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Rashid Z, Munir MM, Woldesenbet S, Tsilimigras DI, Khalil M, Khan MMM, Resende V, Dillhoff M, Ejaz A, Pawlik TM. Care fragmentation in hepatopancreatic surgery and postoperative outcomes. Surgery 2024; 175:1562-1569. [PMID: 38565495 DOI: 10.1016/j.surg.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/07/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Practice fragmentation in surgery may be associated with poor quality of care. We sought to define the association between fragmented practice and outcomes in hepatopancreatic surgery relative to surgeon volume and sex. METHODS Medicare beneficiaries who underwent hepatopancreatic surgery between 2016 and 2021 were identified. Multivariable analysis was performed to determine provider sex-based differences in the rate of fragmented practice relative to the achievement of a textbook outcome and health care expenditures after adjusting for procedure-specific case volume. RESULTS Among 37,416 patients, almost one-half were female (n = 18,333, 49.0%) with the majority treated by male surgeons (n = 33,697, 90.8%). Female surgeons were more likely to have a greater rate of fragmented practice (females: n = 242, 84.9% vs males: n = 1,487, 78.4%, P = .003; odds ratio 2.66, 95% confidence interval 2.33-3.03, P < .001). Patients treated by high rate of fragmented practice surgeons had increased odds of postoperative complications (odds ratio 1.40, 95% confidence interval 1.28-1.54), extended length-of-stay (odds ratio 1.52, 95% confidence interval 1.38-1.68), 90-day-mortality (odds ratio 1.49, 95% confidence interval 1.28-1.72), and lower odds of achieving a textbook outcome (odds ratio 0.76, 95% confidence interval 0.71-0.83). This association persisted independent of surgeon-specific volume (textbook outcome, high vs low rate of fragmented practice: high-volume surgeon, odds ratio 0.53, 95% confidence interval 0.31-0.91, P = .021 vs. low-volume surgeon, odds ratio 0.76, 95% confidence interval 0.69-0.82, P < .001). Among patients treated by male surgeons, a high rate of fragmented practice was associated with reduced odds of achieving a textbook outcome (male surgeons: odds ratio 0.76, 95% confidence interval 0.70-0.82, P < .001; female surgeons: odds ratio 0.81, 95% confidence interval 0.63-1.05, P = .110). Treatment by surgeons with higher fragmented practice was associated with higher expenditures (index expenditure: percentage difference 9.87, 95% confidence interval, 7.42-12.36; P < .05). CONCLUSION A high rate of fragmented practice adversely affected postoperative outcomes and healthcare expenditures even among high-volume surgeons with the impact varying based on surgeon sex.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/ZRashidMD
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/musaabmunir
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/DTsilimigras
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/Mujtabakhalil
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/Muntazirmehdik
| | - Vivian Resende
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil. http://www.twitter.com/vivianresende6
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/mary_dillhoff
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. http://www.twitter.com/AEjaz85
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Elshami M, Hoehn RS, Ammori JB, Hardacre JM, Selfridge JE, Bajor D, Mohamed A, Chakrabarti S, Mahipal A, Winter JM, Ocuin LM. Disparities in guideline-compliant care for patients with pancreatic ductal adenocarcinoma at minority-versus non-minority-serving hospitals. HPB (Oxford) 2023; 25:1502-1512. [PMID: 37558565 DOI: 10.1016/j.hpb.2023.07.903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND We examined disparities in guideline-compliant care at minority-serving hospitals (MSH) versus non-MSH among patients with localized or metastatic pancreatic adenocarcinoma (PDAC). METHODS Patients with PDAC were identified within the National Cancer Database (2004-2018). Guideline-compliant care was defined as surgery + chemotherapy ± radiation therapy for localized and chemotherapy for metastatic disease. Facilities in the top decile of minority patients treated were considered MSH. RESULTS A total of 190,950 patients were identified and most (59.6%) had metastatic disease. Overall, 6.4% of patients with localized and 8.2% of patients with metastatic disease were treated at MSH. Patients treated at MSH were less likely to receive guideline-compliant care (localized: OR = 0.78, 95% CI: 0.67-0.91; metastatic: OR = 0.77, 95% CI: 0.67-0.88). Minority patients were less likely to receive guideline-compliant care at non-MSH (localized: OR = 0.71, 95% CI: 0.67-0.75; metastatic: OR = 0.85, 95% CI: 0.82-0.89) or MSH (localized: OR = 0.85, 95% CI: 0.74-0.98; metastatic: OR = 0.91, 95% CI: 0.82-0.99). Patients treated at non-MSH or MSH who received guideline-compliant care were more likely to have higher OS regardless of stage or race. CONCLUSIONS MSH patients were less likely to receive guideline-compliant care and minority patients were less likely to receive guideline-compliant care regardless of MSH status. Guideline-compliant care was associated with improved OS.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - David Bajor
