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Rice DR, Farooq A, Hyer JM, Paredes AZ, Bae J, Tsilimigras DI, Pawlik TM. Health expenditures and financial burden among patients with major gastrointestinal cancers relative to other common cancers in the United States. Surgery 2020; 167:985-990. [DOI: 10.1016/j.surg.2020.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/11/2020] [Accepted: 02/26/2020] [Indexed: 12/20/2022]
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Hyer JM, Paredes AZ, Cerullo M, Tsilimigras DI, White S, Ejaz A, Pawlik TM. Assessing post-discharge costs of hepatopancreatic surgery: an evaluation of Medicare expenditure. Surgery 2020; 167:978-984. [DOI: 10.1016/j.surg.2020.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/28/2020] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
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Mehta R, Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Ejaz A, Cloyd JM, Dillhoff M, Tsung A, Pawlik TM. Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies. J Gastrointest Surg 2020; 24:1320-1329. [PMID: 31197689 PMCID: PMC7011949 DOI: 10.1007/s11605-019-04288-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care. METHODS Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined. RESULTS In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22-0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34-0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38-0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76-2.71). CONCLUSION Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.
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Palmer Kelly E, Paredes AZ, Tsilimigras DI, Hyer JM, Pawlik TM. The role of religion and spirituality in cancer care: An umbrella review of the literature. Surg Oncol 2020; 42:101389. [PMID: 34103240 DOI: 10.1016/j.suronc.2020.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/22/2020] [Accepted: 05/16/2020] [Indexed: 01/09/2023]
Abstract
Although some studies have suggested a strong relationship between religion and spirituality (R&S) and patient outcomes in cancer care, other data have been mixed or even noted adverse effects associated with R&S in the healthcare setting. We sought to perform an umbrella review to systematically appraise and synthesize the current body of literature on the role of patient R&S in cancer care. A systematic search of the literature was conducted that focused on "cancer" (neoplasm, malignant neoplasm, malignancy), "spirituality" (beliefs, divine), and "religion" (specific practices like Christianity, faith, faith healing, prayer, Theology). A total of 41 review articles published from 1995 to 2019 were included: 8 systematic reviews, 6 meta-analyses, 4 systematic reviews and meta-analysis, and 23 other general reviews. The number of studies included in each review ranged from 7 to 148, while 10 studies did not indicate sample size. Most articles did not focus on a specific cancer diagnosis (n = 36), stage of cancer (n = 32), or patient population (n = 34). Many articles noted that R&S had a positive impact on cancer care, yet some reviews reported inconclusive or negative results. Marked variation in methodological approaches to studying R&S among cancer patients, including operational definitions and measurement, were identified. Resolving these issues will be an important step to understanding how patients seek to have R&S integrated into their patient-centered cancer care experience.
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Palmer Kelly E, Paredes AZ, DiFilippo S, Hyer M, Myers B, McGee J, Rice D, Bae J, Tsilimigras DI, Pawlik TM. Do Religious/Spiritual Preferences and Needs of Cancer Patients Vary Based on Clinical- and Treatment-Level Factors? Ann Surg Oncol 2020; 28:59-66. [PMID: 32424588 DOI: 10.1245/s10434-020-08607-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The objective of this study is to characterize the religion and spiritual (R&S) needs of patients who undergo cancer-directed surgery. In addition, we seek to examine how R&S needs vary based on R&S identity and clinical and surgical treatment characteristics. PATIENTS AND METHODS A cross-sectional survey was administered to potential participants who were recruited through outpatient clinics and online. Respondent desires for R&S resources and engagement with the healthcare team around R&S topics were assessed. RESULTS Among 383 potential participants who were identified, 236 respondents were included in the analytic cohort. Mean age was 58.8 (SD 12.10) years, and most participants were female (75.8%) and White/Caucasian (94.1%). The majority (78.4%) identified as currently cancer free. Commonly treated malignancies included breast (43.2%), male reproductive (8.9%), skin (8.5%), and gastrointestinal (GI) (7.2%). Two-thirds of the respondents indicated a desire to have R&S incorporated into their cancer treatment (63.3%). Patients who identified as highly/moderately religious reported wanting R&S more often (highly religious: 95.2% versus moderately religious: 71.4% vs. nonreligious but spiritual: 4.5%). On multivariable analysis, patients who believed their health would improve in the future were more likely to report wanting R&S service (OR 2.2, 95% CI 1.0-4.7) as well as wanting to engage their healthcare providers on R&S topics (OR 2.4, 95% CI 1.2-4.7). In contrast, perception of current or future health status was not associated with patient desire for the actual surgeon/doctor him/herself to be involved in R&S activities (OR 1.83, 95% CI 0.97-3.45). CONCLUSIONS Two-thirds of patients undergoing cancer-directed surgery expressed a desire to have R&S incorporated into their cancer treatment. Incorporating R&S into cancer treatment can help a subset of patients throughout their cancer experience.
