Bio

Clinical Focus


  • Cancer > GI Oncology
  • Colon and Rectal Surgery
  • Pelvic Floor Disorders
  • Benign Colorectal Disease
  • Healthcare Quality and Outcomes
  • Community-Based Participatory Research
  • General Surgery

Academic Appointments


Administrative Appointments


  • E3 Unit Based Medical Director, Stanford Hospitals and Clinics (2014 - Present)
  • Director, Community Partnerships Program, Stanford Cancer Institute (2010 - Present)
  • E3 Unit Based Medical Director, Stanford Hospitals and Clinics (2008 - 2010)

Honors & Awards


  • Harold Amos Medical Faculty Development Award, Robert Wood Johnson Foundation (January 2009-2012)
  • Philip R. Lee Fellow in Health Policy, UCSF Institute for Health Policy Studies (july 2007)

Professional Education


  • Board Certification: General Surgery, American Board of Colon and Rectal Surgery (2010)
  • Residency:UCSF (2005) CA
  • Internship:UCSF (1999) CA
  • Board Certification, American Board of Colon and Rectal Surgery, Colon and Rectal Surgery (2010)
  • Fellowship, UCSF Health Policy Institute, Health Services Research (2008)
  • Fellowship:UC San Francisco (2007) CA
  • Fellowship, UC San Francisco, Colorectal Surgery (2007)
  • Board Certification: General Surgery, American Board of Surgery (2006)
  • MPH, Harvard School of Public Health, Health Policy and administration (2006)
  • Residency, UC San Francisco, General Surgery (2005)
  • Medical Education:UCSF (1998) CA
  • MD, UC San Francisco, Medicine (1998)
  • MS, UC Berkeley, Health and Medical Sciences (1996)
  • BA, UC Berkeley, Linguistics (1991)

Community and International Work


  • Cancer care access, Monterey County

    Topic

    Access to Care; Migrant Farm Populations; Cancer Disparities

    Partnering Organization(s)

    Local Providers Salinas

    Populations Served

    Latino populations of Salinas Valley

    Location

    Bay Area

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

Research & Scholarship

Current Research and Scholarly Interests


My research attempts to elucidate the links between hospital and health care quality and racial/ethnic disparities in cancer survival. Using nationally endorsed process and outcome measures for cancer, I am testing the hypothesis that exposure to low resource hospitals for cancer care may adversely impact cancer outcomes regardless of individual (patient) factors. Other ongoing research focuses on understanding travel patterns for cancer care in racial and ethnic subgroups and distinguishing the effect of guideline deviant health care from the impact of socioeconomic status on survival in acute leukemia. In my role as the founding Director of the Stanford Cancer Institute-Community Partnerships Program, I have designed Stanford based programs that will address real world cancer disparities across the Greater Bay Area through community engagement, community based participatory research and increasing minority participation in cancer clinical trials.

Teaching

2014-15 Courses


Postdoctoral Advisees


Graduate and Fellowship Programs


Publications

Journal Articles


  • Age and Genetics How Do Prognostic Factors at Diagnosis Explain Disparities in Acute Myeloid Leukemia? AMERICAN JOURNAL OF CLINICAL ONCOLOGY-CANCER CLINICAL TRIALS Patel, M. I., Ma, Y., Mitchell, B. S., Rhoads, K. F. 2015; 38 (2): 159-164

    Abstract

    OBJECTIVES:: Survival disparities in acute myeloid leukemia (AML) among blacks and Hispanics have been described but not studied extensively in adults. Although younger age and cytogenetic profiles of t(8;21) and acute promyelocytic leukemia (APL) subtypes of AML are associated with improved survival, these factors have not been investigated by race. The purpose is to evaluate whether the observed survival differences for blacks and Hispanics with AML are attributable to older age at diagnosis or lower rates of favorable cytogenetic profiles at diagnosis. The hypothesis is that survival disparities for blacks and Hispanics with AML will be explained by older age at diagnosis and lower rates of favorable cytogenetics. METHODS:: Patients with AML were identified in the Surveillance Epidemiology and End Results database (1999 to 2008). Kaplan-Meier (KM) survival curves predicted survival by race/ethnicity, stratified by age. Cox proportional hazard models estimated mortality by race with adjustment for age, sex, year of diagnosis, t(8;21), and APL subtypes. RESULTS:: A total of 25,692 patients were included. Blacks and Hispanics were diagnosed at younger ages (younger than 61 y), and had higher rates of t(8;21) and APL compared with non-Hispanic whites (NHWs). The overall KM curve shows that NHWs had a worse survival compared with other races/ethnicities. However, when KM curves were stratified by age, blacks and Hispanics had worse survival in younger age categories (younger than 61 y). In multivariable models, black race was associated with an increased risk of death compared with NHWs (HR, 1.10; 95% CI, 1.04-1.16). Adjustment for t(8;21) and APL subtypes did not attenuate the disparity. CONCLUSIONS:: Despite younger age and higher prevalence of favorable cytogenetics at diagnosis, blacks and Hispanics have an increased mortality from AML compared with other racial/ethnic groups. Future studies should investigate other factors that may influence outcomes among minority populations.