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Amr Mohamed
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Sakti Chakrabarti
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Amit Mahipal
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH, USA
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Elshami M, Bailey L, Hoehn RS, Ammori JB, Hardacre JM, Selfridge JE, Bajor D, Mohamed A, Chakrabarti S, Mahipal A, Winter JM, Ocuin LM. Differences in the surgical management of early-stage hepatocellular carcinoma at minority versus non-minority-serving hospitals. Surgery 2023; 174:1201-1207. [PMID: 37604756 DOI: 10.1016/j.surg.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND We examined differences in surgical intervention at minority-serving hospitals versus non-minority-serving hospitals among patients with early-stage hepatocellular carcinoma. We also investigated associations between surgical management and overall survival, stratified by minority-serving hospital status. METHODS Patients with early-stage hepatocellular carcinoma, defined as cT1, were identified within the National Cancer Database (2004-2018). The primary outcome was surgical intervention (resection, ablation, or transplantation). The proportion of minority (non-Hispanic Black or Hispanic) patients treated at each facility was determined, and hospitals in the top decile were considered minority-serving hospitals. RESULTS A total of 46,703 patients with early-stage hepatocellular carcinoma were identified, of whom 4,214 (9.0%) were treated at minority-serving hospitals. Patients treated at minority-serving hospitals were less likely to undergo surgical intervention than patients treated at non-minority-serving hospitals (odds ratio = 0.87, 95% confidence interval: 0.81-0.94). Minority patients treated at non-minority-serving hospitals were less likely to undergo surgical intervention than White patients (odds ratio = 0.86, 95% confidence interval: 0.82-0.90) and had a further associated decrease in the likelihood of surgical intervention when treated at minority-serving hospitals (odds ratio = 0.81, 95% confidence interval: 0.69-0.94). Regardless of minority-serving hospital status, surgery was associated with improved overall survival. There were no clinically meaningful differences in overall survival between White and minority patients who underwent surgery either at minority-serving hospitals or non-minority-serving hospitals. CONCLUSIONS Patients with early-stage hepatocellular carcinoma had an associated decrease in the likelihood of surgical intervention when treated at minority-serving hospitals. Minority patients treated at minority-serving hospitals had an associated decrease in the likelihood of surgery, but to a lesser extent when treated at non-minority-serving hospitals. Surgery was associated with improved overall survival regardless of minority or minority-serving hospital status.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH. http://www.twitter.com/MElshamiMD
| | - Lauryn Bailey
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH. http://www.twitter.com/Richard_Hoehn
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH. http://www.twitter.com/AmmoriJohn
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - J Eva Selfridge
- Division of Hematology and Oncology, Department of Medicine, University. Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH. http://www.twitter.com/JEvaSelfridge
| | - David Bajor
- Division of Hematology and Oncology, Department of Medicine, University. Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH. http://www.twitter.com/dlbajor
| | - Amr Mohamed
- Division of Hematology and Oncology, Department of Medicine, University. Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH
| | - Sakti Chakrabarti
- Division of Hematology and Oncology, Department of Medicine, University. Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH. http://www.twitter.com/SaktiChakrabar1
| | - Amit Mahipal
- Division of Hematology and Oncology, Department of Medicine, University. Hospitals Seidman Cancer Center, Case Western Reserve University Cleveland, OH. http://www.twitter.com/Amitmahipal79
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH. http://www.twitter.com/JordanMWinterMD
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, OH.
