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Julian WT, Elshami M, Ammori JB, Hardacre JM, Ocuin LM. Comparison of Hospital Volume and Risk-Standardized Mortality Rate as a Proxy for Hospital Quality in Complex Oncologic Hepatopancreatobiliary Surgery. Ann Surg Oncol 2024; 31:4922-4930. [PMID: 38700800 PMCID: PMC11236847 DOI: 10.1245/s10434-024-15361-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/09/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Centralization of hepatopancreatobiliary procedures to more experienced centers has been recommended but remains controversial. Hospital volume and risk-stratified mortality rates (RSMR) are metrics for interhospital comparison. We compared facility operative volume with facility RSMR as a proxy for hospital quality. PATIENTS AND METHODS Patients who underwent surgery for liver (LC), biliary tract (BTC), and pancreatic (PDAC) cancer were identified in the National Cancer Database (2004-2018). Hierarchical logistic regression was used to create facility-specific models for RSMR. Volume (high versus low) was determined by quintile. Performance (high versus low) was determined by RSMR tercile. Primary outcomes included median facility RSMR and RSMR distributions. Volume- and RSMR-based redistribution was simulated and compared for reductions in 90-day mortality. RESULTS A total of 106,217 patients treated at 1282 facilities were included; 17,695 had LC, 23,075 had BTC, and 65,447 had PDAC. High-volume centers (HVC) had lower RSMR compared with medium-volume centers and low-volume centers for LC, BTC, and PDAC (all p < 0.001). High-performance centers (HPC) had lower RSMR compared with medium-performance centers and low-performance centers for LC, BTC, and PDAC (all p < 0.001). Volume-based redistribution required 16.0 patients for LC, 11.2 for BTC, and 14.9 for PDAC reassigned to 15, 22, and 20 centers, respectively, per life saved within each US census region. RSMR-based redistribution required 4.7 patients for LC, 4.2 for BTC, and 4.9 for PDAC reassigned to 316, 403, and 418 centers, respectively, per life saved within each US census region. CONCLUSIONS HVC and HPC have the lowest overall and risk-standardized 90-day mortality after oncologic hepatopancreatobiliary procedures, but RSMR may outperform volume as a measure of hospital quality.
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Affiliation(s)
- William T Julian
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Nakajima T, Iba Y, Shibata T, Tsushima S, Arihara A, Hosaka I, Ohkawa A, Nakazawa J, Kawaharada N. Multivariate analysis of the factors affecting medical students' decision to join the cardiovascular surgery department. Gen Thorac Cardiovasc Surg 2024; 72:501-504. [PMID: 38117430 DOI: 10.1007/s11748-023-01995-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The purpose of this study was to statistically analyze the factors that influence cardiovascular surgery recruitment. METHODS Fifth- and sixth-year medical students and first-year residents who participated in cardiovascular surgery-related events at our university over a 10-year period from April 2013 to August 2022 were included. The primary endpoint was admission to the department of cardiovascular surgery. Gender, participation in sixth-year elective clinical training, participation in national academic conferences, participation in cardiovascular surgery summer school, and the cost of participation in these events (airfares and lodging) were included as analytic factors. RESULTS Fifty-three participants attended cardiovascular surgery events during the study period. The sample included 48 males (84%) and 9 females (16%), and 3 fifth-year medical students (5%), 45 sixth-year students (79%), and 9 students in their first year of clinical training (16%). Eighteen (32%) of the participants eventually joined the department. Gender, participation in national academic conferences, cardiovascular surgery summer school, and cost of participation were not significantly related to the decision to join the department, but participation in elective clinical training was significantly positively related to the decision to join the department for sixth-year students (p < 0.01). CONCLUSIONS We statistically analyzed the factors involved in the recruitment of students and initial clinical residents to the department of cardiovascular surgery. The results showed that participation in elective clinical training was significantly positively associated with the decision to join the department, suggesting that efforts to encourage participation in elective clinical training are important.
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Affiliation(s)
- Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan.
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Shingo Tsushima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Ayaka Arihara
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Itaru Hosaka
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Akihito Ohkawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Jyunji Nakazawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
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Radtka JF, Zil-E-Ali A, Vicario-Feliciano R, Nwaneri N, Aziz F, Aziz F. Longer Operative Time for Lower Extremity Bypass Surgery is Associated With Inferior Outcomes. J Surg Res 2024; 300:352-362. [PMID: 38843722 DOI: 10.1016/j.jss.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/19/2024] [Accepted: 05/09/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.
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Affiliation(s)
- John F Radtka
- Division of Vascular Surgery, Heart and Vascular Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Heart and Vascular Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
| | - Raquel Vicario-Feliciano
- Division of Vascular Surgery, Heart and Vascular Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Nkemjika Nwaneri
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Faizaan Aziz
- Division of Vascular Surgery, Heart and Vascular Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Faisal Aziz
- Division of Vascular Surgery, Heart and Vascular Institute, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Sahm E, Olutola O, Ata A, Fabian T, Marthy A, Deroo A, Edwards K, Tafen M. When Is Intensive Care Unit Admission Needed After an Esophagectomy? J Surg Res 2024; 300:109-116. [PMID: 38810525 DOI: 10.1016/j.jss.2024.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Due to the high morbidity associated with esophagectomies, patients are often directly admitted to intensive care units (ICUs) for postoperative monitoring. However, critical complications can arise after this initial ICU stay. We hypothesized that the timing of ICU stay was not optimal for the care of patients after esophagectomy and aimed to determine when patients are at risk for developing critical complications. METHODS We searched the National Safety and Quality Improvement Program for patients who underwent an esophagectomy between 2016 and 2021. The outcome of interest was the interval between surgery and first critical complication. A critical complication was defined as one likely to require intensive care, including respiratory failure, septic shock, etc. Multivariate regression was performed to identify the risks of complications. RESULTS This study included 6813 patients from more than 70 institutions. Within the first 30 d postesophagectomy, 21.59% of patients experienced at least one critical complication. Half of first critical complications occurred after postoperative day 5, and 85.05% of them occurred after postoperative day 2. Risk factors for critical complications included age greater than 60 y, preoperative comorbidities, and open surgical approach. Malignancies were associated with a significantly lower incidence of critical complications. CONCLUSIONS Critical complications occurred beyond the immediate postesophagectomy period. Therefore, low-risk patients undergoing minimally invasive esophagectomies can be safely monitored outside the ICU, allowing for better patient care and resource utilization.
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Affiliation(s)
- Erin Sahm
- Albany Medical College, Albany, New York.
| | - Olatoye Olutola
- Division of Trauma, Critical Care, and Acute Care Surgery, Case Western Reserve, Cleveland, Ohio; Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Ashar Ata
- Department of Surgery, Albany Medical Center, Albany, New York
| | - Thomas Fabian
- Division of Thoracic Surgery, Albany Medical Center, Albany, New York
| | - Andrew Marthy
- Division of Thoracic Surgery, Albany Medical Center, Albany, New York
| | - Andrew Deroo
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Kurt Edwards
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
| | - Marcel Tafen
- Division of Trauma Surgery and Critical Care Medicine, Albany Medical Center, Albany, New York
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Chen H, Xing Y, Lang Z, Zhang L, Liao M, He X. Comparison of anesthesia methods for intra-arterial therapy of patients with acute ischemic stroke: an updated meta-analysis and systematic review. BMC Anesthesiol 2024; 24:243. [PMID: 39026147 PMCID: PMC11256490 DOI: 10.1186/s12871-024-02633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Currently, there remains debate regarding the optimal anesthesia approach for patients undergoing intra-arterial therapy for acute ischemic stroke. Therefore, we conducted a comparative analysis to assess the effects of general anesthesia versus non general anesthesia on patient outcomes. METHODS The research methodology entailed comprehensive searches of prominent databases such as the Cochrane Library, PubMed, Scopus, and Web of Science, covering the period from January 1, 2010, to March 1, 2024. Data synthesis employed techniques like risk ratio or standardized mean difference, along with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024523079). RESULTS A total of 27 trials and 12,875 patients were included in this study. The findings indicated that opting for non-general anesthesia significantly decreased the risk of in-hospital mortality (RR, 1.98; 95% CI: 1.50 to 2.61; p<0.00001; I2 = 20%), as well as mortality within three months post-procedure (RR, 1.24; 95% CI: 1.15 to 1.34; p<0.00001; I2 = 26%), while also leading to a shorter hospitalization duration (SMD, 0.24; 95% CI: 0.15 to 0.33; p<0.00001; I2 = 44%). CONCLUSION Ischemic stroke patients who undergo intra-arterial treatment without general anesthesia have a lower risk of postoperative adverse events and less short-term neurological damage. In routine and non-emergency situations, non-general anesthetic options may be more suitable for intra-arterial treatment, offering greater benefits to patients. In addition to this, the neuroprotective effects of anesthetic drugs should be considered more preoperatively and postoperatively.
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Affiliation(s)
- Huijun Chen
- Dingxi People's Hospital, Dingxi, Gansu, 743000, China
| | - Yang Xing
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
- Department of Anesthesia and Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Zekun Lang
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Lei Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Mao Liao
- The Second Clinical Medical College of Lanzhou University, Lanzhou, Gansu, 730000, China
| | - Ximin He
- Dingxi People's Hospital, Dingxi, Gansu, 743000, China.
