Lumbar Imaging With Reporting of Epidemiology: A Pragmatic Cluster Randomized Trial
Phase: NA
Conditions: Low Back Pain, Back Pain, Lumbar Pain, Backache
Sponsor: University of Washington



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LUMBAR SPINE MR IMAGING REPORTS 

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Table 1: Outcomes of Patients Whose Imaging Did and Did Not Include a Statement 
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Table 4: Milestones for UH2 Planning Year Needed to Transition to UH3 Implementation 
UH2 Phase Milestone 
Timeline 
Suitability for 
Assessing UH2 
Success 
Importance to UH3 
Success 
Aim 1:Complete critical literature 
review to refine the information to be 
included in the radiology report so 
that it is specific for imaging modality 
and patient age. 
Jarvik, Bresnahan, Deyo, Halabi, 
Kallmes, Turner, Luetmer, Avins 
3 
months 
 
Highly suitable: 
Necessary to develop 
text describing age-
specific epidemiologic 
benchmarks for plain 
films, CT and MR. 
Critically important: 
Development and 
refinement of the 
intervention text is 
necessary for the timely 
implementation of the 
intervention. 
 Aim 2: Develop site-specific 
deployment methods for the stepped 
wedge, cluster randomization scheme 
Comstock, Anderson, Avins, 
Cherkin, Halabi, Heagerty, James, 
Jarvik, Pathak, Murphy, Ciarelli,  
Needed: KP technical resource 
Needed: GHC technical resource 
3 
months 
Highly suitable: Will 
need detailed 
implementation 
protocols prior to 
implementation of 
intervention. 
Critically important: Sites 
must have proven ability 
to selectively implement 
intervention text in the 
radiologic reports 
generated for providers at 
a given primary care 
clinic. 
Aim 3: Develop and validate a 
composite measure of spine 
intervention intensity that combines 
into a single metric the overall 
intensity of resource utilization for 
back pain care and develop cost 
estimates associated with units of 
resource used and intensity of use. 
Bresnahan, Deyo, James, Jarvik 
6 
months 
Suitable: Definition of 
composite measure 
to be used as primary 
outcome and 
validation using 
existing BOLD data. 
 
Important: The 
achievement is important 
but not critical. While 
other metrics could be 
used successfully, 
including single 
parameters, a composite 
measure enables a more 
comprehensive estimate 
of overall care received 
for back pain. 
Aim 4:Develop and validate 
electronic data methods and tools to 
capture the outcomes of interest 
(subsequent diagnostic testing, opioid 
prescriptions, spinal injections, 
specialist visits, spine surgeries, etc.) 
Anderson, Comstock, James, 
Jarvik, Turner  
 
6 
months 
Highly suitable: Data 
dictionary and 
protocol to query the 
electronic medical 
record (EMR) 
necessary 
Critically Important: 
Feasibility must be 
demonstrated in order to 
passively collect 
outcomes using the EMR. 
Additional Goals: Data Safety 
Monitoring Plan (DSMP) formulation 
and designation of safety officer 
Heagerty, Comstock, James, Jarvik 
6 
months 
Highly suitable: 
Drafting of DSMP, 
submission to 
IRBs,funding agency, 
and designation of 
Safety Officer needed 
prior to study initiation 
Critically Important: A 
safety officer will need to 
review and approve the 
study DSMP. 
Additional Goals: Draft study 
protocol 
James, Comstock, Jarvik 
6 
months 
Highly suitable: Draft 
the study protocol so 
it incorporates the 
decisions made for 
Aims 1-4 
Critically Important: The 
study protocol will need 
to be reviewed by the 
IRBs before the study 
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Additional Goals: IRB approval 
James, Avins, Cherkin, Halabi, 
Jarvik, Kallmes, Project Managers 
from each site (Hamilton, Connelly, 
Wessman, Hawkes) 
9-12 
months 
Highly suitable: 
Conditional IRB 
approval at multiple 
sites always 
challenging 
Critically Important: IRB 
approval is required 
before study procedures 
can be initiated. 
Additional Goals: Establish 
subcontracts with sites 
James, Avins, Cherkin, Halabi, 
Jarvik, Kallmes, Post-award 
personnel at each site 
9-12 
months 
Draft and submit 
subcontracts for the 
UH3 phase at all sites 
Critically Important: 
Subcontracting with sites 
is a required process. 


