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Rashid Z, Munir MM, Woldesenbet S, Khalil M, Katayama E, Khan MMM, Endo Y, Altaf A, Tsai S, Dillhoff M, Pawlik TM. Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy. J Gastrointest Surg 2024; 28:1137-1144. [PMID: 38762337 DOI: 10.1016/j.gassur.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
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Pretzsch E, Koliogiannis D, D’Haese JG, Ilmer M, Guba MO, Angele MK, Werner J, Niess H. Textbook outcome in hepato-pancreato-biliary surgery: systematic review. BJS Open 2022; 6:6855255. [PMID: 36449597 PMCID: PMC9710735 DOI: 10.1093/bjsopen/zrac149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/08/2022] [Accepted: 10/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Textbook outcome (TO) is a multidimensional measure reflecting the ideal outcome after surgery. As a benchmarking tool, it provides an objective overview of quality of care. Uniform definitions of TO in hepato-pancreato-biliary (HPB) surgery are missing. This study aimed to provide a definition of TO in HPB surgery and identify obstacles and predictors for achieving it. METHODS A systematic literature search was conducted using PubMed, Embase, and Cochrane Database according to PRISMA guidelines. Studies published between 1993 and 2021 were retrieved. After selection, two independent reviewers extracted descriptive statistics and derived summary estimates of the occurrence of TO criteria and obstacles for achieving TO using co-occurrence maps. RESULTS Overall, 30 studies were included. TO rates ranged between 16-69 per cent. Commonly chosen co-occurring criteria to define TO included 'no prolonged length of stay (LOS)', 'no complications', 'no readmission', and 'no deaths'. Major obstacles for achieving TO in HPB surgery were prolonged LOS, complications, and readmission. On multivariable analysis, TO predicted better overall and disease-free survival in patients with cancer. Achievement of TO was more likely in dedicated centres and associated with procedural and structural indicators, including high case-mix index and surgical volume. CONCLUSION TO is a useful quality measure to benchmark surgical outcome. Future definitions of TO in HPB surgery should include 'no prolonged LOS', 'no complications', 'no readmission', and 'no deaths'.
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Affiliation(s)
- Elise Pretzsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jan Gustav D’Haese
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Ilmer
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Otto Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Konrad Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hanno Niess
- Correspondence to: Hanno Niess, Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (e-mail: )
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Munir MM, Alaimo L, Moazzam Z, Endo Y, Lima HA, Shaikh C, Ejaz A, Beane J, Dillhoff M, Cloyd J, Pawlik TM. Textbook oncologic outcomes and regionalization among patients undergoing hepatic resection for intrahepatic cholangiocarcinoma. J Surg Oncol 2022; 127:81-89. [PMID: 36136327 PMCID: PMC10087698 DOI: 10.1002/jso.27102] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Textbook oncologic outcome (TOO) and its association with regionalization of care for intrahepatic cholangiocarcinoma (ICC) have not been evaluated. METHODS We identified patients who underwent hepatic resection for ICC between 2004 and 2018 from the National Cancer Database. Facilities were categorized by annual hepatectomy volume for ICC. TOO was defined as no 90-day mortality, margin-negative resection, no prolonged hospitalization, no 30-day readmission, receipt of appropriate adjuvant therapy, and adequate lymphadenectomy. Multivariable regression was used to evaluate the association between annual hepatectomy volume and TOO. RESULTS A total of 5359 patients underwent liver resection for ICC. TOO was achieved in 11.2% (n = 599) of patients. Inadequate lymphadenectomy was the largest impediment to achieving TOO. After adjusting for patient, pathologic, and facility characteristics, high volume facilities had 67% increased odds of achieving TOO (Ref.: low volume; high volume: odds ratio 1.67, 95% confidence interval: 1.24-2.25; p < 0.001). Patients treated at high-volume centers who achieved a TOO had better overall survival (OS) versus patients treated at low-volume facilities (low volume vs. high volume; median OS, 47.3 vs. 71.1 months, p < 0.05). CONCLUSIONS A composite oncologic measure, TOO, provides a comprehensive insight into the performance of liver resection and regionalization of surgical care for ICC.
