentiles, 13.3%–47.0%]). The odds of receiving AVR varied >2‐fold depending on the cardiol...

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Additional file 1 of Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

Additional file 1. Figure S1. Initial attrition diagram leading into cohort selection for current... more Additional file 1. Figure S1. Initial attrition diagram leading into cohort selection for current study. Method S1. Brief description of the machine learning approach to identify patients discharged to the ICU for patients with an undocumented post-surgery care location. Table S1. Comorbidities and additional cohort patient characteristics. Table S2. International Classification of Diseases (ICD) codes. Table S3. List of antihypertensive drug classes. Table S4. Multivariate model results. Table S5. P-values of hazard ratios for primary and secondary outcomes. Table S6. E-values to assess the magnitude of an unobserved or unaccounted confounding effect for postoperative hypotension in intensive care unit setting. Table S7. Hazard/Incidence rate ratios and p-values for length-of-stay and use of intensive care unit-specific endpoints for intensive care unit patients with postoperative hypotension (exploratory outcomes).

Virus Scaffolding of ESCRT Subunits Distribution of ESCRT Machinery at HIV Assembly Sites Reveals

, 653 (2014); 343 Science et al. Schuyler B. Van Engelenburg Virus Scaffolding of ESCRT Subunits ... more

Blocks Antigen-Antibody Union A Structurally Distinct Human Mycoplasma Protein that Generically

, 656 (2014); 343 Science et al. Rajesh K. Grover Blocks Antigen-Antibody Union A Structurally Di... more

390: Postoperative Hypotension in the Critically Ill is Associated with Adverse Clinical Outcomes

Critical Care Medicine, 2020

Introduction/Hypothesis: Postoperative hypotension (POH) in non-cardiac surgery patients admitted... more Introduction/Hypothesis: Postoperative hypotension (POH) in non-cardiac surgery patients admitted to the intensive care unit (ICU) is associated with significant harm. This study examined the association between POH at varying hemodynamic thresholds in non-cardiac surgery patients admitted to the ICU and adverse clinical outcomes. Methods: Multi-institutional United States electronic health record data was used to identify postoperative non-cardiac surgery patients admitted to the ICU from 2008-2017 with no history of intraoperative hypotension ≤65mmHg and with frequent, successive postoperative mean arterial pressure (MAP) readings. POH was defined based on any absolute MAP (≤55mmHg, ≤65mmHg, ≤75mmHg). The primary outcome was 30-day major adverse cardiovascular and cerebrovascular events, based on a composite of 30-day all-cause mortality, acute myocardial infarction, and acute ischemic stroke. The following secondary outcomes were assessed: 30-day and 90-day all-cause mortality, 3...

Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery

Anesthesia & Analgesia

BACKGROUND: Postoperative hypotension (POH) is associated with major adverse events. However, lit... more BACKGROUND: Postoperative hypotension (POH) is associated with major adverse events. However, little is known about the association of blood pressure thresholds and outcomes in postoperative patients without intraoperative hypotension (IOH) on the general-care ward. We evaluated the association of POH with major adverse cardiac or cerebrovascular events (MACCE) in patients without IOH. METHODS: This retrospective analysis included 67,968 noncardiac patient-procedures (2008–2017) for patients discharged to the ward with postoperative mean arterial pressure (MAP) readings, managed for ≥48 hours postsurgery, with no evidence of IOH. The primary outcome was 30-day MACCE evaluated by postoperative MAP thresholds: ≤75, ≤65, and ≤55 mm Hg (POH defined as a single measurement below threshold). Secondary outcomes included all-cause mortality (30-/90-day), 30-day acute myocardial infarction, 30-day acute ischemic stroke, 30-day readmission, 7-day acute kidney injury, and 30-day readmission. Associations between POH and adverse events were also evaluated in a cohort (#2) of 16,034 patient-procedures with IOH (intraoperative MAP ≤65 mm Hg). RESULTS: In patients without IOH, exposure to POH was not associated with MACCE at any investigated MAP threshold (P < .016 was considered significant: ≤75 mm Hg, hazard ratio [HR] 1.18 [98.4% confidence interval {CI} 0.99-1.39], P = .023; ≤65 mm Hg, HR 1.18 [0.99–1.41], P = .028; ≤55 mm Hg, HR 1.23 [0.90–1.71], P = .121); however, associations were observed at all MAP thresholds for secondary outcomes of acute kidney injury and 30-day readmission, for 30-/90-day mortality for MAP ≤65 mm Hg, and 90-day mortality for MAP ≤55 mm Hg, compared to those without POH. No associations were detected between POH and secondary outcomes of acute ischemic stroke or acute myocardial infarction at any MAP threshold. No interaction between POH and IOH was found when we evaluated the association of POH on outcomes in the data set including all patients, regardless of IOH status (P values for interaction terms nonsignificant). When the interaction term was utilized, the association between POH without IOH and MACCE was significant for MAP ≤75 mm Hg (HR 1.20 [1.01–1.41]) and MAP ≤65 mm Hg (HR 1.21 [1.02-1.45]), but not MAP ≤55 mm Hg. Cohort #2 (POH with IOH) showed largely similar results for MACCE: not significant for MAP ≤75 and ≤65 mm Hg, but significant for MAP ≤55 mm Hg (HR 1.53 [1.05–2.22], P = .006). CONCLUSIONS: POH in patients without IOH was not associated with MACCE at any MAP investigated. No interaction was identified between POH and IOH. Large prospective randomized trials are necessary to develop better evidence and inform clinicians the value of postoperative blood pressure management.

Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery

Anesthesia & Analgesia

Is there an association between intraoperative hypotension and postoperative major adverse cardia... more Is there an association between intraoperative hypotension and postoperative major adverse cardiac or cerebrovascular events (MACCE)? • Findings: This multicenter retrospective analysis of 368,222 surgical procedures demonstrated that regardless of how hypotension exposure was defined (ie, mean arterial pressure [MAP] ≤75, ≤65, ≤55 mm Hg), intraoperative hypotension is significantly associated with MACCE in a "dose-dependent" manner. • Meaning: Intraoperative hypotension is a potentially avoidable hazard that appears to be associated with clinically significant morbidity regardless of age group; it remains to be demonstrated whether avoidance of hypotension reduces the incidence of MACCE, and if so, whether the way normotension is maintained matters. BACKGROUND: Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups. METHODS: A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) timeweighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30-and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18-40, 41-50, 51-60, 61-70, 71-80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups. RESULTS: IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg. CONCLUSIONS: IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

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Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation

Structural Heart

Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

Critical Care

BackgroundThe postoperative period is critical for a patient’s recovery, and postoperative hypote... more BackgroundThe postoperative period is critical for a patient’s recovery, and postoperative hypotension, specifically, is associated with adverse clinical outcomes and significant harm to the patient. However, little is known about the association between postoperative hypotension in patients in the intensive care unit (ICU) after non-cardiac surgery, and morbidity and mortality, specifically among patients who did not experience intraoperative hypotension. The goal of this study was to assess the impact of postoperative hypotension at various absolute hemodynamic thresholds (≤ 75, ≤ 65 and ≤ 55 mmHg), in the absence of intraoperative hypotension (≤ 65 mmHg), on outcomes among patients in the ICU following non-cardiac surgery.MethodsThis multi-center retrospective cohort study included specific patient procedures from Optum® healthcare database for patients without intraoperative hypotension (MAP ≤ 65 mmHg) discharged to the ICU for ≥ 48 h after non-cardiac surgery with valid mean ar...