    View details for DOI 10.1097/COC.0b013e31828d7536

    View details for Web of Science ID 000351770500007

    View details for PubMedID 23608826

  • How do integrated health care systems address racial and ethnic disparities in colon cancer? Journal of clinical oncology Rhoads, K. F., Patel, M. I., Ma, Y., Schmidt, L. A. 2015; 33 (8): 854-860

    Abstract

    Colorectal cancer (CRC) disparities have persisted over the last two decades. CRC is a complex disease requiring multidisciplinary care from specialists who may be geographically separated. Few studies have assessed the association between integrated health care system (IHS) CRC care quality, survival, and disparities. The purpose of this study was to determine if exposure to an IHS positively affects quality of care, risk of mortality, and disparities.This retrospective secondary-data analysis study, using the California Cancer Registry linked to state discharge abstracts of patients treated for colon cancer (2001 to 2006), compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, the hazard of mortality, and racial/ethnic disparities in an IHS versus other settings.More than 30,000 patient records were evaluated. The IHS had overall higher rates of adherence to NCCN guidelines. Propensity score-matched Cox models showed an independent and protective association between care in the IHS and survival (hazard ratio [HR], 0.87; 95% CI, 0.85 to 0.90). This advantage persisted across stage groups. Black race was associated with increased hazard of mortality in all other settings (HR, 1.15; 95% CI, 1.04 to 1.27); however, there was no disparity within the IHS for any minority group (P > .11 for all groups) when compared with white race.The IHS delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the IHS. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health care reform.

    View details for DOI 10.1200/JCO.2014.56.8642

    View details for PubMedID 25624437

  • How do differences in treatment impact racial and ethnic disparities in acute myeloid leukemia? Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Patel, M. I., Ma, Y., Mitchell, B., Rhoads, K. F. 2015; 24 (2): 344-349

    Abstract

    We previously demonstrated disparate acute myelogenous leukemia (AML) survival for black and Hispanic patients; these differences persisted despite younger ages and higher prevalence of favorable cytogenetics in these groups. This study determined: (i) whether there are differences in treatment delivered to minorities, and (ii) how these differences affect outcomes in AML. We hypothesize that differences in treatment explain some proportion of survival disparities.We used California Cancer Registry data linked to hospital discharge abstracts for patients with AML (1998-2008). Logistic regression models estimated odds of treatment (chemotherapy and/or hematopoietic stem cell transplant) by race/ethnicity. Cox proportional hazard models estimated mortality by race after adjustment for treatment.We analyzed 11,084 records. Black race was associated with lower odds of chemotherapy [OR, 0.74; 95% confidence interval (CI), 0.61-0.91]. Black and Hispanic patients had decreased odds of transplant [(OR, 0.64; 95% CI, 0.46-0.87); (OR, 0.74; 95% CI, 0.62-0.89), respectively]. Black patients had increased hazard of mortality (HR, 1.14; 95% CI, 1.04-1.25) compared with whites. Adjustment for receipt of any treatment resulted in decreased mortality (HR, 1.09; 95% CI, 1.00-1.20) for black patients.AML treatment differences for black patients explain some proportion of the disparity. Future AML disparities studies should investigate socioeconomic and other characteristics.Study findings may better elucidate drivers of disparities in AML. Cancer Epidemiol Biomarkers Prev; 24(2); 344-9. 2015 AACR.

    View details for DOI 10.1158/1055-9965.EPI-14-0963

    View details for PubMedID 25662426

  • What Factors Influence Minority Use of National Cancer Institute-Designated Cancer Centers? CANCER Huang, L. C., Ma, Y., Ngo, J. V., Rhoads, K. F. 2014; 120 (3): 399-407

    Abstract

    National Cancer Institute (NCI) cancer centers provide high-quality care and are associated with better outcomes. However, racial and ethnic minority populations tend not to use these settings. The current study sought to understand what factors influence minority use of NCI cancer centers.A data set containing California Cancer Registry (CCR) data linked to patient discharge abstracts identified all patients with colorectal cancer (CRC) who were treated from 1996 through 2006. Multivariable models were generated to predict the use of NCI settings by race. Geographic proximity to an NCI center and patient sociodemographic and clinical characteristics were assessed.Approximately 5% of all identified patients with CRC (n?=?79,231) were treated in NCI settings. The median travel distance for treatment for all patients in all hospitals was ??5 miles. A higher percentage of minorities lived near an NCI cancer center compared with whites. A baseline multivariable model predicting use showed a negative association between Hispanic ethnicity and NCI center use (odds ratio, 0.71; 95% confidence interval, 0.64-0.79). Asian/Pacific Islander patients were more likely to use NCI centers (odds ratio, 1.41; 95% confidence interval, 1.28-1.54). There was no difference in use noted among black patients. Increasing living distance from an NCI cancer center was found to be predictive of lower odds of use for all populations. Medicare and Medicaid insurance statuses were positively associated with NCI center use. Neighborhood-level education was found to be a more powerful predictor of NCI use than poverty or unemployment.Select minority groups underuse NCI cancer centers for CRC treatment. Sociodemographic factors and proximity to NCI centers are important predictors of use. Interventions to address these factors may improve minority attendance to NCI cancer centers for care. Cancer 2014;120:399-407. 2013 American Cancer Society.

