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Mon, Aug 21 9:14am · Shared decision making should encourage conversations, researchers contend

Shared decision making involves educating patients so they can work with clinicians to make decisions about their care. Mayo Clinic researchers advocate for tools that promote a conversation during the visit (called conversation aids), and not simply provide information to the patients beforehand for them to make a decision themselves (referred to as patient decision aids).

To improve quality and reduce health care spending at a population level, state and federal agencies have begun requiring shared decision making tools for certain procedures and tests. With legal and financial incentives, the Centers for Medicare and Medicaid Services and others aim to move the industry toward value-based care.

But do shared decision making tools, which involve educating patients so they can work with clinicians to make decisions about their care, improve care? Mayo Clinic is helping answer that question.

Researchers in the Mayo Clinic Knowledge and Evaluation Research Unit published an editorial in JAMA on Aug. 15 on shared decision making. The researchers advocate for tools that promote a conversation during the visit (called conversation aids), and not simply provide information to the patients beforehand for them to make a decision themselves (referred to as patient decision aids). The researchers contend that patient decision aids can burden patients with having to decline their clinicians’ recommendations, but conversation aids directly encourage patient-clinician dialogue and a joint decision.

“While some organizations simply distribute decision aids to patients and consider the job done, we believe that patients are best served by an unhurried consultation,” says senior author Juan Brito Campana, M.B.B.S., medical director of the Mayo Clinic Shared Decision Making National Resource Center.

The Mayo researchers cite research, also published Aug. 15 in JAMA, which looked at 105 clinical trials involving more than 31,000 patients. That research found that shared decision making tools are associated with improved patient knowledge of options and outcomes, and do not consistently reduce the use of invasive or expensive treatments. More importantly, they couldn’t find strong evidence that these tools promote conversations between patients and clinicians. In fact, only five of the clinical trials – all conducted by the Mayo Clinic Shared Decision Making National Resource Center – sought to promote these conversations and observed what happened during these visits.

“Future research must discover new ways to promote meaningful conversations between patients and clinicians,” says co-author Marleen Kunneman, Ph.D., of the Knowledge and Evaluation Research Unit.

The Mayo Clinic researchers argue that conversation aids could achieve the stated goal – patients and clinicians working together to decide which option best fits the patient – while imposing the smallest footprint as possible on patients’ lives.

“Clinicians want to truly appreciate what is going on with their patients and how best to move forward,” Dr. Brito Campana says. “Shared decision making is one way to achieve this goal.”

The Mayo Clinic Shared Decision Making National Resource Center advises clinicians and researchers in the design, evaluation and implementation of shared decision making tools, helping Mayo lead in this field. The center has developed conversation aids for chest pain, diabetes medication, and osteoporosis, among many others.

Dr. Brito Campana is a Kern Health Care Delivery Scholars Program alumnus within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

Thu, Aug 3 7:56am · Mayo researchers seek to manage pain while minimizing opioid prescriptions

Mayo Clinic researchers are studying data on opioid prescriptions after surgery. The goal is the best possible outcome for patients with minimal exposure to opioids.

In the last 15 years, the number of Americans receiving an opioid prescription and the number of deaths involving overdoses have roughly quadrupled, according to the Centers for Disease Control and Prevention. More than 90 people per day died in 2015 from an overdose of a prescription opioid or heroin – an illegal opioid made from morphine.

As the opioid epidemic continues, health care providers are hoping to do their part. For decades, the emphasis nationwide for treating surgical patients was to prescribe enough opioid pain medication to ensure they didn’t have any pain. But health care providers are realizing it’s a balancing act between managing pain and ensuring patients aren’t overprescribed.

To that end, Mayo Clinic researchers are studying the clinic’s opioid prescribing practices after surgery, outlining areas for improvement based on evidence, and implementing change. The team includes scientists in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, along with surgeons, pain medicine specialists, nurses and pharmacists. Their goal is to identify the right amount for each patient.

“The key factor is that we want to make a reduction in opioid prescriptions in an informed way – based on current patient needs – so that we don’t under-treat patients’ pain,” says Tad Mabry, M.D., a Mayo Clinic orthopedic surgeon. “We want to achieve the best possible patient outcomes, and patient experience, with minimal exposure to opioids.”

