What if You Need More Than One? More Acute Care Surgery Procedures Are Associated with Mortality

Background: It is unknown whether having multiple acute care surgery (ACS) procedures performed in one admission confers additional risk. We hypothesized that having multiple procedures (for example, hernia repair plus bowel resection) would be associated with higher mortality. Patients and Methods: We identified all 2017 National Inpatient Sample admissions with ACS procedures including: colon, small bowel/appendix (SB), hernia, adhesiolysis, peptic ulcer procedures, gallbladder, debridement, other laparotomy, other laparoscopy. The total number of procedures for each admission and common dyad (two-procedure) and triad (three-procedure) combinations were identified. Logistic regression estimated the odds of in-hospital mortality for increasing procedure count and specific dyad and triad combinations, using patients with one procedure as the reference. Results: A total of 216,317 ACS patients (median age, 57, interquartile range [IQR], 43-70; 50.6% female) were included; 2.8% died. Patients with multiple procedures were more likely to die than patients with one procedure (7.4% vs. 1.9%). An increasing number of procedures was associated with higher odds of death (two procedures: odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9-3.2] to six or more procedures, OR, 9.5; 95% CI, 4.9-18.5); having more than three procedures was associated with at least fivefold higher odds of death. Specific dyads/triads were associated with particularly high risk of mortality, including ulcer/laparotomy (OR, 15.5; 95% CI, 13.7-17.5) and laparotomy/SB (OR, 8.31; 95% CI, 5.15-13.40). Conclusions: Multiple ACS procedures in one hospitalization confer increased odds of in-hospital mortality. This knowledge enables the ACS providers to better counsel patients by giving more specific expectations regarding mortality based on the number of procedures required or anticipated during an admission.

Disparities and access to thoracic surgeons among esophagectomy patients in the United States

Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.

The Role of Structured Goals of Care Discussions in Critically Ill Thoracic Surgery Patients

Objective: The American College of Surgeons recommends structured family meetings (FM) for high-risk surgical patients. We hypothesized that goals of care discussions (GOCD) in the form of an FM, multidisciplinary family meeting (MDFM), or palliative care consult (PCC) would be underutilized in imminently dying thoracic surgery patients. Methods: A retrospective chart review at a tertiary academic medical center was performed on all inpatient mortalities and discharges to hospice after any thoracic surgery operation. The utilization of GOCDs was compared between the 2 groups. Secondary outcomes were length-of-stay, comatose status and ventilator dependence during initial GOCD, and timing of code status change. Results: In total, 56 patients met inclusion criteria: 44 of 56 (78.6%) died and 12 of 56 (21.4%) were discharged to hospice. Most patients had a FM (79.5% mortality vs 100% hospice, P = .29) and few had an MDFM (25.0% mortality vs 25.0% hospice, P = 1.00). Patients discharged to hospice were more likely to have a PCC (66.7% vs 31.2%, P = .03) and less likely to be comatose (16.7% vs 59.1%, P = .009) or ventilator dependent during initial GOCD (16.7% vs 70.5%, P = .001). Among patients who died and were DNR-CC (do not resuscitate-comfort care; 37 of 44), 75.7% died the same day of code status change and 67.6% died within 48 h of initial GOCD. Discussion: Although FMs were common, MDFMs were infrequent. Patients discharged to hospice were more likely to have a PCC. Most deaths occurred shortly after initial GOCD and most code status changes occurred on day-of-death. This data suggest an opportunity to improve GOCDs in critically ill thoracic surgery patients.

Outcome of Patients with Locally Advanced Rectal Cancer Pursuing Non-Surgical Strategy in National Cancer Database

BACKGROUND

Survival data on patients with locally advanced rectal cancer (LARC) undergoing non-operative management (NOM) in a real-world setting are lacking.