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Jung JH, Won SH, Jung K, Lee JS, Lee JC, Kim JW, Yoon YS, Hwang JH, Han HS, Kim J. Analysis of Recent Improvement of Survival Outcomes in Patients with Pancreatic Cancer Who Underwent Upfront Surgery. Gut Liver 2024; 18:737-746. [PMID: 38146258 PMCID: PMC11249928 DOI: 10.5009/gnl230303] [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: 08/03/2023] [Revised: 10/03/2023] [Accepted: 10/16/2023] [Indexed: 12/27/2023] Open
Abstract
Background/Aims : Recently, patients with pancreatic cancer (PC) who underwent resection have exhibited improved survival outcomes, but comprehensive analysis is limited. We analyzed the trends of contributing factors. Methods : Data of patients with resected PC were retrospectively collected from the Korean Health Insurance Review and Assessment Service (HIRA) database and separately at our institution. Cox regression analysis was conducted with the data from our institution a survival prediction score was calculated using the β coefficients. Results : Comparison between the periods 2013-2015 (n=3,255) and 2016-2018 (n=3,698) revealed a difference in the median overall survival (25.9 months vs not reached, p<0.001) when analyzed with the HIRA database which was similar to our single-center data (2013-2015 [n=119] vs 2016-2018 [n=148], 20.9 months vs 32.2 months, p=0.003). Multivariable analyses revealed six factors significantly associated with better OS, and the scores were as follows: age >70 years, 1; elevated carbohydrate antigen 19-9 at diagnosis, 1; R1 resection, 1; stage N1 and N2, 1 and 3, respectively; no adjuvant treatment, 2; FOLFIRINOX or gemcitabine plus nab-paclitaxel after recurrence, 4; and other chemotherapy or supportive care only after recurrence, 5. The rate of R0 resection (69.7% vs 80.4%), use of adjuvant treatment (63.0% vs 74.3%), and utilization of FOLFIRINOX or gemcitabine plus nab-paclitaxel (25.2% vs 47.3%) as palliative chemotherapeutic regimen, all increased between the two time periods, resulting in decreased total survival prediction score (mean: 7.32 vs 6.18, p=0.004). Conclusions : Strict selection of surgical candidates, more use of adjuvant treatment, and adoption of the latest combination regimens for palliative chemotherapy after recurrence were identified as factors of recent improvement.
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Affiliation(s)
- Jae Hyup Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung Hyun Won
- Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Chen KN. ASO Author Reflections: The Challenging Journey from cCR to pCR After Neoadjuvant Treatment for Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2024; 31:4317-4320. [PMID: 38366184 DOI: 10.1245/s10434-024-15035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Ke-Neng Chen
- State Key Laboratory of Molecular Oncology, Beijing Key Laboratory of Carcinogenesis and Translational Research, Thoracic Surgery of Department, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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Levenson G, Coutrot M, Voron T, Gronnier C, Cattan P, Hobeika C, D'Journo XB, Bergeat D, Glehen O, Mathonnet M, Piessen G, Goéré D. Root cause analysis of mortality after esophagectomy for cancer: a multicenter cohort study from the FREGAT database. Surgery 2024; 176:82-92. [PMID: 38641545 DOI: 10.1016/j.surg.2024.03.012] [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: 08/11/2023] [Revised: 01/17/2024] [Accepted: 03/10/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Esophagectomy is associated with significant mortality. A better understanding of the causes leading to death may help to reduce mortality. A root cause analysis of mortality after esophagectomy was performed. METHODS Root cause analysis was retrospectively applied by an independent expert panel of 4 upper gastrointestinal surgeons and 1 anesthesiologist-intensivist to patients included in the French national multicenter prospective cohort FREGAT between August 2014 and September 2019 who underwent an esophagectomy for cancer and died within 90 days of surgery. A cause-and-effect diagram was used to determine the root causes related to death. Death was classified as potentially preventable or non-preventable. RESULTS Among the 1,040 patients included in the FREGAT cohort, 70 (6.7%) patients (male: 81%, median age 68 [62-72] years) from 17 centers were included. Death was potentially preventable in 37 patients (53%). Root causes independently associated with preventable death were inappropriate indication (odds ratio 35.16 [2.50-494.39]; P = .008), patient characteristics (odds ratio 5.15 [1.19-22.35]; P = .029), unexpected intraoperative findings (odds ratio 18.99 [1.07-335.55]; P = .045), and delay in diagnosis of a complication (odds ratio 98.10 [6.24-1,541.04]; P = .001). Delay in treatment of a complication was found only in preventable deaths (28 [76%] vs 0; P < .001). National guidelines were less frequently followed (16 [43%] vs 22 [67%]; P = .050) in preventable deaths. The only independent risk factor of preventable death was center volume <26 esophagectomies per year (odds ratio 4.71 [1.55-14.33]; P = .006). CONCLUSIONS More than one-half of deaths after esophagectomy were potentially preventable. Better patient selection, early diagnosis, and adequate management of complications through centralization could reduce mortality.
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Affiliation(s)
- Guillaume Levenson
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France.
| | - Maxime Coutrot
- Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Département d'anesthésie réanimation et centre de traitement des brûlés, Paris, France
| | - Thibault Voron
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Chirurgie Générale et Digestive, Paris, France; Sorbonne Université, Paris, France. https://www.twitter.com/ThibaultVORON
| | - Caroline Gronnier
- Unité de Chirurgie Œsogastrique et Endocrinienne, Service de Chirurgie Digestive et Endocrinienne, Centre Médico-Chirurgical Magellan, Centre Hospitalo-Universitaire de Bordeaux, Pessac, France; Faculté de Médecine, Université Bordeaux-Segalen, Bordeaux, France
| | - Pierre Cattan
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France
| | - Christian Hobeika
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, Clichy, Paris-Cité University, Paris, France; UMR Inserm 1275 CAP Paris-Tech, Lariboisière Hospital, Paris, Paris-Cité University, Paris, France
| | - Xavier Benoît D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Damien Bergeat
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire (CHU Rennes), Université de Rennes 1 Centre, Rennes, France
| | - Olivier Glehen
- Department of General Surgery and Surgical Oncology, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France; EMR 3738 Lyon Sud Charles Mérieux Faculty, Claude Bernard University Lyon 1, Oullins, France
| | - Muriel Mathonnet
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, France
| | - Guillaume Piessen
- Centre Hospitalo-Universitaire Lille, Service de Chirurgie Digestive et Oncologique, Lille, France; University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer, Heterogeneity Plasticity and Resistance to Therapies, Lille, France. https://www.twitter.com/PiessenG
| | - Diane Goéré
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France
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Mandigers TJ, Yadavalli SD, Rastogi V, Marcaccio CL, Wang SX, Zettervall SL, Starnes BW, Verhagen HJM, van Herwaarden JA, Trimarchi S, Schermerhorn ML. Surgeon volume and outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2024; 80:53-63.e3. [PMID: 38431064 DOI: 10.1016/j.jvs.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.
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Affiliation(s)
- Tim J Mandigers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Cardio Thoracic Vascular Department, Section of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sophie X Wang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Cardio Thoracic Vascular Department, Section of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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10
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Mallick S, Chervu NL, Balian J, Charland N, Valenzuela AR, Sakowitz S, Benharash P. Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States. PLoS One 2024; 19:e0303586. [PMID: 38875301 PMCID: PMC11178205 DOI: 10.1371/journal.pone.0303586] [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: 07/27/2023] [Accepted: 04/16/2024] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.
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Affiliation(s)
- Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
| | - Jeffrey Balian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nicole Charland
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Alberto R Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
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11
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Balzano G, Reni M, Di Bartolomeo M, Scorsetti M, Caraceni A, Rivizzigno P, Amorosi A, Scardoni A, Abu Hilal M, Ferrari G, Labianca R, Venturini M, Doglioni C, Riva L, Caccialanza R, Carrara S. Translating knowledge into policy: Organizational model and minimum requirements for the implementation of a regional pancreas unit network. Dig Liver Dis 2024:S1590-8658(24)00776-X. [PMID: 38851973 DOI: 10.1016/j.dld.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 06/10/2024]
Abstract
Pancreatic and periampullary cancers pose significant challenges in oncological care due to their complexity and diagnostic difficulties. Global experiences underscore the crucial role of multidisciplinary collaboration and centralized care in improving patient outcomes in this context. Recognizing these challenges, Lombardy, Italy's most populous region, embarked on establishing pancreas units across its territory to enhance clinical outcomes and organizational efficiency. This initiative, driven by a multistakeholder approach involving the Lombardy Welfare Directorate, clinicians, and a patient association, emphasizes the centralization of complex care in high-volume hospitals, adopting a hub-and-spoke model and a multidisciplinary approach. This article outlines the process and criteria set forth for pancreas unit implementation, aiming to provide a structured framework for enhancing pancreatic cancer care. Central to this initiative is the establishment of structured criteria and minimal requirements, not only for surgery but also for other essential components of care, ensuring a comprehensive approach to pancreatic cancer management. The Lombardy model offers a structured framework for enhancing pancreatic cancer care, with potential applicability to other regions and countries seeking to improve their cancer care infrastructure.
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Affiliation(s)
- Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Michele Reni
- Department of Medical Oncology, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
| | - Maria Di Bartolomeo
- Gastrointestinal Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano 20089, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Augusto Caraceni
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano Via della Commenda 19 20122 Milan, Italy
| | - Piero Rivizzigno
- Codice Viola, Pancreatic Cancer Advocacy Group, 20855, Lesmo (MB), Italy
| | - Alessandro Amorosi
- Welfare General Directorate, Regione Lombardia; Palazzo Lombardia, Piazza Città di Lombardia, 1, 20124 Milan, Italy
| | - Alessandro Scardoni
- Welfare General Directorate, Regione Lombardia; Palazzo Lombardia, Piazza Città di Lombardia, 1, 20124 Milan, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Via Bissolati 57, Brescia 25124, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Oncologic Surgery ASST GOM Niguarda Nigurda Hospital, Milan, Italy
| | | | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, ASST Sette Laghi, 21100, Varese, Italy; Department of Medicine and Technological Innovation (DIMIT), Insubria University, Varese, Italy
| | - Claudio Doglioni
- Department of Anatomic Pathology, University Vita-Salute San Raffaele, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Riva
- Frailty Department, Local Network of Palliative Care, ASST, Lecco, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinco San Matteo, Pavia, Italy
| | - Silvia Carrara
- IRCCS Humanitas Research Hospital - Endoscopic Unit, Department of Gastroenterology, Via Manzoni 56, 20089 Rozzano (Milan), Italy
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12
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Cannas S, Casciani F, Vollmer CM. Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor. Ann Surg 2024; 279:1036-1045. [PMID: 37522844 DOI: 10.1097/sla.0000000000006060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). BACKGROUND Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. METHODS Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. RESULTS Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). CONCLUSIONS At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.
