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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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Cawich SO, Dixon E, Shukla PJ, Shrikhande SV, Deshpande RR, Mohammed F, Pearce NW, Francis W, Johnson S, Bujhawan J. Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols. World J Gastrointest Surg 2024; 16:681-688. [PMID: 38577074 PMCID: PMC10989354 DOI: 10.4240/wjgs.v16.i3.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/03/2024] [Accepted: 01/27/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013. AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality. METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications. RESULTS Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024). CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.
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Affiliation(s)
- Shamir O Cawich
- Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Elijah Dixon
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N2T9, Canada
| | - Parul J Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Shailesh V Shrikhande
- Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National University, Mumbai 400012, India
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Fawwaz Mohammed
- Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Wesley Francis
- Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
| | - Shaneeta Johnson
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Johann Bujhawan
- Department of Surgery, General Hospital in Port of Spain, Port of Spain 000000, Trinidad and Tobago
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Leeds IL, Moore MS, Schultz K, Canner JK, Pantel HJ, Mongiu AK, Reddy V, Schneider E. More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery. Surg Open Sci 2023; 16:148-154. [PMID: 38026825 PMCID: PMC10656212 DOI: 10.1016/j.sopen.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Background Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery. Methods We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue. Results We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67). Conclusions High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.
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Affiliation(s)
- Ira L. Leeds
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Miranda S. Moore
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Kurt Schultz
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Joseph K. Canner
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Haddon J. Pantel
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Anne K. Mongiu
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Vikram Reddy
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Eric Schneider
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
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Hyer JM, Beane JD, Spolverato G, Tsilimigras DI, Diaz A, Paro A, Dalmacy D, Pawlik TM. Trends in Textbook Outcomes over Time: Are Optimal Outcomes Following Complex Gastrointestinal Surgery for Cancer Increasing? J Gastrointest Surg 2022; 26:50-59. [PMID: 34506022 DOI: 10.1007/s11605-021-05129-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of composite measures like "textbook outcome" (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer. METHODS Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time. RESULTS Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p < 0.001). The proportion of patients achieving a textbook outcome increased over time for all patients (2004-2007, 53.3% vs. 2008-2011, 56.5% vs. 2012-2016, 60.1%) (5-year increase: OR 1.16 95%CI 1.13-1.18) (p < 0.001). Survival at 1-year following pancreatic, liver, or colon resection for cancer had improved over time among both patients who did and did not achieve a postoperative TO. TO was independently associated with a marked reduction in hazard of death (HR 0.44, 95%CI 0.43-0.45). The association of TO and survival was consistent among patients stratified by procedure. CONCLUSION Less than two-thirds of patients undergoing complex gastrointestinal surgery for a malignant indication achieved a TO. The likelihood of achieving a TO increased over time and was associated with improved survival.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Gaya Spolverato
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Alessandro Paro
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Elfrink AKE, Olthof PB, Swijnenburg RJ, den Dulk M, de Boer MT, Mieog JSD, Hagendoorn J, Kazemier G, van den Boezem PB, Rijken AM, Liem MSL, Leclercq WKG, Kuhlmann KFD, Marsman HA, Ijzermans JNM, van Duijvendijk P, Erdmann JI, Kok NFM, Grünhagen DJ, Klaase JM. Factors associated with failure to rescue after liver resection and impact on hospital variation: a nationwide population-based study. HPB (Oxford) 2021; 23:1837-1848. [PMID: 34090804 DOI: 10.1016/j.hpb.2021.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Failure to rescue (FTR) is defined as postoperative complications leading to mortality. This nationwide study aimed to assess factors associated with FTR and hospital variation in FTR after liver surgery. METHODS All patients who underwent liver resection between 2014 and 2017 in the Netherlands were included. FTR was defined as in-hospital or 30-day mortality after complications Dindo grade ≥3a. Variables associated with FTR and nationwide hospital variation were assessed using multivariable logistic regression. RESULTS Of 4961 patients included, 3707 (74.4%) underwent liver resection for colorectal liver metastases, 379 (7.6%) for other metastases, 526 (10.6%) for hepatocellular carcinoma and 349 (7.0%) for biliary cancer. Thirty-day major morbidity was 11.5%. Overall mortality was 2.3%. FTR was 19.1%. Age 65-80 (aOR: 2.86, CI:1.01-12.0, p = 0.049), ASA 3+ (aOR:2.59, CI: 1.66-4.02, p < 0.001), liver cirrhosis (aOR:4.15, CI:1.81-9.22, p < 0.001), biliary cancer (aOR:3.47, CI: 1.73-6.96, p < 0.001), and major resection (aOR:6.46, CI: 3.91-10.9, p < 0.001) were associated with FTR. Postoperative liver failure (aOR: 26.9, CI: 14.6-51.2, p < 0.001), cardiac (aOR: 2.62, CI: 1.27-5.29, p = 0.008) and thromboembolic complications (aOR: 2.49, CI: 1.16-5.22, p = 0.017) were associated with FTR. After case-mix correction, no hospital variation in FTR was observed. CONCLUSION FTR is influenced by patient demographics, disease and procedural burden. Prevention of postoperative liver failure, cardiac and thromboembolic complications could decrease FTR.