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Diaz A, Paredes AZ, Hyer JM, Pawlik TM. Variation in value among hospitals performing complex cancer operations. Surgery 2020; 168:106-112. [PMID: 32409168 DOI: 10.1016/j.surg.2020.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND While variation in outcomes has driven centralization of complex cancer surgery, variation in cost and value remains unexplored. We evaluated outcomes relative to cost among hospitals performing esophageal and pancreatic resection for cancer. METHODS Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective esophagectomy and pancreatectomy for cancer from 2014 to 2016. Risk- and reliability-adjusted, price-standardized payments for the surgical episode from admission through 30 days post discharge, as well as risk- and reliability-adjusted complication rates for each hospital, were calculated. Hospitals were separated into quintiles relative to payments and outcomes. Highest-value hospitals were defined as hospitals in the top 2 quartiles for both cost and outcomes. RESULTS Among 11,586 Medicare beneficiaries who underwent a complex oncologic operation between 2014 and 2016, 66% had a pancreatic neoplasm, while 33% had an esophageal neoplasm. Overall, 31.1% patients underwent an operation at a high-value hospital. Among patients who underwent pancreatectomy, the risk-adjusted postoperative complication rate was 31.4% at the lowest-value hospitals vs 22.7% at highest-value hospitals (odds ratio: 0.57, 95% confidence interval 0.47-0.70). The esophagectomy, risk-adjusted postoperative complication rate was 48.3% at lowest-value hospitals versus 29.8% at highest-value hospitals (odds ratio: 0.36, 95% confidence interval 0.27-0.47). The average difference in episode cost of care for an esophagectomy at lowest- versus highest-value hospitals was $5,617; the difference for pancreatectomy was $2,748. CONCLUSION There was wide variation in complication rates and average costs among lowest- versus highest-value hospitals performing esophagectomy and pancreatectomy for cancer. Even among highest quality hospitals, wide variation in average episode costs was noted. Surgeons should seek to better understand practice variation to standardize care and decrease variation in outcomes, utilization, and costs.