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Affiliation(s)
- Samuele Cannas
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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13
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Munir MM, Dillhoff M, Tsai S, Pawlik TM. Textbook oncologic outcomes among patients undergoing laparoscopic, robotic and open surgery for intrahepatic and perihilar cholangiocarcinoma. HPB (Oxford) 2024:S1365-182X(24)01736-2. [PMID: 38825434 DOI: 10.1016/j.hpb.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Textbook oncologic outcome (TOO) serves as a composite, oncologic metric for surgical quality of care. We sought to evaluate variations in TOO among patients undergoing laparoscopic, robotic, and open surgery for intrahepatic (iCCA) and perihilar (pCCA) cholangiocarcinoma. METHODS Patients who underwent liver resection for iCCA and pCCA between 2010 and 2018 were identified from the National Cancer Database. Entropy balancing was performed for covariate balancing and multivariable regression was used to evaluate the association between surgical approach and TOO. RESULTS Among 5434 patients who underwent hepatic resection between 2010 and 2018, 3888 (71.6%) had iCCA, and 1546 (28.4%) had pCCA. TOO was achieved in 11.7% (n = 454), and 18.8% (n = 291) of patients with iCCA and pCCA, respectively. There was a difference in achievement of TOO relative to operative approach among patients with iCCA (robotic: 6.2% vs. laparoscopic: 8.1% vs. open: 12.5%; p = 0.002). After entropy balancing, patients with iCCA undergoing laparoscopic surgery had 32% reduced odds of achieving TOO (Ref: open surgery; laparoscopic, OR 0.68, 95%CI 0.49-0.93; p = 0.016; robotic, OR 0.69, 95%CI 0.34-1.39; p = 0.298). CONCLUSIONS Usage of composite oncologic measures such as TOO may allow for a holistic assessment of different approaches to hepatic resection among patients with CCA.
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Affiliation(s)
- Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Tsai
- 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.
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14
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Guo K, Xu F, Li Y, Ma M, Li J, Wang L. Mortality and cardiac arrest rates of emergency surgery in developed and developing countries: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:178. [PMID: 38769493 PMCID: PMC11104000 DOI: 10.1186/s12871-024-02559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The magnitude of the risk of death and cardiac arrest associated with emergency surgery and anesthesia is not well understood. Our aim was to assess whether the risk of perioperative and anesthesia-related death and cardiac arrest has decreased over the years, and whether the rates of decrease are consistent between developed and developing countries. METHODS A systematic review was performed using electronic databases to identify studies in which patients underwent emergency surgery with rates of perioperative mortality, 30-day postoperative mortality, or perioperative cardiac arrest. Meta-regression and proportional meta-analysis with 95% confidence intervals (CIs) were performed to evaluate global data on the above three indicators over time and according to country Human Development Index (HDI), and to compare these results according to country HDI status (low vs. high HDI) and time period (pre-2000s vs. post-2000s). RESULTS 35 studies met the inclusion criteria, representing more than 3.09 million anesthetic administrations to patients undergoing anesthesia for emergency surgery. Meta-regression showed a significant association between the risk of perioperative mortality and time (slope: -0.0421, 95%CI: from - 0.0685 to -0.0157; P = 0.0018). Perioperative mortality decreased over time from 227 per 10,000 (95% CI 134-380) before the 2000s to 46 (16-132) in the 2000-2020 s (p < 0-0001), but not with increasing HDI. 30-day postoperative mortality did not change significantly (346 [95% CI: 303-395] before the 2000s to 292 [95% CI: 201-423] in the 2000s-2020 period, P = 0.36) and did not decrease with increasing HDI status. Perioperative cardiac arrest rates decreased over time, from 113 per 10,000 (95% CI: 31-409) before the 2000s to 31 (14-70) in the 2000-2020 s, and also with increasing HDI (68 [95% CI: 29-160] in the low-HDI group to 21 [95% CI: 6-76] in the high-HDI group, P = 0.012). CONCLUSIONS Despite increasing baseline patient risk, perioperative mortality has decreased significantly over the past decades, but 30-day postoperative mortality has not. A global priority should be to increase long-term survival in both developed and developing countries and to reduce overall perioperative cardiac arrest through evidence-based best practice in developing countries.
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Affiliation(s)
- Kaikai Guo
- Department of pain medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beingjing, China
| | - Fengying Xu
- Department of anesthesiology, No. 971 Hospital of People's Liberation Army Navy, Qingdao, China
| | - Ye Li
- Department of pain medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beingjing, China
| | - Mingxing Ma
- Department of pain medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beingjing, China
| | - Jing Li
- Department of acupuncture, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Long Wang
- Department of pain medicine, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beingjing, China.
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15
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Brauer DG, Gonen M, Drebin JA, Groeger JS, Jewell EL. Establishing Regionalized Acute Care Across a Health Care System to Decentralize Postoperative Care After Oncologic Surgery. JCO Oncol Pract 2024; 20:666-672. [PMID: 38295332 DOI: 10.1200/op.23.00392] [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: 06/28/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024] Open
Abstract
PURPOSE Patients undergoing oncologic surgery at major referral centers frequently experience postdischarge care fragmentation, which has been associated with poor outcomes. This report describes and evaluates the outcomes of an intervention at Memorial Sloan Kettering Cancer Center (MSKCC) to decentralize postdischarge postoperative acute care within our health care system. METHODS In 2018, MSKCC completed the addition of six regional acute care clinics called symptom care clinics (SCCs) to existing regional outpatient clinics. Acute care was previously only available within our system at a single centralized urgent care center (UCC). All patients undergoing surgery in our system between January 1, 2019, and June 30, 2021, were followed for 90 days. The exposure was the site of initial acute care presentation-UCC or SCC-and outcomes included utilization, access, financial toxicity, and mortality. Mortality was adjusted using hierarchical modeling at the level of the region. RESULTS A total of 6,992 postsurgical patients experienced 10,525 acute care visits in our system within 90 days of surgery. Twenty-nine percent of these patients presented to the SCC first. These patients were older but had fewer comorbidities and shorter index length of stay compared with UCC patients. Utilization of SCCs increased substantially while UCC utilization decreased during a period of stable case volume. SCCs were closer to patients' homes, and wait times were shorter. Rates of financial toxicity were similar between groups. Of this high-risk cohort accessing acute care postoperatively, 90-day mortality was similar for UCC and SCC patients (P = .731). CONCLUSION This model of decentralized acute care after oncologic surgery was increasingly used over time with comparable patient safety. Health systems should emphasize patient-centered care by supporting safe strategies for regionalized care even when treatments are delivered at centralized referral centers.
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Affiliation(s)
- David G Brauer
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Mithat Gonen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey S Groeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elizabeth L Jewell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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16
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Munir MM, Woldesenbet S, Endo Y, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants? Ann Surg Oncol 2024; 31:2856-2866. [PMID: 38194046 PMCID: PMC10997543 DOI: 10.1245/s10434-023-14852-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/17/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION We sought to define the individual contributions of patient characteristics (PCs), hospital characteristics (HCs), case volume (CV), and social determinants of health (SDoH) on in-hospital mortality (IHM) after complex cancer surgery. METHODS The California Department of Health Care Access and Information database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PD), or proctectomy (PR) for a malignant diagnosis between 2010 and 2020. Multi-level multivariable regression was performed to assess the proportion of variance explained by PCs, HCs, CV and SDoH on IHM. RESULTS A total of 52,838 patients underwent cancer surgery (ES: n = 2,700, 5.1%; PN: n = 30,822, 58.3%; PD: n = 7530, 14.3%; PR: n = 11,786, 22.3%) across 294 hospitals. The IHM for the overall cohort was 1.7% and varied from 4.4% for ES to 0.8% for PR. On multivariable regression, PCs contributed the most to the variance in IHM (overall: 32.0%; ES: 21.6%; PN: 28.0%; PD: 20.3%; PR: 39.9%). Among the overall cohort, CV contributed 2.4%, HCs contributed 1.3%, and SDoH contributed 1.2% to the variation in IHM. CV was the second highest contributor to IHM among ES (5.3%), PN (5.3%), and PD (5.9%); however, HCs were a more important contributor among patients who underwent PR (8.0%). The unexplained variance in IHM was highest among ES (72.4%), followed by the PD (67.5%) and PN (64.6%) patient groups. CONCLUSIONS PCs are the greatest underlying contributor to variations in IHM following cancer surgery. These data highlight the need to focus on optimizing patients and exploring unexplained sources of IHM to improve quality of surgical care.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
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Hari A, Chang J, Villanueva C, Ziogas A, Vieira V, Bristow RE. Short-term survival analysis of a risk-adjusted model for ovarian cancer care. Gynecol Oncol 2024; 184:123-131. [PMID: 38309029 DOI: 10.1016/j.ygyno.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To quantify the impact on short-term ovarian cancer survival associated with treatment at high-performing hospitals using the observed-to-expected ratio (O/E) for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care. METHODS This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to California Cancer Registry 1996-2017. A fit logistic regression model, risk-adjusted for patient and disease characteristics, was used to calculate O/E for each hospital stratified by hospital annual case volume. Cox proportional hazards model was used for survival analyses at 3, 6, 12, 24 months and stratified according to sociodemographic characteristics. RESULTS The study population included 35,725 subjects treated at 443 hospitals: Low-O/E - 26.4% of cases; Intermediate-O/E - 55.5% of cases; and High-O/E - 18.1% of cases. Overall median survival by hospital category was: High-O/E = 72.5 months (95% CI = 68.6-78.6 months), Intermediate-O/E = 68.6 months (95% CI = 65.9-71.6 months), Low-O/E = 47.0 months (95% CI = 44.2-49.2 months). Initial treatment at a High-O/E hospital (HR = 1.00) was a statistically significant and independent predictor of improved short-term survival compared to Low-O/E hospitals at 3 months (HR = 1.46, 95% CI = 1.29-1.65), 6 months (HR = 1.35, 95% CI = 1.22-1.50), 12 months (HR = 1.27, 95% CI = 1.17-1.38), and 24 months (HR = 1.19, 95% CI = 1.11-1.27). Significant and independent associations between improved sort-term survival and High/O/E care were observed for Whites, Hispanics, Asian/Pacific Islanders (A/PI), across SES strata, and among all payer categories. CONCLUSION Ovarian cancer care at a High-O/E hospital is an independent predictor of improved outcome and the survival advantage is disproportionately weighted toward the short-term time horizon following diagnosis.