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Lima HA, Moazzam Z, Pawlik TM. ASO Author Reflections: Disparities in NCCN Guideline-Compliant Care for Patients with Early-Stage Pancreatic Adenocarcinoma at Minority-Serving Versus Non-minority-Serving Hospitals. Ann Surg Oncol 2023; 30:4373-4374. [PMID: 36808592 DOI: 10.1245/s10434-023-13260-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/05/2023] [Indexed: 02/21/2023]
Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Lima HA, Alaimo L, Moazzam Z, Endo Y, Woldesenbet S, Katayama E, Munir MM, Shaikh C, Ruff SM, Dillhoff M, Beane J, Cloyd J, Ejaz A, Resende V, Pawlik TM. Disparities in NCCN Guideline-Compliant Care for Patients with Early-Stage Pancreatic Adenocarcinoma at Minority-Serving versus Non-Minority-Serving Hospitals. Ann Surg Oncol 2023; 30:4363-4372. [PMID: 36800128 DOI: 10.1245/s10434-023-13230-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Racial/ethnic disparities in pancreatic adenocarcinoma (PDAC) outcomes may relate to receipt of National Comprehensive Cancer Network (NCCN) guideline-compliant care. We assessed the association between treatment at minority-serving hospitals (MSH) and receipt of NCCN-compliant care. PATIENTS AND METHODS Patients who underwent resection of early-stage PDAC between 2006 and 2019 were identified from the National Cancer Database (NCDB). MSH was defined as the top decile of facilities treating minority ethnicities (Black and/or Hispanic). Factors associated with receipt of NCCN-compliant care and its impact on overall survival (OS) were assessed. RESULTS Among 44,873 patients who underwent resection of PDAC, most were treated at non-MSH (n = 42,571, 94.9%), while a smaller subset were treated at MSH (n = 2302, 5.1%). Patients treated at MSH were more likely to be at a younger median age (MSH 66 years versus non-MSH 67 years), Black or Hispanic (MSH 58.4% versus non-MSH 12.0%), and not insured (MSH 7.8% versus non-MSH 1.6%). While 71.7% (n = 31,182) of patients were compliant with NCCN care, guideline-compliant care was lower at MSH (MSH 62.5% versus non-MSH 72.2%). On multivariable analysis, receiving care at MSH was associated with not receiving guideline-compliant care [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.53-0.74]. At non-MSH, non-white patients had lower odds of receiving guideline-compliant PDCA care (OR 0.85, 95% CI 0.78-0.91). Failure to comply was associated with worse overall survival (OS) [hazard ratio (HR) 1.50, 95% CI 1.46-1.54, all p < 0.001]. CONCLUSIONS Patients with PDAC treated at MSH and minorities treated at non-MSH were less likely to receive NCCN-compliant care. Failure to comply with guideline-based PDAC treatment was associated with worse OS.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Laura Alaimo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Samantha M Ruff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Wang D, Hu Y, Liu K, Liu Z, Chen X, Cao L, Zhang W, Li K, Hu J. Issues in patients' experiences of enhanced recovery after surgery (ERAS) : a systematic review of qualitative evidence. BMJ Open 2023; 13:e068910. [PMID: 36810180 PMCID: PMC9945048 DOI: 10.1136/bmjopen-2022-068910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE To explore patients' experiences of enhanced recovery after surgery (ERAS) and to identify issues in the implementation of ERAS from the patient's perspective. DESIGN The systematic review and qualitative analysis were based on the Joanna Briggs Institute's methodology for conducting synthesis. DATA SOURCES Relevant studies published in four databases, that is, Web of Science, PubMed, Ovid Embase and the Cochrane Library, were systematically searched, and some studies were supplemented by key authors and reference lists. STUDY SELECTION Thirty-one studies were identified, involving 1069 surgical patients enrolled in the ERAS programme. The inclusion and exclusion criteria were formulated based on the Population, Interest of phenomena, Context, Study design criteria recommended by the Joanna Briggs Institute to determine the scope of article retrieval. The inclusion criteria were as follows: ERAS patients' experiences; qualitative data; English language and published from January 1990 to August 2021. DATA EXTRACTION Data were extracted from relevant studies using the standardised data extraction tool from Joanna Briggs Institute Qualitative Assessment and Review Instrument for qualitative research. DATA SYNTHESIS The themes in the structure dimension are as follows: (1) patients cared about the timeliness of healthcare professionals' help; (2) patients cared about the professionalism of family care; and (3) patients misunderstood and worried about the safety of ERAS. The themes in the process dimension are as follows: (1) patients needed adequate and accurate information from healthcare professionals; (2) patients needed to communicate adequately with healthcare professionals; (3) patients hoped to develop a personalised treatment plan and (4) patients required ongoing follow-up services. The theme in the outcome dimension is as follows: patients wanted to effectively improve severe postoperative symptoms. CONCLUSIONS Evaluating ERAS from the patient's perspective can reveal the omissions and deficiencies of healthcare professionals in clinical care so that problems in patients' recovery process can be solved in a timely manner, reducing potential barriers to the implementation of ERAS. PROSPERO REGISTRATION NUMBER CRD42021278631.