METHODS

We analyzed LARC patients from the National Cancer Database with the following features: treated between 2010 and 2020, age 18-65 years, Charlson comorbidity index (CCI) ≤ 1, received neoadjuvant multiagent chemotherapy plus radiation ≥ 45 Gray, and underwent surgery or NOM. Patients were stratified into two groups: (A) clinical T1-3 tumors with positive nodes (cT1-3N+) and (B) clinical T4 tumors, N+/- (cT4N+/-). We performed a comparative analysis of overall survival (OS) with NOM versus surgery by the Kaplan-Meier method and propensity score matching. Additionally, a multivariable analysis explored the association between NOM and OS.

RESULTS

NOM exhibited significantly lower OS than surgery in both groups. In cT1-3N+ patients, NOM resulted in a 5-year OS of 73.9% (95% confidence interval [CI] = 69.7-77.6%) versus 84.5% (95% CI = 83.6-85.3%) with surgery (p < 0.001). In the cT4N+/- group, NOM yielded a 5-year OS of 44.5% (95% CI = 37.0-51.8%) versus 72.5% (95% CI = 69.9-74.8%) with surgery (p < 0.001). Propensity score matching and multivariable analyses revealed similar conclusions.

CONCLUSION

Patients with LARC undergoing NOM versus surgery in real-world settings appear to have inferior survival.

Adjuvant chemotherapy is associated with an overall survival benefit regardless of age in patients with ER+/HER2-breast cancer with 1-3 positive nodes and Oncotype DX recurrence score 20 to 25: A National Cancer Database analysis

540

Background: Based on the results of the RxPonder trial, post-menopausal women over age 50 with estrogen receptor (ER)+ breast cancer, 1-3+ nodes, and a 21-gene Oncotype DX recurrence score (RS) score of <25, did not benefit from receiving adjuvant chemotherapy. By contrast, adjuvant chemotherapy was beneficial in premenopausal women. We aimed to replicate the RxPonder trial using a larger sample sizes with real world data to determine whether a threshold with RS exists where adjuvant chemoendocrine therapy (CET) is beneficial regardless of age. Methods: The National Cancer Database (NCDB) was queried for women with ER+, human epidermal growth factor receptor 2 (HER2) negative breast cancer, 1-3 positive axillary nodes, and RS <25 who received endocrine therapy (ET) only or CET. Interaction was explored between CET and age as a surrogate for menopausal status in the Cox regression models. Results: The final analytic cohort included 28,427 eligible women: 7,487 (26.3%) received adjuvant CET and 20,940 (73.7%) ET. In the entire cohort, RS had a normal distribution, with a median score of 14. After correcting for demographic and clinical variables, a threshold effect was observed with RS >20 being associated with a significantly inferior overall survival (OS) (P value range: < 0.001-0.019). In women with RS of 20-25, CET was associated with a significant improvement in OS compared to ET alone, regardless of age (age < = 50: HR = 0.334, P = 0.002; age > 50: HR = 0.521, P = 0.019). Conclusions: Among women with ER+/HER2- breast cancer with 1–3 positive nodes, and RS of 20-25, in contrast to the RxPonder trial we observed that CET was associated with an OS benefit in women regardless of age.

Computational risk model for predicting 2-year malignancy of pulmonary nodules using demographic and radiographic characteristics

OBJECTIVES

To determine whether discriminatory performance of a computational risk model in classifying pulmonary lesion malignancy using demographic, radiographic, and clinical characteristics is superior to the opinion of experienced providers. We hypothesized that computational risk models would outperform providers.

METHODS

Outcome of malignancy was obtained from selected patients enrolled in the NAVIGATE trial (NCT02410837). Five predictive risk models were developed using an 80:20 train-test split: univariable logistic regression model based solely on provider opinion, multivariable logistic regression model, random forest classifier, extreme gradient boosting model, and artificial neural network. Area under the receiver operating characteristic curve achieved during testing of the predictive models was compared to that of prebiopsy provider opinion baseline using the DeLong test with 10,000 bootstrapped iterations.