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Affiliation(s)
- Muhammad M Munir
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Laura Alaimo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Zorays Moazzam
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Henrique A Lima
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Chanza Shaikh
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Joal Beane
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Jordan Cloyd
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
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Hyer JM, Diaz A, Ejaz A, Tsilimigras DI, Dalmacy D, Paro A, Pawlik TM. Fragmentation of practice: The adverse effect of surgeons moving around. Surgery 2022; 172:480-485. [PMID: 35074175 DOI: 10.1016/j.surg.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/01/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome. METHOD Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis. RESULTS Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05). CONCLUSION Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH; Secondary Data Core, Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/madisonhyer
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/DiazAdrian10
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/AEjaz85
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/DTsilimigras
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Alessandro Paro
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH.
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Capretti G, Bonifacio C, De Palma C, Nebbia M, Giannitto C, Cancian P, Laino ME, Balzarini L, Papanikolaou N, Savevski V, Zerbi A. A machine learning risk model based on preoperative computed tomography scan to predict postoperative outcomes after pancreatoduodenectomy. Updates Surg 2021; 74:235-243. [PMID: 34596836 DOI: 10.1007/s13304-021-01174-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/20/2021] [Indexed: 11/09/2022]
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a life-threatening complication following pancreaticoduodenectomy (PD). Individualized preoperative risk assessment could improve clinical management and prevent or mitigate adverse outcomes. The aim of this study is to develop a machine learning risk model to predict occurrence of CR-POPF after PD from preoperative computed tomography (CT) scans. A total of 100 preoperative high-quality CT scans of consecutive patients who underwent pancreaticoduodenectomy in our institution between 2011 and 2019 were analyzed. Radiomic and morphological features extracted from CT scans related to pancreatic anatomy and patient characteristics were included as variables. These data were then assessed by a machine learning classifier to assess the risk of developing CR-POPF. Among the 100 patients evaluated, 20 had CR-POPF. The predictive model based on logistic regression demonstrated specificity of 0.824 (0.133) and sensitivity of 0.571 (0.337), with an AUC of 0.807 (0.155), PPV of 0.468 (0.310) and NPV of 0.890 (0.084). The performance of the model minimally decreased utilizing a random forest approach, with specificity of 0.914 (0.106), sensitivity of 0.424 (0.346), AUC of 0.749 (0.209), PPV of 0.502 (0.414) and NPV of 0.869 (0.076). Interestingly, using the same data, the model was also able to predict postoperative overall complications and a postoperative length of stay over the median with AUCs of 0.690 (0.209) and 0.709 (0.160), respectively. These findings suggest that preoperative CT scans evaluated by machine learning may provide a novel set of information to help clinicians choose a tailored therapeutic pathway in patients candidated to pancreatoduodenectomy.
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Affiliation(s)
- Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Cristiana Bonifacio
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Crescenzo De Palma
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Martina Nebbia
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Caterina Giannitto
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Pierandrea Cancian
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Maria Elena Laino
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Luca Balzarini
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | | | - Victor Savevski
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, MI, Italy
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County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA. J Gastrointest Surg 2021; 25:1736-1744. [PMID: 32918677 DOI: 10.1007/s11605-020-04778-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer. METHODS Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level. RESULTS Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy. CONCLUSION Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.
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Patient Social Vulnerability and Hospital Community Racial/Ethnic Integration: Do All Patients Undergoing Pancreatectomy Receive the Same Care Across Hospitals? Ann Surg 2021; 274:508-515. [PMID: 34397453 DOI: 10.1097/sla.0000000000004989] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy. BACKGROUND The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined. METHODS Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed. RESULTS Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11). CONCLUSION Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.