The research team published a study July 13 in the Annals of Surgery which highlighted prescribing practices from January 2013 to December 2015 for 25 common surgeries at Mayo Clinic campuses in Arizona, Florida and Rochester. In particular, the researchers examined patients who weren’t taking opioids in the 90 days before surgery. Within that group of 5,756 patients, they found 4 of 5 patients received more than recommended by Minnesota state guidelines now in development.

The median opioid prescription for that subgroup was equal to 50 pills of five-milligram oxycodone. That’s almost twice the amount the draft guidelines from the state of Minnesota recommend for a maximum, which is roughly a seven-day supply or about 27 pills of five-milligram oxycodone.

And, within that group, the prescriptions varied within specific surgical procedures and among the three campuses after adjusting for other factors. The Rochester campus median equaled 40 pills of oxycodone; whereas, the Arizona and Florida campuses’ median equaled 50 and 60 pills, respectively.

Based on these data, the Mayo Clinic Department of Orthopedic Surgery already has transformed its prescribing practices for patients who weren’t taking opioids in the 90 days before surgery. The department is developing four recommended levels based on surgical procedure and patient need.

“Furthermore, we have encouraged all our providers to maximize non-opioid pain strategies, such as ice, compression and over-the-counter medications,” Dr. Mabry says.

Next steps

Other departments – such as Neurosurgery, General Surgery and Obstetrics and Gynecology – are following suit with their own guidelines. And the Mayo Enterprise Opioid Stewardship Program Oversight Group is using this research to make institution-wide improvements.

While the researchers say this is just the first step, it’s advancing the practice in the right direction for the benefit of Mayo patients and the community.

“By publishing our experience we hope other institutions across the country begin a process similar to Mayo’s,” says co-author Robert Cima, M.D., a colorectal surgeon and medical director of surgical outcomes research.

It also provides a foundation for evidence-based guidelines for prescribing opioids post-surgery, something that was previously lacking.

“When I first looked at the medical literature I was surprised that, even for common surgeries, there wasn’t data to help guide surgeons on post-operative opioid prescribing practices,” says lead author Cornelius Thiels, D.O., a general surgery resident in the Mayo Clinic School of Graduate Medical Education, and alumnus of the Surgical Outcomes Research Fellowship.

The team also is hoping the study will help shape government policy and health care guidelines. The state of Minnesota is considering the study as it finalizes its guidelines, which in their current form aren’t appropriate for all cases, the researchers say.

“For some of the procedures, the guideline is probably appropriate and we have an opportunity to reduce the amount prescribed,” says senior author Elizabeth Habermann, Ph.D., scientific director of surgical outcomes research in the Kern Center for the Science of Health Care Delivery. “For some of the more painful procedures, in orthopedics, for example, the draft guideline is likely too low.”

Now, the team is surveying patients after surgery to see which types of patients are receiving excess opioids, and to determine how well they’re managing their pain.

“That’s important because pain is a very subjective experience and health care providers have to make sure they take the patients perspective into account when they alter how they treat their pain after surgery,” Dr. Thiels says.

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery funded the research. The center analyzes data with the goal of making broad-based quality and efficiency improvements in patient care at Mayo and beyond.

The other authors ─ all from Mayo Clinic ─ are:

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Wed, Aug 2 8:19am · Mayo researchers to explore safety of combining blood-thinners

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Millions of Americans are taking blood-thinning drugs for common medical conditions. Often, they receive prescriptions for more than one when they have multiple chronic diseases or conditions. As Americans age and the number of people on these drugs is expected to steadily increase over the coming decades, researchers are trying to better understand how the drugs interact with each other.

With an RO1 grant from the Agency for Healthcare Research and Quality, Mayo Clinic researchers are doing exactly that.

Researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery in Arizona will use the grant to explore bleeding risks within certain groups of patients and with specific drug combinations. The grant is for four years, beginning this month, and $1.58 million total.

Blood-thinning drugs are generally either anticoagulants, which lengthen the time it takes to form a blood clot, or antiplatelet drugs, which prevent blood cells called platelets from collecting to form clots. Anticoagulants are often used for atrial fibrillation, an irregular and often rapid heart rate, and venous thromboembolism, a blood clot in a vein – usually in the legs. Antiplatelets are used for conditions such as acute coronary syndrome, which causes decreased blood flow from the heart.