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Tsilimigras DI, Sahara K, Moris D, Mehta R, Paredes AZ, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Weiss M, Bauer TW, Maithel SK, Pulitano C, Shen F, Koerkamp BG, Endo I, Pawlik TM. Assessing Textbook Outcomes Following Liver Surgery for Primary Liver Cancer Over a 12-Year Time Period at Major Hepatobiliary Centers. Ann Surg Oncol 2020; 27:3318-3327. [DOI: 10.1245/s10434-020-08548-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Indexed: 12/14/2022]
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Sweigert PJ, Eguia E, Baker MS, Paredes AZ, Tsilimigras DI, Dillhoff M, Ejaz A, Cloyd J, Tsung A, Pawlik TM. Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma. J Surg Oncol 2020; 121:936-944. [DOI: 10.1002/jso.25861] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/19/2020] [Indexed: 12/15/2022]
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Ejaz A, Pawlik TM. In-hospital Mortality Following Pancreatoduodenectomy: a Comprehensive Analysis. J Gastrointest Surg 2020; 24:1119-1126. [PMID: 31292889 DOI: 10.1007/s11605-019-04307-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed. METHODS Retrospective review of the National Inpatient Sample database (January 2004-December 2014) was conducted to identify patients undergoing PD. Factors associated with in-hospital mortality after PD were analyzed after adjusting for previously defined patient- and hospital-level risk factors. RESULTS A total of 9639 patients who underwent a PD at 2325 hospitals were identified. Median patient age was 57 years (IQR 66-73). Overall, mortality following PD was 3.2%. When patient- and hospital-level characteristics were analyzed in the same model, patient-level characteristic associated with increased odds of in-hospital mortality included increasing patient age (OR 1.05, 95% CI 1.03-1.06/per 5 years increase), male sex (OR 1.47, 95% CI 1.16-1.86), the presence of liver disease (OR 3.03, 95% CI 1.99-4.61), chronic kidney disease (OR 1.78, 95% CI 1.18-2.68), and congestive heart failure (OR 2.48, 95% CI 1.65-3.74). The only hospital characteristic associated with odds of mortality following PD included compliance with Leapfrog volume standards (OR 0.70, 95% CI 0.54-0.92). CONCLUSION Patient-level factors, such as advanced comorbidities, male sex, and increased age, contributed the most to increased risk of mortality after PD. Hospital volume was the only hospital-level factor contributing to risk of in-hospital mortality following PD.
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Farooq A, Merath K, Paredes AZ, Wu L, Tsilimigras DI, Hyer JM, Sahara K, Mehta R, Beal EW, Pawlik TM. Outcomes of Patients with Scirrhous Hepatocellular Carcinoma: Insights from the National Cancer Database. J Gastrointest Surg 2020; 24:1049-1060. [PMID: 31243715 DOI: 10.1007/s11605-019-04282-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/20/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Scirrhous hepatocellular carcinoma (HCC) is a rare primary liver tumor characterized by extensive fibrosis and production of parathyroid hormone-related peptide. There have been conflicting reports on patient survival in scirrhous versus non-scirrhous HCC. The objective of the present study was to define the clinical features, practice patterns, and long-term outcomes of patients with scirrhous HCC versus non-scirrhous HCC in a propensity score-matched cohort. METHODS A propensity score-matched cohort was created using data from the National Cancer Database for 2004 to 2015. A multivariable Cox proportional hazards regression analysis was performed to assess the effect of the scirrhous HCC variant on overall survival. RESULTS Among the 70,426 patients with a diagnosis of HCC who met the inclusion criteria, 99.8% had non-scirrhous HCC (n = 70,290) whereas a small subset had scirrhous HCC (n = 136, 0.19%). While 20,330 (28.9%) patients underwent liver-directed therapy (resection, ablation, and transplantation), the majority did not (n = 50,096, 71.1%). After propensity matching, there were no difference in 1-, 3-, or 5-year overall survival among patients with scirrhous versus non-scirrhous HCC (1-year overall survival (OS), 53.7% versus 51.0%; 3-year OS, 34.6% versus 28.7%; and 5-year OS, 18.0% versus 21.0%, respectively; p = 0.52). While the scirrhous HCC variant was not associated with survival (hazard ratio [HR] 0.93, 95% CI 0.74-1.16), non-receipt of liver-directed therapy (HR 0.24, 95% CI 0.18-0.32), advanced AJCC stage (III/IV) (HR 2.14, 95% CI 1.55-2.95), and non-academic facilities (HR 0.60, 95% CI 0.49-0.73) remained associated with worse survival. CONCLUSION Patients with the scirrhous variant had a comparable overall survival compared with individuals who had non-scirrhous HCC. Failure to receive liver-directed therapy, advanced AJCC stage (III/IV), and treatment at a non-academic facility was strongly associated with a worse long-term prognosis.