RESULTS

The cohort included 984 patients, 735 (74.7%) of which were diagnosed with malignancy. Factors associated with malignancy from multivariable logistic regression included age, history of cancer, largest lesion size, lung zone, and positron-emission tomography positivity. Testing area under the receiver operating characteristic curve were 0.830 for provider opinion baseline, 0.770 for provider opinion univariable logistic regression, 0.659 for multivariable logistic regression model, 0.743 for random forest classifier, 0.740 for extreme gradient boosting, and 0.679 for artificial neural network. Provider opinion baseline was determined to be the best predictive classification system.

CONCLUSIONS

Computational models predicting malignancy of pulmonary lesions using clinical, demographic, and radiographic characteristics are inferior to provider opinion. This study questions the ability of these models to provide additional insight into patient care. Expert clinician evaluation of pulmonary lesion malignancy is paramount.

Frailty is associated with 90-day mortality in urgent thoracic surgery conditions

Objective

In patients undergoing elective thoracic surgery, frailty is associated with worse outcomes. However, the magnitude by which frailty influences outcomes of urgent thoracic surgery (UTS) is unknown.

Methods

We identified patients admitted with a UTS condition from January to September 2017 in the National Readmissions Database. UTS conditions were classified as esophageal perforation, hemo/pneumothorax, rib fracture, and obstructed hiatal hernia. Outcome of interest was mortality within 90 days of index admission. Frailty score was calculated using a deficit accumulation method. Cox proportional hazard modeling was used to calculate a hazard ratio for each combination of UTS disease type and frailty score, adjusted for sex, insurance payor, hospital size, and hospital and patient location, and was compared with the effect of frailty on elective lung lobectomy.

Results

We identified 107,487 patients with a UTS condition. Among UTS conditions overall, increasing frailty elements were associated with increased mortality (hazard ratio, 2270; 95% CI, 1463-3523; P < .001). Compared with patients without frailty undergoing elective lobectomy, increasing frailty demonstrated trending toward increased mortality in all diagnoses. The magnitude of the effect of frailty on 90-day mortality differed depending on the disease and level of frailty.

Conclusions

The effect of frailty on 90-day mortality after admission for urgent thoracic surgery conditions varies by disease type and level of frailty. Among UTS disease types, increasing frailty was associated with a higher 90-day risk of mortality. These findings suggest a valuable role for frailty evaluation in both clinical settings and administrative data for risk assessment.

Neuroinflammatory Pathways Associated with Chronic Post-Thoracotomy Pain: A Review of Current Literature

Chronic post-thoracotomy pain (CPTP) is a major clinical problem that affects up to 35-55% of patients undergoing thoracic incisions. Evidence suggests that multiple cellular signaling pathways and neuro-inflammatory mediators may play an essential role in the pathogenesis of CPTP. In this comprehensive review, we present the current evidence on the cellular signaling pathways and inflammatory changes associated with the initiation and maintenance of CPTP, focusing on the potential application of these findings in the clinical setting. An electronic search of Medline, EMBASE, Cochrane, Google Scholar, and ClinicalTrials.gov was performed, and 3652 abstracts were identified. After an initial abstract screening, 131 studies underwent a full-text review, and nine papers were eventually included in this review. Studies were included if they assessed the cellular signaling pathways or inflammatory processes associated with the induction and/or maintenance of CPTP. All the identified studies were pre-clinical studies conducted on animal models. Our search identified seven cellular pathways (NK-1 receptor (NK-1), Glutaminase 1, Toll-like receptor 4 (TLR4), Resolvins, Ror-2, Sonic hedgehog signaling (Shh), and Wnt5a/Wnts) and six cytokines (IL-1β, IL-6, IL-8, IL-10, IFN-γ, and TNF-α) that were investigated in the context of CPTP. Multiple cellular signaling pathways and inflammatory cytokines may play an important role in the neuroinflammatory changes associated with the induction and maintenance of chronic post-thoracotomy pain in animal models. However, the clinical impact and therapeutic utility of these neuroinflammatory changes in routine clinical practice have yet to be demonstrated.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis

INTRODUCTION

Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC.

MATERIALS AND METHODS

In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery.

RESULTS

Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001).