Anticoagulants include apixaban, dabigatran, edoxaban, rivaroxaban and warfarin. Examples of antiplatelets are aspirin, clopidogrel, dipyridamole, prasugrel and ticlopidine. Each of these blood-thinning drugs can cause gastrointestinal bleeding on their own, so researchers say it’s important to know more about what they do when used together.

mss_0001323549[1]“Knowing the real-world bleeding risks of these blood-thinners and which patients are most at risk will help health care providers and their patients make informed decisions,” says the grant’s principal investigator, Neena S. Abraham, M.D., a gastroenterologist and health sciences researcher at Mayo Clinic.

The researchers plan to fill this knowledge gap by showing what percentage of patients are at risk for gastrointestinal bleeding based on the presence of individual and combinations of certain factors. Those factors include age, patients with multiple conditions, liver failure and renal failure. The study will also look at the risk of bleeding when blood-thinners are used in combination for atrial fibrillation, acute coronary syndrome or venous thromboembolism.

“Using scientific data and machine learning techniques to predict risk factors and at at-risk groups is the first step in improving outcomes for patients,” Dr. Abraham says.

Dr. Abraham is site director in Arizona of the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The center analyzes data with the goal of making broad-based quality and efficiency improvements in patient care at Mayo and beyond.

The center’s research team also has published related studies on the safety and effectiveness of blood-thinning drugs, comparing newer drugs’ risk of bleeding, and health care providers’ prescribing practices, among others.

Wed, Jun 28 8:03am · Underused cancer test could improve treatment for thousands, Mayo Clinic study finds

A simple blood test could improve treatment for 1 in 6 stage 2 colon cancer patients, new Mayo Clinic research finds.

Colorectal cancer is the fourth most common cancer in the U.S. and the second deadliest. With colon cancer, some earlier stage patients fare worse than some later stage patients, who usually benefit most from chemotherapy. But a research team at Mayo Clinic has discovered that a simple blood test could help determine which patients are at a higher risk and therefore could benefit from therapy.

The researchers also found many patients who could benefit from the test likely aren’t receiving it.

The team of physicians and scientists, using data from the National Cancer Database for 40,844 patients, looked at a blood test that measures the protein called carcinoembryonic antigen, or CEA. Carcinoembryonic antigen can be found in higher levels in people with certain cancers, especially colon cancer.

The findings, published in the Journal of Gastrointestinal Surgery, showed that knowing these blood test results prior to treatment could have changed the classification from average to high risk for more than 1 in 6 stage 2 colon cancer patients. That change could have altered treatment options, including whether to use chemotherapy.

“The decision to give a patient chemotherapy after surgery is not a light one, and physicians must weigh the risks and benefits,” says senior author Kellie Mathis, M.D., a Mayo Clinic colon and rectal surgeon. “We are currently using the blood test to help make these difficult decisions, and we suggest other physicians do the same.”

The blood test has been around for decades but is not broadly used across the country. It was recorded in 54 percent of cases meeting other relevant criteria for the study. While in some cases the test may not have been entered in the database, many other patients may not be getting it.

“There is no good reason for a physician to omit this blood test, and more work needs to be done to ensure that all patients receive it,” Dr. Mathis says.

When patients get the blood test, the authors point out it is often done after surgery to monitor the cancer’s development. Greater, and earlier, consideration of protein level may be warranted, the researchers say.

The researchers also discovered that, for stage 2 patients who had surgery but not chemotherapy, the five-year survival rate was 66 percent for those with elevated protein levels and 76 percent for those without elevated levels. And for patients with elevated protein levels, those who had chemotherapy and surgery fared better than those who only had surgery.

“If a patient with a new diagnosis of stage 2 colon cancer has an elevated carcinoembryonic antigen level, physicians should consider chemotherapy in addition to surgery,” says Dr. Mathis.

There are four primary stages of colon cancer. Generally, with stage 2, the cancer hasn’t spread to nearby lymph nodes or distant organs but has grown into or through the wall of the colon.

To perform the patient-centered research, physicians in the Mayo Clinic Division of Colon and Rectal Surgery collaborated with scientists in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

The lead author is Blake Spindler, M.D., a resident in the Mayo Clinic School of Graduate Medical Education. The other authors are John Bergquist, M.D., and Cornelius Thiels, D.O., both residents in the Mayo Clinic School of Graduate Medical Education, and Elizabeth Habermann, Ph.D., Scott Kelley, M.D., and David W. Larson, M.D., all from Mayo Clinic.