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Hyer JM, Tsilimigras DI, Diaz A, Mirdad RS, Pawlik TM. A higher hospital case mix index increases the odds of achieving a textbook outcome after hepatopancreatic surgery in the Medicare population. Surgery 2021; 170:1525-1531. [PMID: 34090674 DOI: 10.1016/j.surg.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The objective of the current study was to assess the impact of case mix index at the hospital level on postoperative outcomes among Medicare beneficiaries who underwent hepatopancreatic surgery. METHODS Medicare beneficiaries who underwent hepatopancreatic surgery between 2013 and 2017 were identified and analyzed. The primary independent variable, Case Mix Index, is a freely available metric; the primary outcome was textbook outcome defined as the absence of complications, extended length of stay, readmission, and mortality. RESULTS Among 37,412 Medicare beneficiaries, 64.9% (n = 24,299) underwent a pancreatectomy and 35.1% (n = 13,113) underwent hepatectomy. The overall incidence of textbook outcome was 47.2%, which varied by case mix index (low case mix index: 41.6% vs high case mix index: 51.3%), as did extended length of stay (low case mix index: 27.9% versus high case mix index: 19.3%), complications (low case mix index: 33.3% vs high case mix index: 24.7%), and 90-day mortality (low case mix index: 12.5% vs high case mix index: 6.3%). After controlling for hepatopancreatic-specific surgical volume and hospital teaching status, multivariable analyses revealed that patients who underwent surgery at a low case mix index hospital had 28% decreased odds (95% confidence interval 0.66-0.79) of achieving a textbook outcome versus patients from a high case mix index hospital. Moreover, patients at a low case mix index hospital had 39% increased odds of extended length of stay (95% confidence interval 1.23-1.59), 48% increased odds of experiencing a complication (95% confidence interval 1.32-1.65), and 56% increased odds of 90-day mortality (95% confidence interval 1.31-1.87). CONCLUSION Case mix index was strongly associated with the probability of achieving a textbook outcome after hepatopancreatic surgery. Hospitals with a higher case mix index were more likely to perform hepatopancreatic surgeries with no adverse postoperative outcomes.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/MadisonHyer
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH. https://twitter.com/DTsilimigras
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH.
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Mehta R, Tsilimigras DI, Pawlik TM. Assessment of Magnet status and Textbook Outcomes among medicare beneficiaries undergoing hepato-pancreatic surgery for cancer. J Surg Oncol 2021; 124:334-342. [PMID: 33961716 DOI: 10.1002/jso.26521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The relationship between hospital Magnet status recognition and postoperative outcomes following complex cancer surgery remains ill-defined. We sought to characterize Textbook Outcome (TO) rates among patients undergoing (HP) surgery for cancer in Magnet versus non-Magnet centers. METHODS Medicare beneficiaries undergoing HP surgery between 2015 and 2017 were identified. The association of postoperative TO (no complications/extended length-of-stay/90-day mortality/90-day readmission) with Magnet designation was examined after adjusting for competing risk factors. RESULTS Among 10,997 patients, 21.3% (n = 2337) patients underwent surgery at Magnet hospitals (non-Magnet centers: 78.7%, n = 8660). On multivariable analysis, patients undergoing HP surgery had comparable odds of achieving a TO at Magnet versus non-Magnet hospitals (hepatectomy: odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.94-1.17; pancreatectomy-OR: 0.88, 95% CI: 0.74-1.06). Patients treated at hospitals with a high nurse-to-bed ratio had higher odds of achieving a TO irrespective of whether they received surgery at Magnet (high vs. low nurse-to-bed ratio; OR: 1.38; 95% CI: 1.01-1.89) or non-Magnet centers (OR: 1.26; 95% CI: 1.10-1.45). Similarly, hospital HP volume was strongly associated with higher odds of TO following HP surgery in both Magnet (Leapfrog compliant vs. noncompliant; OR: 1.24, 95% CI: 1.06-1.44) and non-Magnet centers (OR: 1.18; 95% CI: 1.11-1.26). CONCLUSION Hospital Magnet designation was not an independent factor of superior outcomes after HP surgery. Rather, hospital-level factors such as nurse-to-bed ratio and HP procedural volume drove outcomes.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Tsilimigras DI, Pawlik TM, Moris D. Textbook outcomes in hepatobiliary and pancreatic surgery. World J Gastroenterol 2021; 27:1524-1530. [PMID: 33958840 PMCID: PMC8058657 DOI: 10.3748/wjg.v27.i15.1524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
The concept of textbook outcome (TO) has recently gained popularity in surgical research and has been used to evaluate the quality or success of different surgical procedures, including hepatopancreatobiliary (HPB) operations. TO consists of individual outcome parameters that each reflect different domains of care including structure, process, and individual outcomes; in turn, the composite TO metric represents the optimal course after a surgical episode. TO can be used to assess patient-level outcomes, hospital performance, center designation and quality metrics. In addition to being an outcome measurement, TO may also be linked to healthcare costs. Future efforts should be directed towards establishing a universal definition of TO in HPB surgery so that surgeons and hospitals can assess and compare outcomes, identify shortcomings and improve real world patient outcomes.