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Affiliation(s)
- Anjali Hari
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA.
| | - Jenny Chang
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Carolina Villanueva
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, USA
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Veronica Vieira
- Chao Family Comprehensive Cancer Center, Orange, CA, USA; Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, USA
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA
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Jaffray B. Defining surgical success. Arch Dis Child 2024; 109:357-358. [PMID: 38499322 DOI: 10.1136/archdischild-2024-326899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
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Werba G, Zureikat AH. Centralized Care of the Surgical Oncology Patient: A Simple Task with Complex Solutions. Ann Surg Oncol 2024; 31:2190-2191. [PMID: 38225479 DOI: 10.1245/s10434-023-14881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/21/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Gregor Werba
- Bernard F Fisher Chair in Surgery, Division of Surgical Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Bernard F Fisher Chair in Surgery, Division of Surgical Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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20
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Lee JD, Zheng R, Okusanya OT, Evans NR, Grenda TR. Association between surgical quality and long-term survival in lung cancer. Lung Cancer 2024; 190:107511. [PMID: 38417278 DOI: 10.1016/j.lungcan.2024.107511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES There are significant variations in both perioperative and long-term outcomes after lung cancer resection. While perioperative outcomes are often used as comparative measures of quality, they are unreliable, and their association with long-term outcomes remain unclear. In this context, we evaluated whether historical perioperative mortality after lung cancer resection is associated with 5-year survival. PATIENTS AND METHODS The National Cancer Database (NCDB) was queried to identify patients diagnosed with non-small cell lung cancer (NSCLC) in 2010-2016 who underwent surgical resection (n = 234200). Hospital-level reliability-adjusted 90-day mortality rate quartiles for 2010-2013 was used as the independent variable to analyze 5-year survival for patients diagnosed in 2014-2016 (n = 85396). RESULTS There were 85,396 patients in the 2014-2016 cohort across 1,086 hospitals. Overall observed 90-day mortality rate was 3.2% (SD 17.6%) with 2.6% (SD 16.0%) for the historically best performing quartile vs. 3.9% (SD 19.4%) for the worst performing quartile (p < 0.0001). Patients who underwent resection at hospitals with the best historical mortality rate had significantly better 5-year survival across all stages compared to those treated at hospitals in the worst performing quartile in multivariate Cox regression analysis (all stages - HR 1.21 [95% CI 1.15-1.26]; stage I - HR 1.19 [95% CI 1.12-1.25]; stage II - HR 1.20 [95% CI 1.09-1.32]; stage III - HR 1.36 [95% CI 1.20-1.54]) and Kaplan-Meier survival estimates (all stages - p < 0.0001, stage I - p < 0.0001; stage II - p = 0.0004; stage III - p < 0.0001). CONCLUSION With expanded lung cancer screening criteria and likely increase in early-stage detection, profiling performance is paramount to ensuring mortality benefits. We found that episodes surrounding surgical resection may be used to profile long-term outcomes that likely reflect quality across a broader context of care. Evaluating lung cancer care quality using perioperative outcomes may be useful in profiling provider performance and guiding value-based payment policies.
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Affiliation(s)
- James D Lee
- Division of Pulmonary, Allergy, and Critical Care, Penn Presbyterian Medical Center, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Richard Zheng
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Olugbenga T Okusanya
- Division of Thoracic Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nathaniel R Evans
- Division of Thoracic Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Tyler R Grenda
- Division of Thoracic Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Silber JH, Fleisher LA. Assessing the Ambulatory Surgery Center Volume-Outcome Association. JAMA Surg 2024; 159:397-403. [PMID: 38265816 PMCID: PMC10809135 DOI: 10.1001/jamasurg.2023.7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
Importance In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
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22
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Liang JN, Anklowitz AJ, Livezey JB, O'Hara TA, Aranda MC, Bandera B. Practice Patterns of Pancreatic Surgery Within the Military. Am Surg 2024:31348241241746. [PMID: 38513255 DOI: 10.1177/00031348241241746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. METHODS This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. RESULTS Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. CONCLUSIONS Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.
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Affiliation(s)
- Joy N Liang
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Andrew J Anklowitz
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Jonathan B Livezey
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Thomas A O'Hara
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Marcos C Aranda
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Bradley Bandera
- Reno School of Medicine, University of Nevada, Reno, NV, USA
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Allanson E, Hari A, Ndaboine E, Cohen PA, Bristow R. Medicolegal, infrastructural, and financial aspects in gynecologic cancer surgery and their implications in decision making processes: Quo Vadis? Int J Gynecol Cancer 2024; 34:451-458. [PMID: 38438180 DOI: 10.1136/ijgc-2023-004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Surgical decision making is complex and involves a combination of analytic, intuitive, and cognitive processes. Medicolegal, infrastructural, and financial factors may influence these processes depending on the context and setting, but to what extent can they influence surgical decision making in gynecologic oncology? This scoping review evaluates existing literature related to medicolegal, infrastructural, and financial aspects of gynecologic cancer surgery and their implications in surgical decision making. Our objective was to summarize the findings and limitations of published research, identify gaps in the literature, and make recommendations for future research to inform policy.
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Affiliation(s)
- Emma Allanson
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Anjali Hari
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
| | - Edgard Ndaboine
- Department of Obstetrics & Gynecology, Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Paul A Cohen
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Robert Bristow
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
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24
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Shaikh CF, Woldesenbet S, Munir MM, Lima HA, Moazzam Z, Endo Y, Alaimo L, Azap L, Yang J, Katayama E, Dawood Z, Pawlik TM. Is surgical treatment of hepatocellular carcinoma at high-volume centers worth the additional cost? Surgery 2024; 175:629-636. [PMID: 37741780 DOI: 10.1016/j.surg.2023.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/18/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Case volume has been associated with improved outcomes for patients undergoing treatment for hepatocellular carcinoma, often with higher hospital expenditures. We sought to define the cost-effectiveness of hepatocellular carcinoma treatment at high-volume centers. METHODS Patients diagnosed with hepatocellular carcinoma from 2013 to 2017 were identified from Medicare Standard Analytic Files. High-volume centers were defined as the top decile of facilities performing hepatectomies in a year. A multivariable generalized linear model with gamma distribution and a restricted mean survival time model were used to estimate costs and survival differences relative to high-volume center status. The incremental cost-effectiveness ratio was used to define the additional cost incurred for a 1-year incremental gain in survival. RESULTS Among 13,666 patients, 8,467 (62.0%) were treated at high-volume centers. Median expenditure was higher ($19,148, interquartile range $15,280-$29,128) among patients treated at high-volume centers versus low-volume centers ($18,209, interquartile range $14,959-$29,752). Despite similar median length-of-stay (6 days, interquartile range 4-9), a slightly higher proportion of patients were discharged to home from high-volume centers (n = 4,903, 57.9%) versus low-volume centers (n = 2,868, 55.2%) (P = .002). A 0.14-year (95% confidence interval 0.06-0.22) (1 month and 3 weeks) survival benefit was associated with an incremental cost of $1,070 (95% confidence interval $749-$1,392) among patients undergoing surgery at high-volume centers. The incremental cost-effectiveness ratio for treatment at a high-volume center was $7,951 (95% confidence interval $4,236-$21,217) for an additional year of survival, which was below the cost-effective threshold of $21,217. CONCLUSION Surgical care at high-volume centers offers the potential to deliver cancer care in a more cost-effective and value-based manner.
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Affiliation(s)
- Chanza Fahim Shaikh
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/cfshaikh
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/musaabmunir
| | - Henrique A Lima
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zorays Moazzam
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lovette Azap
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zaiba Dawood
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, OH.
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25
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Khalil M, Munir MM, Woldesenbet S, Katayama E, Diaz A, Chen JC, Obeng-Gyasi S, Pawlik TM. Association Between Historical Redlining and Access to High-Volume Hospitals Among Patients Undergoing Complex Cancer Surgery in California. Ann Surg Oncol 2024; 31:1477-1487. [PMID: 38082168 DOI: 10.1245/s10434-023-14679-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/13/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations. METHODS The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners' Loan Corporation grades (A: 'Best'; B: 'Still Desirable'; C: 'Definitely Declining'; and D: 'Hazardous/Redlined'). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance. RESULTS Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the 'Best', whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1-14.4) and travel time was 16.1 min (IQR 10.7-25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44-2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH. CONCLUSION Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.