The study was funded by the Mayo Clinic Department of Surgery, the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Mayo Clinic Clinician-Investigator Training Program.

Mon, Jun 19 7:56am · 1 in 6 taking blood-thinning drugs may not be getting right dose, research shows

Dr. Peter Noseworthy is a Mayo Clinic cardiologist and a senior author of the research. He is also a former Kern Health Care Delivery Scholar in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

Over the coming decades, a growing number of Americans are expected to develop atrial fibrillation, a common heart condition characterized by an irregular and often rapid heart rate. The Centers for Disease Control and Prevention estimates that between 2.7 and 6.1 million Americans are living with the condition, which is also associated with a fivefold greater risk of stroke.

But almost 1 in 6 of the millions of Americans on new blood-thinning medications for atrial fibrillation may not be receiving the recommended dose, Mayo Clinic research finds.

Roughly 10 percent of patients on these drugs have severe kidney disease, and the research, published June 5 in the Journal of the American College of Cardiology, found that more than 40 percent of them are receiving a higher dose than recommended. That could lead to serious bleeding risks.

Also, among the 90 percent of patients without severe kidney disease, 13 percent may be underdosed. The researchers found that for one medication in the group – apixaban – underdosing may be less effective at preventing strokes.

Xiaoxi Yao, Ph.D.

“Dosing errors of these blood-thinning medications in patients with atrial fibrillation are common and have concerning adverse outcomes,” says Xiaoxi Yao, Ph.D., a health sciences researcher at Mayo Clinic and the paper’s lead author.

The paper looked at 14,865 patients from October 2010 to September 2015 on the blood-thinning drugs apixaban, dabigatran or rivaroxaban for atrial fibrillation. All three medications have a standard dose for most patients and a lower dose for patients with kidney issues. Blood-thinners are recommended for up to 90 percent of patients with atrial fibrillation as lifelong therapy.

“The number of patients using these drugs has quickly increased since the introduction of this new class of drugs in 2010,” says Dr. Yao. Before that, the standard blood-thinning drug since the 1950s was warfarin, which requires constant monitoring and doctor visits.

Using the OptumLabs Data Warehouse, a database of de-identified, linked clinical and administrative claims information, the study found that 16 percent of the patients received a dose inconsistent with U.S. Food and Drug Administration labeling. Among the patients with severe kidney impairment, 43 percent received the standard dose ─ a potential overdose. Overdosing was associated with a higher risk of major bleeding but no significant difference in stroke prevention.

Among patients without severe kidney disease, 13 percent got the lower dose ─ a potential underdose. The lower dose was associated with a higher risk of stroke but no difference for bleeding risks for apixaban users. There wasn’t a significant relationship between underdosing and the risks of stroke or bleeding for dabigatran or rivaroxaban users.

Peter Noseworthy, M.D.

“We conducted this study to highlight the prevalence of inappropriate dosing in routine clinical practice and the associated adverse outcomes,” says Peter Noseworthy, M.D., a Mayo Clinic cardiologist and the paper’s senior author. “This study underscores the importance for physicians to be vigilant of kidney function when selecting or adjusting dose.”

Blood-thinning medication dosing is complex, and there are many factors health care providers consider when prescribing the drugs. They have to weigh the benefits and harms, and account for possible drug interactions, among other concerns.

The researchers also note that, because these blood-thinners are preventive, health care providers can’t be certain the medication prevented a stroke, but they can link bleeding events to the drugs. This could cause some providers to be cautious and prescribe a lower dose.

“Overdosing is a fairly straightforward problem and can be avoided by regularly monitoring kidney function,” says Dr. Noseworthy. “However, underdosing is more complex. These medications need to strike a balance between stroke reduction and risk of bleeding. I think physicians often choose to reduce the dose when they anticipate their patients are at a particularly high bleeding risk ─ independent of kidney function.”

For the patients’ part, they should ensure health care providers have updated medical history information and a current list of medications, especially if they see multiple providers at different hospitals or clinics.

“Physicians will also need to regularly follow up with patients on these medications to detect change in kidney function and adapt the dose accordingly,” says Dr. Yao.