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Affiliation(s)
| | | | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27710, United States
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11
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Diaz A, Hyer JM, Azap R, Tsilimigras D, Pawlik TM. Association of social vulnerability with the use of high-volume and Magnet recognition hospitals for hepatopancreatic cancer surgery. Surgery 2021; 170:571-578. [PMID: 33775393 DOI: 10.1016/j.surg.2021.02.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND In an effort to improve perioperative and oncologic outcomes, there have been multiple quality improvement initiatives, including regionalization of high-risk procedures and hospital accreditation designations from independent organizations. These initiatives may, however, hinder access to high-quality surgical care for certain patients living in areas with high social vulnerability who may be disproportionally affected, leading to disparities in access and worse postoperative outcomes. METHODS Medicare beneficiaries who underwent liver or pancreas resection for cancer were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals were designated as high-volume based on Leapfrog criteria. The Centers for Disease Control and Prevention's social vulnerability index database was used to abstract social vulnerability index information based on each beneficiary's county of residence at the time of operation. The probability that a patient received care at a high-volume hospital stratified by the social vulnerability of the patient's county of residence was examined. Risk-adjusted postoperative outcomes were compared across low, average, and high levels of vulnerability at both low- and high-volume hospitals. RESULTS Among 16,978 Medicare beneficiaries who underwent a pancreatectomy (n = 13,393, 78%) or a liver resection (n = 3,594, 21.2%) for cancer, the mean age was 73.3 years (standard deviation: 5.8), nearly half the cohort was female (n = 7,819, 46%), and the overwhelming majority were White (n = 15,034, 88.5%). Mean social vulnerability index was 49.8 (standard deviation 24.8) and mean Charlson comorbidity index was 4.8 (standard deviation: 3). Overall, 8,251 (48.6%) of patients had their operations at a high-volume hospital, and 3,802 patients had their operations at a hospital with Magnet recognition. Age and sex were similar within the low-, average-, and high-social vulnerability index cohorts (P > .05); however, race differed across social vulnerability index groups. White patients made up 93% (n = 3,241) of the low social vulnerability index compared with 83.9% (n = 2,706) of the high-social vulnerability index group, whereas non-Whites made up 7% (n = 244) of the low-social vulnerability index group compared with 16.1% (n = 556) of the high-social vulnerability index group (P < .001). The risk-adjusted overall probability of having surgery at a high-volume hospital decreased as social vulnerability increased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Risk-adjusted probability of postoperative complications increased with social vulnerability index; however, among patients with high social vulnerability, risk of postoperative complications was lower at high-volume hospitals compared with low-volume hospitals. In contrast, there was no difference in postoperative complications between hospitals with and without Magnet recognition across social vulnerability index. CONCLUSION Patients residing in communities characterized by a high social vulnerability index were less likely to undergo high-risk cancer surgery at a high-volume hospital. Although postoperative complications and mortality increased as social vulnerability index increased, some of the risk appeared to be mitigated by having surgery at a high-volume hospital. These data highlight the importance of access to high-quality surgical care, especially among patients who may already be more vulnerable.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/MadisonHyer
| | - Rosevine Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/rosevineazap
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/DTsilimigras
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/timpawlik
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12
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Diaz A, Pawlik TM. Insurance status and high-volume surgical cancer: Access to high-quality cancer care. Cancer 2020; 127:507-509. [PMID: 33084043 DOI: 10.1002/cncr.33234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Adrian Diaz
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio
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13
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Is Hospital Occupancy Rate Associated with Postoperative Outcomes Among Patients Undergoing Hepatopancreatic Surgery? Ann Surg 2020; 276:153-158. [DOI: 10.1097/sla.0000000000004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Denbo J, Anaya DA. Textbook Outcomes Following Liver Resection for Cancer: A New Standard for Quality Benchmarking and Patient Decision Making. Ann Surg Oncol 2020; 27:3118-3120. [DOI: 10.1245/s10434-020-08550-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Indexed: 12/19/2022]
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15
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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: 52] [Impact Index Per Article: 13.0] [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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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
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Needleman BJ, Brethauer SA, Pawlik TM. Assessing a Surgeon's Competency for High-Risk Procedures: Should We Be Looking at the Bigger Picture? JAMA Netw Open 2020; 3:e203888. [PMID: 32347946 DOI: 10.1001/jamanetworkopen.2020.3888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bradley J Needleman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Stacy A Brethauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
- The James Comprehensive Cancer Center, The Ohio State University, Columbus
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