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Affiliation(s)
- Arthur K E Elfrink
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, The Netherlands; Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Pim B Olthof
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Arjen M Rijken
- Department of Surgery, Amphia Medical Center, Breda, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Koert F D Kuhlmann
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, The Netherlands
| | | | - Jan N M Ijzermans
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Joris I Erdmann
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, The Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Diaz A, Beane JD, Hyer JM, Tsilimigras D, Pawlik TM. Impact of hospital quality on surgical outcomes in patients with high social vulnerability: Association of textbook outcomes and social vulnerability by hospital quality. Surgery 2021; 171:1612-1618. [PMID: 34774291 DOI: 10.1016/j.surg.2021.10.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/01/2021] [Accepted: 10/08/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to define the impact of high- versus low-quality hospitals on the risk of adverse outcomes among patients undergoing hepatopancreatic surgery relative to social vulnerability. Social vulnerability is an important factor associated with risk of adverse postoperative outcomes. METHODS Patients from 2013 to 2017 were identified from the Medicare Inpatient Standard Analytic File. Hospital quality was determined by calculating risk-adjusted probability to achieve a textbook outcome. The Social Vulnerability Index was used to categorize patients. Risk-adjusted probability of mortality, morbidity, and textbook outcome was examined across varying social vulnerability indices stratified by low-, average-, and high-quality hospitals. RESULTS Among 27,000 patients who underwent a pancreatectomy (67%) or hepatectomy (33%%), median patient age was 72 years, 48% were female, and 89% were White; mean Social Vulnerability Index was 49. Risk-adjusted 90-day mortality (odds ratio: 1.32, 95% CI: 1.20-1.59, P = .004) and postoperative complications (odds ratio: 1.12, 95% confidence interval: 1.00-1.24, P = .044) were both higher among beneficiaries from the highest social vulnerability counties versus the lowest counties. At low-quality hospitals, patients from the highest vulnerability counties had 70% higher odds of mortality (odds ratio: 1.70, 95% confidence interval: 1.16-2.48, P = .007), 31% higher odds of overall morbidity odds ratio: 1.31, 95% confidence interval: 1.05-2.63, P = .013), and 19% lower odds of achieving a textbook outcome (odds ratio: 0.81, 95% confidence interval: 0.66-0.99, P = .035)-all of which were markedly worse compared with outcomes achieved at high-quality hospitals. CONCLUSION Among patients with increased social vulnerability, outcomes were considerably better at high-quality hospitals. Referral of socially vulnerable patients to high-quality hospitals represents an important opportunity to ensure optimal outcomes after complex surgery.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Ann Arbor, MI; 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.