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Sahara K, Tsilimigras DI, Mehta R, Moro A, Paredes AZ, Lopez-Aguiar AG, Rocha F, Kanji Z, Weber S, Fisher A, Fields RC, Krasnick BA, Idrees K, Smith PM, Poultsides GA, Makris E, Cho C, Beems M, Dillhoff M, Maithel SK, Endo I, Pawlik TM. Correction to: Trends in the Number of Lymph Nodes Evaluated Among Patients with Pancreatic Neuroendocrine Tumors in the United States: A Multi-Institutional and National Database Analysis. Ann Surg Oncol 2020; 27:969. [PMID: 32342296 DOI: 10.1245/s10434-020-08397-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In the original article, Ryan C. Fields' middle initial is missing.
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Palmer Kelly E, Hyer M, Paredes AZ, McGee J, Cloyd J, Ejaz A, Park KU, Pawlik TM. Assessing Differences in Cancer Surgeon Approaches to Patient-Centered Decision-Making Using Vignette-Based Methodology. Ann Surg Oncol 2020; 27:2149-2156. [PMID: 32318948 DOI: 10.1245/s10434-020-08488-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this study is to assess surgeon-patient-centered decision-making (PCDM) strategies relative to surgeon and patient factors. METHODS Approaches to PCDM were evaluated using a cross-sectional survey based on clinical vignettes assessing surgeon likeliness (0 = not at all likely, 100 = very likely) to utilize PCDM strategies. Data were analyzed using repeated-measures mixed-effects linear regression. Adjusted estimates are provided as least-squares mean (LSM) values. RESULTS The final analytic sample consisted of 208 respondents (58.5% response rate); the majority of respondents were male (67.7%) and Caucasian (82.0%) with an average age of 51.6 years (standard deviation, SD = 9.9 years, range 34.0-78.0 years). Specialties included breast (18.9%), hepatopancreatobiliary (21.4%), and other (59.7%). Surgeons practicing at academic (versus nonacademic) hospitals were less likely to be directive (LSM: 66.2 vs. 70.3, p = 0.004), spend equal time discussing all treatment options (LSM: 77.9 vs. 82.3, p = 0.001), and make explicit treatment recommendations (LSM: 67.7 vs. 71.7, p = 0.005). Surgeons who specialized in breast cancer (versus other specialties), in practice 10+ years (versus < 10 years), and female (versus male) were more likely to spend time discussing all treatment options (LSM: 82.8 vs. 77.3; 81.6 vs. 78.6; and 82.1 vs. 78.0, all p < 0.05). Surgeons perceived patients who had blue-collar (versus white-collar) jobs as less likely to want active participation in decision-making (LSM: 62.9 vs. 65.6, p = 0.02). CONCLUSION Surgeon approaches to PCDM varied based on a number of surgeon and patient characteristics. Further studies are needed to understand how surgeon PCDM strategies can be tailored to specific care contexts and patient needs.
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Palmer Kelly E, Tsilimigras DI, Paredes AZ, Pawlik TM. ASO Author Reflections: The Influence of Surgeon Characteristics on Patient-Centered Approaches to Treatment Decision-Making. Ann Surg Oncol 2020; 27:2157-2158. [PMID: 32314158 DOI: 10.1245/s10434-020-08490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Indexed: 11/18/2022]
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Mehta R, Paredes AZ, Tsilimigras DI, Moro A, Sahara K, Farooq A, Dillhoff M, Cloyd JM, Tsung A, Ejaz A, Pawlik TM. Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries. Surgery 2020; 168:92-100. [PMID: 32303348 DOI: 10.1016/j.surg.2020.02.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/13/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. METHODS The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. RESULTS Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53). CONCLUSION The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.