CONCLUSIONS

This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

Lung Cancer in Young Patients is Associated With More Advanced Disease but Better Overall Survival

INTRODUCTION

It is unclear whether nonsmall cell lung cancer (NSCLC) is associated with more aggressive disease and worse overall survival (OS) among younger patients. The aim of this study is to evaluate outcomes in young patients. We hypothesize that young age is associated with more advanced disease upon presentation, but better OS.

METHODS

We identified patients with NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized in 3 groups: age≤50, 51-84, and ≥85 y. The outcomes were OS, stage IV NSCLC and clinical nodal metastasis. OS was analyzed using multivariate cox and Kaplan-Meier analysis accounting for stage, comorbidities, and other factors. The association of age, presentation with stage IV NSCLC and node positivity was analyzed using multivariate logistic regression.

RESULTS

In total 1,651,744 patients were identified: 92,506 (5.57%) age ≤50, 1,477,723 (88.90%) age 51-84, and 91,964 (5.53%) age ≥85. Multivariate model showed stage IV NSCLC was associated with age ≤50 (OR 1.17 (1.15-1.20) P < 0.001) and ≥85 (odds ratio (OR) 1.03 (1.02-1.04) P < 0.001). Clinical lymph node positivity was associated with age ≤50 (OR 1.27 (1.23-1.30) P < 0.001). Relative to patients 51-84, the ≤50 group was associated with better survival in Stage I (hazard ratio (HR) 0.61 versus 1.00), stage II (HR 1.12 versus 1.50), stage III (HR 2.12 versus 2.53), and stage IV (HR 6.65 versus 7.53).

CONCLUSIONS

Patients ≤50-y-old present with more advanced NSCLC, but better OS compared to patients 51-84. These findings suggest the need for increased awareness regarding NSCLC among age groups seen as low risk.

Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample

Background

The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.

Methods

We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.

Results

Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).

Conclusions

Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.

Level of evidence

III.

Estimating the overall survival benefit of adjuvant chemo-endocrine therapy in women over age 50 with pT1-2N0 early stage breast cancer and 21-gene recurrence score ≥26: A National Cancer Database analysis

BACKGROUND

Validation studies of the 21-gene recurrence score (RS) previously demonstrated that adjuvant chemotherapy plus endocrine therapy (CET) was associated with a significant survival benefit in women with node negative breast cancer (BC) and RS >31. However, the TAILORx trial, did not quantify the benefit of adjuvant CET in older women with node negative hormone receptor positive (HR+) BC with RS ≥26. We hypothesized that CET would be associated with improved overall survival (OS) compared to endocrine therapy (ET) in women >50 with HR+/HER2-node negative BC and RS ≥26.

METHODS

The National Cancer Database (NCDB) was queried to identify women >50 with RS ≥26 ER+/HER2-BC pT1-2N0M0. Chi-square and logistic regression analysis determined the difference between ET and CET. OS was analyzed using a multivariable Cox model.

RESULTS

We included 16,745 women-4740 (28.3%) received ET and 12,005 (71.7%) received CET. Women who received CET had: moderately (OR = 1.853, p < 0.001) or poorly/undifferentiated tumors (OR = 3.875, p < 0.001), pT2 (OR = 1.356, p < 0.001), or lymph-vascular invasion (OR = 1.206, p = 0.001). After accounting for demographic and oncologic factors, 5-year OS rates were significantly superior in women receiving CET vs. ET alone (95.4% vs. 92.0%, Hazard Ratio = 0.680, p < 0.001).

CONCLUSIONS

We observed that CET was associated with a clinically and statistically significant higher OS compared to ET alone in women >50 years of age with RS ≥26 pT1 and pT2 N0M0 HR+/HER2-breast cancer, and which suggests that cytotoxic chemotherapy has an impact on reducing mortality that is independent of induction of premature ovarian failure.

