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Articles by D. C Chang
Total Records ( 7 ) for D. C Chang
  A. J Hayanga , A. K Waljee , H. E Kaiser , D. C Chang and A. M. Morris

Background  Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level.

Design  A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists.

Setting  All counties in the United States.

Participants  Prevalence rate of African Americans and Asian Americans within a county.

Main Outcome Measure  Rate of colorectal surgeons, gastroenterologists, and radiation oncologists.

Results  Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13).

Conclusion  Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

  E. R Haut , D. C Chang , A. J Hayanga , D. T Efron , A. H Haider and E. E. Cornwell

Hypothesis  The mechanism by which trauma systems improve mortality is unknown. Outcomes may be influenced by experienced trauma surgeons treating more patients (surgeon effect) or improving the overall system of care (system effect). We hypothesized that mortality is lower in patients treated by a fellowship-trained senior trauma program director (experienced) vs first-year general surgery attending surgeon (novice) and that patient mortality for novice surgeons would improve after adding a new senior trauma director.

Design  Retrospective cohort study.

Setting  Academic level I trauma center.

Patients  Individuals who had experienced trauma.

Main Outcome Measures  We concurrently compared mortality in trauma patients treated by an experienced trauma surgeon with those admitted by novice surgeons during 51/2 years. We also compared mortality in patients treated by novice surgeons before vs after implementation of a more structured trauma program. The 2 test and multiple logistic regression analysis were used to compare the groups. Odds ratios (95% confidence intervals) for death were examined.

Results  Concurrent comparison of patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15). At unadjusted univariate analysis, mortality in patients treated by novice surgeons significantly improved over time in the blunt trauma group and all emergency department survivor subgroups. Multivariate analysis demonstrated significantly improved mortality over time in patients treated by novice surgeons (odds ratio, 0.56; 95% confidence interval, 0.37-0.85).

Conclusions  In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.

  D Mukherjee , H. A Zaidi , T Kosztowski , K. L Chaichana , H Brem , D. C Chang and A. Quinones Hinojosa

Hypothesis  Race/ethnicity and social status influence admission to high-volume hospitals among patients who undergo craniotomy for tumor biopsy or resection.

Design  Retrospective analysis of the Nationwide Inpatient Sample (1988-2005), with additional factors from the Area Resource File.

Setting  A 20% representative sample of all hospitals in 37 US states.

Patients  A total of 76 436 patients 18 years or older who were admitted and underwent craniotomy for tumor biopsy or resection.

Main Outcome Measures  Odds ratios (ORs) for the association of age, sex, race/ethnicity, insurance status, Charlson Comorbidity Index, and county-level characteristics with admission to high-volume hospitals (>50 craniotomies per year) or low-volume hospitals.

Results  A total of 25 481 patients (33.3%) were admitted to high-volume hospitals. Overall access to high-volume hospitals improved over time. However, racial/ethnic disparities in access to high-volume hospitals dramatically worsened for Hispanics (OR, 0.49) and African Americans (OR, 0.62) in recent years. Factors associated with better access to high-volume hospitals included years since 1988 (OR, 1.11), greater countywide neurosurgeon density (OR, 1.66), and higher countywide median household income (OR, 1.71). Factors associated with worse access to high-volume hospitals included older age (OR, 0.34 per year increase), increased countywide poverty rate (OR, 0.57), Hispanic race/ethnicity (OR, 0.68), and higher Charlson Comorbidity Index (OR, 0.96 per point increase).

Conclusions  African Americans and Hispanics have disproportionately worse access to high-quality neuro-oncologic care over time compared with whites. Higher countywide median household income and decreased countywide poverty rate were associated with better access to high-volume hospitals, implicating socioeconomic factors in predicting admission to high-quality centers.

  D Mukherjee , Y Zhang , D. C Chang , L. A Vricella , J. I Brenner and F. Abdullah

Through an analysis of 2 databases, we describe outcomes among 11 958 neonates with congenital heart disease undergoing cardiac procedures, with 194 developing necrotizing enterocolitis (NEC). Neonates with congestive heart failure or those undergoing systemic to pulmonary artery shunting were more likely to develop NEC, but these patients had inpatient mortality similar to that of their non-NEC counterparts.

  S. R Downing , G Datoo , T. A Oyetunji , T Fullum , D. C Chang and N. Ahuja

Iatrogenic bile duct injury (BDI) is an uncommon but serious complication of cholecystectomy, with identified risk factors of acute cholecystitis, male sex, older age, and aberrant biliary anatomy. The Nationwide Inpatient Sample (1998-2006) was queried for cholecystectomy performed on hospital day 0 or 1. Bile duct injury repair procedure codes were used as a surrogate for BDI. We identified 377 424 patients who underwent cholecystectomy, with 1124 BDIs (0.3%). On multivariate logistic regression analysis, Asian race/ethnicity was a significant risk factor for BDI (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.59-3.23; P < .001). This persisted for laparoscopic (OR, 2.62; 95% CI, 1.28-5.39; P = .009) and open (2.21; 1.59-3.07; P < .001) cholecystectomies. No other race/ethnicity was identified as a risk factor for BDI. We report a new finding that Asian race/ethnicity is a significant risk factor for BDI in laparoscopic and open cholecystectomies.

  M Camp , D. C Chang , Y Zhang , K Chrouser , P. M Colombani and F. Abdullah

Objective  To determine risk factors and outcomes associated with a foreign body left during a procedure in a population of pediatric surgical patients.

Design  Case-control study.

Setting  The Nationwide Inpatient Sample and Kids' Inpatient Database were used to identify hospitalized pediatric surgical patients in the United States (aged 0-18 years) from 1988 to 2005.

Patients  After data from 1 946 831 hospitalizations in children were linked to the Agency for Healthcare Research and Quality Pediatric Quality Indicator (PDI) software, 413 pediatric patients with foreign bodies left during a procedure (PDI 3) were identified. A 1:3 matched case-control design was implemented with 413 cases and 1227 controls. Cases and controls were stratified into procedure categories based on diagnosis related group procedure codes.

Main Outcome Measures  To examine the relationship between PDI 3 and procedure category, as well as the outcomes of in-hospital mortality, length of stay, and total hospital charges.

Results  Logistic regression analysis revealed a statistically significant higher odds of PDI 3 in the gynecology procedure category (odds ratio, 4.13; P = .01). Multivariable regression analysis revealed that patients with PDI 3 had an 8-day longer length of stay (95% confidence interval, 5.6-10.3 days; P < .001) and $35 681 higher total hospital charges (95% confidence interval, $22 358-$49 004; P < .001) but were not more likely to die (odds ratio, 1.07; P = .92).

Conclusions  Among pediatric surgical admissions, a foreign body left during a procedure was observed to occur with highest likelihood during gynecologic operations. The occurrence of this adverse event was associated with longer length of stay and greater total hospital charges, but not with increased mortality.

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