| | - Joal D Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Ann Arbor, MI
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Ann Arbor, MI
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Ann Arbor, MI
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Ann Arbor, MI. https://www.twitter.com/timpawlik
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Dagorno C, Sommacale D, Laurent A, Attias A, Mongardon N, Levesque E, Langeron O, Rhaiem R, Leroy V, Amaddeo G, Brustia R. Prehabilitation in hepato-pancreato-biliary surgery: A systematic review and meta-analysis. A necessary step forward evidence-based sample size calculation for future trials. J Visc Surg 2021; 159:362-372. [PMID: 34489200 DOI: 10.1016/j.jviscsurg.2021.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Prehabilitation is defined as preoperative conditioning of patients in order to improve post-operative outcomes. Some studies showed an increase in functional recovery following colorectal surgery, but its effect in hepato-pancreato-biliary (HPB) surgery is unclear. The aim of this study was to realize a systematic literature review and meta-analysis on the current available evidence on prehabilitation in HPB surgery. MATERIALS AND METHODS A systematic review and a metanalysis were carried out on prehabilitation (physical, nutritional and psychological interventions) in HPB surgery (2009-2019). Assessed outcomes were postoperative complications, length of stay (LOS), 30-day readmission, and mortality. MAIN RESULTS Four studies among the 191 screened were included in this systematic review (3 randomized controlled trials, 1 case-control propensity score study), involving 419 patients (prehabilitation group, n=139; control group, n=280). After pooling, no difference was observed on LOS ((-4.37 days [95% CI: -8.86; 0.13]) or postoperative complications (RR 0.83 [95%CI: 0.62; 1.10]), reported by all the included studies. Two trials reported on readmission rate, but given the high heterogeneity, a meta-analysis was not realized. No deaths were reported among the included studies. CONCLUSION No effect of prehabilitation programs in HPB surgery was observed on LOS or postoperative complications rate. Future trials with standardized outcomes of measure, and adequately powered samples calculations are thus required. PROSPERO REGISTRATION CRD42020165218.
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Affiliation(s)
- C Dagorno
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Department of Digestive and Hepato-pancreatic-biliary Surgery, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - D Sommacale
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Department of Digestive and Hepato-pancreatic-biliary Surgery, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; Inserm U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", France-Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - A Laurent
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Department of Digestive and Hepato-pancreatic-biliary Surgery, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - A Attias
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France
| | - N Mongardon
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, University Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), 94700 Maisons-Alfort, France
| | - E Levesque
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France
| | - O Langeron
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France
| | - R Rhaiem
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Champagne-Ardennes, Reims, France
| | - V Leroy
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Inserm U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", France-Assistance Publique-Hôpitaux de Paris, Créteil, France; Department of Hepatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France
| | - G Amaddeo
- Université Paris Est Creteil, Faculté de Santé, 94010 Créteil, France; Inserm U955, Team "Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers", France-Assistance Publique-Hôpitaux de Paris, Créteil, France; Department of Hepatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France
| | - R Brustia
- Department of Digestive and Hepato-pancreatic-biliary Surgery, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
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Training Paradigms in Hepato-Pancreatico-Biliary Surgery: an Overview of the Different Fellowship Pathways. J Gastrointest Surg 2021; 25:2119-2128. [PMID: 33948865 PMCID: PMC9350681 DOI: 10.1007/s11605-021-05019-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/16/2021] [Indexed: 02/06/2023]
Abstract
Hepato-pancreatico-biliary (HPB) surgery, and the training of HPB surgeons, has evolved significantly over the last several decades. The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO) ACGME fellowship, the American Society of Transplant Surgeons (ASTS) fellowship, and the Americas Hepatopancreaticobiliary Association (AHPBA) fellowship. These fellowships offer variable experiences in pancreas, liver, and biliary cases, and each pathway offers a unique perspective on HPB surgery. The CGSO ACGME, ASTS, and AHPBA fellowships represent decades of work by the three major surgical leadership stakeholders to improve and ensure quality training of future HPB surgeons. The best care is provided by the HPB surgeon who has been trained to understand the importance of all available treatment options within the context of a multidisciplinary setting. The three fellowship pathways are outlined in this paper with the nuances and variations characteristic of the different training programs highlighted.
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Hyer JM, Tsilimigras DI, Diaz A, Mirdad RS, Azap RA, Cloyd J, Dillhoff M, Ejaz A, Tsung A, Pawlik TM. High Social Vulnerability and "Textbook Outcomes" after Cancer Operation. J Am Coll Surg 2021; 232:351-359. [PMID: 33508426 DOI: 10.1016/j.jamcollsurg.2020.11.024] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.
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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
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | | | - Rosevine A Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Allan Tsung
- 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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10
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County-Level Social Vulnerability is Associated with Worse Surgical Outcomes Especially Among Minority Patients. Ann Surg 2020; 274:881-891. [PMID: 33351455 DOI: 10.1097/sla.0000000000004691] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to characterize the association between patient county-level vulnerability with postoperative outcomes. SUMMARY BACKGROUND DATA While the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes. METHODS Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016-2017 Medicare database, which was merged with CDC vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures. RESULTS Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (SD: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3,531, 5.8% vs. high SVI: n = 7,895, 13.3%; p < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10-20% higher following colectomy (OR 1.1 95%CI 1.1-1.2) or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28-68% increased odds of a serious complication and a 58-60% increased odds of 30-day mortality compared with a black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than white patients (all p > 0.05). CONCLUSION Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among black/minority patients, rather than white individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.