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Year of 
Project 
UH3 Milestone 
Comment 
Year 2 
Final testing of intervention deployment 
To be completed before Wave 1 of 
randomization scheduled for April, 2014 
 
Intervention implemented at 40% of clinical sites 
Planned staggered implementation using 
stepped wedge design will require close 
monitoring of progress.   
 
Algorithm finalized for electronic medical record 
extraction and tested at all sites 
This will continue the work started as 
UH2 Milestone #4. Each site will require 
a customized algorithm- hence the need 
for site-specific development and testing 
 
Protocol paper submitted for publication 
We will prepare a manuscript describing 
our study protocol and procedures. 
Year 3 
Randomized intervention implemented at 80% of 
clinical sites 
Planned staggered implementation using 
stepped wedge design will require close 
monitoring of progress. 
 
Medical record extraction complete for 12mo 
outcomes on randomization waves 1-2  
Data extraction ongoing for duration of 
project for 12 and 24mo time-points. 
 
Comparison of abstraction methods for radiology 
reports (natural language processing vs. Amazon 
Turk) 
 
Year 4 
Intervention implementation completed 
All clinical sites randomized to 
intervention by this time. 
 
Medical record extraction complete for 12mo 
outcomes on randomization waves 3-4 and 24mo 
outcomes on randomization waves 1-2 
 
 
Abstraction of radiology reports through 12mo for 
waves 1-4 using preferred method from yr 3 
 
Year 5 
Medical record extraction including imaging 
reports complete for 12mo outcomes on 
randomization wave 5 and 24 mo outcomes on 
randomization waves 3-4  
 

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LIRE literature search strategy for Intervention Text 
 
1. The LIRE WG1 team worked with University of Washington librarians to develop our search 
strategy and list of search terms. 
 
2. Using PubMed, we used the following terms for our initial WG1 literature search: 
 
("Morbidity"[Mesh] OR ("epidemiology"[Subheading] OR "epidemiology"[All Fields] OR 
"prevalence"[All Fields] OR "prevalence"[MeSH Terms]) OR "Epidemiology"[Mesh] OR 
"epidemiology"[Subheading] OR "Epidemiologic Factors"[Mesh] OR "Incidental 
Findings"[Mesh] OR incidental[All Fields] OR "Asymptomatic Diseases"[Mesh] OR 
asymptomatic[All Fields] OR "Unnecessary Procedures"[MeSH Terms]) AND ("Lumbar 
Vertebrae"[Mesh] OR "Low Back Pain"[Mesh] OR "Intervertebral Disc Displacement"[Mesh] 
OR "Sciatica"[Mesh] OR "Spinal Stenosis"[Mesh] OR "Synovial Cyst"[Mesh] OR 
"Scoliosis"[Mesh] OR "Spondylolysis"[Mesh] OR "Spinal Osteochondrosis"[Mesh] OR "disc 
degeneration"[All Fields] OR "disc height loss"[All Fields] OR "disc bulge"[All Fields] OR 
"disc protrusion"[All Fields] OR annular[All Fields] OR anular[All Fields] OR "high intensity 
zone"[All Fields] OR anulus[All Fields] OR annulus[All Fields] OR listhesis[All Fields] OR 
(disc[All Fields] AND ("desiccation"[MeSH Terms] OR "desiccation"[All Fields] OR 
"dessication"[All Fields])) OR "disc dehydration"[All Fields] OR (modic[All Fields] AND 
endplate[All Fields] AND ("Change"[Journal] OR "change"[All Fields])) OR "nerve root 
displacement"[All Fields] OR "nerve root compression"[All Fields] OR "disc sequestration"[All 
Fields] OR "intravertebral herniations"[All Fields] OR (intravertebral[All Fields] AND 
("hernia"[MeSH Terms] OR "hernia"[All Fields])) OR (intradiscal[All Fields] AND 
("hernia"[MeSH Terms] OR "hernia"[All Fields])) OR (intradiscal[All Fields] AND 
("hernia"[MeSH Terms] OR "hernia"[All Fields] OR "herniation"[All Fields])) OR "intradural 
herniation"[All Fields] OR (intravertebral[All Fields] AND ("hernia"[MeSH Terms] OR 
"hernia"[All Fields])) OR (intravertebral[All Fields] AND ("hernia"[MeSH Terms] OR 
"hernia"[All Fields] OR "herniation"[All Fields])) OR "prolapsed disc"[All Fields] OR "radial 
fissure"[All Fields]) AND ("Magnetic Resonance Imaging"[Mesh] OR "Tomography, X-Ray 
Computed"[Mesh] OR "Radiography"[Mesh]) 
 
