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Tsilimigras DI, Chatzipanagiotou O, Woldesenbet S, Endo Y, Altaf A, Katayama E, Pawlik TM. Practice Patterns and Outcomes Among Surgical Oncology Fellowship Graduates Performing Complex Cancer Surgery in the United States Across Different Career Stages. Ann Surg Oncol 2024:10.1245/s10434-024-15436-0. [PMID: 38762637 DOI: 10.1245/s10434-024-15436-0] [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: 03/06/2024] [Accepted: 04/24/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Practice patterns and potential quality differences among surgical oncology fellowship graduates relative to years of independent practice have not been defined. METHODS Medicare claims were used to identify patients who underwent esophagectomy, pancreatectomy, hepatectomy, or rectal resection for cancer between 2016 and 2021. Surgical oncology fellowship graduates were identified, and the association between years of independent practice, serious complications, and 90-day mortality was examined. RESULTS Overall, 11,746 cancer operations (pancreatectomy [61.2%], hepatectomy [19.5%], rectal resection [13.7%], esophagectomy [5.6%]) were performed by 676 surgical oncology fellowship graduates (females: 17.7%). The operations were performed for 4147 patients (35.3%) by early-career surgeons (1-7 years), for 4104 patients (34.9%) by mid-career surgeons (8-14 years), and for 3495 patients (29.8%) by late-career surgeons (>15 years). The patients who had surgery by early-career surgeons were treated more frequently at a Midwestern (24.9% vs. 14.2%) than at a Northeastern institution (20.6% vs. 26.9%) compared with individuals treated by late-career surgeons (p < 0.05). Surgical oncologists had comparable risk-adjusted serious complications and 90-day mortality rates irrespective of career stage (early career [13.0% and 7.2%], mid-career [12.6% and 6.3%], late career [12.8% and 6.5%], respectively; all p > 0.05). Surgeon case-specific volume independently predicted serious complications across all career stages (high vs. low volume: early career [odds ratio {OR}, 0.80; 95% confidence interval {CI}, 0.65-0.98]; mid-career [OR, 0.81; 95% CI, 0.66-0.99]; late career [OR, 0.78; 95% CI, 0.62-0.97]). CONCLUSION Among surgical oncology fellowship graduates performing complex cancer surgery, rates of serious complications and 90-day mortality were comparable between the early-career and mid/late-career stages. Individual surgeon case-specific volume was strongly associated with postoperative outcomes irrespective of years of independent practice or career stage.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Odysseas Chatzipanagiotou
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- 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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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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Munir MM, Lima HA, Endo Y, Moazzam Z, Woldesenbet S, Azap L, Katayama E, Dilhoff M, Cloyd J, Ejaz A, Pawlik TM. Association of Racial and Economic Privilege on Postoperative Outcomes Among Medicare Beneficiaries. J Surg Res 2024; 296:37-46. [PMID: 38215675 DOI: 10.1016/j.jss.2023.12.005] [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: 06/12/2023] [Revised: 11/15/2023] [Accepted: 12/17/2023] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Social determinants of health can play an important role in patient health. Privilege is a right, benefit, advantage, or opportunity that can positively affect all social determinants of health. We sought to assess variations in the prevalence of privilege among patient populations and define the association of privilege on postoperative surgical outcomes. METHODS Medicare beneficiaries who underwent elective coronary artery bypass grafting, abdominal aortic aneurysm repair, total hip arthroplasty, total knee arthroplasty, colectomy, and lung resection were identified. The Index of Concentration of Extremes (ICE), a validated metric of both social spatial polarization and privilege was calculated and merged with county-level data obtained from the American Community Survey. Textbook outcome (TO) was defined as absence of postoperative complications, extended length of stay, 90-day mortality, and 90-day readmission. Multivariable regression analysis was performed to assess the relationship between ICE and TO. RESULTS Among 1,885,889 Medicare beneficiaries who met inclusion criteria, 655,980 (34.8%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 221,314 (11.7%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). The overall incidence of TO was 66.2% (n = 1,247,558). On multivariable regression, residence in the most advantaged neighbourhoods was associated with a lower chance of surgical complications (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.88-0.91), a prolonged length of stay (OR 0.81, 95% CI 0.79-82), 90-day readmission (OR 0.94, 95% CI 0.92-0.95), and 90-day mortality (OR 0.71, 95% CI 0.68-0.74) (all P < 0.001). Residence in the most privileged areas was associated with 19% increased odds of achieving TO (OR 1.19, 95% CI 1.18-1.21), as well as a 6% reduction in Medicare expenditures versus individuals in the least privileged counties (OR 0.94, 95% CI 0.94-0.94) (both P < 0.001). CONCLUSIONS Privilege, based on the ICE joint measure of racial/ethnic and economic spatial concentration, was strongly associated with the likelihood to achieve an "optimal" TO following surgery. As healthcare is a basic human right, privilege should not be associated with disparities in surgical care.