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Shah R, Diaz A, Tripepi M, Bagante F, Tsilimigras DI, Machairas N, Sigala F, Moris D, Barreto SG, Pawlik TM. Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition. J Gastrointest Surg 2020; 24:2874-2883. [PMID: 32705613 DOI: 10.1007/s11605-020-04748-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care. METHODS The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs. RESULTS The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care. CONCLUSIONS The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.
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Affiliation(s)
- Rohan Shah
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Marzia Tripepi
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Fragiska Sigala
- Department of Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Hyer JM, Paredes AZ, Tsilimigras DI, Azap R, White S, Ejaz A, Pawlik TM. Preoperative continuity of care and its relationship with cost of hepatopancreatic surgery. Surgery 2020; 168:809-815. [DOI: 10.1016/j.surg.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 01/20/2023]
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13
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Paredes AZ, Hyer JM, Tsilimigras DI, Sahara K, White S, Pawlik TM. Interaction of Surgeon Volume and Nurse-to-Patient Ratio on Post-operative Outcomes of Medicare Beneficiaries Following Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:2551-2559. [PMID: 31745895 DOI: 10.1007/s11605-019-04449-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume. METHODS Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated. RESULTS Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86). CONCLUSION Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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14
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Merath K, Cerullo M, Farooq A, Canner JK, He J, Tsilimigras DI, Mehta R, Paredes AZ, Sahara K, Dillhoff M, Tsung A, Cloyd J, Ejaz A, Pawlik TM. Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition? J Gastrointest Surg 2020; 24:2491-2499. [PMID: 31630368 DOI: 10.1007/s11605-019-04408-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission. METHODS Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed. RESULTS In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively). CONCLUSION Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jen He
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Merath K, Hyer JM, Mehta R, Farooq A, Bagante F, Sahara K, Tsilimigras DI, Beal E, Paredes AZ, Wu L, Ejaz A, Pawlik TM. Use of Machine Learning for Prediction of Patient Risk of Postoperative Complications After Liver, Pancreatic, and Colorectal Surgery. J Gastrointest Surg 2020; 24:1843-1851. [PMID: 31385172 DOI: 10.1007/s11605-019-04338-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. RESULTS Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). CONCLUSION Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Hyer JM, Ejaz A, Tsilimigras DI, Paredes AZ, Mehta R, Pawlik TM. Novel Machine Learning Approach to Identify Preoperative Risk Factors Associated With Super-Utilization of Medicare Expenditure Following Surgery. JAMA Surg 2020; 154:1014-1021. [PMID: 31411664 DOI: 10.1001/jamasurg.2019.2979] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Typically defined as the top 5% of health care users, super-utilizers are responsible for an estimated 40% to 55% of all health care costs. Little is known about which factors may be associated with increased risk of long-term postoperative super-utilization. Objective To identify clusters of patients with distinct constellations of clinical and comorbid patterns who may be associated with an elevated risk of super-utilization in the year following elective surgery. Design, Setting, and Participants A retrospective longitudinal cohort study of 1 049 160 patients who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, colectomy, total hip arthroplasty, total knee arthroplasty, or lung resection were identified from the 100% Medicare inpatient and outpatient Standard Analytic Files at all inpatient facilities performing 1 or more of the evaluated surgical procedures from 2013 to 2015. Data from 2012 to 2016 were used to evaluate expenditures in the year preceding and following surgery. Using a machine learning approach known as Logic Forest, comorbidities and interactions of comorbidities that put patients at an increased chance of becoming a super-utilizer were identified. All comorbidities, as defined by the Charlson (range, 0-24) and Elixhauser (range, 0-29) comorbidity indices, were used in the analysis. Higher scores indicated higher comorbidity burden. Data analysis was completed on November 16, 2018. Main Outcome and Measures Super-utilization of health care in the year following surgery. Results In total, 1 049 160 patients met inclusion criteria and were included in the analytic cohort. Their median (interquartile range) age was 73 (69-78) years, and approximately 40% were male. Super-utilizers comprised 4.8% of the overall cohort (n = 79 746) yet incurred 31.7% of the expenditures. Although the difference in overall expenditures per person between super-utilizers ($4049) and low users ($2148) was relatively modest prior to surgery, the difference in expenditures between super-utilizers ($79 698) vs low users ($2977) was marked in the year following surgery. Risk factors associated with super-utilization of health care included hemiplegia/paraplegia (odds ratio, 5.2; 95% CI, 4.4-6.2), weight loss (odds ratio, 3.5; 95% CI, 2.9-4.2), and congestive heart failure with chronic kidney disease stages I to IV (odds ratio, 3.4; 95% CI, 3.0-3.9). Conclusions and Relevance Super-utilizers comprised only a small fraction of the surgical population yet were responsible for a disproportionate amount of Medicare expenditure. Certain subpopulations were associated with super-utilization of health care following surgical intervention despite having lower overall use in the preoperative period.