3. Using PubMed advance search tool, the above search criteria generates N=2957 identified 
articles. LIRE WG1 used the following reviewers and inclusion criteria to evaluate the 
abstracts. 
 
 
Start 
End 
reviewer 1 
reviewer 2 
1 
330 avins 
bresnahan 
331 
660 bresnahan 
chen 
661 
990 chen 
deyo 
991 
1320 deyo 
halabi 
1321 
1650 halabi 
jarvik 
1651 
1980 jarvik 
kallmes 
1981 
2310 kallmes 
luetmer 
2311 
2640 luetmer 
turner 
2641 
2957 turner 
avins 

 
Inclusion criteria for articles: 
1. article included subjects without low back pain (LBP) 
2. listed prevalence of imaging finding in patients without LBP 
3. subjects were >=18 (exclude series that were strictly peds) 
4. subjects were human and alive (no cadaver or animal studies) 
5. imaging study prevalence data was for either MR, CT or plain film 
6. prevalence for at least one of the following was included :  
4. spinal stenosis,  
5. disc bulge,  
6. disc protrusion,  
7. disc extrusion,  
8. disc herniation, 
9. disc degeneration,  
10. disc dessication (or dehydration), 
11. disc height loss,  
12. nerve root involvement (contact, displacement or compression), 
13. anular fissure (or anular tear or HIZ), 
14. spondylolysis, 
15. spondylolisthesis, 
16. modic change, 
17. Schmorl’s node, 
18. synovial cyst, 
19. osteochondrosis 
 

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Intervention implementation inclusion criteria to verify in pilot test 
Required Inclusion Criteria 
1. Can the intervention text be delivered based upon a specific CPT code (Xray: 72100, 
72110, 72114, 72080; CT: 72131, 72132, 72133; MR: 72148, 72149, 72158)? 
2. Can modality-specific (Xray, CT, MR) intervention text be inserted? 
3. Can the intervention text be delivered based upon patient age (patients 18 and older)? 
4. Can the intervention text be delivered to clinics on a scheduled basis at the 5 pre-
specified dates listed above?  
5. Through an electronic medical record or radiology information system data pull, can 
you verify that the text was inserted into a patient’s record with an eligible imaging CPT 
code? 
Must meet one of the following two criteria: 
6.1 Can age range-specific (Section 3, Option 1) text be displayed in the radiology 
report depending on patient age? 
6.2 Can tabular information by age (Section 3, Option 2) be displayed in the radiology 
report? 

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The following MRI findings are so common in people without low back pain that while 
we report their presence, they must be interpreted with caution and in the context of the 
clinical situation. 
 