    View details for DOI 10.1002/cncr.28413

    View details for Web of Science ID 000330267700013

  • Do Hospitals that Serve a High Percentage of Medicaid Patients Perform Well on Evidence-based Guidelines for Colon Cancer Care? Journal of health care for the poor and underserved Rhoads, K. F., Ngo, J. V., Ma, Y., Huang, L., Welton, M. L., Dudley, R. A. 2013; 24 (3): 1180-1193

    Abstract

    Background. Previous work suggests hospitals serving high percentages of patients with Medicaid are associated with worse colon cancer survival. It is unclear if practice patterns in these settings explain differential outcomes. Hypothesis: High Medicaid hospitals (HMH) have lower compliance with evidence-based care processes (examining 12 or more lymph nodes (LN) during surgical staging and providing appropriate chemo-therapy). Methods. Retrospective analysis of stage I-III colon cancers from California Cancer Registry (1996-2006) linked to discharge abstracts and hospital profiles predicted hospital compliance with guidelines and trends in compliance over time. Results. Cases (N=60,000) in 439 hospitals analyzed. High Medicaid hospital settings had lower odds of compliance with the 12 LN exam (ORHMH0.91, CIHMH[0.85, 0.98]) and with the delivery of appropriate chemotherapy (ORHMH0.76, CIHMH[0.67, 0.86]). Conclusions. High Medicaid hospital status is associated with poor performance on evidence-based colon cancer care. Policies to improve the quality of colon cancer care should target these settings.

    View details for DOI 10.1353/hpu.2013.0122

    View details for PubMedID 23974390

  • Understanding disparities in leukemia: a national study CANCER CAUSES & CONTROL Patel, M. I., Ma, Y., Mitchell, B. S., Rhoads, K. F. 2012; 23 (11): 1831-1837

    Abstract

    Disparities in solid tumors have been well studied. However, disparities in hematologic malignancies have been relatively unexplored on population-based levels. The purpose of this study is to examine the relationship between race/ethnicity and acute leukemia mortality.All patients with acute leukemia [acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML)] were identified in the Surveillance Epidemiology and End Results database, 1999-2008. Kaplan-Meier curves were generated to reflect survival probabilities by race/ethnicity. Multivariable Cox proportional hazard models estimated hazard of mortality by race with adjustment for individual (age, gender, year of diagnosis) and select genetic factors.A total of 39,002 patients with acute leukemia were included in the study. Overall, there was a mortality disparity in acute leukemia for blacks (HR 1.17, p < 0.0001) and Hispanics (HR 1.13, p < 0.0001) compared with non-Hispanic whites. In stratified analysis, disparities in ALL were greater than AML; blacks (HR[ALL]1.45, p < 0.0001; HR[AML]1.12, p < 0.0011); Hispanics (HR[ALL]1.46, p < 0.0001; HR[AML]1.06, p < 0.0001). Adjustment for individual patient and select genetic factors did not explain disparities.Blacks and Hispanics suffer decreased survival in acute leukemia as compared to others. Further investigation is needed to understand the drivers of poor cancer outcomes in these populations.

    View details for DOI 10.1007/s10552-012-0062-3

    View details for Web of Science ID 000309671300009

    View details for PubMedID 22971999

  • Racial and ethnic differences in lymph node examination after colon cancer resection do not completely explain disparities in mortality CANCER Rhoads, K. F., Cullen, J., Ngo, J. V., Wren, S. M. 2012; 118 (2): 469-477

    Abstract

    In 1999, a multidisciplinary panel of experts in colorectal cancer reviewed the relevant medical literature and issued a consensus recommendation for a 12-lymph node (LN) minimum examination after resection for colon cancer. Some authors have shown racial/ethnic differences in receipt of this evidence-based care. To date, however, none has investigated the correlation between disparities in LN examination and disparities in outcomes after colon cancer treatment.This retrospective analysis used California Cancer Registry linked to California Office of Statewide Health Planning and Development discharge data (1996-2006). Chi-square analysis, logistic regression, and Cox proportional hazard models predicted disparities in receipt of an adequate examination and the effect of an inadequate exam on mortality and disparities. Patients with stage I and II colon cancers undergoing surgery in California were included; patients with stage III and IV disease were excluded.A total of 37,911 records were analyzed. Adequate staging occurred in fewer than half of cases. An inadequate examination (<12 LNs) was associated with higher mortality rates. Hispanics had the lowest odds of receiving an adequate exam; however, blacks, not Hispanics, had the highest risk of mortality compared with whites. This disparity was not completely explained by inadequate LN examination.Inadequate LN exam occurs often and is associated with increased mortality. There are disparities in receipt of the minimum exam, but this only explains a small part of the observed disparity in mortality. Improving the quality of LN examination alone is unlikely to correct colon cancer disparities.

