The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study

BACKGROUND

The misuse of opioid analgesics is a major public health concern, and guidelines regarding postoperative opioid use are sparse. The authors examined the use of opioids following outpatient upper extremity procedures to discern the variation by procedure type and patient factors.

METHODS

The authors studied opioid prescriptions among 296,452 adults older than 18 years who underwent carpal tunnel release, trigger finger release, cubital tunnel release, or thumb carpometacarpal arthroplasty from 2009 to 2013 using insurance claims drawn from the Truven Health MarketScan Commercial Claims and Encounters, which encompasses over 100 health plans in the United States. Using multivariable regression, the authors compared the receipt of opioids, number of days supplied, indicators of inappropriate prescriptions, and number of refills by patient factors.

RESULTS

In this cohort, 59 percent filled a postoperative prescription for opioid medication, and 8.8 percent of patients had an indicator of inappropriate prescribing. The probability of filling an opioid prescription declined linearly with advancing age. On multivariate analysis, patients who had previously received opioids were more likely to fill a postoperative opioid prescription (66 percent versus 59 percent), receive longer prescriptions (24 versus 5 days), receive refills following surgery (24 percent versus 5 percent), and have at least one indicator of potentially inappropriate prescribing (19 percent versus 6 percent).

CONCLUSIONS

Current opioid users are more likely to require postoperative opioid analgesics for routine procedures and more likely to receive inappropriate prescriptions. More evidence is needed to identify patients who derive the greatest benefit from opioids to curb opioid prescriptions when alternative analgesics may be equally effective and available.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A National Study of the Impact of Initial Débridement Timing on Outcomes for Patients with Deep Sternal Wound Infection

BACKGROUND

Excisional débridement for patients with deep sternal wound infection is a main component of treatment. This study aims to evaluate the impact of delayed excisional débridement on mortality and associated outcomes.

METHODS

The authors analyzed the MarketScan database from 2009 to 2013 to identify patients with deep sternal wound infection who received surgical intervention. A logistic regression model was created to model mortality. Poisson regression models were used to model number of procedures, number of hospitalizations, and length of stay. A log-linear regression model was used for cost analysis. All analyses were adjusted for patient risk factors.

RESULTS

The final cohort included 1335 patients with 12 percent in-hospital mortality. There was considerable variation in timing of débridement among patients with deep sternal wound infection, with more than 25 percent undergoing initial débridement 4 or more days after diagnosis, and 10 percent undergoing débridement more than 1 week after diagnosis. Patients undergoing delayed débridement had progressively higher risk for greater number of admissions and total hospital days compared with those undergoing early débridement. Patients undergoing débridement on the day of diagnosis of deep sternal wound infection had a predicted 34 total hospital days, compared with 49 total hospital days for patients undergoing débridement more than 7 days after diagnosis.

CONCLUSIONS

Patients treated with early surgical intervention had fewer hospital admissions and fewer hospital days than patients undergoing delayed surgical treatment. Protocols to facilitate early débridement have the potential to improve quality and efficiency of deep sternal wound infection care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Utilization of Post-Acute Care Following Distal Radius Fracture Among Medicare Beneficiaries

PURPOSE

To examine the utilization and cost of post-acute care following isolated distal radius fractures (DRFs) among Medicare beneficiaries.

METHODS

We examined utilization of post-acute care among Medicare beneficiaries who experienced an isolated DRF (n = 38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post-acute care delivered by skilled nursing facilities, inpatient rehabilitation facilities, home health care agencies, and outpatient occupational therapy/physical therapy for the recovery of DRF.

RESULTS

In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post-acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post-acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post-acute care services from inpatient rehabilitation facilities and skilled nursing facilities ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation.

CONCLUSIONS

Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post-acute care following isolated DRFs, and post-acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post-acute care can inform strategies to improve the cost efficiency of rehabilitation and optimize scarce health care resources.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Complications of compressive neuropathy: prevention and management strategies

Compressive neuropathies of the upper extremity are common and can result in profound disability if left untreated. Nerve releases are frequently performed, but can be complicated by both iatrogenic events and progression of neuropathy. In this review, we examine the management of postoperative complications after 2 common nerve compression release procedures: carpal tunnel release and cubital tunnel release.