The findings are a collaboration between Mayo Clinic physicians and researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The teamwork ensures the research questions address unmet patient needs and places the findings in a perspective that can improve clinical practice.

Additional research team members ─ all from Mayo Clinic ─ are:

A version of this post originally appeared on the Mayo Clinic News Network

Wed, May 10 8:04am · Research looks to improve patient satisfaction, reduce costs by predicting surgery length

Accurately predicting the length of an operation has benefits beyond simply informing patients and their families. Doing so means improved patient satisfaction and has the potential to prevent over- or under-utilization of operating rooms, which has significant implications on both resources and staff. Ultimately, that leads to improved quality of care for patients, improved well-being for surgical teams, and reduced costs for hospitals.

With that in mind, Mayo Clinic researchers have shown that by looking at patients’ specific traits they can more accurately predict the length of an operation.

“From an efficiency stand-point the current systems are often unreliable and contribute to costly overestimation and underestimation of surgery length,” says Cornelius Thiels, D.O., M.B.A., a Mayo Clinic resident and a lead author for the research.

Making the most of available resources means more patients can get the care they need more efficiently and with less overtime for hospitals.

“Patients do not want to wait weeks to have their surgery due to a backlog, but patients also do not want to wait all day for their surgery to start due to poorly planned operating room schedules,” says Dr. Thiels, who did the research as a fellow in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

The research team published a pair of papers to show which factors can help predict surgery length. The team found male gender, obesity, younger age, abnormal liver function, and patients with other significant health problems are all possible predictors of longer surgeries for a common procedure: minimally invasive gallbladder removal. The model they used predicted the operation length more accurately, and it also better identified groups of patients who are more likely to have extremely short or long operations.

“Predicting these outliers is equally important, as outliers are the most costly to the system,” the researchers wrote. “Even small gains can have significant impact.”

The first paper, published recently in The American Journal of Surgery, used 24,099 cases in the American College of Surgeons National Surgical Quality Improvement Program database. The paper looked at patients who underwent minimally invasive gallbladder removal surgery to find which factors can help predict operative duration, and which aren’t as useful, including smoking, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, and an abnormal white blood cell count. The second paper, published recently in the journal Surgical Endoscopy, confirmed the findings using 1,801 cases at Mayo Clinic from 2007 through June 2013, and 11,842 cases between 2005 and 2013 from the database. That paper also determined the time impact for each useful patient factor.

“Using the American College of Surgeons National Surgical Quality Improvement Program database, we were able to broaden our patient sample and strengthen our prediction model beyond what would be possible when limited to our internal data,” says Bethany Lowndes, Ph.D., a health sciences researcher in the Center for the Science of Health Care Delivery and a lead author for the research.

The research was done in collaboration between the Mayo Clinic Division of Subspecialty General Surgery, and the Surgical Outcomes and Health Care Systems Engineering programs in the Center for the Science of Health Care Delivery.

“This type of cross-divisional research has the greatest potential to be not only scientifically fruitful but also is more likely to result in translational research,” says Dr. Thiels.

An aging U.S. population and an increasing percentage of obese patients also complicate scheduling predictions, and make a model that accounts for those factors more useful.

Current scheduling systems are fairly inaccurate, and typically predict the average operation length, but don’t account for significantly longer or shorter cases, the researchers wrote. Other studies have looked at patient factors related to operative duration, but they haven’t been translated into a model that can be used in practice yet.

This research began with that in mind, and because it was initiated by clinicians looking to solve that problem, it should help with execution.

“When the research is complete, the desire to implement it into practice has already been fostered,” says Dr. Lowndes.

To improve their model’s accuracy, researchers suggest using other potential factors for this operation – which weren’t available in the database – including the presence of gallstones or previous abdominal scarring, surgery or tenderness.  Researchers also will need to test and validate the model for other procedures.

“This will allow us to apply it to various surgical procedures and improve predictability,” says Dr. Lowndes.

At that point, the researchers hope it can be implemented into the surgical scheduling process and improve access for patients.

“Given that every hospital could benefit financially from improved operative time prediction, we feel this first step is important,” the researchers wrote.

Mon, May 8 8:03am · When medical literature is sparse or not clear, where do doctors turn?

Mayo research shows surgery adds years for kidney cancer patients

It started with anecdotal evidence.