    View details for DOI 10.1002/cncr.26316

    View details for Web of Science ID 000298846600025

    View details for PubMedID 21751191

  • Understanding Racial Disparities in Cancer Treatment and Outcomes JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Morris, A. M., Rhoads, K. F., Stain, S. C., Birkmeyer, J. D. 2010; 211 (1): 105-113
  • Quality of colon cancer outcomes in hospitals with a high percentage of Medicaid patients JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Rhoads, K. F., Ackerson, L. K., Jha, A. K., Dudley, R. A. 2008; 207 (2): 197-204

    Abstract

    There is evidence that patients with Medicaid insurance suffer worse outcomes from surgical conditions; but there is little research about whether this reflects clustering of such patients at hospitals with worse outcomes. We assess the outcomes of patients with colon and rectal cancers at hospitals with a high proportion of Medicaid patients.California Cancer Registry patient-level records were linked to discharge abstracts from California's Office of Statewide Health Planning and Development. All operative California Cancer Registry patients from 1998 and 1999 were included. Hospitals with > 40% Medicaid patients were labeled high Medicaid hospitals (HMH). We analyzed the odds of mortality at 30 days, 1, and 5 years for colon cancer and rectal cancer separately. Multilevel logistic regression models were constructed, using MLwiN 2.0, to include patient and hospital-level characteristics.Thirty-day mortality after colon operation was worse in HMH (1% versus 0.6%; p = 0.04); as was 1-year mortality (3.4% versus 2.4%; p = 0.001). There was no substantial difference in rates of 5-year mortality. Individuals who were insured by Medicaid had worse outcomes at 5 years. Adjustment for surgical volume eliminated the effect of HMH at 30 days (1% versus 0.7%; p = 0.45) but not at 1 year (3.4% versus 2.5%; p = 0.01). Adjustment for academic affiliation did not alter these results. There were an insufficient number of rectal cancer patients to detect any differences by hospital type.HMH have higher postoperative colon cancer mortality rates at 30 days and 1 year but not at 5 years. The early effect can be explained by surgical volume, but additional research is needed to determine which factors contribute to differences in intermediate outcomes after operations in HMH settings.

    View details for DOI 10.1016/j.jamcollsurg.2008.02.014

    View details for Web of Science ID 000258517600007

    View details for PubMedID 18656047

  • Patient safety in plastic surgery: identifying areas for quality improvement efforts. Annals of plastic surgery Hernandez-Boussard, T., McDonald, K. M., Rhoads, K. F., Curtin, C. M. 2015; 74 (5): 597-602

    Abstract

    Improving quality of health care is a global priority. Before quality benchmarks are established, we first must understand rates of adverse events (AEs). This project assessed risk-adjusted rates of inpatient AEs for soft tissue reconstructive procedures.Patients receiving soft tissue reconstructive procedures from 2005 to 2010 were extracted from the Nationwide Inpatient Sample. Inpatient AEs were identified using patient safety indicators (PSIs), established measures developed by Agency for Healthcare Research and Quality.We identified 409,991 patients with soft tissue reconstruction and 16,635 (4.06%) had a PSI during their hospital stay. Patient safety indicators were associated with increased risk-adjusted mortality, longer length of stay, and decreased routine disposition (P < 0.01). Patient characteristics associated with a higher risk-adjusted rate per 1000 patients at risk included older age, men, nonwhite, and public payer (P < 0.05). Overall, plastic surgery patients had significantly lower risk-adjusted rate compared to other surgical inpatients for all events evaluated except for failure to rescue and postoperative hemorrhage or hematoma, which were not statistically different. Risk-adjusted rates of hematoma hemorrhage were significantly higher in patients receiving size-reduction surgery, and these rates were further accentuated when broken down by sex and payer.In general, plastic surgery patients had lower rates of in-hospital AEs than other surgical disciplines, but PSIs were not uncommon. With the establishment of national basal PSI rates in plastic surgery patients, benchmarks can be devised and target areas for quality improvement efforts identified. Further prospective studies should be designed to elucidate the drivers of AEs identified in this population.