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Affiliation(s)
- J Madison Hyer
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Anghela Z Paredes
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Rittal Mehta
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus.,Deputy Editor
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Hyer JM, Paredes AZ, Cerullo M, Tsilimigras DI, White S, Ejaz A, Pawlik TM. Assessing post-discharge costs of hepatopancreatic surgery: an evaluation of Medicare expenditure. Surgery 2020; 167:978-984. [DOI: 10.1016/j.surg.2020.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/28/2020] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
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18
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Mehta R, Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Ejaz A, Cloyd JM, Dillhoff M, Tsung A, Pawlik TM. Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies. J Gastrointest Surg 2020; 24:1320-1329. [PMID: 31197689 PMCID: PMC7011949 DOI: 10.1007/s11605-019-04288-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care. METHODS Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined. RESULTS In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22-0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34-0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38-0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76-2.71). CONCLUSION Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.
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Affiliation(s)
- Rittal Mehta
- 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
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J. Madison Hyer
- 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
| | - Anghela Z. Paredes
- 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
| | - Jordan M Cloyd
- 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
| | - Allan Tsung
- 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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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Ejaz A, Pawlik TM. In-hospital Mortality Following Pancreatoduodenectomy: a Comprehensive Analysis. J Gastrointest Surg 2020; 24:1119-1126. [PMID: 31292889 DOI: 10.1007/s11605-019-04307-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed. METHODS Retrospective review of the National Inpatient Sample database (January 2004-December 2014) was conducted to identify patients undergoing PD. Factors associated with in-hospital mortality after PD were analyzed after adjusting for previously defined patient- and hospital-level risk factors. RESULTS A total of 9639 patients who underwent a PD at 2325 hospitals were identified. Median patient age was 57 years (IQR 66-73). Overall, mortality following PD was 3.2%. When patient- and hospital-level characteristics were analyzed in the same model, patient-level characteristic associated with increased odds of in-hospital mortality included increasing patient age (OR 1.05, 95% CI 1.03-1.06/per 5 years increase), male sex (OR 1.47, 95% CI 1.16-1.86), the presence of liver disease (OR 3.03, 95% CI 1.99-4.61), chronic kidney disease (OR 1.78, 95% CI 1.18-2.68), and congestive heart failure (OR 2.48, 95% CI 1.65-3.74). The only hospital characteristic associated with odds of mortality following PD included compliance with Leapfrog volume standards (OR 0.70, 95% CI 0.54-0.92). CONCLUSION Patient-level factors, such as advanced comorbidities, male sex, and increased age, contributed the most to increased risk of mortality after PD. Hospital volume was the only hospital-level factor contributing to risk of in-hospital mortality following PD.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Mehta R, Ejaz A, Hyer JM, Tsilimigras DI, White S, Merath K, Sahara K, Bagante F, Paredes AZ, Cloyd JM, Dillhoff M, Tsung A, Pawlik TM. The Impact of Dedicated Cancer Centers on Outcomes Among Medicare Beneficiaries Undergoing Liver and Pancreatic Cancer Surgery. Ann Surg Oncol 2019; 26:4083-4090. [DOI: 10.1245/s10434-019-07677-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Indexed: 12/28/2022]
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Characterizing and Assessing the Impact of Surgery on Healthcare Spending Among Medicare Enrolled Preoperative Super-utilizers. Ann Surg 2019; 270:554-563. [DOI: 10.1097/sla.0000000000003426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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