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Racial Differences in the Use of Aortic Valve Replacement for Treatment of Symptomatic Severe Aortic Valve Stenosis in the Transcatheter Aortic Valve Replacement Era

Journal of the American Heart Association

Background Aortic valve replacement (AVR) is a life‐saving treatment for patients with symptomati... more Background Aortic valve replacement (AVR) is a life‐saving treatment for patients with symptomatic severe aortic valve stenosis. We sought to determine whether transcatheter AVR has resulted in a more equitable treatment rate by race in the United States. Methods and Results A total of 32 853 patients with symptomatic severe aortic valve stenosis were retrospectively identified via Optum’s deidentified electronic health records database (2007–2017). AVR rates in non‐Hispanic Black and White patients were assessed in the year after diagnosis. Multivariate Fine‐Gray hazards models were used to evaluate the likelihood of AVR by race, with adjustment for patient factors and the managing cardiologist. Time‐trend and 1‐year symptomatic severe aortic valve stenosis survival analyses were also performed. From 2011 to 2016, the rate of AVR increased from 20.1% to 37.1%. Overall, Black individuals were less likely than Whites to receive AVR (22.9% versus 31.0%; unadjusted hazard ratio [HR], 0...

Sex disparities in patients with symptomatic severe aortic stenosis

American Heart Journal

BACKGROUND We evaluated whether there is equitable distribution across sexes of treatment and out... more BACKGROUND We evaluated whether there is equitable distribution across sexes of treatment and outcomes for aortic valve replacement (AVR), via surgical (SAVR) or transcatheter (TAVR) methods, in symptomatic severe aortic stenosis (ssAS) patients. METHODS Using de-identified data, we identified 43,822 patients with ssAS (2008-2016). Multivariate competing risk models were used to determine the likelihood of any AVR, while accounting for the competing risk of death. Association between sex and one-year mortality, stratified by AVR status, was evaluated using multivariate Cox regression models with AVR as a time-dependent variable. RESULTS Among patients with ssAS, 20,986 (47.9%) were female. Females were older (median age 81 vs. 78, p<0.001), more likely to have body mass index <20 (8.5% vs. 3.5%), and home oxygen use (4.4% vs. 3.4%, p<0001 for all). Overall, 12,129 (27.7%) patients underwent AVR for ssAS. Females were less likely to undergo AVR compared with males (24.1% vs. 31.0%, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.77-0.83), but when treated, were more likely to undergo TAVR (37.9% vs. 30.9%, adjusted HR 1.21, 95% CI 1.15-1.27). Untreated females and males had similarly high rates of mortality at one year (31.1% vs. 31.3%, adjusted HR 0.98, 95% CI 0.94-1.03). Among those undergoing AVR, females had significantly higher mortality (10.2% vs. 9.4%, adjusted HR 1.24, 95% CI 1.10-1.41), driven by increased SAVR-associated mortality (9.0% vs. 7.6%, adjusted HR 1.43, 95% CI 1.21-1.69). CONCLUSIONS Treatment rates for ssAS patients remain suboptimal with disparities in female treatment.

The impact of individual surgeons on the likelihood of mastectomy in breast cancer

Journal of Clinical Oncology

Integration of multiple technical aspects like treatment prescription, planning, delivery and qua... more Integration of multiple technical aspects like treatment prescription, planning, delivery and quality assurance is paramount for smooth and efficient functioning of any radiotherapy department. In the developing world, bearing 60% of global cancer burden, efficient management of available resources assumes even greater importance. Workflow management software is a tool available for effective resource management in radiotherapy. The purpose of this audit is to evaluate the impact of implementation of workflow management on the organisational ergonomics of our department.