    View details for DOI 10.1097/SAP.0b013e318297791e

    View details for PubMedID 24108144

  • Compliance With Gastric Cancer Guidelines is Associated With Improved Outcomes. Journal of the National Comprehensive Cancer Network Worhunsky, D. J., Ma, Y., Zak, Y., Poultsides, G. A., Norton, J. A., Rhoads, K. F., Visser, B. C. 2015; 13 (3): 319-325

    Abstract

    Limited data are available on the implementation and effectiveness of NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer.We sought to assess rates of compliance with NCCN Guidelines, specifically stage-specific therapy during the initial episode of care, and to determine its impact on outcomes.The California Cancer Registry was used to identify cases of gastric cancer from 2001 to 2006. Logistic regression and Cox proportional hazard models were used to predict guideline compliance and the adjusted hazard ratio for mortality. Patients with TNM staging or summary stage (SS) were also analyzed separately.Compliance with NCCN Guidelines occurred in just 45.5% of patients overall. Patients older than 55 years were less likely to receive guideline-compliant care, and compliance was associated with a median survival of 20 versus 7 months for noncompliant care (P<.001). Compliant care was also associated with a 55% decreased hazard of mortality (P<.001). Further analysis revealed that 50% of patients had complete TNM staging versus an SS, and TNM-staged patients were more likely to receive compliant care (odds ratio, 1.59; P<.001). TNM-staged patients receiving compliant care had a median survival of 25.3 months compared with 15.1 months for compliant SS patients.Compliance with NCCN Guidelines and stage-specific therapy at presentation for the treatment of patients with gastric cancer was poor, which was a significant finding given that compliant care was associated with a 55% reduction in the hazard of death. Additionally, patients with TNM-staged cancer were more likely to receive compliant care, perhaps a result of having received more intensive therapy. Combined with the improved survival among compliant TNM-staged patients, these differences have meaningful implications for health services research.

    View details for PubMedID 25736009

  • Collateral damage: taxane-induced colonic perforation. Digestive diseases and sciences Erdrich, J., Kastenberg, Z. J., DiMaio, M. A., Longacre, T. A., Rhoads, K. F. 2015; 60 (2): 313-315

    View details for DOI 10.1007/s10620-014-3305-1

    View details for PubMedID 25081225

  • Capsule Commentary on Anderson et al., Quality of Care and Racial Disparities in Medicare among Potential ACOs. Journal of general internal medicine Rhoads, K. F. 2014; 29 (9): 1273-?

    View details for DOI 10.1007/s11606-014-2934-6

    View details for PubMedID 25002160

  • Understanding the reliability of american college of surgeons national surgical quality improvement program as a quality comparator. JAMA surgery Rhoads, K. F., Wren, S. M. 2014; 149 (5): 474-?

    View details for DOI 10.1001/jamasurg.2013.4253

    View details for PubMedID 24623013

  • Adequacy of Lymph Node Examination in Colorectal Surgery Contribution of the Hospital Versus the Surgeon MEDICAL CARE Rhoads, K. F., Ackerson, L. K., Ngo, J. V., Gray-Hazard, F. K., Subramanian, S. V., Dudley, R. A. 2013; 51 (12): 1055-1062

    Abstract

    Examination of at least 12 lymph nodes (LNs) in the staging of colon cancer (CC) was recommended by the National Comprehensive Cancer Network in 2000; however, rates of an adequate examination remain low. This study compares the impact of the hospital contextual variance against that of the operating surgeon on delivery of an adequate LN examination.Retrospective analysis of California Cancer Registry data for all CC operations (2001-2006). Hierarchical models predicted the adequacy of LN examination as a function of patient, surgeon, and hospital characteristics. Models were created using penalized quasi-likelihood approximation with second order Taylor linearization as implemented in MLwiN 2.15.A total of 25,606 resections involving 3376 surgeons operating in 346 hospitals were analyzed. Half of cases had an adequate examination. Hierarchical models showed the median odds of an adequate examination associated with the hospital context [(MORhosp 2.05; 95% confidence interval, 1.9-2.2) was much higher than that associated with the surgeon (MORsurg 1.34; 95% confidence interval, 1.2-1.4)]. Hospital characteristics teaching and high volume predicted higher odds of an adequate examination. There was no association with hospital revenue.Approximately half of patients undergoing surgery for CC received an adequate LN examination. Hospital contextual factors had a stronger association with receipt of an adequate examination than surgeon factors. Our results suggest that quality improvement initiatives and incentives should be targeted at the hospital level to achieve the highest impact. Furthermore, we have identified nonteaching and low volume settings as rational targets for these efforts.

    View details for DOI 10.1097/MLR.0b013e3182a53d72

    View details for Web of Science ID 000327375500005

  • Improving the accuracy of prolapse and incontinence procedure epidemiology by utilizing both inpatient and outpatient data INTERNATIONAL UROGYNECOLOGY JOURNAL Elliott, C. S., Rhoads, K. F., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 24 (11): 1939-1946