Variation in rheumatoid hand and wrist surgery among medicare beneficiaries: a population-based cohort study

OBJECTIVE

To examine the rate and variation in rheumatoid arthritis (RA)-related hand and wrist surgery among Medicare (elderly) beneficiaries in the United States, and to identify the patient and provider factors that influence surgical rates.

METHODS

Using the 2006-2010 100% Medicare claims data of beneficiaries with RA diagnosis, we examined rates of rheumatoid hand and wrist arthroplasty, arthrodesis, and hand tendon reconstruction in the United States. We used multivariate logistic regression models to examine variation in receipt of surgery by patient and regional characteristics (density of providers, intensity of use of biologic disease-modifying antirheumatic drugs).

RESULTS

Between 2006 and 2010, the annual rate of RA-related hand and wrist arthroplasty or arthrodesis was 23.1 per 10,000 patients, and the annual rate of hand tendon reconstruction was 4.2 per 10,000 patients. The rates of surgery varied 9-fold across hospital referral regions in the United States. Younger patient age, female sex, white race, higher socioeconomic status (SES), and rural residence were associated with a higher likelihood of undergoing arthroplasty and arthrodesis. We observed a significant decline in rate of arthroplasty and arthrodesis with increasing density of rheumatologists. Tendon reconstruction was not influenced by provider factors, but was correlated with age, race, SES, and rural status of the patients.

CONCLUSION

Surgical reconstruction of rheumatoid hand deformities varies widely across the United States, driven by both regional availability of subspecialty care in rheumatology and individual patient factors.

Quality assessment in hand surgery

Measuring quality assessment in hand surgery remains an underexplored area. However, measuring quality is becoming increasingly transparent and important. Patients now have direct access to hospital and physician metrics and large payers have linked financial incentives to quality metrics. It is critical for hand surgeons to understand the essential elements of quality and its assessment. This article reviews several areas of hand surgery quality assessments including safety, outcomes, satisfaction, and cost.

Health services research: evolution and applications

Health services research (HSR) is broadly focused on characterizing and improving the access, quality, delivery, and cost of health care. HSR is a multidisciplinary field, engaging experts in clinical medicine and surgery, policy, economics, implementation science, statistics, psychology, and education to improve the care of patients across all specialties. This article summarizes the evolution and distinctive attributes of HSR and present several real-world applications.

Collaborative quality improvement in surgery

Collaborative quality improvement has demonstrated success in improving quality and reducing health care costs in several state-based examples. Professional societies and payers are keen on identifying the most effective strategies to improve the safety and efficiency of surgical care. This review highlights the development and features of collaborative quality improvement programs, their advantages and examples of successful collaborations for several surgical conditions, and their potential application for surgeons caring for patients with upper extremity trauma and disability.

An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group

BACKGROUND

Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE).

OBJECTIVE

We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression.

METHODS

Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means.

RESULTS

Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness.

CONCLUSION

Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Current management of metacarpal fractures

Metacarpal fractures are common, and many can be managed nonoperatively with appropriate reduction and immobilization. As with any hand fracture, the primary goals are to achieve anatomic and stable reduction, bony union, and early mobilization to minimize disability. Appropriate treatment requires a keen understanding of the types of fractures, their inherent stability, and the available treatment options. Functional outcomes depend on appropriate treatment and early range of motion whenever possible.

Toe-to-hand transfer: evolving indications and relevant outcomes

Toe-to-hand transfer is indicated for many types of congenital and traumatic thumb absences. This review will highlight the applications of toe-to-hand transfer and their functional, aesthetic, and psychosocial outcomes. Despite its technical complexity, toe to hand reconstruction techniques can provide an elegant option to restore function for patients with difficult hand disabilities.

Developing the art of scientific presentation

PURPOSE

Few guidelines exist regarding the most effective approach to scientific oral presentations. Our purpose is to (1) develop a standardized instrument to evaluate scientific presentations based on a comprehensive review of the available literature regarding the components and organization of scientific presentations and (2) describe the optimal characteristics of scientific presentations.

METHODS

At the Sixty-sixth (2011) Annual Meeting of the American Society for Surgery of the Hand, 69 presentations were evaluated by at least 2 independent observers. A rating instrument was developed a priori to examine presentation content (background, methods, results, and conclusions), presentation style (speech, structure, delivery, slide aesthetics), and overall quality. We examined correlations between reviewers' ratings of each component as well as overall perceived quality of the presentation using regression analysis. Intraclass correlation coefficients were calculated to measure the degree of variation because of reviewer disagreement and identify the aspects of presentations that contribute to overall quality.