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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, Ohio
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Mary Dilhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.
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Clocchiatti L, Marino R, Ratti F, Pedica F, Casadei Gardini A, Lorenzin D, Aldrighetti L. Defining and predicting textbook outcomes for perihilar cholangiocarcinoma: analysis of factors improving achievement of desired postoperative outcomes. Int J Surg 2024; 110:209-218. [PMID: 37800550 PMCID: PMC10793762 DOI: 10.1097/js9.0000000000000793] [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: 05/24/2023] [Accepted: 09/09/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Definition of textbook outcome (TO), defined as a single indicator combining the most advantageous short-term outcomes, is still lacking for perihilar cholangiocarcinoma (PHC). The primary endpoint of the present study is to analyze the rate of achievement of a disease-specific TO for PHC within a high volume tertiary referral centre. Secondary endpoints are to identify predictive factors of TO-achievement and to analyze the impact of achieving TO on long-term results. METHODS Between 2010 and 2022, a total of 237 patients undergoing combined liver and biliary resection for PHC at tertiary referral centre were included. Disease-specific TO were defined as: no 90-day mortality, no postoperative complications, no readmission, no intraoperative transfusions and resection margins. A logistic regression model was developed to identify predictors associated with TO-achievement. Kaplan-Meier curves were designed to determine TO's impact on survival. RESULTS TO was achieved in 60 (25.3%) patients. At multivariate logistic regression, preoperative biliary drainage [odds ratio (OR) 2.90 (1.13-3.40), P =0.026], high prognostic nutritional index [OR 7.11 (6.71-9.43), P =0.007[ and minimally invasive approach [OR 3.57 (2.31-3.62), P =0.013] were identified as independent predictors of TO. High ASA score [OR 0.38 (0.17-0.82), P =0.013] decreased the odds of TO. A significant improvement in both overall survival and disease-free survival was associated to TO fulfilment. CONCLUSION Since the achievement of TO correlates with better disease-free and overall survival, every effort should be made to ameliorate modifiable aspects prior to surery: management within referral centres with dedicated experience in biliary tract cancer and preoperative optimization protocol may positively contribute to improve postoperative outcomes, increasing the chance to obtain TO. Moreover, the implementation of advanced minimally invasive programs plays as well.
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Affiliation(s)
| | | | - Francesca Ratti
- Hepatobiliary Surgery Division
- Vita-Salute San Raffaele University
| | | | - Andrea Casadei Gardini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan
| | - Dario Lorenzin
- General Surgery Clinic and Liver Transplant Center, University Hospital of Udine, Udine, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division
- Vita-Salute San Raffaele University
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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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Mclauchlan J, de Burlet K, Nonis M, Hore T, Connor S. Textbook outcomes for liver resection: can a medium sized centre have acceptable outcomes? ANZ J Surg 2023; 93:2892-2896. [PMID: 37784257 DOI: 10.1111/ans.18724] [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: 01/02/2023] [Revised: 08/01/2023] [Accepted: 09/16/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Textbook outcome (TO) is an objective, composite measure of clinical outcomes in surgery. TO in liver surgery has been used in previous international studies to define and compare performance across centres. This study aimed to review TO rates following liver resection at a single institution. The secondary aim was to use a CuSum analysis to evaluate monitoring of performance quality over time for colorectal cancer liver metastases (CRCLM). METHODS All patients undergoing liver resection for benign and malignant causes from Christchurch Hospital hepatobiliary unit between 2005 and 2022 were included. Textbook outcomes measures were the absence of; intraoperative incidents, Clavien-Dindo >3 complication, 90 day re-admission, 90 day mortality, R1 resection, and post-operative bile leak/liver failure. Sequential CuSum analysis was performed to review achievement of TO in liver resections for colorectal cancer liver metastases (CRCLM). RESULTS Four hundred and seventy-eight patients were included in this study, 54 had resection for benign pathology, 290 for CRCLM and 134 for other malignancies. TO was achieved in 74% of cases overall, with rates for benign, CRCLM and other malignancy being 82%, 73% and 74% respectively (P = 0.405). CuSum analysis documented a deterioration in performance after patient 60, with return to baseline by end of study period. CONCLUSIONS TO for liver resection in a medium sized centre in New Zealand are comparable to published rates. It is possible to use process control techniques like CuSum with the binary result of TO to monitor performance, providing opportunity for continuous improvement in surgical units.