A Rare Cause of Colon Perforation After Percutaneous Nephrolithotomy-A Case Report and Review of the Literature

Staghorn calculi pose challenges in urology, often necessitating more invasive procedures such as percutaneous nephrolithotomy (PCNL) to clear a large stone burden with fewer procedures. Here we present a case of a 76-year-old female with chronic kidney disease and a malrotated right pelvic kidney who underwent PCNL for a 3.5 cm staghorn calculus. Postoperatively, she developed a rare complication of ascending colon perforation, requiring emergent surgical intervention including exploratory laparotomy and right hemicolectomy. Colon perforation during PCNL is rare (0.3%-0.8%). Preoperative imaging, namely computed tomography (CT) of the abdomen and pelvis, is crucial to identify anatomical variations and mitigate the risk of injury. Conservative management strategies have demonstrated success in similar cases, emphasizing the importance of prompt recognition and multidisciplinary management. This case contributes to the paucity of literature regarding this rare complication underscoring the necessity for detailed preoperative planning to avoid complications in PCNL, especially in patients with complex renal anatomy. Future research should focus on developing tailored guidelines for PCNL in patients with anatomical abnormalities to enhance procedural safety and optimize outcomes.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions

BACKGROUND

Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.

METHODS

We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.

RESULTS

Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.

CONCLUSION

Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Obstacles to needle exchange participation in Rhode Island

OBJECTIVE

This study explores obstacles to participation in needle exchange programs (NEPs) among injection drug users (IDUs) in the state of Rhode Island, U.S.A.

METHODS

A written questionnaire was administered at two Rhode Island drug detoxification sites in 1998.

RESULTS

488 self-administered surveys were completed, 226 (46.3%) respondents had injected drugs in the past 6 months. 62.1% reported sharing syringes in the past 6 months, and each syringe was used a mean of 10.7 times. Major obstacles to NEP participation were a lack of awareness of the program (25.6%), inconvenient location or hours (15.9%), and fear of identification and/or police harassment (12.2%). Non-white race was a significant predictor of being unaware of the NEP (p = .01) and not participating in the NEP (p = .03). 13.1% of IDUs who used the NEP were referred to the detoxification program by the NEP. Among all IDUs surveyed, 51.0% had participated in a NEP.

CONCLUSIONS

NEPs are important in reducing the spread of bloodborne pathogens among IDUs and are effective referral sources for drug treatment. Surveys of IDUs at sites other than NEPs, such as detoxification facilities, can identify obstacles to the use of NEPs.

Adoption of Minimally Invasive Lung Resection: A National Cancer Database Study

INTRODUCTION

Minimally invasive lung resection has been associated with improved outcomes; however, institutional characteristics associated with utilization are unclear. We hypothesized that the presence of surgical robots at institutions would be associated with increased utilization of minimally invasive techniques .

METHODS

Patients with cT1/2N0M0 non-small cell lung cancer who underwent lung lobectomy between 2010 and 2020 in the National Cancer Database were identified. Patients were categorized by operative approach as minimally invasive surgery (MIS) versus open. Institutions were categorized as "high utilizers" of MIS technique if their proportion of MIS lobectomies was >50%. Multivariate logistic regressions were used to determine factors associated with proportion of procedures performed minimally invasively. Further multivariate models were used to evaluate the association of proportion of MIS procedures with 90-d mortality, hospital length of stay, and hospital readmission.

RESULTS

In multivariate analysis, passage of time by year (odds ratio [OR] 1.26; confidence interval [CI] 1.22-1.30) and presence of a robot at the facility (OR 3.48; CI 2.84-4.24) were associated with high MIS-utilizing facilities. High utilizers of MIS were associated with lower 90-d mortality (OR 0.89; CI 0.83-0.97) and hospital length of stay (coeff -0.88; CI -1.03 to -0.72). Hospital readmission was similar between high and low MIS-utilizing facilities (compared to low MIS-utilizing facilities: OR 1.06; CI 0.95-1.09).

CONCLUSIONS

Passage of time and the presence of surgical robots were independently associated with increased utilization of MIS lobectomy. In addition to being associated with improved patient-level outcomes, robotic surgery is correlated with a higher proportion of procedures being performed minimally invasively.