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Affiliation(s)
- Dan Wang
- Post-doctoral Mobile Research Station of Public Health and Preventive Medicine, School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, China
- School of Nursing, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yanjie Hu
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Kai Liu
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenmi Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinrong Chen
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Liujiao Cao
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Weihan Zhang
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Jiankun Hu
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Abstract
There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient's social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA.
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Invited Commentary: Challenging Current Notions in Foregut Surgery: A Veterans Affairs Surgical Quality Improvement Program Database Analysis of the Robotic and Laparoscopic Approach to Benign Foregut Surgery. J Am Coll Surg 2022; 235:157-158. [PMID: 35839389 DOI: 10.1097/xcs.0000000000000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sichieri K, Regina Secoli S. Cost-effectiveness analysis of the implementation of advanced practice nursing: how to move forward? Rev Esc Enferm USP 2022; 56:e20210463. [PMID: 35723249 DOI: 10.1590/1980-220x-reeusp-2021-0463en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
This essay explores possibilities of advances in cost-effectiveness analysis (CEA) in advanced practice nursing (APN). The arguments were structured according to the current health landscape, the need to evaluate APN practices as health technology and evidence and recommendations for conducting CEA. Benefits of APN were evidenced in the improvement of indicators such as mortality, hospital readmission, among others. However, the absence of a standard of care, combined with the existence of different models and short time horizon interfered with the estimation of direct costs. The studies on CEA were inconclusive, mainly due to the lack of cost per unit of success and calculation of the CEA ratio. In the context of the APN, to conduct CEA that really contributes to robust results, thus subsidizing decision-making requires a joint effort of training institutions, delimitation and standardization of practice by regulatory agencies of the profession and health services, based especially on accreditation policies.
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Affiliation(s)
- Karina Sichieri
- Universidade de São Paulo, Hospital Universitário, Departamento de Enfermagem, São Paulo, SP, Brazil
| | - Sílvia Regina Secoli
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
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Wang D, Liu Z, Zhou J, Yang J, Chen X, Chang C, Liu C, Li K, Hu J. Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: a multicentre qualitative study. BMJ Open 2022; 12:e053687. [PMID: 35288383 PMCID: PMC8921855 DOI: 10.1136/bmjopen-2021-053687] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To explore the attitudes and barriers encountered in the implementation of enhanced recovery after surgery (ERAS) in China from the perspective of multidisciplinary team members. DESIGN Based on Donabedian's structure-process-outcome (SPO) model, a multicentre qualitative study using semistructured interviews was conducted. SETTING From September 2020 to December 2020, the participants of this study were interviewed from six tertiary hospitals in Sichuan province (n=3), Jiangsu province (n=2) and Guangxi province (n=1) in China. PARTICIPANTS A total of 42 members, including surgeons (n=11), anaesthesiologists (n=10), surgical nurses (n=14) and dietitians(n=7) were interviewed. RESULTS Multidisciplinary team (MDT) members still face many barriers during the process of implementing ERAS. Eight main themes are described around the barriers in the implementation of ERAS. Themes in the structure dimension are: (1) shortage of medical resources, (2) lack of policy support and (3) outdated concepts. Themes in the process dimension are: (1) poor doctor-patient collaboration, (2) poor communication and collaboration among MDT members and (3) lack of individualised management. Themes in the outcome dimension are: (1) low compliance and (2) high medical costs. The current implementation of ERAS is still based on ideas more than reality. CONCLUSIONS In general, barriers to ERAS implementation are broad. Identifying key elements of problems in the application and promotion of ERAS from the perspective of the MDT would provide a starting point for future quality improvement of ERAS, enhance the clinical effect of ERAS and increase formalised ERAS utilisation in China.