Disk 
Degeneration 
Disk T2 
Signal 
Loss 
Disk 
Height 
Loss 
Disk 
Bulge 
Disk 
Protrusion 
Annular 
Fissure 
21-30 
A1% 
A2% 
A3% 
A4% 
A5% 
A6% 
31-40 
B1% 
B2% 
B3% 
B4% 
B5% 
B6% 
41-50 
C1% 
C2% 
C3% 
C4% 
C5% 
C6% 
51-60 
D1% 
D2% 
D3% 
D4% 
D5% 
D6% 
61-70 
E1% 
E2% 
E3% 
E4% 
E5% 
E6% 
71-80 
F1% 
F2% 
F3% 
F4% 
F5% 
F6% 
81-90 
G1% 
G2% 
G3% 
G4% 
G5% 
G6% 
>91 
H1% 
H2% 
H3% 
H4% 
H5% 
H6% 

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# 
Group Health Clinic Name 
#PCPs 
 
Meets 
Inclusion 
Criteria  
1 - 5 
 
Meets 
Inclusion 
Criteria    
6.1 or 6.2 
 
 
 
Reasons 
for Failure 
1 Bellevue Medical Center 
12 
 
 
 
 
2 Burien Medical Center 
15 
 
 
 
 
3 Capitol Hill Campus 
32 
 
 
 
 
4 Downtown Seattle Medical Center 
7 
 
 
 
 
5 Everett Medical Center 
20 
 
 
 
 
6 Factoria Medical Center 
12 
 
 
 
 
7 Federal Way Medical Center 
14 
 
 
 
 
8 Kent Medical Center 
7 
 
 
 
 
9 
Spokane-Lidgerwood Medical 
Center 
13 
 
 
 
 
10 Northgate Medical Center 
31 
 
 
 
 
11 Northshore Medical Center 
8 
 
 
 
 
12 Olympia Medical Center 
41 
 
 
 
 
13 Port Orchard Medical Center 
18 
 
 
 
 
14 Poulsbo Medical Center 
8 
 
 
 
 
15 Puyallup Medical Center 
11 
 
 
 
 
16 Rainier Medical Center 
8 
 
 
 
 
17 Redmond Medical Center 
10 
 
 
 
 
18 Renton Medical Center 
13 
 
 
 
 
19 
Spokane-Riverfront Medical 
Center 
17 
 
 
 
 
20 Silverdale Medical Center 
16 
 
 
 
 
21 Spokane-South Hill Medical Center 
5 
 
 
 
 
22 Tacoma Medical Center 
10 
 
 
 
 
23 Tacoma South Medical Center 
15 
 
 
 
 
24 Spokane-Veradale Medical Center 
8 
 
 
 
 
25 Lynnwood Medical Center 
15 
 
 
 