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TCT-134 Current Management and Disparities in Care for Patients With Symptomatic Severe Aortic Regurgitation

Journal of the American College of Cardiology

Symptomatic severe aortic regurgitation (ssAR) is a Class I recommendation for surgical aortic va... more

Race and Sex-Based Disparities Persist in the Treatment of Patients with Severe, Symptomatic Aortic Valve Stenosis

Journal of the American College of Cardiology

Transcatheter aortic valve replacement (TAVR) has revolutionized the care of patients with severe... more

Provider-Level Variability in the Treatment of Patients with Severe Symptomatic Aortic Valve Stenosis

Journal of the American College of Cardiology

Patients with severe symptomatic aortic stenosis (ssAS) have high mortality and compromised quali... more

The Impact of Surgeons on the Likelihood of Mastectomy in Breast Cancer

Annals of surgery, Jan 20, 2018

This study evaluates the impact of individual surgeons and institutions on the use of mastectomy ... more This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer. Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process. A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution. Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quinti...

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Impact of Radiation Oncologist Provider Volume on Clinical Outcomes in Head and Neck Cancer

International Journal of Radiation Oncology*Biology*Physics

$Research paper thumbnail of Outcomes of Hypofractionated Versus Standard Fractionated Breast Cancer Radiation in the Real World: A Population-Based Analysis$

Outcomes of Hypofractionated Versus Standard Fractionated Breast Cancer Radiation in the Real World: A Population-Based Analysis

International Journal of Radiation Oncology*Biology*Physics

The Impact of Radiation Cost on Patient Outcomes After Definitive Radiation Therapy in Prostate Cancer

International Journal of Radiation Oncology*Biology*Physics

vs 4.2%, P Z 0.01). Of patients receiving ADT, 14.3% were regretful. Patients were regretful of s... more vs 4.2%, P Z 0.01). Of patients receiving ADT, 14.3% were regretful. Patients were regretful of surgery due to toxicity, not being adequately informed about radiotherapy as an alternative, positive margins, and cost of surgery (83%, 33%, 25%, and 8% of regretful patients, respectively). Toxicity was the main cause for regret in the 3 radiotherapy-regretful and 4 ADT-regretful patients. Patients were more regretful overall, and of surgery, for salvage vs adjuvant approaches (both 19.6% vs 10%). Conclusion: Patients are rarely regretful of post-prostatectomy IG-IMRT, but are significantly more regretful of their initial surgery due to surgical toxicity, not being informed adequately pre-operatively about radiotherapy as an alternative to surgery, positive margins, and cost of surgery. Patients are less regretful of surgery when radiotherapy is delivered in an immediate adjuvant approach. These findings have significant implications for urologists and radiation oncologists alike, particularly in relation to patient selection for radical prostatectomy (and likelihood of obtaining clear margins), the ability of urologists to adequately discuss radiotherapy as an alternative to radical prostatectomy, and the usage of immediate adjuvant (vs. early salvage) radiotherapy.

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$Research paper thumbnail of The Impact of Radiation Oncology Provider on the Likelihood of Receiving Hypofractionated Whole-Breast Radiation Therapy for Early-Stage Breast Cancer$

The Impact of Radiation Oncology Provider on the Likelihood of Receiving Hypofractionated Whole-Breast Radiation Therapy for Early-Stage Breast Cancer

International Journal of Radiation Oncology*Biology*Physics

enter management decisions into an online, menu-driven support tool that integrates with electron... more enter management decisions into an online, menu-driven support tool that integrates with electronic medical records. Data were collected from the support tool including the rate of on-and off-pathway treatment selections, peer-review decisions performed by disease site directors, time to complete peer review, and associated factors. Results: A total of 6,965 treatment decisions were entered in 2015, of which 605 (8.7%) were made off-pathway and thus subject to peer review. Six hundred of these selections (99.2%) were approved for treatment. The most common reason for off-pathway selections was poor performance status (53.2%) followed by financial burden (1.0%), good performance status (17.1%), patient refusal (13.8%), and physician does not agree with CP (14.9%). The median time to peer review decision was 2 days (range, 0-83). Factors associated with time to peer review decision >48 hours on univariate analysis include disease site (P < 0.0001) with a trend toward significance (P Z 0.066) for radiation treatment modality (i.e. external beam, IMRT, brachytherapy, or no radiation). There was no significant difference between recurrent and non-recurrent disease (P Z 0.267). Multivariable analysis revealed disease site was associated with time to peer review (P < 0.001), with lymphoma, lung, and skin/sarcoma most strongly influencing decision time >48 hours. Conclusion: CP are an integral tool for standardizing evidence-based care throughout our large integrated cancer network with 91.3% of all treatment decisions being made as per pathway. The most common reason for offpathway selection was poor performance status limiting definitive treatment. Peer review process was feasible with < 1% selections ultimately rejected suggesting that awareness of peer review of treatment decisions encourages compliance with CP recommendations among physicians.

