UT Southwestern Medical School
Permanent URI for this collectionhttps://hdl.handle.net/2152.5/6690
Welcome to the UT Southwestern Medical School’s electronic theses and dissertations (ETD) collection.
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Print theses and dissertations from 1943 to 2004 are located in the Library's Special Collections and Archives (Room E3.314) and are available by appointment. (Note: Former students may request a digitized copy of their work by email, but other users may submit an Interlibrary Loan request.) For more information, contact archives@utsouthwestern.edu.
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Browsing UT Southwestern Medical School by Author "Anandam, Joselin"
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Item Anal Cancer Screening in a High-Risk Population: A Quality Improvement Initiative(2019-03-29) Bieterman, Andrew; Reed, W. Gary; Anandam, Joselin; Lau, Abby; Quinn, AndrewBACKGROUND: The main risk factor for the development of anal cancer is acquisition of the human papilloma virus (HPV). Individuals infected with the human immunodeficiency virus (HIV) have a higher prevalence of HPV and subsequently developing HPV induced dysplasia. The incidence of anal cancer among HIV positive men who have sex with men (MSM) has been estimated to be approximately twice that of HIV negative MSM with rates as high as 112-144 per 100,000. By relying on similarities between the anus and the cervix, and the established success of cervical cytology screening in reducing the incidence of cervical cancer, anal cancer screening programs have been established to identify pre-cancerous lesions. LOCAL PROBLEM: A retrospective chart review of anal cancer incidence at Parkland Hospital revealed a significant burden of anal cancer amongst HIV positive patients. As such, Parkland has decided to implement a policy of annual anal cancer screening among all HIV patients via anal cytology screening and referrals to proctology for any abnormal anal cytology samples. METHODS: In order to assess the monthly anal cancer screening rate, we looked at the absolute number of anal cytology samples performed in a 28 day period. The list of anal cytology samples performed was pulled from the Cerner laboratory information system (LIS) and correlated with a quarterly chart review using the electronic medical record (EMR). Utilizing, QI MACROS in EXCEL, we were able to create a run chart to identify trends in anal cancer screening rates over the duration of the project. We used chi-squared test of independence and unpaired t-test to determine statistical significance. INTERVENTIONS: We implemented a multi-step process involving over 10 Plan-Do-Study Act (PDSA) cycles for increasing the number of anal cytology samples performed in the clinic. The three most impactful PDSA cycles are discussed in the article. RESULTS: The primary outcome of monthly anal cancer screening rate increased over the duration of the project from an average of 19.5 in 2015 to 58.6 samples collected per month in 2018, a 199.3% increase relative to baseline (p < 0.001). While the interventions implemented were successful in increasing anal cancer screening rates, we were unable to determine which of the PDSA intervention cycles had the biggest impact on altering the clinic practice. Over the duration of the project, we screened 1908 patients. Of the patients screened, we identified 249 patients with abnormal anoscopy findings. Amongst the patients that had anal lesions on anoscopy, 10 developed anal cancer, 4.0%. When taking a closer look at these individuals and the electronic medical record, 3 patients were found to be completely asymptomatic at the most recent clinic prior to collection of the anal pap and would not have been referred to proctology if it weren't for the screening test, which ultimately resulted in an earlier diagnosis CONCLUSION: We were successful in taking previously proven interventions for increasing cervical cancer and adapting them for anal cancer. By increasing awareness to both patients and providers on the risks of anal cancer, instructing providers on the methods to screen for the disease, and providing timely feedback, we were able to increase the anal cancer screening rate in this large urban clinic with limited resources.Item Enhanced Recovery Pathway for Colorectal Surgery Improves Outcomes in Private and Safety-Net Settings(2018-03-26) Roberts, Taylor Jean; Reed, W. Gary; Rabaglia, Jennifer; Anandam, JoselinBACKGROUND: Although it is known that Enhanced Recovery Pathways (ERP) decrease length of stay (LOS) and improve outcomes in colorectal surgery, these studies predominantly represent the private health care setting. There is a paucity of information regarding the effectiveness of ERP in the public arena, comprised of the under and uninsured who may have different social determinants of health. This study aims to compare the effect of an ERP on LOS and readmission for colorectal surgery across the private and safety-net settings in a large urban academic medical center. METHODS: A multidisciplinary panel of experts utilized professionally recognized standards and evidence-based best practice to create a comprehensive ERP for elective colorectal surgery. The ERP included standardization of patient education, optimization of co-morbidities, multimodal analgesia, carbohydrate loading, intraoperative goal-directed fluid therapy, minimization of opioids, and early ambulation, removal of urinary catheter, and resumption of diet. There were no social interventions. The ERP was implemented in the safety-net hospital (SNH) in September 2014 and the private hospital (PH) in December 2014. Process and outcome metrics from 100 consecutive patients having surgery in the 18 months prior to ERP at each institution were compared to a similar group post ERP. Surgeons and discharge criteria remained constant. Primary endpoints were LOS and readmissions. RESULTS: Patients in the post-ERP cohorts at both facilities were significantly older than pre-ERP (p=0.047, 0.034), with no significant difference in gender and BMI. The rate of open versus minimally invasive was similar at SNH (p=0.067), while more post-ERP patients at PH underwent open surgery (p=0.002). 96% of PH patients were funded through private insurance or Medicare, verses only 6% at the SNH. ERP implementation reduced total LOS at both facilities, while readmission and reoperation remained constant. LOS at PH fell from 8.1 to 5.9 days (p=0.028), and at SNH from 7.0 to 5.1 days (p=0.004). 30-day all-cause readmission and return to surgery were stable (PH p=0.634; SNH p=1) and (PH p=0.610; SNH p=0.066) respectively. Surgical site infection rate was unchanged at PH (p=0.485) and significantly reduced at SNH (p=0.021, OR 0.39). Mean time to ambulation and mean time to first bowel movement were reduced at SNH (p=0.002, 0.001). Mean time to resumption of solids was reduced at both PH and SNH (p<0.001). CONCLUSIONS: Implementation of ERP is similarly effective across private and safety net settings, without interventions to address social determinants of health. Both cohorts experienced reduced LOS without increasing readmission or reoperation. The data suggest ERP may have a more dramatic impact on outcomes in the safety net setting, perhaps through standardization in a group with more varied baseline health status. Utilization of ERP appears to be advantageous for all populations regardless of funding.