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Tsilimigras DI, Bagante F, Moris D, Hyer JM, Sahara K, Paredes AZ, Mehta R, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Recurrence Patterns and Outcomes after Resection of Hepatocellular Carcinoma within and beyond the Barcelona Clinic Liver Cancer Criteria. Ann Surg Oncol 2020; 27:2321-2331. [PMID: 32285278 DOI: 10.1245/s10434-020-08452-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Several investigators have advocated for extending the Barcelona Clinic Liver Cancer (BCLC) resection criteria to select patients with BCLC-B and even BCLC-C hepatocellular carcinoma (HCC). The objective of the current study was to define the outcomes and recurrence patterns after resection within and beyond the current resection criteria. PATIENTS AND METHODS Patients who underwent resection for HCC within (i.e., BCLC 0/A) and beyond (i.e. BCLC B/C) the current resection criteria between 2005 and 2017 were identified from an international multi-institutional database. Overall survival (OS), disease-free survival (DFS), as well as patterns of recurrence of patients undergoing HCC resection within and beyond the BCLC guidelines were examined. RESULTS Among 756 patients, 602 (79.6%) patients were BCLC 0/A and 154 (20.4%) were BCLC B/C. Recurrences were mostly intrahepatic (within BCLC: 74.3% versus beyond BCLC: 70.8%, p = 0.80), with BCLC B/C patients more often having multiple tumors at relapse (69.6% versus 49.4%, p = 0.001) and higher rates of early (< 2 years) recurrence (88.0% versus 75.5%, p = 0.011). During the first postoperative year, annual recurrence was 38.3% and 21.3% among BCLC B/C and BCLC 0/A patients, respectively; 5-year OS among BCLC 0/A and BCLC B/C patients was 76.9% versus 51.6% (p = 0.003). On multivariable analysis, only a-fetoprotein (AFP) > 400 ng/mL (HR = 1.84, 95% CI 1.07-3.15) and R1 resection (HR = 2.36, 95% CI 1.32-4.23) were associated with higher risk of recurrence among BCLC B/C patients. CONCLUSIONS Surgery can provide acceptable outcomes among select patients with BCLC B/C HCC. The data emphasize the need to further refine the BCLC treatment algorithm as well as highlight the need for surveillance protocols with a particular focus on the liver, especially for patients undergoing resection outside the BCLC criteria.
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Tsilimigras DI, Mehta R, Aldrighetti L, Poultsides GA, Maithel SK, Martel G, Shen F, Koerkamp BG, Endo I, Pawlik TM, Paredes AZ, Moris D, Sahara K, Bagante F, Guglielmi A, Weiss M, Bauer TW, Alexandrescu S, Marques HP, Pulitano C, Soubrane O, Cloyd JM, Ejaz A. Development and Validation of a Laboratory Risk Score (LabScore) to Predict Outcomes after Resection for Intrahepatic Cholangiocarcinoma. J Am Coll Surg 2020; 230:381-391.e2. [DOI: 10.1016/j.jamcollsurg.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/10/2019] [Indexed: 02/07/2023]
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Moro A, Mehta R, Sahara K, Tsilimigras DI, Paredes AZ, Farooq A, Hyer JM, Endo I, Shen F, Guglielmi A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Soubrane O, Koerkamp BG, Sasaki K, Pawlik TM. The Impact of Preoperative CA19-9 and CEA on Outcomes of Patients with Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2020; 27:2888-2901. [DOI: 10.1245/s10434-020-08350-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Indexed: 12/12/2022]
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Mehta R, Tsilimigras DI, Paredes AZ, Sahara K, Moro A, Farooq A, White S, Ejaz A, Tsung A, Dillhoff M, Cloyd JM, Pawlik TM. Comparing textbook outcomes among patients undergoing surgery for cancer at U. S. News & World Report ranked hospitals. J Surg Oncol 2020; 121:927-935. [PMID: 32124433 PMCID: PMC9292307 DOI: 10.1002/jso.25833] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/28/2019] [Indexed: 01/26/2023]
Abstract