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Affiliation(s)
- Jared Mclauchlan
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Kirsten de Burlet
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Maria Nonis
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Saxon Connor
- Department of General Surgery, Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
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Shaikh CF, Woldesenbet S, Munir MM, Moazzam Z, Endo Y, Alaimo L, Azap L, Yang J, Katayama E, Lima HA, Dawood Z, Pawlik TM. Association between the Environmental Quality Index and Textbook Outcomes Among Medicare Beneficiaries Undergoing Surgery for Early-Stage Pancreatic Adenocarcinoma. J Gastrointest Surg 2023; 27:1883-1892. [PMID: 37340109 DOI: 10.1007/s11605-023-05757-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/11/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Access to high-quality cancer care is affected by environmental exposures and structural inequities. This study sought to investigate the association between the environmental quality index (EQI) and achievement of textbook outcomes (TO) among Medicare beneficiaries over the age of 65 who underwent surgical resection for early-stage pancreatic adenocarcinoma (PDAC). METHODS Patients diagnosed with early-stage PDAC from 2004 to 2015 were identified using the SEER-Medicare database and combined with the US Environmental Protection Agency's EQI data. High EQI category indicated poor environmental quality, whereas low EQI indicated better environmental conditions. RESULTS A total of 5,310 patients were included, of which 45.0% (n = 2,387) patients achieved TO. Median age was 73 years and more than half were female (n = 2,807, 52.9%), married (n = 3,280, 61.8%), and resided in the Western region of the US (n = 2,712, 51.1%). On multivariable analysis, patients residing in moderate and high EQI counties were less likely to achieve a TO (referent: low EQI; moderate EQI: OR 0.66, 95% CI 0.46-0.95; high EQI: OR 0.65, 95% CI 0.45-0.94; p < 0.05). Increasing age (OR 0.98, 95%CI 0.97-0.99), racial minorities (OR 0.73, 95% CI 0.63-0.85), having a Charlson co-morbidity index > 2 (OR 0.54, 95%CI 0.47-0.61) and stage II disease (OR 0.82, 95%CI 0.71-0.96) were also associated with not achieving a TO (all p < 0.001). CONCLUSION Older Medicare patients residing in moderate or high EQI counties were less likely to achieve an "optimal" TO after surgery. These results demonstrate that environmental factors may drive post-operative outcomes among patients with PDAC.
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Affiliation(s)
- Chanza F Shaikh
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zaiba Dawood
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave, Suite 670, Columbus, OH, USA.
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Shaikh CF, Woldesenbet S, Munir MM, Moazzam Z, Endo Y, Alaimo L, Azap L, Yang J, Katayama E, Lima HA, Dawood Z, Pawlik TM. Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic. J Gastrointest Surg 2023; 27:1611-1620. [PMID: 37254021 PMCID: PMC10228881 DOI: 10.1007/s11605-023-05711-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Telemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver. METHODS Patients who underwent HP surgery between 2013-2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI. RESULTS Pre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66-74) with the majority of patients being age 65-69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86-1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55-0.94, p = 0.001) and individuals with advancing age (referent 18-64; 65-69, OR 0.68, 95%CI 0.54-0.86; 70-74, OR 0.56, 95%CI 0.44-0.71; 75-79, OR 0.57, 95%CI 0.44-0.75; 80-84, OR 0.43, 95%CI 0.30-0.61; 85 + , OR 0.25, 95%CI 0.13-0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65-3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28-1.71) were more likely to use telemedicine (all p < 0.001). CONCLUSIONS Medicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.