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Affiliation(s)
- Mujtaba Khalil
- 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
| | - 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
| | - Adrian Diaz
- 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
| | - J C Chen
- 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
| | - Samilia Obeng-Gyasi
- 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
| | - 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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26
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Chen VW, Rosen T, Dong Y, Richardson PA, Kramer JR, Petersen LA, Massarweh NN. Case Sampling for Evaluating Hospital Postoperative Morbidity in US Surgical Quality Improvement Programs. JAMA Surg 2024; 159:315-322. [PMID: 38150240 PMCID: PMC10753439 DOI: 10.1001/jamasurg.2023.6524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/04/2023] [Indexed: 12/28/2023]
Abstract
Importance US surgical quality improvement (QI) programs use data from a systematic sample of surgical cases, rather than universal review of all cases, to assess and compare risk-adjusted hospital postoperative complication rates. Given decreasing postoperative complication rates over time and the types of cases eligible for abstraction, it is unclear whether case sampling is robust for identifying hospitals with higher than expected complications. Objective To compare the assessment of hospital 30-day complication rates derived from sampling strategy used by some US surgical QI programs relative to universal review of all cases. Design, Setting, and Participants This US hospital-level analysis took place from January 1, 2016, through September 30, 2020. Data analysis was performed from July 1, 2022, through December 21, 2022. Quarterly, risk-adjusted, 30-day complication observed to expected (O-E) ratios were calculated for each hospital using the sample (n = 502 730) and universal review (n = 1 725 364). Outlier hospitals (ie, those with higher than expected mortality) were identified using an O-E ratio significantly greater than 1.0. Patients 18 years and older who underwent a noncardiac operation at US Department of Veterans Affairs (VA) hospitals with a record in the VA Surgical Quality Improvement Program (systematic sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases) were included. Main Outcome Measure Thirty-day complications. Results Most patients in both the representative sample and the universal sample were men (90.2% vs 91.2%) and White (74.7% vs 74.5%). Overall, 30-day complication rates were 7.6% and 5.3% for the sample and universal review cohorts, respectively (P < .001). Over 2145 hospital quarters of data, hospitals were identified as an outlier in 15.0% of quarters using the sample and 18.2% with universal review. Average hospital quarterly complication rates were 4.7%, 7.2%, and 7.4% for outliers identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly complication rates were 7.0% at outliers and 4.4% at nonoutliers. Among outlier hospital quarters in the sample, 54.2% were concurrently identified with universal review. For those identified with universal review, 44.6% were concurrently identified using the sample. Conclusion In this observational study, case sampling identified less than half of hospitals with excess risk-adjusted postoperative complication rates. Future work is needed to ascertain how to best use currently collected data and whether alternative data collection strategies may be needed to better inform local QI efforts.
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Affiliation(s)
- Vivi W. Chen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Yongquan Dong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Peter A. Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A. Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Ambrosetti MC, Ambrosetti A, Perri G, Gasparini C, Marchegiani G, Salvia R, Montemezzi S, Mansueto G, Zamboni GA. Quantitative edge analysis of pancreatic margins in patients with head pancreatic tumors: correlations between pancreatic margins and the onset of postoperative pancreatic fistula. Eur Radiol 2024; 34:1515-1523. [PMID: 37658898 DOI: 10.1007/s00330-023-10200-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 07/09/2023] [Accepted: 07/20/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE To assess the correlation between pancreatic quantitative edge analysis as a surrogate of parenchymal stiffness and the incidence of postoperative pancreatic fistula (POPF), in patients undergoing pancreaticoduodenectomy (PD). METHODS All consecutive patients who underwent PD at our Institution between March 2018 and November 2019 with an available preoperative CT were included. Pancreatic margin score (PMS) was calculated through computer-assisted quantitative edge analysis on the margins of the pancreatic body and tail (the expected pancreatic remnant) on non-contrast scans with in-house software. Intraoperative assessment of pancreatic stiffness by manual palpation was also performed, classifying pancreatic texture into soft and non-soft. PMS values were compared between groups using an unpaired T-test and correlated with the intraoperative evaluation of stiffness and with the grading of postoperative pancreatic fistula according to the International Study Group on Pancreatic Surgery (ISGPS). RESULTS Patient population included 200 patients (mean age 64.6 years), 146 without onset of POPF (73%, non-POPF group), and 54 with POPF (27%, POPF group). A significant difference in PMS values was observed between POPF and non-POPF (respectively 1.88 ± 0.05 vs 0.69 ± 0.01; p < 0.0001). PMS values of pancreatic parenchymas intraoperatively considered "soft" were significantly higher than those evaluated as "non-soft" (1.21 ± 0.04 vs 0.73 ± 0.02; p < 0.0001). A significant correlation between PMS values and POPF grade was observed (r = 0.8316), even in subgroups of patients with soft (r = 0.8016) and non-soft (r = 0.7602) pancreas (all p < 0.0001). CONCLUSIONS Quantitative edge analysis with dedicated software may stratify patients with different pancreatic stiffness, thus potentially improving preoperative risk assessment and strategies for POPF mitigation. CLINICAL RELEVANCE STATEMENT This study proposes quantitative pancreas edge analysis as a predictor for postoperative pancreatic fistula. The test has high accuracy and correlation with fistula grade according to the International Study Group on Pancreatic Surgery. KEY POINTS • Prediction of postoperative pancreatic fistula (POPF) onset risk after pancreaticoduodenectomy is based only on intraoperative evaluation. • Quantitative edge analysis may preoperatively identify patients with higher risk of POPF. • Quantification of pancreatic stiffness through the analysis of pancreatic margins could be done on preoperative CT.
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Affiliation(s)
- Maria-Chiara Ambrosetti
- Radiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata - Verona, P.Le Stefani 1, 37126, Verona, Italy.
| | - Alberto Ambrosetti
- Department of Physics and Astronomy "Galileo Galilei", University of Padova, Padua, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Clizia Gasparini
- Institute of Radiology, Department of Diagnostics and Public Health, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Giovanni Marchegiani
- Hepato Biliary Pancreatic (HPB) and Liver Transplant Surgery - DISCOG - Padova University Hospital, Padua, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Montemezzi
- Radiology Unit, Department of Pathology and Diagnostics, Azienda Ospedaliera Universitaria Integrata - Verona, P.Le Stefani 1, 37126, Verona, Italy
| | - Giancarlo Mansueto
- Institute of Radiology, Department of Diagnostics and Public Health, Policlinico GB Rossi, University of Verona, Verona, Italy
| | - Giulia A Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, Policlinico GB Rossi, University of Verona, Verona, Italy
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Stüben BO, Plitzko GA, Stern L, Schmeding R, Karstens KF, Reeh M, Treckmann JW, Izbicki JR, Saner FH, Neuhaus JP, Tachezy M, Hoyer DP. Risk Factor Analysis for Developing Major Complications Following Esophageal Surgery-A Two-Center Study. J Clin Med 2024; 13:1137. [PMID: 38398449 PMCID: PMC10889828 DOI: 10.3390/jcm13041137] [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: 01/24/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed. METHODS A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications. RESULTS The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001). CONCLUSIONS Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies.
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Affiliation(s)
- Björn-Ole Stüben
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
| | - Gabriel Andreas Plitzko
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Louisa Stern
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Rainer Schmeding
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
| | - Karl-Frederick Karstens
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Jürgen Walter Treckmann
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
| | - Jakob Robert Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Fuat Hakan Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
| | - Jan Peter Neuhaus
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (G.A.P.); (L.S.); (K.-F.K.); (M.R.); (J.R.I.); (M.T.)
| | - Dieter Paul Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (R.S.); (J.W.T.); (F.H.S.); (J.P.N.); (D.P.H.)
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Peters MLB, Eckel A, Seguin CL, Davidi B, Howard DH, Knudsen AB, Pandharipande PV. Cost-Effectiveness Analysis of Screening for Pancreatic Cancer Among High-Risk Populations. JCO Oncol Pract 2024; 20:278-290. [PMID: 38086003 PMCID: PMC10911581 DOI: 10.1200/op.23.00495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/05/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
PURPOSE We evaluated the potential cost-effectiveness of combined magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) screening for pancreatic ductal adenocarcinoma (PDAC) among populations at high risk for the disease. METHODS We used a microsimulation model of the natural history of PDAC to estimate the lifetime health benefits, costs, and cost-effectiveness of PDAC screening among populations with specific genetic risk factors for PDAC, including BRCA1 and BRCA2, PALB2, ATM, Lynch syndrome, TP53, CDKN2A, and STK11. For each high-risk population, we simulated 29 screening strategies, defined by starting age and frequency. Screening included MRI with follow-up EUS in a subset of patients. Costs of tests were based on Medicare reimbursement for MRI, EUS, fine-needle aspiration biopsy, and pancreatectomy. Cancer-related cost by stage of disease and phase of treatment was based on the literature. For each high-risk population, we performed an incremental cost-effectiveness analysis, assuming a willingness-to-pay (WTP) threshold of $100,000 US dollars (USD) per quality-adjusted life year (QALY) gained. RESULTS For men with relative risk (RR) 12.33 (CDKN2A) and RR 28 (STK11), annual screening was cost-effective, starting at age 55 and 40 years, respectively. For women, screening was only cost-effective for those with RR 28 (STK11), with annual screening starting at age 45 years. CONCLUSION Combined MRI/EUS screening may be a cost-effective approach for the highest-risk populations (among mutations considered, those with RR >12). However, for those with moderate risk (RR, 5-12), screening would only be cost-effective at higher WTP thresholds (eg, $200K USD/QALY) or with once-only screening.