    Abstract

    INTRODUCTION AND HYPOTHESIS: The epidemiologic description of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) procedures is documented in several large studies using national database cohorts. These studies, however, may underestimate the number of procedures performed because they only capture procedures performed in either the inpatient or outpatient settings alone. We present a complete annual description of all inpatient and outpatient surgeries for POP and SUI in California. METHODS: We reviewed a record of all inpatient and outpatient POP and SUI surgeries performed in California in 2008 using data from the Office of Statewide Health Planning (OSHPD). RESULTS: In 2008, 20,004 and 20,330 women in California underwent POP and SUI procedures, respectively. Of these, 3,134 (15.6%) and 9,016 (44.3%) were performed in an outpatient setting. The age-adjusted rates of POP and SUI were 1.20 and 1.20 per 1,000 US females, respectively. This correlates to 186,000 POP and 186,000 SUI procedures per year nationally. Vaginal apical suspensions were more common in those undergoing surgery as an inpatient (45.1 vs 19.4%). The use of mesh to augment prolapse repairs was similar (22.3% inpatient vs 19.3% outpatient). SUI procedures performed in the outpatient setting were more likely to be performed as stand-alone procedures (82.9 vs 18.8%, respectively). CONCLUSIONS: In California, 16% of POP and 44% of SUI procedures were performed in an outpatient surgical setting in 2008. Epidemiologic studies of POP and SUI should account for the fact that a substantial number of repairs are performed in the outpatient setting in order to achieve accuracy.

    View details for DOI 10.1007/s00192-013-2113-z

    View details for Web of Science ID 000325828800020

  • Predictors of Postoperative Urinary Retention After Colorectal Surgery DISEASES OF THE COLON & RECTUM Kin, C., Rhoads, K. F., Jalali, M., Shelton, A. A., Welton, M. L. 2013; 56 (6): 738-746

    Abstract

    : National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate.: The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery.: This was a prospective observational study.: A colorectal unit within a single institution was the setting for this study.: Adults undergoing elective colorectal operations were included.: Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured.: The primary outcomes measured were urinary retention and urinary tract infection.: The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ? 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%.: The lack of documentation of preoperative urinary function was a limitation of this study.: The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.

    View details for DOI 10.1097/DCR.0b013e318280aad5

    View details for Web of Science ID 000318782800013

    View details for PubMedID 23652748

  • Seventh Edition (2010) of the AJCC/UICC Staging System for Gastric Adenocarcinoma: Is there Room for Improvement? ANNALS OF SURGICAL ONCOLOGY Patel, M. I., Rhoads, K. F., Ma, Y., Ford, J. M., Visser, B. C., Kunz, P. L., Fisher, G. A., Chang, D. T., Koong, A., Norton, J. A., Poultsides, G. A. 2013; 20 (5): 1631-1638

    Abstract

    The gastric cancer AJCC/UICC staging system recently underwent significant revisions, but studies on Asian patients have reported a lack of adequate discrimination between various consecutive stages. We sought to validate the new system on a U.S. population database.California Cancer Registry data linked to the Office of Statewide Health Planning and Development discharge abstracts were used to identify patients with gastric adenocarcinoma (esophagogastric junction and gastric cardia tumors excluded) who underwent curative-intent surgical resection in California from 2002 to 2006. AJCC/UICC stage was recalculated based on the latest seventh edition. Overall survival probabilities were calculated using the Kaplan-Meier method.Of 1905 patients analyzed, 54 % were males with a median age of 70 years. Median number of pathologically examined lymph nodes was 12 (range, 1-90); 40 % of patients received adjuvant chemotherapy, and 31 % received adjuvant radiotherapy. The seventh edition AJCC/UICC system did not distinguish outcome adequately between stages IB and IIA (P = 0.40), or IIB and IIIA (P = 0.34). By merging stage II into 1 category and moving T2N1 to stage IB and T2N2, T1N3 to stage IIIA, we propose a new grouping system with improved discriminatory abilityIn this first study validating the new seventh edition AJCC/UICC staging system for gastric cancer on a U.S. population with a relatively limited number of lymph nodes examined, we found stages IB and IIA, as well as IIB and IIIA to perform similarly. We propose a revised stage grouping for the AJCC/UICC staging system that better discriminates between outcomes.

    View details for DOI 10.1245/s10434-012-2724-5

    View details for Web of Science ID 000317308200032

    View details for PubMedID 23149854

  • The Influence of Intern Home Call on Objectively Measured Perioperative Outcomes JAMA SURGERY Kastenberg, Z. J., Rhoads, K. F., Melcher, M. L., Wren, S. M. 2013; 148 (4): 347-351

    Abstract

    HYPOTHESIS In July 2011, surgical interns were prohibited from being on call from home by the new residency review committee guidelines on work hours. In support of the new Accreditation Council for Graduate Medical Education work-hour restrictions, we expected that a period of intern home call would correlate with increased rates of postoperative morbidity and mortality. DESIGN Prospective cohort. SETTING University-affiliated tertiary Veterans Affairs Medical Center. PATIENTS All patients identified in the Veterans Affairs National Surgical Quality Improvement Program database who underwent an operation performed by general, vascular, urologic, or cardiac surgery services between fiscal years (FYs) 1999 and 2010 were included. MAIN OUTCOME MEASURES During FYs 1999-2003, the first call for all patients went to an in-hospital intern. In the subsequent period (FYs 2004-2010), the first call went to an intern on home call. Thirty-day unadjusted morbidity and mortality rates and risk-adjusted observed to expected ratios were analyzed by univariate analysis and joinpoint regression, respectively. RESULTS Unadjusted overall morbidity rates decreased between 1999-2003 and 2004-2010 (12.14% to 10.19%, P= .003). The risk-adjusted morbidity observed to expected ratios decreased at a uniform annual percentage change of -6.03% (P<.001). Unadjusted overall mortality rates also decreased between the 2 periods (1.76% to 1.26%; P= .05). There was no significant change in the risk-adjusted mortality observed to expected ratios during the study. CONCLUSIONS The institution of an intern home call schedule was not associated with increased rates of postoperative morbidity or mortality.