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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, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Zaiba Dawood
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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10
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Sweigert PJ, Ramia JM, Villodre C, Carbonell-Morote S, De-la-Plaza R, Serradilla M, Pawlik TM. Textbook Outcomes in Liver Surgery: a Systematic Review. J Gastrointest Surg 2023:10.1007/s11605-023-05673-1. [PMID: 37069461 DOI: 10.1007/s11605-023-05673-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Assessment of the quality of care among patients undergoing hepatectomy may be inadequate using traditional "siloed" postoperative surgical outcome metrics. In turn, the combination of several quality metrics into a single composite Textbook Outcome in Liver Surgery (TOLS) may be more representative of "ideal" surgical care. METHODS Adhering to PRISMA guidelines, a search for primary articles on post-operative TOLS evaluation after hepatectomy was performed. Studies that did not present hepatectomy outcomes, pediatric or transplantation populations, duplicated series, and editorials were excluded. Studies were evaluated in aggregate for methodological variation, TOLS rates, factors associated with TOLS, hospital variation, and overall findings. RESULTS Among 207 identified publications, 32 observational cohort studies were selected for inclusion in the review. There was a total of 90,077 hepatic resections performed from 1993 to 2020 in the analytic cohort. While TOLS definitions varied widely, all studies used an "all-or-none" composite structure combining a median of 5 (range: 4-7) discrete parameters. Observed TOLS rates varied in the different reported populations from 11.2 to 77.0%. TOLS was associated with patient, hospital, and operative factors. CONCLUSIONS This systematic review summarizes the contemporary international experience with TOLS to assess surgical performance following hepatobiliary surgery. TOLS is a single composite metric that may be more patient-centered, as well as better suited to quantify "optimal" care and compare performance among centers performing liver surgery.
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Affiliation(s)
- Patrick J Sweigert
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jose M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain.
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain.
- Universidad Miguel Hernández, Alicante, Spain.
| | - Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain
| | - Silvia Carbonell-Morote
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain
| | | | | | - 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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11
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Lluís N, Serradilla-Martín M, Achalandabaso M, Jehaes F, Dasari BV, Mambrilla-Herrero S, Sparrelid E, Balakrishnan A, Hoogwater FJ, Amaral MJ, Andersson B, Berrevoet F, Doussot A, López-López V, Alsammani M, Detry O, Domingo-del Pozo C, Machairas N, Pekli D, Alcázar-López CF, Asbun H, Björnsson B, Christophides T, Díez-Caballero A, Francart D, Noel CB, Sousa-Silva D, Toledo-Martínez E, Tzimas GN, Yaqub S, Cauchy F, Prieto-Calvo M, D’Souza MA, Spiers HV, van den Heuvel MC, Charco R, Lesurtel M, Ramia JM. Intraductal papillary neoplasms of the bile duct: a European retrospective multicenter observational study (EUR-IPNB study). Int J Surg 2023; 109:760-771. [PMID: 36917142 PMCID: PMC10389541 DOI: 10.1097/js9.0000000000000280] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/19/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND/PURPOSE Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease in Western countries. The main aim of this study was to characterize current surgical strategies and outcomes in the mainly European participating centers. METHODS A multi-institutional retrospective series of patients with a diagnosis of IPNB undergoing surgery between 1 January 2010 and 31 December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association. The textbook outcome (TO) was defined as a non-prolonged length of hospital stay plus the absence of any Clavien-Dindo grade at least III complications, readmission, or mortality within 90 postoperative days. RESULTS A total of 28 centers contributed 85 patients who underwent surgery for IPNB. The median age was 66 years (55-72), 49.4% were women, and 87.1% were Caucasian. Open surgery was performed in 72 patients (84.7%) and laparoscopic in 13 (15.3%). TO was achieved in 54.1% of patients, reaching 63.8% after liver resection and 32.0% after pancreas resection. Median overall survival was 5.72 years, with 5-year overall survival of 63% (95% CI: 50-82). Overall survival was better in patients with Charlson comorbidity score 4 or less versus more than 4 ( P =0.016), intrahepatic versus extrahepatic tumor ( P =0.027), single versus multiple tumors ( P =0.007), those who underwent hepatic versus pancreatic resection ( P =0.017), or achieved versus failed TO ( P =0.029). Multivariable Cox regression analysis showed that not achieving TO (HR: 4.20; 95% CI: 1.11-15.94; P =0.03) was an independent prognostic factor of poor overall survival. CONCLUSIONS Patients undergoing liver resection for IPNB were more likely to achieve a TO outcome than those requiring a pancreatic resection. Comorbidity, tumor location, and tumor multiplicity influenced overall survival. TO was an independent prognostic factor of overall survival.