RESULTS

Reviewer agreement was high for presentation content, and less than 1% of variation was caused by reviewer disagreement for background, methods, and conclusions. With respect to presentation style, reviewers agreed most frequently regarding speech and slide appearance, and only 9% and 13%, respectively, of the variation was caused by reviewer disagreement. Disagreement was higher for delivery and presentation structure, and 21% of the variation was attributable to reviewer disagreement. Speaker delivery and slide appearance were the most important predictors of presentation quality, followed by the quality of the presentation of conclusions and background information. Presentation of methods and results were not associated with overall presentation quality.

CONCLUSIONS

Distinct aspects of presentation content and style correlate with quality, which can be reliably and objectively measured. By focusing on selected concepts with visually simple slides, speakers can enhance their delivery and may potentially improve the audience's comprehension of the study findings.

Objective functional outcomes and patient satisfaction after silicone metacarpophalangeal arthroplasty for rheumatoid arthritis

PURPOSE

Patient satisfaction is an essential measure of quality of care for rheumatoid arthritis. Prior research demonstrates that patient satisfaction improves after silicone metacarpophalangeal arthroplasty (SMPA) despite minimal change in hand function. The purpose of this study was to identify the level of objective functional recovery that yields satisfaction after SMPA. We hypothesized that measurable gains in objective hand function after SMPA will discriminate between satisfied and dissatisfied patients.

METHODS

In this prospective, multicenter, cohort study, we observed 46 patients with rheumatoid arthritis and metacarpophalangeal (MCP) joint subluxation for 2 years after reconstructive surgery. We derived satisfaction scores from the Michigan Hand Outcomes Questionnaire, ranging from 0 (least satisfied) to 100 (most satisfied), and dichotomized them using the Cohen large effect size. We measured hand function at baseline and follow-up including strength (grip strength and pinch strength), finger position (extensor lag and ulnar drift), and MCP arc of motion. We constructed receiver operating characteristic curves to identify optimal cutoffs in hand function that correspond with satisfaction.

RESULTS

At 2 years of follow-up, patients who achieved an extension lag of 30° or less were considered satisfied, which represented a 52% improvement (preoperative lag = 63°). Similarly, patients who gained improvement in ulnar drift from an average of preoperatively 62° to 9° postoperatively were satisfied. Finally, patients who achieved an improvement in MCP arc of motion from an average of 21° to 31° postoperatively were satisfied. No improvements in grip or pinch strength corresponded with postoperative patient satisfaction.

CONCLUSIONS

Patients were satisfied with only modest gains in grip and pinch strength after silicone metacarpophalangeal arthroplasty. However, maintaining finger position, without recurrence of ulnar drift or extensor lag, and MCP arc of motion corresponded with patient satisfaction in the postoperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Proximity to disease and perception of utility: physicians' vs patients' assessment of treatment options for ulcerative colitis

BACKGROUND

Physician values regarding the benefit of continued medical therapy vs colectomy for moderate ulcerative colitis have not been defined. If physicians perceive these states differently than patients, their therapeutic recommendations may not align with patient values.

OBJECTIVE

This study aimed to compare physician and patient willingness to trade life years with moderately active ulcerative colitis vs undergoing colectomy.

DESIGN

This survey of physicians' and patients' utility values used standardized scenarios for moderately active ulcerative colitis and colectomy.

SETTING

The investigation was conducted at a tertiary academic medical center.

METHODS

Gastroenterologists, colorectal surgeons, and patients with ulcerative colitis who were either living with moderate disease or were postcolectomy completed the survey.

MAIN OUTCOME MEASURES

Utility values were measured by the use of the time trade-off method.

RESULTS

We surveyed 17 physicians, 150 postcolectomy patients, and 69 patients with moderate ulcerative colitis. Utility values for ulcerative colitis and colectomy states were (0.87, 0.95), (0.86, 0.92), and (0.91, 0.91). On average, physicians and postcolectomy patients assessed the utility of life with ulcerative colitis more poorly than the postcolectomy state. Patients with moderately active ulcerative colitis who had not undergone colectomy viewed both health states equally.

LIMITATIONS

This study was limited by the physician subject sample size.