Mayo Clinic urologist Bradley Leibovich, M.D., says he had long seen indications that surgically removing secondary tumor growths, called metastases, in patients with kidney cancer would result in a longer life expectancy.

However, studies on the subject were not conclusive, because they did not sufficiently address selection bias, meaning patients with fewer growths or growths in areas that were easier to operate on were naturally chosen for surgery more often. And those types of patients often lived longer, too.

The answers may have been there in previous studies, but doctors couldn’t find them to form a conclusion. That’s where the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery entered the picture.

With the help of the center, Mayo urologists and other researchers analyzed previous studies. This meta-analysis looked at eight studies of 2,267 patients with the kidney cancer called renal cell carcinoma. The result was a “clinically meaningful difference in survival,” the researchers wrote in a paper published recently in The Journal of Urology.

Dr. Brad Leibovich

In this case, they discovered that surgery could more than double life expectancy for many patients with late-stage kidney cancer, giving them anywhere from two to almost 10 years more than they’d have without the surgery. The total life expectancy for patients whose metastases weren’t surgically removed was between eight months and just over two years, but that jumped to three to 12 years for those who had the surgery.

“The research found patients who had surgery to remove metastases were about half as likely to have died from their metastatic disease at every point in time after diagnosis,” says Dr. Leibovich, the paper’s senior author.

Over the past two decades, cases of kidney cancer have increased in the U.S., and the American Cancer Society anticipates 63,990 new diagnoses and 14,400 deaths in 2017. Scientific advances have improved outcomes, but long-term remission and cure remain rare.

Dr. Harras Zaid

“At the end of the day, we’re trying to target patients who have an unfortunate diagnosis and trying to really optimize the outcome,” says Harras Zaid, M.D., a Mayo urologic oncology fellow and the paper’s lead author.

Adds Dr. Leibovich, “With a lot of cancers, we know there’s a range of survival, but kidney cancer is notable for very significant variability in survival after finding spread of disease, with some patients dying much sooner and some living much longer than expected.”

This study helps answer that question through meta-analysis – analyzing previous analyses to provide guidance when prior research was inconclusive or incomplete. Researchers in the Center for the Science of Health Care Delivery perform this type of work often, providing critical support to research and studies that then are implemented broadly and transform the practice for many health care providers across departments to improve access and satisfaction for patients.

“These types of projects take a lot of effort and collaboration,” says Dr. Zaid.

Dr. M. Hassan Murad

Dr. Zaid performed the meta-analysis with guidance from M. Hassan Murad, M.D., a health services researcher in the Center for the Science of Health Care Delivery and a co-author. For their paper, they only chose “observational studies with a low to moderate risk of bias,” the researchers wrote, but the potential still existed.

“Dr. Murad helped guide me through the steps of acquiring the data, finding the specific research papers, doing our analysis, and putting forward a meaningful conclusion,” says Dr. Zaid. “Synthesizing a large amount of data, it’s sometimes a little bit overwhelming, but he was critical in that regard. He’s also just a great mentor and an endless wealth of knowledge.”

Since the majority of the data analyzed in this study was published, immunotherapies and other drug therapies for kidney cancer have advanced considerably. The U.S. Food and Drug Administration approved the first drug for kidney cancer treatment in 1992, but there are more than 10 today, and most were approved in the past decade, according to the National Cancer Institute.

“Now that we have some better drugs for treating these patients, does our conclusion still hold true? We suspect that it will,” says Dr. Leibovich. “In people who haven’t had complete removal of the metastases, drug therapy seems to benefit. But in patients who have that surgery, drug therapy doesn’t seem to make a difference.”

With one of their next studies, the team is evaluating the interaction of surgery and drugs to determine if the combination increases survival even more.

Dr. Leibovich says the concern is that, because there are myriad drug treatments available, patients may not be referred to surgeons, or medical oncologists may not consider surgery as an option.

“Is that so bad if we have all these drugs? The answer is maybe yes, because the drugs, while they have improved survival, are not usually curative,” says Dr. Leibovich. “If they work for only a finite period, and if surgery can lengthen the time before we need to enter that period, then we think that’s potentially additive to overall survival.”