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Affiliation(s)
- Núria Lluís
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Miguel Servet University Hospital, Zaragoza
| | - Mar Achalandabaso
- HPB Surgery and Transplantation, Hospital Universitario Vall d’Hebron
| | - François Jehaes
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Bobby V.M. Dasari
- Liver Transplant and HPB Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Ernesto Sparrelid
- Department of Clinical Science, Division of Surgery, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm
| | - Anita Balakrishnan
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust
- Department of Surgery, University of Cambridge, Cambridge
| | - Frederik J.H. Hoogwater
- Department of HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria J. Amaral
- Department of General Surgery, Centro Hospitalar e Universitário de Coimbra
- Faculty of Medicine, University of Coimbra, Coimbra
| | - Bodil Andersson
- Department of Surgery, Lund University
- Skane University Hospital, Lund
| | - Frederik Berrevoet
- Department of General and HPB Surgery, and Liver Transplantation, University Hospital Gent, Gent
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, CHU Besançon, Besancon
| | - Víctor López-López
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, Murcia
| | | | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege
| | | | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, National and Kapodistrian University of Athens
| | - Damján Pekli
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Cándido F. Alcázar-López
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL)
| | - Horacio Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thalis Christophides
- General Surgery Department, HPB Division, Nicosia General Hospital, Nicosia, Cyprus
| | | | - David Francart
- Department of Abdominal Surgery, CHC Groupe Santé, Liège, Belgium
| | - Colin B. Noel
- HPB Clinical Unit, Gastrointestinal Surgery, Universitas Academic Hospital, University of the Free State, Bloemfontein
| | - Donzília Sousa-Silva
- Department of Surgery, HEBIPA – Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Enrique Toledo-Martínez
- Servicio de Cirugía, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - George N. Tzimas
- Hepatobiliary Surgery Department, Hygeia Hospital, Athens, Greece
| | - Sheraz Yaqub
- Department of HPB Surgery, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Mikel Prieto-Calvo
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao
| | - Melroy A. D’Souza
- Department of Clinical Science, Division of Surgery, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm
| | - Harry V.M. Spiers
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust
- Department of Surgery, University of Cambridge, Cambridge
| | - Marius C. van den Heuvel
- Department of HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ramón Charco
- HPB Surgery and Transplantation, Hospital Universitario Vall d’Hebron
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - José M. Ramia
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL)
- Miguel Hernández University, Alicante
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12
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Sinnamon AJ, Luo E, Xu A, Zhu S, Denbo JW, Fleming JB, Anaya DA. Simultaneous Hepatic and Visceral Resection: Preoperative Risk Stratification and Implications on Return to Intended Oncologic Therapy. Ann Surg Oncol 2023; 30:1772-1783. [PMID: 36418800 DOI: 10.1245/s10434-022-12834-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Sequence of therapies for synchronous liver metastasis (LM) is complex, with data supporting individualized approaches, although no guiding tools are currently available. We assessed the impact of simultaneous hepatic and visceral resections (SHVR) on textbook outcome (TO) and return to intended oncologic therapy (RIOT), and provide risk-stratification tools to guide individualized decision making and counseling. METHODS Patients with synchronous LM undergoing hepatectomy ± SHVR were included (2015-2021). Primary and secondary outcomes were TO and RIOT (days), respectively. Using multivariable modeling, a risk score for TO was developed. Decision tree analysis using recursive partitioning was performed for hierarchical risk stratification. The associations between SHVR, TO, and RIOT were examined. RESULTS Among 533 patients identified, 124 underwent SHVR. TO overall was 71.7%; 79.2% in the non-SHVR group and 46.8% in the SHVR group (p < 0.001). SHVR was the strongest predictor of non-TO (right colon/small bowel: odds ratio [OR] 4.63, 95% confidence interval [CI] 2.65-8.08; left colon/rectum: OR 6.09, 95% CI 2.59-14.3; stomach/pancreas: OR 6.69, 95% CI 1.46-30.7; multivisceral: OR 10.9, 95% CI 3.03-39.5). A composite score was developed yielding three risk strata for TO (score 0-2: 89% vs. score 3-5: 67% vs. score ≥ 6: 37%; p < 0.001). Decision tree analysis was congruent, identifying SHVR as the most important determinant of TO. In patients with colorectal LM, SHVR was associated with delayed time to RIOT (p = 0.004); the risk-stratification tool for TO was equally predictive of RIOT (p < 0.01). CONCLUSIONS SHVR is associated with reduced likelihood of TO and in turn delayed RIOT. As SHVR is increasingly performed in order to consolidate cancer care, patient selection considering these different outcomes is critical.