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Affiliation(s)
- Mary Linton B. Peters
- Division of Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Claudia L. Seguin
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH
| | - Barak Davidi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - David H. Howard
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Pari V. Pandharipande
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH
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Hirpara DH, Irish J, Rashid M, Martin T, Zhu A, Hunter A, Jayaraman S, Wei AC, Coburn NG, Wright FC. Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes. J Am Coll Surg 2024; 238:157-165. [PMID: 37796140 DOI: 10.1097/xcs.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. STUDY DESIGN This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. RESULTS A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. CONCLUSIONS Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.
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Affiliation(s)
- Dhruvin H Hirpara
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Jonathan Irish
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of Head and Neck Oncology and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada (Irish)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Mohammed Rashid
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Tharsiya Martin
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Alice Zhu
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Amber Hunter
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Shiva Jayaraman
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Unity Health, St Joseph's Health Center, Toronto, Ontario, Canada (Jayaraman)
| | - Alice C Wei
- Memorial Sloan Kettering Cancer Center, New York, NY (Wei)
| | - Natalie G Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
| | - Frances C Wright
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
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Kooragayala K, Lou J, Dibato J, Hong YK. Disparities in Pancreatic Cancer Outcomes in the Disaggregated Asian American Population. Ann Surg Oncol 2024; 31:1298-1309. [PMID: 37880517 DOI: 10.1245/s10434-023-14454-8] [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: 08/01/2023] [Accepted: 10/04/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) population is among the fastest-growing population in the USA. However, this is not reflected in scientific research, in which ethnic groups are often combined. We identified trends in treatment and outcomes for pancreatic cancer in a disaggregated AANHPI population. We hypothesize that patients from different AANHPI groups have differences in survival. PATIENTS AND METHODS A retrospective analysis of the National Cancer Database between 2010 and 2019 identified patients treated for pancreatic cancer. We identified demographic factors for patients of Caucasian, African American, and disaggregated Asian subpopulations. Survival curves were generated and multivariate analysis was performed to help determine which factors impacted overall survival. RESULTS A total of 296,448 patients met the inclusion criteria. Of those, 8568 (3%) patients were Asian. Median survival of AANHPI patients was 11.3 months, as compared with Caucasians (8.9 months) and African Americans (8.1 months) (p < 0.0001). Asian Indians had the highest median survival (14.3 months), whereas the Japanese subpopulation had the lowest (7.6 months) (p < 0.0001). There were significant differences in median survival between the different AANHPI subpopulations irrespective of stage. Multivariate analysis demonstrated that belonging to an AANHPI racial/ethnic group, excluding Japanese and Filipino, was associated with decreased risk of overall mortality. DISCUSSION Significant differences were identified in the overall median survival for patients with pancreatic cancer between AANHPI subpopulations. Disparities in socioeconomic factors may have played a role in overall survival. This study highlights the need to include disaggregated data in future studies to subdue disparities in cancer care for patients.
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Affiliation(s)
| | - Johanna Lou
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - John Dibato
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Young Ki Hong
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA.
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Pyrgidis N, Volz Y, Ebner B, Kazmierczak PM, Enzinger B, Hermans J, Buchner A, Stief C, Schulz GB. The effect of hospital caseload on perioperative mortality, morbidity and costs in bladder cancer patients undergoing radical cystectomy: results of the German nationwide inpatient data. World J Urol 2024; 42:19. [PMID: 38197902 PMCID: PMC10781819 DOI: 10.1007/s00345-023-04742-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/21/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVES To determine a data-based optimal annual radical cystectomy (RC) hospital volume threshold and evaluate its clinical significance regarding perioperative mortality, complications, length of hospital stay, and hospital revenues. MATERIAL AND METHODS We used the German Nationwide inpatient Data, provided by the Research Data Center of the Federal Bureau of Statistics (2005-2020). 95,841 patients undergoing RC were included. Based on ROC analyses, the optimal RC threshold to reduce mortality, ileus, sepsis, transfusion, hospital stay, and costs is 54, 50, 44, 44, 71 and 76 cases/year, respectively. Therefore, we defined an optimal annual hospital threshold of 50 RCs/year, and we also used the threshold of 20 RCs/year proposed by the EAU guidelines to perform multiple patient-level analyses. RESULTS 28,291 (29.5%) patients were operated in low- (< 20 RC/year), 49,616 (51.8%) in intermediate- (20-49 RC/year), and 17,934 (18.7%) in high-volume (≥ 50 RC/year) centers. After adjusting for major risk factors, high-volume centers were associated with lower inpatient mortality (OR 0.72, 95% CI 0.64-0.8, p < 0.001), shorter length of hospital stay (2.7 days, 95% CI 2.4-2.9, p < 0.001) and lower costs (457 Euros, 95% CI 207-707, p < 0.001) compared to low-volume centers. Patients operated in low-volume centers developed more perioperative complications such as transfusion, sepsis, and ileus. CONCLUSIONS Centralization of RC not only improves inpatient morbidity and mortality but also reduces hospital stay and costs. We propose a threshold of 50 RCs/year for optimal outcomes.
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Affiliation(s)
- Nikolaos Pyrgidis
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Yannic Volz
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Benedikt Ebner
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | | | - Benazir Enzinger
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Julian Hermans
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Alexander Buchner
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Stief
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Gerald Bastian Schulz
- Department of Urology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Ilgen A, Köhler H, Pfahl A, Stelzner S, Mehdorn M, Jansen-Winkeln B, Gockel I, Moulla Y. Intraoperative Laparoscopic Hyperspectral Imaging during Esophagectomy-A Pilot Study Evaluating Esophagogastric Perfusion at the Anastomotic Sites. Bioengineering (Basel) 2024; 11:69. [PMID: 38247946 PMCID: PMC10812999 DOI: 10.3390/bioengineering11010069] [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: 11/04/2023] [Revised: 12/01/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Hyperspectral imaging (HSI) is a non-invasive and contactless technique that enables the real-time acquisition of comprehensive information on tissue within the surgical field. In this pilot study, we investigated whether a new HSI system for minimally-invasive surgery, TIVITA® Mini (HSI-MIS), provides reliable insights into tissue perfusion of the proximal and distal esophagogastric anastomotic sites during 21 laparoscopic/thoracoscopic or robotic Ivor Lewis esophagectomies of patients with cancer to minimize the risk of dreaded anastomotic insufficiency. In this pioneering investigation, physiological tissue parameters were derived from HSI measurements of the proximal site of the anastomosis (esophageal stump) and the distal site of the anastomosis (tip of the gastric conduit) during the thoracic phase of the procedure. Tissue oxygenation (StO2), Near Infrared Perfusion Index (NIR-PI), and Tissue Water Index (TWI) showed similar median values at both anastomotic sites. Significant differences were observed only for NIR-PI (median: 76.5 vs. 63.9; p = 0.012) at the distal site (gastric conduit) compared to our previous study using an HSI system for open surgery. For all 21 patients, reliable and informative measurements were attainable, confirming the feasibility of HSI-MIS to assess anastomotic viability. Further studies on the added benefit of this new technique aiming to reduce anastomotic insufficiency are warranted.
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Affiliation(s)
- Annalena Ilgen
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (A.I.); (S.S.); (I.G.)
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Semmelweisstr. 14, 04103 Leipzig, Germany; (H.K.); (A.P.)
| | - Annekatrin Pfahl
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Semmelweisstr. 14, 04103 Leipzig, Germany; (H.K.); (A.P.)
| | - Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (A.I.); (S.S.); (I.G.)
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (A.I.); (S.S.); (I.G.)
| | - Boris Jansen-Winkeln
- Department of General, Visceral, Thoracic and Vascular Surgery, Klinikum St. Georg, Delitzscher Str. 141, 04129 Leipzig, Germany;
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (A.I.); (S.S.); (I.G.)
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (A.I.); (S.S.); (I.G.)
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Ikuta S, Fujikawa M, Nakajima T, Kasai M, Aihara T, Yamanaka N. Machine learning approach to predict postpancreatectomy hemorrhage following pancreaticoduodenectomy: a retrospective study. Langenbecks Arch Surg 2024; 409:29. [PMID: 38183456 DOI: 10.1007/s00423-023-03223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/29/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a rare yet dreaded complication following pancreaticoduodenectomy (PD). This retrospective study aimed to explore a machine learning (ML) model for predicting PPH in PD patients. METHODS A total of 284 patients who underwent open PD at our institute were included in the analysis. To address the issue of imbalanced data, the adaptive synthetic sampling (ADASYN) technique was employed. The best-performing ML model was selected using the PyCaret library in Python and evaluated based on recall, precision, and F1 score metrics. In addition to assessing the model's performance on the test data, bootstrap validation (n = 1000) with the original dataset was conducted. RESULTS PPH occurred in 11 patients (3.9%), with a median onset time of 22 days postoperatively. These minority cases were oversampled to 85 using ADASYN. The extra trees classifier demonstrated superior performance with recall, precision, and F1 score of 0.967, 0.914, and 0.937, respectively. Both validation using the test data and bootstrap resampling consistently demonstrated recall, precision, and F1 score exceeding 0.9. The model identified the peak value of C-reactive protein during the first 7 postoperative days as the most significant feature, followed by the preoperative neutrophil-to-lymphocyte ratio. CONCLUSIONS This study highlights the potential of the ML approach to predict PPH occurrence following PD. Vigilance and early interventions guided by such model predictions could positively impact outcomes for high-risk patients.