 
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<comments here>
 

LIRE Working Group 3
Appendix of Relevant Articles Using RVU-based Assessment
1.
Adelgais KM, Grossman DC, Langer SG, Mann FA. Use of helical computed tomography 
for imaging the pediatric cervical spine. Academic emergency medicine : official journal 
of the Society for Academic Emergency Medicine. Mar 2004;11(3):228-236.
2.
Allen B, Jr., Donovan WD, McGinty G, et al. Professional component payment 
reductions for diagnostic imaging examinations when more than one service is rendered 
by the same provider in the same session: an analysis of relevant payment policy. 
Journal of the American College of Radiology : JACR. Sep 2011;8(9):610-616.
3.
Appleton P, Chacko A, Rodriguez EK. Financial implications of nonoperative fracture 
care at an academic trauma center. Journal of orthopaedic trauma. Nov 2012;26(11):
617-619.
4.
Archila AM, Jarecke AJ, Damiani TN, Boorady J. Tri-service optometry productivity 
findings and benchmark recommendation. Military medicine. Apr 2007;172(4):418-420.
5.
Arenson RL, Lu Y, Elliott SC, Jovais C, Avrin DE. Measuring the academic radiologist's 
clinical productivity: applying RVU adjustment factors. Academic radiology. Jun 
2001;8(6):533-540.
6.
Barnes SL, Robinson BR, Richards JT, et al. The devil is in the details: maximizing 
revenue for daily trauma care. Surgery. Oct 2008;144(4):670-675; discussion 675-676.
7.
Becker ER, Hall K. Physician services in an academic neurology department: using the 
resource-based relative-value scale to examine physician activities. Journal of health 
care finance. Summer 2001;27(4):79-91.
8.
Becker ER, Mauldin PD, Culler SD, Kosinski AS, Weintraub WS, King SB. Applying the 
resource-based relative value scale to the Emory angioplasty versus surgery trial. The 
American journal of cardiology. Mar 15 2000;85(6):685-691.
9.
Begaz T, Decker MC, Treat R, Tews M. No relationship between measures of clinical 
efficiency and teaching effectiveness for emergency medicine faculty. Emergency 
medicine journal : EMJ. Jan 2011;28(1):37-39.
10.
Bender JR, Johnson AJ, Schenk TW. The economic value of automotive occupational 
health services: business metrics for performance management. Journal of occupational 
and environmental medicine / American College of Occupational and Environmental 
Medicine. Feb 2008;50(2):138-145.
11.
Bergersen L, Gauvreau K, McElhinney D, et al. Capture of Complexity of Specialty Care 
in Pediatric Cardiology by Work RVU Measures. Pediatrics. Feb 2013;131(2):258-267.
12.
Bernard AM, Hayward RA, Rosevear J, Chun H, McMahon LF. Comparing the 
hospitalizations of transfer and non-transfer patients in an academic medical center. 
Academic medicine : journal of the Association of American Medical Colleges. Mar 
1996;71(3):262-266.
13.
Bittner JGt, Kang R, Stern PJ. Management of flexor tendon sheath ganglions: a cost 
analysis. The Journal of hand surgery. Jul 2002;27(4):586-590.
14.
Bree RL, Kazerooni EA, Katz SJ. Effect of mandatory radiology consultation on inpatient 
imaging use. A randomized controlled trial. JAMA : the journal of the American Medical 
Association. Nov 20 1996;276(19):1595-1598.
15.
Brennan DF, Silvestri S, Sun JY, Papa L. Progression of emergency medicine resident 
productivity. Academic emergency medicine : official journal of the Society for Academic 
Emergency Medicine. Sep 2007;14(9):790-794.
16.
Bronstein JM, Adams EK. Rural-urban differences in health risks, resource use and 
expenditures within three state medicaid programs: implications for medicaid managed 
care. The Journal of rural health : official journal of the American Rural Health 
Association and the National Rural Health Care Association. Winter 2002;18(1):38-48.
17.
Buntin MJ, Escarce JJ, Goldman D, Kan H, Laugesen MJ, Shekelle P. Increased 
Medicare expenditures for physicians' services: what are the causes? Inquiry : a journal 
of medical care organization, provision and financing. Spring 2004;41(1):83-94.