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Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis

Journal of the American Heart Association

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Additional file 1 of Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

Virus Scaffolding of ESCRT Subunits Distribution of ESCRT Machinery at HIV Assembly Sites Reveals

, 653 (2014); 343 Science et al. Schuyler B. Van Engelenburg Virus Scaffolding of ESCRT Subunits ... more

Blocks Antigen-Antibody Union A Structurally Distinct Human Mycoplasma Protein that Generically

, 656 (2014); 343 Science et al. Rajesh K. Grover Blocks Antigen-Antibody Union A Structurally Di... more

390: Postoperative Hypotension in the Critically Ill is Associated with Adverse Clinical Outcomes

Critical Care Medicine, 2020

Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery

Anesthesia & Analgesia

Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery

Anesthesia & Analgesia

Download

Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation

Structural Heart

Postoperative hypotension in patients discharged to the intensive care unit after non-cardiac surgery is associated with adverse clinical outcomes

Critical Care

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Racial Differences in the Use of Aortic Valve Replacement for Treatment of Symptomatic Severe Aortic Valve Stenosis in the Transcatheter Aortic Valve Replacement Era

Journal of the American Heart Association

Sex disparities in patients with symptomatic severe aortic stenosis

American Heart Journal

The impact of individual surgeons on the likelihood of mastectomy in breast cancer

Journal of Clinical Oncology

Download

TCT-134 Current Management and Disparities in Care for Patients With Symptomatic Severe Aortic Regurgitation

Journal of the American College of Cardiology

Symptomatic severe aortic regurgitation (ssAR) is a Class I recommendation for surgical aortic va... more

Race and Sex-Based Disparities Persist in the Treatment of Patients with Severe, Symptomatic Aortic Valve Stenosis

Journal of the American College of Cardiology

Transcatheter aortic valve replacement (TAVR) has revolutionized the care of patients with severe... more

Provider-Level Variability in the Treatment of Patients with Severe Symptomatic Aortic Valve Stenosis

Journal of the American College of Cardiology

Patients with severe symptomatic aortic stenosis (ssAS) have high mortality and compromised quali... more

The Impact of Surgeons on the Likelihood of Mastectomy in Breast Cancer

Annals of surgery, Jan 20, 2018

Download

Impact of Radiation Oncologist Provider Volume on Clinical Outcomes in Head and Neck Cancer

International Journal of Radiation Oncology*Biology*Physics

$Research paper thumbnail of Outcomes of Hypofractionated Versus Standard Fractionated Breast Cancer Radiation in the Real World: A Population-Based Analysis$

Outcomes of Hypofractionated Versus Standard Fractionated Breast Cancer Radiation in the Real World: A Population-Based Analysis

International Journal of Radiation Oncology*Biology*Physics

The Impact of Radiation Cost on Patient Outcomes After Definitive Radiation Therapy in Prostate Cancer

International Journal of Radiation Oncology*Biology*Physics

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$Research paper thumbnail of The Impact of Radiation Oncology Provider on the Likelihood of Receiving Hypofractionated Whole-Breast Radiation Therapy for Early-Stage Breast Cancer$

The Impact of Radiation Oncology Provider on the Likelihood of Receiving Hypofractionated Whole-Breast Radiation Therapy for Early-Stage Breast Cancer

International Journal of Radiation Oncology*Biology*Physics

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Isabel Boero

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