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Affiliation(s)
- Dan Wang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenmi Liu
- West China School of Public Health/West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Zhou
- Hepatobiliary and pancreatic surgery, The Second People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinrong Chen
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chengting Chang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changqing Liu
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiankun Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Kokko P. Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health Policy 2022; 126:302-309. [DOI: 10.1016/j.healthpol.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 12/30/2022]
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Raptis DA, Hanna T, Machairas N, Owen T, Davies D, Fusai GK. The Economic Burden of Postoperative Complications Predicted by the Comprehensive Complication Index ® in Patients Undergoing Elective Major Hepatopancreaticobiliary Surgery for Malignancy - A Prospective Cost Analysis. In Vivo 2021; 35:1065-1071. [PMID: 33622903 DOI: 10.21873/invivo.12351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM Postoperative complications have a tremendous impact on in-hospital costs. The novel Comprehensive Complication Index® (CCI®) summarizes all complications together and is more sensitive than existing morbidity endpoints. The purpose of this study was to assess the correlation of CCI® with in-hospital costs and externally validate a novel cost prediction calculator. PATIENTS AND METHODS This was a prospective study including consecutive patients undergoing elective major hepatopancreaticobiliary (HPB) surgery for malignancy at a London tertiary referral hospital. A priori sample size and post-hoc power calculations were performed. RESULTS Thirty patients were included in the analysis, 14 were female, and the median age was 67 [interquartile range (IQR)=54-74] years. The median Charlson Comorbidity Index was 6 (IQR=5-8). Eighteen patients underwent liver, 9 pancreatic surgery and three a palliative bypass; 11 patients had a major complication (≥grade 3a) according to the Clavien-Dindo classification. The median CCI® was 30.2 (IQR=12.18-39.5). The mean cost per case was 13,908 (SD=4,600) GBP. There was no correlation between the Charlson Comorbidity Index or age with actual cost. However, there was very good correlation of actual cost with the CCI® (r=0.77, 95% confidence interval=0.57-0.89, p<0.001) as well as with the predicted cost (Clavien Cost Prediction Calculator) (r=0.70, 95% confidence interval=0.44-0.85, p<0.001). CONCLUSION These findings support the hypothesis that complications are the most important predictor of overall cost in the setting of elective major HPB surgery for malignancy. Furthermore, CCI® and the novel Cost Prediction Calculator can be used in this setting to accurately predict costs using no additional resources.
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Affiliation(s)
| | - Thomas Hanna
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Timothy Owen
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Daniel Davies
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K
| | - Giuseppe Kito Fusai
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, U.K.
