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Rashid Z, Munir MM, Woldesenbet S, Khalil M, Katayama E, Khan MMM, Endo Y, Altaf A, Tsai S, Dillhoff M, Pawlik TM. Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy. J Gastrointest Surg 2024; 28:1137-1144. [PMID: 38762337 DOI: 10.1016/j.gassur.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/20/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
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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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Koh YX, Zhao Y, Tan IEH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. The impact of hospital volume on liver resection: A systematic review and Bayesian network meta-analysis. Surgery 2024; 175:393-403. [PMID: 38052675 DOI: 10.1016/j.surg.2023.10.034] [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: 08/14/2023] [Revised: 10/07/2023] [Accepted: 10/25/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND This study aims to compare the outcomes of high-volume, medium-volume, and low-volume hospitals performing hepatic resections using a network meta-analysis. METHODS A literature search until June 2023 was conducted across major databases to identify studies comparing outcomes in high-volume, medium-volume, and low-volume hospitals for liver resection. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area values, odds ratio, and mean difference with 95% credible intervals were reported for postoperative mortality, failure-to-rescue, morbidity, length of stay, and hospital costs. RESULTS Twenty studies comprising 248,707 patients undergoing liver resection were included. For the primary mortality outcome, overall and subgroup analyses were performed: group I: high-volume = 5 to 20 resections/year; group II: high-volume = 21 to 49 resections/year; group III: high-volume ≥50 resections/year. Results demonstrated a significant association between hospital volume and mortality (overall-high-volume versus medium-volume: odds ratio 0.66, 95% credible interval 0.49-0.87; high-volume versus low-volume: odds ratio 0.52, 95% credible interval 0.41-0.65; group I-high-volume versus low-volume: odds ratio 0.34, 95% credible interval 0.22-0.50; medium-volume versus low-volume: odds ratio 0.56, 95% credible interval 0.33-0.92; group II-high-volume versus low-volume: odds ratio 0.67, 95% credible interval 0.45-0.91), as well as length of stay (high-volume versus low-volume: mean difference -1.24, 95% credible interval -2.07 to -0.41), favoring high-volume hospitals. No significant difference was observed in failure-to-rescue, morbidity, or hospital costs across the 3 groups. CONCLUSION This study supports a positive relationship between hospital volume and surgical outcomes in liver resection. Patients from high-volume hospitals experience superior outcomes in terms of lower postoperative mortality and shorter lengths of stay than medium-volume and low-volume hospitals.
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Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore.
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore; Finance, SingHealth Community Hospitals, Singapore; Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
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