    View details for DOI 10.1001/jamasurg.2013.1063

    View details for Web of Science ID 000320134900010

    View details for PubMedID 23715944

  • Surgical Site Infection: Is It Time to Change Our Expectations? JAMA surgery Rhoads, K. F. 2013

    View details for PubMedID 23863993

  • Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes HPB Visser, B. C., Ma, Y., Zak, Y., Poultsides, G. A., Norton, J. A., Rhoads, K. F. 2012; 14 (8): 539-547

    Abstract

    There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes.The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ? 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality.In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)].There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.

    View details for DOI 10.1111/j.1477-2574.2012.00496.x

    View details for Web of Science ID 000305993800007

    View details for PubMedID 22762402

  • Predictors of Surgical Intervention for Hepatocellular Carcinoma ARCHIVES OF SURGERY Zak, Y., Rhoads, K. F., Visser, B. C. 2011; 146 (7): 778-784

    Abstract

    To define current use of surgical therapies for hepatocellular carcinoma (HCC) and evaluate the correlation of various patient and hospital characteristics with the receipt of these interventions.Retrospective cohort.California Cancer Registry data linked to the Office of Statewide Health Planning and Development patient discharge abstracts between 1996 and 2006.Patients with primary HCC.Receipt of liver transplant, hepatic resection, or local ablation.Of 12,148 HCC cases, 2390 (20%) underwent surgical intervention. Three hundred eleven (2.56%) received a liver transplant, 1307 (10.8%) underwent resection, and 772 (6.35%) had local ablation. There were wide variations in treatment by race and hospital type. African American and Hispanic patients were less likely than white patients to undergo transplant (P < .05). African American and Hispanic patients were less likely than white and Asian/Pacific Islander patients to have hepatectomy or ablation (P < .05). In multivariable analysis, the apparent differences in surgical intervention by race/ethnicity were decreased when adjusting for the patients' socioeconomic and insurance statuses. Patients with lower socioeconomic status and no private insurance were less likely to receive any surgery (P < .01). Hospital characteristics also explained some variations. Disproportionate Share Hospitals and public, rural, and nonteaching hospitals were less likely to offer surgical treatment (P < .01).There are significant racial, socioeconomic, and hospital-type disparities in surgical treatment of HCC.

    View details for DOI 10.1001/archsurg.2011.37

    View details for Web of Science ID 000292877800002

    View details for PubMedID 21422327

  • Performance Measurement, Public Reporting, and Pay-for-Performance UROLOGIC CLINICS OF NORTH AMERICA Rhoads, K. F., Konety, B. M., Dudley, R. A. 2009; 36 (1): 37-?

    Abstract

    The use of incentives to improve quality of care is spreading rapidly across the health care system. Public reporting (PR) and pay-for-performance (PFP) are two examples of incentive-based programs. Although conclusive level I evidence for the positive impacts of these PR and PFP is limited, individual states and the federal government have begun to adopt and pilot these programs for a variety of specific clinical conditions. This article reviews the principles of health care quality performance measurement; current reporting and pay-for-performance programs; and the most recent literature documenting positive, negative and future impacts of these types of programs on urologic practice.

    View details for DOI 10.1016/j.ucl.2008.08.003

    View details for Web of Science ID 000262172300006

    View details for PubMedID 19038634

  • A role for Hox A5 in regulating angiogenesis and vascular patterning. Lymphatic research and biology Rhoads, K., Arderiu, G., Charboneau, A., Hansen, S. L., Hoffman, W., Boudreau, N. 2005; 3 (4): 240-252

    Abstract

    Homeobox (Hox) genes are transcriptional regulators which modulate embryonic morphogenesis and pathological tissue remodeling in adults via regulation of genes associated with cell-cell or cell extracellular matrix (ECM) interactions. We previously showed that while Hox 3 genes promote angiogenesis, Hox D10 inhibits this process.Here we show that another Hox family gene, Hox A5, also blocks angiogenesis but accomplishes this by targeting different downstream genes than Hox D10. Sustained expression of Hox A5 leads to down regulation of many pro-angiogenic genes including VEGFR2, ephrin A1, Hif1alpha and COX-2. In addition, Hox A5 also upregulates expression of anti-angiogenic genes including Thrombospondin-2. Furthermore, we show that while Hox A5 mRNA is expressed in quiescent endothelial cells (EC), its expression is diminished or absent in active angiogenic EC found in association with breast tumors or in proliferating infantile hemangiomas.Together our results suggest that restoring Hox A5 expression may provide a novel means to limit breast tumor growth or expansion of hemangiomas.