Background The objective of the current study was to define and compare rates of textbook outcomes (TO) among patients undergoing colorectal, lung, esophagus, liver, and pancreatic surgery for cancer at U.S. News & World Report (USNWR) ranked hospitals. Methods Medicare Inpatient Standard Analytic Files 2013‐2015 were utilized to examine the relationship of TO and USNWR hospital ratings following surgery for colorectal, lung, esophageal, pancreatic, and liver cancer. TO was defined as no postoperative surgical complications, no prolonged length of hospital stay, no readmission within 90 days after discharge, and no postoperative mortality within 90 days after surgery. Results Among the 35,352 Medicare patients included in the cohort, 16,820 (47.6%) underwent surgery at honor roll hospitals, whereas 18 532 (52.4%) underwent surgery at non‐honor roll hospitals. The overall proportion of patients who achieved TO was 50.1%. In examining the clinical outcomes of patients who underwent surgery, there was no difference in the odds of achieving TO at honor roll vs non‐honor roll hospitals (colorectal: odds ratio [OR], 0.87; 95% confidence interval [CI], 0.69‐1.10; lung: OR, 1.07; 95% CI, 0.87‐1.32; esophagus: OR, 1.44; 95% CI, 0.72‐2.89; liver: OR, 1.27; 95% CI, 0.87‐1.84; pancreas: OR, 1.04; 95% CI, 0.67‐1.62). Conclusion and Relevance Patients undergoing surgery for lung, esophageal, liver, pancreatic, and colorectal cancer had comparable rates of TO at honor roll vs non‐honor roll hospitals. No linear association was observed between hospital position in the rank and postoperative outcomes such as TO indicating that patients should not overly focus on the exact position within USNWR ranked hospitals. These data highlight to patients and physicians that up to one‐half of patients undergoing surgery for cancer should anticipate at least one adverse outcome.
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Sahara K, Paredes AZ, Merath K, Tsilimigras DI, Bagante F, Ratti F, Marques HP, Soubrane O, Beal EW, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Aklile W, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Evaluation of the ACS NSQIP Surgical Risk Calculator in Elderly Patients Undergoing Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2020; 24:551-559. [PMID: 30937717 DOI: 10.1007/s11605-019-04174-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.
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Mehta R, Tsilimigras DI, Paredes AZ, Sahara K, Dillhoff M, Cloyd JM, Ejaz A, White S, Pawlik TM. Dedicated Cancer Centers are More Likely to Achieve a Textbook Outcome Following Hepatopancreatic Surgery. Ann Surg Oncol 2020; 27:1889-1897. [PMID: 32108924 DOI: 10.1245/s10434-020-08279-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The aim of the current study is to assess rates of textbook outcome (TO) among Medicare beneficiaries undergoing hepatopancreatic (HP) surgery for cancer at dedicated cancer centers (DCCs) and National Cancer Institute affiliated cancer centers (NCI-CCs) versus non-DCC non-NCI hospitals. PATIENTS AND METHODS Medicare Inpatient Standard Analytic Files were utilized to identify patients undergoing HP surgery between 2013 and 2017. TO was defined as no postoperative surgical complications, no 90-day mortality, no prolonged length of hospital stay, and no 90-day readmission after discharge. RESULTS Among 21,234 Medicare patients, 8.2% patients underwent surgery at DCCs whereas 32.1% underwent surgery at NCI-CCs and 59.7% underwent an operation at neither DCCs nor NCI-CCs. Although DCCs more often cared for patients with severe comorbidities [Charlson score > 5: DCCs, 1195 (68.9%), NCI-CCs, 3687 (54.1%), others, 3970 (31.3%); p < 0.001], DCCs achieved higher rates of TO compared with NCI-CCs and other US hospitals. Interestingly, DCCs were more likely to perform surgery with a minimally invasive approach versus NCI-CCs and other US hospitals (17.0%, n = 295, vs. 12.6%, n = 856 vs. 11.9%, n = 1504, p < 0.001). On multivariable analysis, patients undergoing liver surgery at DCCs had 31% and 36% higher odds of achieving TO compared with NCI-CCs and other US hospitals, respectively. Medicare expenditure was substantially lower for patients achieving TO at DCCs compared with patients who achieved a TO at NCI-CCs. CONCLUSIONS Even though DCCs more frequently took care of patients with high comorbidity burden, the likelihood of achieving TO for HP surgery at DCCs was higher compared with NCI-CCs and other US hospitals. The data suggest that DCCs provide higher-value surgical care for patients with HP malignancies.