CONCLUSIONS

Patients living with moderate ulcerative colitis value the pre- and postcolectomy states differently than physicians and postcolectomy patients. Recognizing the differences between their own and patients' values may help physicians to better counsel patients preoperatively. In addition, exposure to postcolectomy patients may help those with moderate disease who are weighing the comparative benefits of colectomy.

Individual health discount rate in patients with ulcerative colitis

BACKGROUND

In cost-effectiveness analysis, discount rates are used in calculating the value of future costs and benefits. However, standard discount rates may not accurately describe the decision-making of patients with ulcerative colitis (UC). These patients often choose the long-term risks of immunosuppressive therapy over the short-term risks of colectomy, demonstrating very high discount rates for future health. In this study we aimed to measure the discount rate in UC patients and identify variables associated with the discount rate.

METHODS

We surveyed patients with UC and patients who were postcolectomy for UC to measure their valuations of UC and colectomy health states. We used Standard Gamble (SG) and Time-Trade-Off (TTO) methods to assess current and future health state valuations and calculated the discount rate.

RESULTS

Participants included 150 subjects with UC and 150 subjects who were postcolectomy for UC. Adjusted discount rates varied widely (0%-100%), with an overall median rate of 55.0% (interquartile range [IQR] 20.6-100), which was significantly higher than the standard rate of 5%. Within the normal range of discount rates, patients' expected discount rate increased by 0.80% for each additional year of age, and female patients had discount rates that averaged ≈ 8% less than their age-matched counterparts and approached statistical significance.

CONCLUSIONS

The accepted discount rate of 5% grossly underestimates UC patients' preference for long-term over short-term risk. This might explain UC patients' frequent choice of the long-term risks of immunosuppressive medical therapy over the short-term risks of colectomy.

Perceived and actual quality of life with ulcerative colitis: a comparison of medically and surgically treated patients

OBJECTIVES

Patients with chronic ulcerative colitis (UC) often refuse colectomy, despite data indicating that it might improve quality of life. We hypothesized that perceived utility values are different for patients living with UC compared with UC patients after total proctocolectomy. Our aims were to compare the perceived utility assigned by UC patients with and without a colectomy to standardized chronic UC and post-colectomy scenarios, and to compare the utility of actual health states among groups.

METHODS

We surveyed patients in a tertiary referral center from three groups, including non-UC, UC patients without colectomy, and UC patients who were post-colectomy. We measured the Time-Trade-Off (TTO) utilities of subjects for standardized scenarios, describing moderate UC and a post-colectomy state. Among all UC patients (with and without colectomy), we measured TTO utility for their own health state.

RESULTS

Responses were obtained from 150 patients per group (n=450). The non-UC patients considered UC and colectomy scenarios equally (0.92), which was similar to UC patients without colectomy (0.90 and 0.91). Post-colectomy patients strongly preferred the colectomy scenario to the UC scenario (0.86 vs. 0.92, P<0.001). The median utility of UC patients without colectomy for their actual health state was higher than that of post-colectomy patients (0.96 and 0.92, P<0.05). Patients with more social support were more likely to have undergone colectomy compared with patients with little social support (odds ratio=1.20 per dependent/supporter).

CONCLUSIONS

Patients living with UC prefer their actual health state to a perceived UC scenario or a post-colectomy scenario. Patients who have undergone colectomy equate the quality of life in their actual state with that in a post-colectomy scenario, and prefer each to a perceived chronic UC state. Given the variety of preferences and the importance of social support, opportunities to interact with UC patients who have previously undergone colectomy could help patients living with UC and their physicians to navigate these complex choices.

The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma?

BACKGROUND

To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood.

MATERIALS AND METHODS

Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income.

RESULTS

Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001).

CONCLUSION

Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.

Validity and responsiveness of the Michigan Hand Questionnaire in patients with rheumatoid arthritis: a multicenter, international study

OBJECTIVE

Millions of patients experience the disabling hand manifestations of rheumatoid arthritis (RA), yet few hand-specific instruments are validated in this population. Our objective was to assess the reliability, validity, and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with RA.

METHODS

At enrollment and at 6 months, 128 RA patients with severe subluxation of the metacarpophalangeal joints completed the MHQ, a 37-item questionnaire with 6 domains: function, activities of daily living (ADL), pain, work, aesthetics, and satisfaction. Reliability was measured using Spearman's correlation coefficients between time periods. Internal consistency was measured using Cronbach's alpha. Construct validity was measured by correlating MHQ responses with the Arthritis Impact Measurement Scales 2 (AIMS2). Responsiveness was measured by calculating standardized response means (SRMs) between time periods.