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Tsilimigras DI, Dalmacy D, Hyer JM, Diaz A, Abbas A, Pawlik TM. Disparities in NCCN Guideline Compliant Care for Resectable Cholangiocarcinoma at Minority-Serving Versus Non-Minority-Serving Hospitals. Ann Surg Oncol 2021; 28:8162-8171. [PMID: 34036428 DOI: 10.1245/s10434-021-10202-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/07/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Racial/ethnic disparities in cancer outcomes may relate to variations in receipt of National Comprehensive Cancer Network (NCCN) guideline compliant care. PATIENTS AND METHODS Patients undergoing resection of cholangiocarcinoma (CCA) between 2004 and 2015 were identified using the National Cancer Database (NCDB). Institutions treating Black and Hispanic patients within the top decile were categorized as minority-serving hospitals (MSH). Factors associated with receipt of NCCN-compliant care, and the impact of NCCN compliance on overall survival (OS), were evaluated. RESULTS Among 16,108 patients who underwent resection of CCA, the majority of patients were treated at non-MSH (n = 14,779, 91.8%), while a smaller subset underwent resection of CCA at MSH (n = 1329, 8.2%). Patients treated at MSH facilities tended to be younger (MSH: 65 years versus non-MSH: 67 years), Black or Hispanic (MSH: 59.9% versus non-MSH: 13.4%), and uninsured (MSH: 11.6% versus non-MSH: 2.2%). While overall compliance with NCCN care was 73.0% (n = 11,762), guideline-compliant care was less common at MSH (MSH: 68.8% versus non-MSH: 73.4%; p < 0.001). On multivariable analyses, the odds of receiving non-NCCN compliant care remained lower at MSH (OR 0.76, 95% CI 0.65-0.88). While white patients had similar odds of NCCN-compliant care with minority patients when treated at MSH (OR 0.98, 95% CI 0.75-1.28), minority patients had lower odds of receiving guideline-compliant care when treated at non-MSH (OR 0.85, 95% CI 0.75-0.96). Failure to comply with NCCN guidelines was associated with worse long-term outcomes (HR 1.60, 95% CI 1.52-1.69). CONCLUSIONS Patients treated at MSH had decreased odds to receive NCCN-compliant care following resection of CCA. Failure to comply with guideline-based cancer care was associated with worse long-term outcomes.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alizeh Abbas
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Karunakaran M, Jonnada PK, Barreto SG. Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy. World J Clin Cases 2021; 9:3024-3037. [PMID: 33969088 PMCID: PMC8080740 DOI: 10.12998/wjcc.v9.i13.3024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/06/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
AIM To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
METHODS A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models.
RESULTS Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; P < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; P < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; P < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; P < 0.00001).
CONCLUSION Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Gurgaon 122001, Haryana, India
- Department of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon 122001, Haryana, India
| | - Pavan Kumar Jonnada
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru 560029, Karnataka, India
| | - Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park 5042, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia
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Tsilimigras DI, Hyer JM, Diaz A, Moris D, Abbas A, Dillhoff M, Cloyd JM, Ejaz A, Beane JD, Tsung A, Pawlik TM. Impact of cancer center accreditation on outcomes of patients undergoing resection for hepatocellular carcinoma: A SEER-Medicare analysis. Am J Surg 2021; 222:570-576. [PMID: 33485619 DOI: 10.1016/j.amjsurg.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/01/2021] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We sought to assess variations in outcomes among patients undergoing resection for hepatocellular carcinoma (HCC) at centers with varied accreditation status. METHODS Patients undergoing resection for HCC from 2004 to 2016 were identified from the linked SEER-Medicare database. Short- and long-term outcomes as well as expenditures associated with receipt of surgery were examined based on cancer center accreditation. RESULTS Among 1390 patients, 46.1% (n = 641) were treated at unaccredited centers, 39.3% (n = 546) at CoC-accredited and 14.6% (n = 203) at NCI-designated centers. Patients undergoing resection of HCC at NCI-designated hospitals had lower odds of complications (OR = 0.66, 95%CI: 0.45-0.98) and 90-day mortality (OR = 0.31, 95%CI: 0.11-0.85) after major liver resection compared with individuals treated at CoC-accredited centers. Receipt of surgery at NCI-designated hospitals (ref: CoC-accredited; HR = 0.81, 95%CI: 0.66-0.99) was an independent predictor of improved survival. Medicare payments for liver resection were comparable at different accreditation status centers (NCI: $21,760 vs CoC: $24,059 vs unaccredited: $24,724, p = 0.18). CONCLUSION Patients undergoing resection of HCC at NCI-designated hospitals had improved outcomes for the same level of Medicare expenditure compared with patients treated at CoC-accredited centers.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alizeh Abbas
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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