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Tsilimigras DI, Moris D, Hyer JM, Bagante F, Sahara K, Moro A, Paredes AZ, Mehta R, Ratti F, Marques HP, Silva S, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Sasaki K, Rodarte AI, Aucejo FN, Pawlik TM. Hepatocellular carcinoma tumour burden score to stratify prognosis after resection. Br J Surg 2020; 107:854-864. [PMID: 32057105 DOI: 10.1002/bjs.11464] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/23/2019] [Accepted: 11/15/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have emphasized the need for further refinement and subclassification of this system. METHODS Patients who underwent hepatectomy with curative intent for BCLC-0, -A or -B hepatocellular carcinoma (HCC) between 2000 and 2017 were identified using a multi-institutional database. The tumour burden score (TBS) was calculated, and overall survival (OS) was examined in relation to TBS and BCLC stage. RESULTS Among 1053 patients, 63 (6·0 per cent) had BCLC-0, 826 (78·4 per cent) BCLC-A and 164 (15·6 per cent) had BCLC-B HCC. OS worsened incrementally with higher TBS (5-year OS 77·9, 61 and 39 per cent for low, medium and high TBS respectively; P < 0·001). No differences in OS were noted among patients with similar TBS, irrespective of BCLC stage (61·6 versus 58·9 per cent for BCLC-A/medium TBS versus BCLC-B/medium TBS, P = 0·930; 45 versus 13 per cent for BCLC-A/high TBS versus BCLC-B/high TBS, P = 0·175). Patients with BCLC-B HCC and a medium TBS had better OS than those with BCLC-A disease and a high TBS (58·9 versus 45 per cent; P = 0·005). On multivariable analysis, TBS remained associated with OS among patients with BCLC-A (medium TBS: hazard ratio (HR) 2·07, 95 per cent c.i. 1·42 to 3·02, P < 0·001; high TBS: HR 4·05, 2·40 to 6·82, P < 0·001) and BCLC-B (high TBS: HR 3·85, 2·03 to 7·30; P < 0·001) HCC. TBS could also stratify prognosis among patients in an external validation cohort (5-year OS 79, 51·2 and 28 per cent for low, medium and high TBS respectively; P = 0·010). CONCLUSION The prognosis of patients with HCC varied according to the BCLC stage but was largely dependent on the TBS.
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Wu L, Merath K, Farooq A, Hyer JM, Tsilimigras DI, Paredes AZ, Mehta R, Sahara K, Shen F, Pawlik TM. Photodynamic therapy may provide a benefit over systemic chemotherapy among non-surgically managed patients with extrahepatic cholangiocarcinoma. J Surg Oncol 2020; 121:286-293. [PMID: 31742706 DOI: 10.1002/jso.25773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/11/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Systemic chemotherapy is the standard treatment for patients with unresectable extrahepatic cholangiocarcinoma (ECC), however, the survival benefit of chemotherapy is limited. Photodynamic therapy (PDT) has been associated with improved survival among patients with advanced ECC, yet utilization of PDT remains low. We sought to compare the outcomes of patients with unresectable ECC following treatment with PDT versus chemotherapy. METHODS A review of the National Cancer Database was conducted to identify patients with ECC who were nonsurgically managed between 2004 and 2013. Overall survival (OS) of patients receiving PDT vs systemic chemotherapy was compared using propensity score matching. RESULTS After propensity matching (PDT, n = 59; chemotherapy, n = 177), 5-year OS was 17.6% (95% confidence interval [CI], 9.0%-28.6%) among patients who underwent PDT vs 3.8% (95%CI, 0.4%-14.0%) among patients receiving chemotherapy (P < .001). On multivariable analysis PDT was associated with an OS benefit (hazard ratio, 0.72; 95%CI, 0.52-0.998; P = .048). Subset analysis of patients receiving PDT only (n = 45) and patients receiving chemotherapy demonstrated similar results. In subset analysis of patients undergoing PDT-only vs PDT-chemotherapy, OS was comparable. CONCLUSION PDT was associated with a survival benefit compared with chemotherapy alone among patients with unresectable ECC.