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Affiliation(s)
- Shinichi Ikuta
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan.
| | - Masataka Fujikawa
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Takayoshi Nakajima
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Tsukasa Aihara
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
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Diaz A, Pawlik TM. Rural Versus Urban Cancer Care: Unpacking the Centralization Dilemma and the Impact of the COVID-19 Pandemic. JCO Oncol Pract 2024; 20:1-3. [PMID: 37976455 DOI: 10.1200/op.23.00679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Adrian Diaz
- The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Department of Surgery, Columbus, OH
| | - Timothy M Pawlik
- The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Department of Surgery, Columbus, OH
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Westra D, Makai P, Kemp R. Return to sender: Unraveling the role of structural and social network ties in patient sharing networks. Soc Sci Med 2024; 340:116351. [PMID: 38043439 DOI: 10.1016/j.socscimed.2023.116351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 09/22/2023] [Accepted: 10/22/2023] [Indexed: 12/05/2023]
Abstract
Healthcare is increasingly delivered through networks of organizations. Well-structured patient sharing networks are known to have positive associations with the quality of delivered services. However, the drivers of patient sharing relations are rarely studied explicitly. In line with recent developments in network and integration theorizing, we hypothesize that structural and social network ties between organizations are uniquely associated with a higher number of shared patients. We test these hypotheses using a Bayesian zero-dispersed Poisson regression model within the Additive and Multiplicative Effects Framework based on administrative claims data from 732,122 dermatological patients from the Netherlands in 2017. Our results indicate that 2.6% of all dermatological patients are shared and that the amount of shared patients is significantly associated with structural (i.e. emergency contracts) and social (i.e. shared physicians) ties between organizations, confirming our hypotheses. We also find some evidence that patients are shared with more capable organizations. Our findings highlight the role of relational ties in the way health services are delivered. At the same time, they also raise some potential anti-trust concerns.
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Affiliation(s)
- Daan Westra
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Peter Makai
- Healthcare Department, Netherlands Authority for Consumers and Markets (ACM), The Hague, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Ron Kemp
- Healthcare Department, Netherlands Authority for Consumers and Markets (ACM), The Hague, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Diaz A, Loehrer A, Pawlik TM. Expanding Access to High-Quality Cancer Care Through Policy-California Cancer Care Equity Act. JAMA Oncol 2024; 10:27-28. [PMID: 37991779 DOI: 10.1001/jamaoncol.2023.5010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
This Viewpoint describes key domains in which the California Cancer Care Equity Act may benefit patients, recommends potential improvements to further expand access and reduce disparities, and suggests possible safeguards to monitor and minimize unintended consequences.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University College of Medicine, Columbus
| | - Andrew Loehrer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University College of Medicine, Columbus
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Ramian H, Sun Z, Yabes J, Jacobs B, Sabik LM. Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds. JCO Oncol Pract 2024; 20:123-130. [PMID: 37590899 PMCID: PMC10827295 DOI: 10.1200/op.22.00851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.
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Affiliation(s)
- Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Jacobs
- Department of Urology, Division of Health Services Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
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De Marziani L, Boffa A, Di Martino A, Andriolo L, Reale D, Bernasconi A, Corbo VR, de Caro F, Delcogliano M, di Laura Frattura G, Di Vico G, Manunta AF, Russo A, Filardo G. The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis. J Exp Orthop 2023; 10:146. [PMID: 38135778 PMCID: PMC10746689 DOI: 10.1186/s40634-023-00699-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA). METHODS A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options. RESULTS Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects. CONCLUSIONS This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.
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Affiliation(s)
- Luca De Marziani
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy.
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Davide Reale
- Ortopedia e Traumatologia, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessio Bernasconi
- Orthopaedics and Traumatology Unit, Department of Public Health, University Federico II of Naples Federico II, Naples, Italy
| | | | - Francesca de Caro
- Department of Orthopaedic Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
| | - Marco Delcogliano
- Servizio di Ortopedia e Traumatologia dell'Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, Ticino, Switzerland
| | | | - Giovanni Di Vico
- Department of Orthopaedics and Trauma Surgery, Clinica San Michele, Maddaloni, Italy
| | | | | | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Oh CH. Clinical efficacy and safety of percutaneous drainage for post-operative fluid collection in patients with bladder cancer undergoing radical cystectomy and urinary diversion. Medicine (Baltimore) 2023; 102:e36488. [PMID: 38065871 PMCID: PMC10713095 DOI: 10.1097/md.0000000000036488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
To evaluate the success rates of percutaneous drainage for fluid collection after radical cystectomy, with emphasis on factors affecting the clinical success, including lesion, patient, and procedure characteristics. In this retrospective study, 31 percutaneous drainage catheters were placed in 29 consecutive patients between January 2021 and September 2023. Most fluid collections formed near the uretero-ileal anastomosis site in the right pelvic cavity (80.6%). The technical success rate was 100%. The primary and final clinical success was 80.6% and 96.9%, respectively. Lymphoceles notably increased the primary clinical failure risk (odds ratio and 95% confidential interval: 22.667 (1.839-279.366), P = .015). Significant differences were observed between transabdominal and transgluteal approaches in terms of fluoroscopic time, dose, and location. Leakage indications on computed tomography prompted differing interventions, but all achieved final clinical success. Percutaneous drainage for post-operative fluid collection is safe and effective in patients with radical cystectomy and urinary diversion.
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Affiliation(s)
- Chang Hoon Oh
- Department of Radiology, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Diaz A, Chhabra KR, Byrnes ME, Rajkumar A, Yang P, Ibrahim A, Dimick JB, Nathan H. Optimizing care delivery in expanding health systems: Views from clinical leaders. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100722. [PMID: 38000229 DOI: 10.1016/j.hjdsi.2023.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 12/14/2021] [Accepted: 11/01/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored. METHODS Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis. RESULTS Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality. CONCLUSIONS Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.
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Affiliation(s)
- 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, Ohio State University, Columbus, OH, USA.
| | - Karan R Chhabra
- 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, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary E Byrnes
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Phillip Yang
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan, Taubman College of Architecture & Urban Planning, USA
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Munir MM, Endo Y, Woldesenbet S, Beane J, Dillhoff M, Ejaz A, Cloyd J, Pawlik TM. Variations in Travel Patterns Affect Regionalization of Complex Cancer Surgery in California. Ann Surg Oncol 2023; 30:8044-8053. [PMID: 37659977 DOI: 10.1245/s10434-023-14242-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/26/2023] [Indexed: 09/04/2023]
Abstract
INTRODUCTION Regionalization of complex surgical procedures may improve healthcare quality. We sought to define the impact of regionalization on access to high-volume hospitals for complex oncologic procedures in the state of California. METHODS The California Department of Health Care Access and Information Database (2012-2016) identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR). Geospatial analysis was conducted to determine travel patterns. Clustered multivariable regression was performed to assess the probability of receiving care at a high-volume center. RESULTS Among 25,070 patients (ES: n = 1216, 4.9%; PN: n = 13,247, 52.8%; PD: n = 3559, 14.2%; PR: n = 7048, 28.1%), 6575 (26.2%) individuals resided within 30 min, 11,046 (44.1%) resided within 30-60 min, 7125 (28.4%) resided within 60-90 min, and 324 (1.3%) resided beyond a 90-min travel window from a high-volume center. Median travel distance was 13.4 miles (interquartile range [IQR] 6.0-28.7). On multivariable regression, patients residing further away were more likely to bypass a low-volume center to undergo care at a high-volume hospital (odds ratio 1.32, 95% confidence interval 1.12-1.55) versus individuals residing closer to high-volume centers. Approximately one-third (29.7%) of patients lived beyond a 1-h travel window to the nearest high-volume hospital, of whom 5% traveled over 90 min. While hospital mortality rates across different travel time windows did not differ, surgery at a high-volume center was associated with an overall 1.2% decrease in in-hospital mortality. CONCLUSIONS Regionalization of complex cancer surgery may be associated with a significant travel burden for a large subset of patients with complex cancer.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Munir MM, Endo Y, Alaimo L, Moazzam Z, Lima HA, Woldesenbet S, Azap L, Beane J, Kim A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Impact of Community Privilege on Access to Care Among Patients Following Complex Cancer Surgery. Ann Surg 2023; 278:e1250-e1258. [PMID: 37436887 DOI: 10.1097/sla.0000000000005979] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE We sought to define the impact of community privilege on variations in travel patterns and access to care at high-volume hospitals for complex surgical procedures. BACKGROUND With increased emphasis on centralization of high-risk surgery, social determinants of health play a critical role in preventing equitable access to care. Privilege is a right, benefit, advantage, or opportunity that positively impacts all social determinants of health. METHODS The California Office of State-wide Health Planning Database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for a malignant diagnosis between 2012 and 2016 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated metric of both spatial polarization and privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the probability of undergoing care at a high-volume center, bypassing the nearest and high-volume center, and total real driving time and travel distance. RESULTS Among 25,070 patients who underwent a complex oncologic operation (ES: n=1216, 4.9%; PN: n=13,247, 52.8%; PD: n=3559, 14.2%; PR: n=7048, 28.1%), 5019 (20.0%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 4994 (19.9%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). Median travel distance was 33.1 miles (interquartile range 14.4-72.2). Roughly, three-quarters of patients (overall: 74.8%, ES: 35.0%; PN: 74.3%; PD: 75.2%; PR: 82.2%) sought surgical care at a high-volume center. On multivariable regression, patients residing in the least advantaged communities were less likely to undergo surgery at a high-volume hospital (overall: odds ratio 0.65, 95% CI 0.52-0.81). Of note, individuals in the least privileged areas had longer travel distances (28.5 miles, 95% CI 21.2-35.8) to reach the destination facility, as well as over 70% greater odds of bypassing a high-volume hospital to undergo surgical care at a low-volume center (odds ratio 1.74, 95% CI 1.29-2.34) versus individuals living in the highest privileged areas. CONCLUSIONS AND RELEVANCE Privilege had a marked effect on access to complex oncologic surgical care at high-volume centers. These data highlight the need to focus on privilege as a key social determinant of health that influences patient access to and utilization of health care resources.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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Zheng M, Niu T, Peng J, Shi L, Shao C. Active Intra-Abdominal Drainage Following Abdominal Digestive System Surgery: A Meta-Analysis and Systematic Review. J INVEST SURG 2023; 36:2180115. [PMID: 37733388 DOI: 10.1080/08941939.2023.2180115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/08/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Our objective is to compare the early outcomes associated with passive (gravity) drainage (PG) and active drainage (AD) after surgery. METHODS Studies published until April 28, 2022 were retrieved from the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science databases. RESULTS Nine studies with 14,169 patients were identified. Two groups had the same intra-abdominal infection rate (RR: 0.55; P = 0.13); In subgroup analysis of pancreaticoduodenectomy, active drainage had no significant effect on postoperative pancreatic fistula (POPF) rate (RR: 1.21; P = 0.26) and clinically relevant POPF (CR-POPF) (RR: 1.05; P = 0.72); Active drainage was not associated with lower percutaneous drainage rate (RR: 1.00; P = 0.96), incidence of sepsis (RR: 1.00; P = 0.99) and overall morbidity (RR: 1.02; P = 0.73). Both groups had the same POPF rate (RR: 1.20; P = 0.18) and CR-POPF rate (RR: 1.20; P = 0.18) after distal pancreatectomy. There was no difference between two groups on the day of drain removal after pancreaticoduodenectomy (Mean difference: -0.16; P = 0.81) and liver surgery (Mean difference: 0.03; P = 0.99). CONCLUSIONS Active drainage is not superior to passive drainage and both drainage methods can be considered.
