Mary Rojas

Bio: Mary Rojas is an academic researcher from Icahn School of Medicine at Mount Sinai. The author has contributed to research in topics: Carotid endarterectomy & Population. The author has an hindex of 10, co-authored 15 publications receiving 1017 citations.

How Time Affects the Risk of Rupture in Appendicitis

Abstract: Background Increasing time between symptom onset and treatment may be a risk factor for a ruptured appendix, but little is known about how the risk changes with passing time This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention Study design We conducted a retrospective chart review of physician office, clinic, emergency room, and inpatient records of a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals Conditional risks of rupture were calculated using life table methods Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment Results Rupture risk was≤2% in patients with less than 36hours of untreated symptoms For patients with untreated symptoms beyond 36hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period Rupture was greater in patients with36hours or more of untreated symptoms (estimated relative risk [RR]=66; 95% CI: 19 to 83), age 65 years and older (RR=42; 95% CI: 19 to 61), fever>389°C (RR=36; 95% CI: 12 to 57), and tachycardia (heart rate≥100 beats/minute; RR=34; 95% CI: 18 to 54) Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 71hours versus 109hours; p Conclusions Risk of rupture in ensuing 12-hour periods rises to 5% after 36hours of untreated symptoms Physicians should be cautious about delaying surgery beyond 36hours from symptom onset in patients with appendicitis

Has evidence changed practice? appropriateness of carotid endarterectomy after the clinical trials

Abstract: Objective: To assess how appropriateness of and indications for carotid endarterectomy (CEA) have changed following the publication of several large international randomized controlled trials (RCTs) designed to rationalize use of CEA. Methods: The New York Carotid Artery Surgery Study (NYCAS) is a population-based cohort study of all CEAs performed on elderly patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess indications for and appropriateness of surgery using a list of 1,557 indications for CEA developed by national experts using RAND appropriateness methods. Deaths and strokes within 30 days of surgery were ascertained and confirmed by two physicians. Results: Among the 9,588 patients, the mean age was 74.6 years and 93.6% had 70 to 99% carotid stenosis. Nearly three-quarters of patients (72.3%) underwent CEA for asymptomatic stenosis, 18.6% for TIA, and 9.1% for stroke. Overall, 87.1% of operations were done for appropriate reasons, 4.3% for uncertain reasons, and 8.6% for inappropriate reasons (vs 32% inappropriate before the RCTs, p p Conclusions: Since publication of the randomized controlled trials, there has been a reduction in the proportion of patients undergoing carotid endarterectomy (CEA) for inappropriate reasons. The shift toward many asymptomatic patients undergoing CEA is concerning because the net benefit from surgery for these patients is low and is reduced further for patients with high comorbidity.

Racial and Ethnic Disparities in Outcomes and Appropriateness of Carotid Endarterectomy: Impact of Patient and Provider Factors

Abstract: Background and Purpose— Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities. Methods— This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using χ 2 tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors. Results— Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (N=9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals ( P P P Conclusions— Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying presurgical risk factors and provider characteristics explained the higher risk of complications in blacks, but not Hispanics.

Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration.

Abstract: Adequate reporting of randomized, controlled trials (RCTs) is necessary to allow accurate critical appraisal of the validity and applicability of the results. The CONSORT (Consolidated Standards of Reporting Trials) Statement, a 22-item checklist and flow diagram, is intended to address this problem by improving the reporting of RCTs. However, some specific issues that apply to trials of nonpharmacologic treatments (for example, surgery, technical interventions, devices, rehabilitation, psychotherapy, and behavioral intervention) are not specifically addressed in the CONSORT Statement. Furthermore, considerable evidence suggests that the reporting of nonpharmacologic trials still needs improvement. Therefore, the CONSORT group developed an extension of the CONSORT Statement for trials assessing nonpharmacologic treatments. A consensus meeting of 33 experts was organized in Paris, France, in February 2006, to develop an extension of the CONSORT Statement for trials of nonpharmacologic treatments. The participants extended 11 items from the CONSORT Statement, added 1 item, and developed a modified flow diagram. To allow adequate understanding and implementation of the CONSORT extension, the CONSORT group developed this elaboration and explanation document from a review of the literature to provide examples of adequate reporting. This extension, in conjunction with the main CONSORT Statement and other CONSORT extensions, should help to improve the reporting of RCTs performed in this field.

The effect of emergency department crowding on clinically oriented outcomes

Abstract: Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated. Objectives: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs). Methods: We reviewed the English-language literature for the years 1989–2007 for case series, cohort studies, and clinical trials addressing crowding’s effects on COOs. Keywords searched included “ED crowding,”“ED overcrowding,”“mortality,”“time to treatment,”“patient satisfaction,”“quality of care,” and others. Results: A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding’s effects on patient satisfaction and other quality endpoints. Conclusions: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

Thirty-day readmission rates for Medicare beneficiaries by race and site of care.

Abstract: Context Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions. Objective To determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care. Design Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non–minority-serving hospitals. Setting and Participants Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008. Main Outcome Measure Risk-adjusted odds of 30-day readmission. Results Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P Conclusion Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.

Health effects of media on children and adolescents.

Abstract: Youth spend an average of >7 hours/day using media, and the vast majority of them have access to a bedroom television, computer, the Internet, a video-game console, and a cell phone. In this article we review the most recent research on the effects of media on the health and well-being of children and adolescents. Studies have shown that media can provide information about safe health practices and can foster social connectedness. However, recent evidence raises concerns about media's effects on aggression, sexual behavior, substance use, disordered eating, and academic difficulties. We provide recommendations for parents, practitioners, the media, and policy makers, among others, for ways to increase the benefits and reduce the harm that media can have for the developing child and for adolescents.

Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors.

Abstract: It is well known that there are significant racial disparities in health care outcomes, including surgery. However, the mechanisms that lead to these disparities are still not fully understood. In this comprehensive review of the currently published surgical disparity literature in the United States, we assess racial disparities in outcomes after surgical procedures, focusing on patient, provider, and systemic factors. The PubMed, EMBASE, and Cochrane Library electronic databases were searched with the keywords: healthcare disparities AND surgery AND outcome AND US. Only primary research articles published between April 1990 and December 2011 were included in the study. Studies analyzing surgical patients of all ages and assessing the endpoints of mortality, morbidity, or the likelihood of receiving surgical therapy were included. A total of 88 articles met the inclusion criteria. This evidence-based review was compiled in a systematic manner, relying on retrospective, cross-sectional, case-control, and prospective studies in the absence of Class I studies. The review found that patient factors such as insurance status and socioeconomic status (SES) need to be further explored, as studies indicated only a premature understanding of the relationship between racial disparities and SES. Provider factors such as differences in surgery rates and treatment by low volume or low quality surgeons also appear to play a role in minority outcome disparities. Finally, systemic factors such as access to care, hospital volume, and hospital patient population have been shown to contribute to disparities, with research consistently demonstrating that equal access to care mitigates outcome disparities.