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Sahara K, Farooq SA, Tsilimigras DI, Merath K, Paredes AZ, Wu L, Mehta R, Hyer JM, Endo I, Pawlik TM. Immunotherapy utilization for hepatobiliary cancer in the United States: disparities among patients with different socioeconomic status. Hepatobiliary Surg Nutr 2020; 9:13-24. [PMID: 32140475 DOI: 10.21037/hbsn.2019.07.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Patients with advanced hepatobiliary cancer (HBC) have a dismal prognosis and limited treatment options. Immunotherapy has been considered as a promising treatment, especially for cancers not amenable to surgery. Methods Between 2004, and 2015, patients diagnosed with hepatocellular carcinoma (HCC), intra- and extrahepatic cholangiocarcinoma and gallbladder cancer (GBC) were identified in the National Cancer Database. Results Among 249,913 patients with HBC, only 585 (0.2%) patients received immunotherapy. Among patients who received immunotherapy, most patients were diagnosed between 2012 and 2015, had private insurance, as well as an income ≥$46,000 and were treated at an academic facility. The use of immunotherapy among HBC patients varied by diagnosis (HCC, 67.7%; bile duct cancer, 14%). On multivariable analysis, a more recent period of diagnosis (OR 1.80, 95% CI: 1.44-2.25), median income >$46,000 (OR 1.43, 95% CI: 1.11-1.87), and higher tumor stage (stage III, OR 2.22, 95% CI: 1.65-3.01; stage IV, OR 3.24, 95% CI: 2.41-4.34) were associated with greater odds of receiving immunotherapy. Conclusions Overall utilization of immunotherapy in the US among patients with HBC was very low, yet has increased over time. Certain socioeconomic factors were associated with an increased likely of receiving immunotherapy, suggesting disparities in access of patients with lower socioeconomic status.
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Paredes AZ, Hyer JM, Tsilimigras DI, Merath K, Mehta R, Sahara K, Farooq SA, Wu L, White S, Pawlik TM. Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries. HPB (Oxford) 2020; 22:109-115. [PMID: 31231061 DOI: 10.1016/j.hpb.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/27/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown. METHODS The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy. RESULTS Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71-80] vs. 71 [IQR 68-76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32-15.29, p = 0.016). CONCLUSION While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days.
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Beal EW, Mehta R, Tsilimigras DI, Hyer JM, Paredes AZ, Merath K, Dillhoff ME, Cloyd JM, Ejaz A, Pawlik TM. Travel to a high volume hospital to undergo resection of gallbladder cancer: does it impact quality of care and long-term outcomes? HPB (Oxford) 2020; 22:41-49. [PMID: 31186198 DOI: 10.1016/j.hpb.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relationship of volume and travel distance to patient outcomes after resection of gallbladder cancer (GBC) remains poorly defined. METHODS The 2004-2015 National Cancer Database was used to identify GBC resection patients and examine the impact of travel distance, hospital volume and both on overall survival (OS) and quality of care indicators. RESULTS Among 10,174 patients undergoing surgery for GBC, the majority of patients were Caucasian (N = 8,175, 80%) and had a Charlson-Deyo comorbidity score of 0 (N = 6,785, 67%). On unadjusted survival analysis increasing travel distance and hospital volume were associated with improved OS (both p < 0.001). After controlling for competing risk factors, the 4th quartile of hospital volume was associated with a decreased hazard of death (HR 0.831, 95% CI 0.751-0.920, p < 0.001). When both hospital volume and travel distance were included, the association with improved OS persisted only for hospital volume (4th quartile HR 0.835, 95% CI 0.753-0.925, p < 0.001), whereas there was no independent association of increasing travel distance with OS. CONCLUSIONS Both increasing travel distance and hospital volume were associated with improved OS; however, adjusted models demonstrated that the impact of travel distance was mediated through hospital volume.
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