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Affiliation(s)
- Minghui Zheng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ting Niu
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Junfeng Peng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ligang Shi
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Chenghao Shao
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Dvorak MF, Evaniew N, Chen M, Waheed Z, Rotem-Kohavi N, Fallah N, Noonan VK, Fisher C, Charest-Morin R, Dea N, Ailon T, Street J, Kwon BK. Impact of Specialized Versus Non-Specialized Acute Hospital Care on Survival Among Patients With Acute Incomplete Traumatic Spinal Cord Injuries: A Population-Based Observational Study from British Columbia, Canada. J Neurotrauma 2023; 40:2638-2647. [PMID: 37294210 PMCID: PMC10698776 DOI: 10.1089/neu.2022.0496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Given the complexity of care necessitated after an acute traumatic spinal cord injury (SCI), it seems intuitively beneficial for such care to be delivered at hospitals with specialized SCI expertise. Demonstrating these benefits is not straightforward, however. We sought to determine whether specialized acute hospital care influenced the most fundamental outcomes after SCI: mortality within the first year of injury. We compared survival among patients with incomplete tSCI admitted to a single quaternary-level trauma hospital with a specialized acute SCI program versus those admitted to trauma hospitals without specialized acute SCI care. We performed a population-based retrospective observational cohort study using administrative and clinical data linked from multiple sources in British Columbia (BC) from 2001 to 2017. Among a cohort of 1920 patients, there were 193 deaths within one year. We failed to identify a significant overall benefit for survival after adjusting for potential confounders, and the confidence intervals (CIs) were compatible with both benefit and harm (odds ratio [OR] 1.01, 95% CI 0.17 to 6.11, p = 0.99). Significant associations were observed with age greater than 65 (OR 4.92, 95% CI 1.66 to 14.57, p < 0.01), Charlson Comorbidity Index (OR 1.61, 95% CI 1.42 to 1.83, p < 0.01), Injury Severity Score (OR 1.08, 95% CI 1.06 to 1.11, p < 0.01), and traumatic brain injury (OR 2.12, 95% CI 1.32 to 3.41, p < 0.01). Among patients with acute tSCI, admission to a hospital with specialized acute SCI care was not associated with improved overall one-year survival. Subgroup analyses, however, suggested heterogeneity of effects, with little benefit for older patients with less polytrauma and substantial benefit for younger patients with greater polytrauma.
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Affiliation(s)
- Marcel F. Dvorak
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Nathan Evaniew
- University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Melody Chen
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Zeina Waheed
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | | | - Nader Fallah
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | | | - Charles Fisher
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raphaële Charest-Morin
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tamir Ailon
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Street
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian K. Kwon
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
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Lizalek JM, Reames BN. Time, Space, and Place: Can Geospatial Information Systems Clarify the Tension Between Regionalization and Access for Complex Cancer Surgery? Ann Surg Oncol 2023; 30:7915-7917. [PMID: 37684367 DOI: 10.1245/s10434-023-14292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Jason M Lizalek
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
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Martins RS, Chang YH, Etzioni D, Stucky CC, Cronin P, Wasif N. Understanding Variation in In-hospital Mortality After Major Surgery in the United States. Ann Surg 2023; 278:865-872. [PMID: 36994756 DOI: 10.1097/sla.0000000000005862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US). BACKGROUND The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown. STUDY DESIGN Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each. RESULTS Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups. CONCLUSIONS Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM.
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Affiliation(s)
- Russell Seth Martins
- Centre for Clinical Best Practices (CCBP), Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ
| | - David Etzioni
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Chee-Chee Stucky
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Patricia Cronin
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Nabil Wasif
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Hsiao YW, Hsiao CY, Huang J, Lai PS, Chen PY. Surgical Outcomes and Quality of Care Among Adult Appendicitis Patients: A Comparative Study of Tertiary Care Hospitals and Regional Hospitals. World J Surg 2023; 47:3149-3158. [PMID: 37851067 DOI: 10.1007/s00268-023-07219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Acute appendicitis is one of the most common abdominal emergencies, with management approaches that vary depending on the available resources and setting. However, there is a lack of studies on the differences of surgical outcomes and quality of care between tertiary care hospitals and regional hospitals. METHODS This multicenter retrospective study included 2158 consecutive adult patients between January 2014 and June 2018 at three hospitals. The patient cohort was divided into regional hospital group (N = 1223) and tertiary care hospital group (N = 935). Baseline characteristics and perioperative outcomes were compared, and factors associated with surgical delay and postoperative complication were investigated. RESULTS Patients in tertiary care hospital group had longer surgical waiting time (17.3 vs. 12.0 h, p < 0.001), higher risks of surgical delay exceeding 24 h (OR = 2.94, 95% CI 2.17-4.01, p < 0.001), longer operation time (64 vs. 50 min, p < 0.001), more appendix perforation (22.4 vs. 13.3%, p < 0.001), and higher hospital cost compared with regional hospital group. In multivariate analysis, factors associated with surgical delay were tertiary care hospital (OR = 2.94, 95% CI 2.18-4.01, p < 0.001) and delay diagnosis (OR = 18.7, 95% CI 11.7-30.1, p < 0.001), while those associated with postoperative complications were older age (OR = 1.02, 95% CI 1.00-1.04, p = 0.013), male sex (OR = 2.38, 95% CI 1.11-5.52, p = 0.031), surgical delay (OR = 2.99, 95% CI 1.30-6.47, p = 0.007), and appendix perforation (OR = 5.61, 95% CI 2.72-11.85, p < 0.001). CONCLUSIONS Patients at tertiary care hospitals had longer waiting time, more surgical delays, and appendix perforations, and these were risk factors of postoperative complications. Establishing an effective referral system to redirect appendicitis patients with less complex medical histories from tertiary care hospitals to regional hospitals may enhance the quality of patient care and outcomes, while also reducing medical costs.
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Affiliation(s)
- Ya-Wen Hsiao
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan
| | - Chih-Yang Hsiao
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan.
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - John Huang
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhongzheng District, Taipei, Taiwan
| | - Peng-Sheng Lai
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yunlin County, Taiwan
| | - Po-Yen Chen
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu County, Taiwan
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49
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Severina AS, Tskaeva AA, Yevloyeva MI, Shamhalova MS, Shestakova MV. [Simultaneous living donor pancreas-kidney transplantation in a patient with type 1 diabetes mellitus after program hemodialysis. Case report]. TERAPEVT ARKH 2023; 95:859-863. [PMID: 38159018 DOI: 10.26442/00403660.2023.10.202428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Indexed: 01/03/2024]
Abstract
Simultaneous pancreas-kidney transplantation is an effective treatment option for end-stage renal disease with diabetes mellitus. Successful simultaneous pancreas-kidney transplantation allows achieving euglycemia, stabilizing existing microvascular complications and slowing their progression, improving the patient's quality of life, lipid and calcium-phosphorus metabolism, reducing the risks of cardiovascular events. Therefore, in view of the patient's severe general condition due to prolonged intoxication, hyperglycemia and other complications of chronic kidney disease, the earliest possible surgical treatment with minimization of the patient's stay on dialysis therapy is crucial to improve the outcome of transplantation.
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Affiliation(s)
- A S Severina
- National Medical Research Center for Endocrinology
| | - A A Tskaeva
- National Medical Research Center for Endocrinology
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50
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Wallis CJ, Jerath A, Ikesu R, Satkunasivam R, Dimick JB, Orav EJ, Maggard-Gibbons M, Li R, Salles A, Klaassen Z, Coburn N, Bass BL, Detsky AS, Tsugawa Y. Association between patient-surgeon gender concordance and mortality after surgery in the United States: retrospective observational study. BMJ 2023; 383:e075484. [PMID: 37993130 PMCID: PMC10664070 DOI: 10.1136/bmj-2023-075484] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States. DESIGN Retrospective observational study. SETTING Acute care hospitals in the US. PARTICIPANTS 100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19. MAIN OUTCOME MEASURES Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital). RESULTS Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures. CONCLUSIONS Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads.
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Affiliation(s)
- Christopher Jd Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Urology, Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Ruixin Li
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arghavan Salles
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia-Augusta University, Augusta, GA, USA
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Barbara L Bass
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Allan S Detsky
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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