18.
Chaudhry R, Kottke TE, Naessens JM, et al. Busy physicians and preventive services 
for adults. Mayo Clinic proceedings. Mayo Clinic. Feb 2000;75(2):156-162.
19.
Cheriff AD, Kapur AG, Qiu M, Cole CL. Physician productivity and the ambulatory EHR 
in a large academic multi-specialty physician group. International journal of medical 
informatics. Jul 2010;79(7):492-500.
20.
Chin MH, Zhang JX, Merrell K. Specialty differences in the care of older patients with 
diabetes. Medical care. Feb 2000;38(2):131-140.
21.
Chung KC, Walters MR, Greenfield ML, Chernew ME. Endoscopic versus open carpal 
tunnel release: a cost-effectiveness analysis. Plastic and reconstructive surgery. Sep 
1998;102(4):1089-1099.
22.
Conoley PM, Vernon SW, Burtram SG. Growth profiles for radiology in the United States, 
1973-1989: commentary based upon analysis of relative value units. European journal of 
radiology. Oct 1992;15(3):264-269.
23.
Conoley PM, Vernon SW, Burtram SG. Productivity of radiologists in the United States 
by imaging technique: a 16-year analysis based upon relative value units. European 
journal of radiology. Oct 1992;15(3):258-263.
24.
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prepaid group practice: effects on primary care physician productivity. Health services 
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25.
Cook SP. Candidate's Thesis: Laryngotracheal separation in neurologically impaired 
children: long-term results. The Laryngoscope. Feb 2009;119(2):390-395.
26.
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for teaching residents: who profits? Pediatrics. Jul 2003;112(1 Pt 1):40-48.
27.
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Multivariable predictors of postoperative cardiac adverse events after general and 
vascular surgery: results from the patient safety in surgery study. Journal of the 
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28.
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of care and augments clinical and economic outcomes. The Journal of trauma. Dec 
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29.
Davis PL. Assessing the potential versus the actual earnings of academic radiologists: 
effects of unequal duty service assignments. Academic radiology. Aug 2001;8(8):
782-791.
30.
Dobrez D, Sasso AL, Holl J, Shalowitz M, Leon S, Budetti P. Estimating the cost of 
developmental and behavioral screening of preschool children in general pediatric 
practice. Pediatrics. Oct 2001;108(4):913-922.
31.
Dorr DA, Wilcox A, McConnell KJ, Burns L, Brunker CP. Productivity enhancement for 
primary care providers using multicondition care management. The American journal of 
managed care. Jan 2007;13(1):22-28.
32.
Dudas RA, Monroe D, McColligan Borger M. Community pediatric hospitalists providing 
care in the emergency department: an analysis of physician productivity and financial 
performance. Pediatric emergency care. Nov 2011;27(11):1099-1103.
33.
Duszak R, Jr., Harris AB. Percutaneous abscess drainage: use of related radiology 
services and associated economic impact on a radiology practice. Journal of vascular 
and interventional radiology : JVIR. May 2003;14(5):597-601.
34.
Fahy BN, Bold RJ, Schneider PD, Khatri V, Goodnight JE, Jr. Cost-benefit analysis of 
biopsy methods for suspicious mammographic lesions; discussion 994-5. Archives of 
surgery (Chicago, Ill. : 1960). Sep 2001;136(9):990-994.
35.
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satisfaction: comparison of part-time and full-time primary care physicians. Journal of 
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36.
Fleming NS, Becker ER, Culler S, Cheng D, McCorkle R, Ballard DJ. Financial 
performance of primary care physician practices prior to electronic health record 
implementation. Proceedings (Baylor University. Medical Center). Apr 2009;22(2):

112-118.
37.
Grace C, Alston WK, Ramundo M, Polish L, Kirkpatrick B, Huston C. The complexity, 
relative value, and financial worth of curbside consultations in an academic infectious 
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Diseases Society of America. Sep 15 2010;51(6):651-655.
38.
Green PH, Neugut AI, Naiyer AJ, Edwards ZC, Gabinelle S, Chinburapa V. Economic 
benefits of increased diagnosis of celiac disease in a national managed care population 
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39.
Griffin TC, Hutter JJ, Johnson KK, Moscow JA. A survey of clinical productivity and 
current procedural terminology (CPT) coding patterns of pediatric hematologist/
oncologists. Pediatric blood & cancer. Aug 2004;43(2):140-147.
40.
Henke PK, Kubus J, Englesbe MJ, Harbaugh C, Campbell DA. A statewide consortium 
of surgical care: a longitudinal investigation of vascular operative procedures at 16 
hospitals. Surgery. Oct 2010;148(4):883-889; discussion 889-892.
41.
Henley MB, Mann FA, Holt S, Marotta J. Trends in case-mix-adjusted use of radiology 
resources at an urban level 1 trauma center. AJR. American journal of roentgenology. 
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42.
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43.
Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. 
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surgery: results from the patient safety in surgery study. Journal of the American College 
of Surgeons. Jun 2007;204(6):1188-1198.
44.
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45.
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46.
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47.
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48.
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49.
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50.
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51.
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52.
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55.
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72.
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