    View details for PubMedID 16379594

  • Cholelithiasis and perforated gallbladder in an infant JOURNAL OF PEDIATRIC SURGERY Rhoads, K., Snyder, J., LEE, H. 2002; 37 (9): 1374-1375

    Abstract

    An infant presented with abdominal distension and failure to thrive. This patient was a 3.5-month-old, ex-26-week premature infant at the time of presentation who required supplemental parenteral nutrition until day 9 of life. Workup found ascites and a complex cystic mass in the porta hepatis. A perforated gallbladder with gallstones was found at laparotomy. The gallstones were removed, and the bed of the gallbladder was drained. Output from the drain was minimal by postoperative day 6, and the drain subsequently was removed. The child did well postoperatively; hematologic and metabolic workups were unrevealing. Perforation of the gallbladder is an exceedingly uncommon finding in infants. Appropriate management includes laparotomy and drainage of the gallbladder bed.

    View details for DOI 10.1053/jpsu.2002.35029

    View details for Web of Science ID 000177881400030

    View details for PubMedID 12194140

  • Breast Cancer Beliefs and Behaviors at the San Francisco General Hospital. The breast journal Rhoads, K. F., Luce, J. A., Knudson, M. M. 2000; 6 (1): 20-26

    Abstract

    This study compared an ethnically mixed population of lower socioeconomic status women regarding their breast cancer beliefs, surgical decision making, sources of information, reactions to the diagnosis, and use of support groups. A 20-item oral survey was administered to a convenience sample recruited at the San Francisco General Hospital breast clinic during 1997. Data were analyzed by chi-square analysis with stratification according to age, ethnicity, education, and language. Corrections were made for small frequencies. P values of less than 0.05 were considered significant. The mean age (n = 30) was 56 years (range 39-72 years). Ten participants were African American, 7 Caucasian, 6 Filipino, 4 Chinese, and 3 Latina. Education averaged 12 years. Ten were non-English speakers. Breast cancer beliefs varied by ethnicity, age, and education. Surgical decision making showed that less formally educated women tended to include the doctor in decision making more often. Sources of information varied by English language capacity. Reactions to the diagnosis and use of support groups showed no difference among the categories. Some results of this study corroborate reports of breast cancer beliefs and decision-making styles published in the literature. Differences noted in the study may be explained in part by socioeconomic and ethnic differences between our population and those commonly sampled in the literature. These results suggest the need for further research in multiethnic and low-income populations with breast cancer. They also suggest some important implications for understanding community educational needs.

    View details for PubMedID 11348330

  • The health status of women of color. Journal of the American Medical Women's Association (1972) Felder, K. 1996; 51 (4): 171-?

    View details for PubMedID 8840736

Conference Proceedings


  • Variation in the Quality of Surgical Care for Uterovaginal Prolapse Rhoads, K. F., Sokol, E. R. LIPPINCOTT WILLIAMS & WILKINS. 2011: 46-51

    Abstract

    Pelvic organ prolapse is a common disorder, affecting an estimated 24% of women in the United States, with more than 200,000 surgical procedures performed annually. Current treatment recommendations from the American College of Obstetricians and Gynecologists include pelvic floor reconstruction (or pexy) procedures to correct prolapse, with or without hysterectomy; however, many women are treated by hysterectomy alone.To determine whether hospital characteristics predict compliance with recommended surgical care for uterovaginal prolapse.Retrospective analysis of linked California hospital discharge and financial data. International Classification of Diseases, ninth Edition Clinical Modification codes identified records with a primary diagnosis of prolapse and concomitant coding for surgical procedures. ?2 analysis and multivariable models were used to characterize the associations between hospital characteristics and compliance. Compliant care was defined as prolapse treatment by pelvic floor reconstruction (pexy) procedure with or without hysterectomy. Failed compliance was defined as hysterectomy alone.A total of 28,539 cases in 343 hospitals were analyzed. Low compliance rates were detected in all hospital types, though some were better than others. High-volume (odds ratios [OR] = 1.75; 95% CI: [1.62, 1.89]), teaching (OR = 2.03; 95% CI: [1.84, 2.25]), and private (OR = 1.28; 95% CI: [1.14, 1.46]) hospitals were more likely, while disproportionate share hospitals were less likely (OR = 0.58; 95% CI: [0.54, 0.63]) to comply with evidence-based recommendation.Although we did find significant variation in compliance by hospital characteristics, compliance rates were low in all settings. Quality improvement efforts in the surgical treatment of uterovaginal prolapse should focus on increasing adherence to evidence-based practice.

    View details for DOI 10.1097/MLR.0b013e3181f37fed

    View details for Web of Science ID 000285407100007

    View details for PubMedID 21102358

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