Other co-authors are:

  • William P. Parker, M.D., Mayo Clinic resident
  • Nida Safdar M.D., Mayo Clinic
  • Boris Gershman, M.D., Mayo Clinic
  • Patricia Erwin, Mayo Clinic
  • Stephen Boorjian, M.D., Mayo Clinic
  • Brian Costello, M.D., Mayo Clinic
  • Houston Thompson, M.D., Mayo Clinic

Research was supported by the National Institutes of Health.

Tue, Mar 14 8:00am · Exploration of six alternatives nets policy that cuts surgical delay and overtime

Study finds one strategy decreases overtime by 52 percent with same access for patients

A few years back, the Mayo Clinic Division of Colon and Rectal Surgery approached Mayo scientists with a problem: a backlog of patients waiting for surgery. They wanted the scientists, in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, to help them solve the problem.

The center provides research expertise through collaborations such as this to help Mayo’s continuous efforts to transform the practice for the welfare of its patients and staff.

The researchers created and simulated six policies that could reduce overtime and improve patient access to care. What’s more, the study showed one policy reduced overtime by 52 percent.

“Overtime is a big concern for hospitals because it is both costly and often associated with dissatisfaction of doctors, nurses and staff,” the researchers wrote in the study, which was published recently in the Journal of Biomedical Informatics. “It is well known that high levels of overtime cause increased staff turnover.”

The researchers said reducing the wait for surgery alleviates other concerns, too, such as patient dissatisfaction.

The paper used five years of data, 2011-2015, from the Division of Colon and Rectal Surgery to simulate appointments based on the current surgical scheduling policy and six alternatives. With the new policies, instead of waiting until the clinic consultation to book a surgery, the scientists propose reserving surgery slots when the consultations are scheduled.

Kalyan Pasupathy, Ph.D.

“Even though we don’t know if the patient is going to have surgery, we pick the surgeon based on their surgical availability,” says Kalyan Pasupathy, Ph.D., associate professor of health care systems engineering and the study’s senior author.

The study found that the best option, which they named “Policy D,” decreased overtime by 52 percent when fine-tuned, and allowed the most urgent cases to be seen sooner. That policy starts by grouping patients by priority level, which accounts for urgency and the patients’ location. Then it calculates the expected surgical workload based on probability of surgery and estimated duration, and reserves slots on the days with the least anticipated workload. Finally, working backward, it uses three options for days between consultation and surgery; one, three and five days, depending on priority.

Mustafa Sir, Ph.D.

“That’s what prioritization is about. Based on medical necessity, we prioritize some patients and we delay others,” says Mustafa Sir, Ph.D., an assistant professor of health care systems engineering and a co-author.

“It’s triaging,” adds Dr. Pasupathy. “We do it in the emergency department all the time. If you go to the ED with chest pain, of course you’re going to be in front of the queue. If you go there with an ankle sprain, you’ll probably wait a lot longer.”

Here are the other five policies:

  • Policy A: Assign the highest priority patients, such as those with colon cancer, to the surgeon with the earliest operating room availability. If there isn’t a slot, reserve a time with the surgeon with the lowest workload within the defined safe time frame and use overtime. For patients at lower priority levels, proceed to the next five policies.
  • Policy B: Assign the patient to a surgeon starting with the last day within the defined safe time frame and work toward the present. This policy defers the surgery of lower priority patients, keeping time slots open for higher priority ones.
  • Policy C: Reserve a time for the patient on the day starting with the least workload, and continue the process from the least busy to busiest day. This policy aims to balance the workload by day in the operating room.
  • Policy E: Follow Policy C, but limit the search for a surgery date to the dates defined by the priority level, keeping earlier dates open for more urgent surgeries. For example, Priority Level 2 patients should not be tentatively scheduled within three business days, which is reserved for Priority Level 1 patients.
  • Policy F: Follow Policy D, but limit the search for a surgery reservation to the dates defined by the priority level.

The Division of Colon and Rectal Surgery, working with the Center’s Health Care Systems Engineering team, has begun a pilot program based on the findings. The scientists say the pilot already is working and showing signs of improved access in practice. The pilot is expected to wrap up in March.

“The surgeons’ calendars are like a jigsaw puzzle,” says Dr. Pasupathy. Now, they just need to fit the pieces together.

This research reports the first findings in the study initiated and sponsored by staff in the Division of Colon and Rectal Surgery, including  David Larson, M.D., Colon and Rectal Surgery, and Brian Bernard, who is operations manager for the division.

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