Inaccurate Clinical Stage Is Common and Associated With Poor Survival in Patients With Lung Cancer

INTRODUCTION

Clinical staging in lung cancer has implications for treatment planning and prognosis. We sought to determine the rate of inaccurate clinical stage (relative to pathologic), identify risk factors for inaccuracy, and evaluate the association of inaccuracy on survival. We hypothesized that inaccurate staging was associated with poor survival.

METHODS

In this retrospective cohort study, adult patients who received surgical resection without neoadjuvant treatment for nonsmall cell lung cancer from 2004 to 2020 in the National Cancer Database were categorized by accuracy of clinical stage (relative to pathologic stage). Multivariate models were used to determine risk factors for inaccuracy. The association between inaccuracy and overall survival was also analyzed.

RESULTS

We identified 255,598 patients with lung cancer, including 84,543 patients (33.1%) who were inaccurately staged. Stage inaccuracy was associated with higher tumor, node, metastasis stage (T-category 3: odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.15-1.28; N-category 2: OR = 2.6, 95% CI 2.47-2.79), greater quantity of lymph nodes evaluated, and more extensive resection (extended lobectomy/bilobectomy: OR = 1.3, 95% CI 1.20-1.37; pneumonectomy: OR = 1.6, 95% CI 1.54-1.74). Patients undergoing robotic surgery were less likely to be inaccurately staged (OR = 0.89, 95% CI 0.852-0.939). Inaccurate staging was associated with worse overall survival (5-y 67.5% accurate versus 55.4% inaccurate, P < 0.001). Inaccurate staging was also associated with worse survival in a multivariate Cox model (hazard ratio [HR] = 1.3, 95% CI 1.29-1.33). Both "understaging" (path > clinical) and "overstaging" (clinical > path) were associated with inferior survival.

CONCLUSIONS

Inaccurate clinical stage (relative to pathologic) occurs in one-third of patients receiving surgery for lung cancer. Inaccuracy is associated with poor survival. Quality improvement initiatives should focus on improving clinical staging accuracy.

National enrollment of lung cancer clinical trials is disproportionate based on race and health care access

OBJECTIVE

Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives.

METHODS

We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering.

RESULTS

A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll.

CONCLUSIONS

Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.

Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis

Background

Surgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.

Methods

The Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.

Results

Among 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.

Conclusion

The majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.

Type

Therapeutic/care management.

Level of evidence

IV

Lymph Node Yield in Lung Cancer Resection is Associated With Demographic and Institutional Factors

INTRODUCTION

Lymphadenectomy is routinely performed during surgical resection of nonsmall cell lung cancer (NSCLC). Lymph node yield and number of nodal stations sampled are important prognostic markers viewed as surrogates of surgical quality. The purpose of this study was to identify factors associated with these quality metrics after resection of NSCLC.

MATERIALS AND METHODS

We identified NSCLC patients undergoing resection at a single institution from 2010 to 2021. Cases were matched to detailed pathologist reports, which included lymph node yield and number of stations sampled. Demographic and clinical characteristics were analyzed individually using unadjusted linear regression to identify factors associated with lymph node yield and number of stations sampled. Multivariable linear regression analyses were performed to evaluate the same end points, using covariates determined through stepwise-backwards selection.

RESULTS

The study cohort included 836 patients. Multivariable regression demonstrated that male sex, history of cardiothoracic surgery, and individual pathologist were independently associated with lymph node yield. Among 18 pathologists, interpathologist coefficients with respect to lymph node yield varied from -5.61 to 11.25. Multivariable regression demonstrated White race and history of cardiothoracic surgery to be independently associated with number of nodal stations sampled, as well as individual surgeon and pathologist.

CONCLUSIONS

Lymph node yield and number of nodal stations sampled after NSCLC resection may vary based on patient demographic and clinical characteristics, as well as institutional factors. These factors should be accounted for when using these metrics as markers of surgical quality and prognosis of NSCLC.

Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database

BACKGROUND

Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes.

METHODS

A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed.

RESULTS

In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality.

DISCUSSION

Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.