RESULTS

The MHQ demonstrated good test-retest reliability (r = 0.66, P < 0.001). Cronbach's alpha scores were high for ADL (α = 0.90), function (α = 0.87), aesthetics (α = 0.79), and satisfaction (α = 0.89), indicating redundancy. The MHQ correlated well with AIMS2 responses. Function (r = -0.63), ADL (r = -0.77), work (r = -0.64), pain (r = 0.59), and summary score (r = -0.74) were correlated with the physical domain. Affect was correlated with ADL (r = -0.47), work (r = -0.47), pain (r = 0.48), and summary score (r = -0.53). Responsiveness was excellent among arthroplasty patients in function (SRM 1.42), ADL (SRM 0.89), aesthetics (SRM 1.23), satisfaction (SRM 1.76), and summary score (SRM 1.61).

CONCLUSION

The MHQ is easily administered, reliable, and valid to measure rheumatoid hand function, and can be used to measure outcomes in rheumatic hand disease.

Effect of Esthetic Outcome After Breast-Conserving Surgery on Psychosocial Functioning and Quality of Life

Purpose

Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery.

Patients and Methods

All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications.

Results

Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P < .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002).

Conclusion

Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.

Factors predicting additional disease in the axilla in patients with positive sentinel lymph nodes after neoadjuvant chemotherapy

BACKGROUND

The utility of sentinel lymph node (SNL) biopsy (SLNB) as a predictor of axillary lymph node status is similar in patients who receive neoadjuvant chemotherapy and patients who undergo surgery first. The authors of this study hypothesized that patients with positive SLNs after neoadjuvant therapy would have unique clinicopathologic factors that would be predictive of additional positive non-SLNs distinct from patients who underwent surgery first.

METHODS

One hundred four patients were identified who received neoadjuvant chemotherapy, had a positive SLN, and underwent axillary dissection between 1997 and 2005. At the time of presentation, 66 patients had clinically negative lymph nodes by ultrasonography, and 38 patients had positive lymph nodes confirmed by fine-needle aspiration. Eighteen factors were assessed for their ability to predict positive non-SLNs using chi-square and logistic regression analysis with a bootstrapped, backwards elimination procedure. The resulting nomogram was tested by using a patient cohort from another institution.

RESULTS

Patients with clinically negative lymph nodes at presentation were less likely than patients with positive lymph nodes to have positive non-SLNs (47% vs 71%; P=.017). On multivariate analysis, lymphovascular invasion, the method for detecting SLN metastasis, multicentricity, positive axillary lymph nodes at presentation, and pathologic tumor size retained grouped significance with a bootstrap-adjusted area under the curve (AUC) of 0.762. The resulting nomogram was validated in the external patient cohort (AUC, 0.78).

CONCLUSIONS

A significant proportion of patients with positive SLNs after neoadjuvant chemotherapy had no positive non-SLNs. The use of a nomogram based on 5 predictive variables that were identified in this study may be useful for predicting the risk of positive non-SLNs in patients who have positive SLNs after chemotherapy.

Correlates of patient satisfaction and provider trust after breast-conserving surgery

BACKGROUND

Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear.

METHODS

All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n=714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics.

RESULTS

Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21-0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21-0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14-0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P= .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P= .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers.

CONCLUSIONS

Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes.

Patient Satisfaction With Treatment of Breast Cancer: Does Surgeon Specialization Matter?

Purpose

Experience and practice setting vary greatly among surgeons who treat breast cancer patients. However, less is known about how these factors influence patient satisfaction with their care.

Patients and Methods

We surveyed all ductal carcinoma in situ patients and a 20% random sample of invasive breast cancer patients diagnosed in 2002 reported to the Detroit, MI, and Los Angeles, CA, Surveillance, Epidemiology, and End Results registries. Attending surgeons were surveyed, yielding dyad information for 64.6% of patients (n = 1,539) and 69.7% of surgeons (n = 318). Logistic regression was used to examine the associations between surgeon specialization (percentage of practice devoted to breast disease) and hospital cancer program status, with four domains of patient satisfaction: (1) the surgical decision, (2) decision-making process, (3) surgeon-patient relationship, and (4) surgeon-patient communication, adjusting for patient and surgeon demographics and disease stage.

