Person: Sethi, Rosh
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Sethi
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Rosh
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Sethi, Rosh
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Publication Technology Adoption in the United States: The Impact of Hospital Market Competition(2014-07-07) Sethi, RoshObjectives: Technological innovation in medicine is a significant driver of healthcare spending growth in the United States. Factors driving adoption and utilization of new technology is poorly understood, however market forces may play a significant role. Vascular surgery has experienced a surge in development of new devices and serves as an ideal case study. Specifically, the share of total abdominal aortic aneurysm (AAA) repairs performed by endovascular aneurysm repair (EVAR) increased rapidly from 32% in 2001 to 65% in 2006 with considerable variation between states. This paper hypothesizes that that hospitals in competitive markets were early EVAR adopters and had improved AAA repair outcomes. Methods: The Nationwide Inpatient Sample (NIS) and linked Hospital Market Structure (HMS) data was queried for patients who underwent repair for non-ruptured AAA in 2003. In HMS the Herfindahl Hirschman Index (HHI, range 0-1) is a validated and widely accepted economic measure of competition. Hospital markets were defined using a variable geographic radius that encompassed 90% of discharged patients. Bivariable and multivariable linear and logistic regression analyses were performed for the dependent variable of EVAR use. A propensity score-adjusted multivariate logistic regression model was used to control for treatment bias in the assessment of competition on AAA-repair outcomes. Results: A weighted total of 21,600 patients was included in the analyses. Patients at more competitive hospitals (lower HHI) were at increased odds of undergoing EVAR vs. open repair (Odds Ratio 1.127 per 0.1 decrease in HHI, P<0.0127) after adjusting for patient demographics, co-morbidities and hospital level factors (bed size, teaching status, AAA repair volume and ownership). Competition was not associated with differences in in-hospital mortality or vascular, neurologic or other minor post-operative complications. Conclusion: Greater hospital competition is significantly associated with increased EVAR adoption at a time when diffusion of this technology passed its tipping point. Hospital competition does not influence post-AAA repair outcomes. These results suggest that adoption of novel technology is not solely driven by clinical indications, but may also be influenced by market forces.Publication Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure(Sociedade Brasileira de Cardiologia, 2015) Barkoudah, Ebrahim; Kodali, Sindhura; Okoroh, Juliet; Sethi, Rosh; Hulten, Edward; Suemoto, Claudia; Bittencourt, Marcio SommerIntroduction: Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF. Objective: The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome. Results: A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993). Conclusion: Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.Publication Postoperative Care in an Intermediate-Level Medical Unit After Head and Neck Microvascular Free Flap Reconstruction(Wiley, 2018-11-28) Yu, Phoebe K.; Sethi, Rosh; Rathi, Vinay; Puram, Sidharth; Lin, Derrick; Emerick, Kevin; Durand, Marlene; Deschler, DanielObjective: The need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non-ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer. Materials and Methods: We performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate-level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression. Results: The vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty-five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer. Conclusions: Among head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate-level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate-level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high-value, disease-centered care. Level Of Evidence: 3bPublication Improvement in word recognition following treatment failure for sudden sensorineural hearing loss(KeAi Publishing, 2016) Jan, Taha A.; Kozin, Elliott; Kanumuri, Vivek; Sethi, Rosh; Jung, DavidObjectives: Patients with sudden sensorineural hearing loss (SSNHL) may have word recognition scores (WRS) that correlate with pure tone average (PTA). We hypothesize that there is a subset of patients with SSNHL who have improved WRS despite stable PTA. Methods: Retrospective case review at a tertiary otolaryngology practice. Results: We identified 13 of 113 patients with SSNHL whose WRS increased despite overall stable pure tone averages. There was an observed average improvement in WRS by 23.8 points in this patient cohort at follow-up, with mean initial PTA in the affected ear at 48.7 dB. Conclusions: We identify a novel cohort of SSNHL patients that have failed treatment as measured by PTA, but who have increased WRS over time. These data have implications for patient counseling and lend insight into the pathophysiology of SSNHL.