Results

In this sample, 34.5% of patients were treated by surgeons who devoted less than 30% (low volume) of their practice to breast disease, 32.5% by surgeons who devoted 30% to 60% (medium volume) of their practice to breast disease, and 33.0% by surgeons who devoted more than 60% (high volume) of their practice to breast disease. Compared to patients treated by low-volume surgeons, patients treated by higher volume surgeons were more satisfied with the decision-making process (medium volume, odds ratio [OR], 1.16; 95% CI, 0.80 to 1.67; high volume: OR, 1.79; 95% CI, 1.14 to 2.80) and with the surgeon-patient relationship (medium volume: OR, 1.13; 95% CI, 0.72 to 1.76; high volume: OR, 1.98; 95% CI, 1.08 to 3.61). Treatment setting was not associated with patient satisfaction after controlling for other factors.

Conclusion

Surgeon specialization is correlated with patient satisfaction. Examining the processes underlying these associations can inform strategies to improve breast cancer care.

Neoadjuvant Systemic Therapy and the Surgical Management of Breast Cancer

Neoadjuvant chemotherapy is standard management for women who have locally advanced or inflammatory breast cancer, but can be applied to all women who may require postoperative chemotherapy for early-stage breast cancer. Disease-free survival and overall survival are equivalent between patients treated with neoadjuvant chemotherapy and patients treated with the same regimen postoperatively. Preoperative chemotherapy can offer women less morbid surgical treatment by down-staging both the primary breast tumor and axillary metastases. Finally, response to chemotherapy can inform clinicians of the chemosensitivity of the tumor, and can predict long-term outcome for women who have breast cancer.

Decision Aids and Breast Cancer: Do They Influence Choice for Surgery and Knowledge of Treatment Options?

Purpose

To describe the effect of decision aids on the choice for surgery and knowledge of surgical therapy among women with early-stage breast cancer.

Methods

A systematic review was conducted between years 1966 to 2006 of all studies designed to assess the effect of decision aids on surgical therapy. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Network, HAPI databases, and bibliographies were searched. Of the 123 studies screened, 11 studies met criteria. Meta-analyses were performed to assess the pooled relative risk for surgical choice and the pooled mean difference in patient knowledge.

Results

Results from randomized controlled trials indicated that women who used a decision aid were 25% more likely to choose breast-conserving surgery over mastectomy (risk ratio, 1.25; 95% CI, 1.11 to 1.40). Decision aids significantly increased patient knowledge by 24% (P = .024). The data also suggested that decision aids decreased decisional conflict and increased satisfaction with the decision-making process. Decision aids were well received by surgeons and patients, facilitated patients’ desire for shared decision making, and were feasible to implement into practice.

Conclusion

Decision aids are important adjuncts for counseling women with early-stage breast cancer. Their use increases the likelihood that women will choose breast-conserving surgery, and enhances patient knowledge of treatment options.

Surgeon age and operative mortality in the United States

OBJECTIVES

Although recent studies suggest that physician age is inversely related to clinical performance in primary care, relationships between surgeon age and patient outcomes have not been examined systematically.

METHODS

Using national Medicare files, we examined operative mortality in approximately 461,000 patients undergoing 1 of 8 procedures between 1998 and 1999. We used multiple logistic regression to assess relationships between surgeon age (< or =40 years, 41-50 years, 51-60 years, and >60 years) and operative mortality (in-hospital or within 30 days), adjusting for patient characteristics, surgeon procedure volume, and hospital attributes.

RESULTS

Although older surgeons had slightly lower procedure volumes than younger surgeons for some procedures, there were few clinically important differences in patient characteristics by surgeon age. Compared with surgeons aged 41 to 50 years, surgeons over 60 years had higher mortality rates with pancreatectomy (adjusted odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.49), coronary artery bypass grafting (OR, 1.17; 95% CI, 1.05-1.29), and carotid endarterectomy (OR, 1.21; 95% CI, 1.04-1.40). The effect of surgeon age was largely restricted to those surgeons with low procedure volumes and was unrelated to mortality for esophagectomy, cystectomy, lung resection, aortic valve replacement, or aortic aneurysm repair. Less experienced surgeons (< or =40 years of age) had comparable mortality rates to surgeons aged 41 to 50 years for all procedures.

CONCLUSIONS

For some complex procedures, surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts. For most procedures, however, surgeon age is not an important predictor of operative risk.