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Affiliation(s)
- Andrew J Sinnamon
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA. .,University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Eric Luo
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Aileen Xu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sarah Zhu
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jason W Denbo
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jason B Fleming
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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13
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de Graaff MR, Elfrink AKE, Buis CI, Swijnenburg RJ, Erdmann JI, Kazemier G, Verhoef C, Mieog JSD, Derksen WJM, van den Boezem PB, Ayez N, Liem MSL, Leclercq WKG, Kuhlmann KFD, Marsman HA, van Duijvendijk P, Kok NFM, Klaase JM, Dejong CHC, Grünhagen DJ, den Dulk M. Defining Textbook Outcome in liver surgery and assessment of hospital variation: A nationwide population-based study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2414-2423. [PMID: 35773091 DOI: 10.1016/j.ejso.2022.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/24/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Textbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to assess factors associated with TO, and evaluate hospital and network variation after case-mix correction in TO rates for liver surgery. METHODS This was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of hospital stay, and readmission, and obtaining adequate resection margins. Multivariable logistic regression was used for case-mix adjustment. RESULTS 2376 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51-0.95 p = 0.02), extrahepatic disease (aOR 0.64, CI 0.44-0.95, p = 0.02), tumour size >55 mm on preoperative imaging (aOR 0.56, CI 0.34-0.94, p = 0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54-0.98, p = 0.04), and major liver resection (aOR 0.50, CI 0.36-0.69, p < 0.001). After case-mix correction, no significant hospital or oncological network variation was observed. CONCLUSION TO differs between indications for liver resection and can be used to assess between hospital and network differences.
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Affiliation(s)
- Michelle R de Graaff
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands.
| | - Arthur K E Elfrink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carlijn I Buis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Ninos Ayez
- Department of Surgery, Amphia Medical Center, Breda, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Koert F D Kuhlmann
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | | | | | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
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14
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Pretzsch E, Koliogiannis D, D’Haese JG, Ilmer M, Guba MO, Angele MK, Werner J, Niess H. Textbook outcome in hepato-pancreato-biliary surgery: systematic review. BJS Open 2022; 6:6855255. [PMID: 36449597 PMCID: PMC9710735 DOI: 10.1093/bjsopen/zrac149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/08/2022] [Accepted: 10/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Textbook outcome (TO) is a multidimensional measure reflecting the ideal outcome after surgery. As a benchmarking tool, it provides an objective overview of quality of care. Uniform definitions of TO in hepato-pancreato-biliary (HPB) surgery are missing. This study aimed to provide a definition of TO in HPB surgery and identify obstacles and predictors for achieving it. METHODS A systematic literature search was conducted using PubMed, Embase, and Cochrane Database according to PRISMA guidelines. Studies published between 1993 and 2021 were retrieved. After selection, two independent reviewers extracted descriptive statistics and derived summary estimates of the occurrence of TO criteria and obstacles for achieving TO using co-occurrence maps. RESULTS Overall, 30 studies were included. TO rates ranged between 16-69 per cent. Commonly chosen co-occurring criteria to define TO included 'no prolonged length of stay (LOS)', 'no complications', 'no readmission', and 'no deaths'. Major obstacles for achieving TO in HPB surgery were prolonged LOS, complications, and readmission. On multivariable analysis, TO predicted better overall and disease-free survival in patients with cancer. Achievement of TO was more likely in dedicated centres and associated with procedural and structural indicators, including high case-mix index and surgical volume. CONCLUSION TO is a useful quality measure to benchmark surgical outcome. Future definitions of TO in HPB surgery should include 'no prolonged LOS', 'no complications', 'no readmission', and 'no deaths'.
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Affiliation(s)
- Elise Pretzsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jan Gustav D’Haese
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Ilmer
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Otto Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Konrad Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hanno Niess
- Correspondence to: Hanno Niess, Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (e-mail: )
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15
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Beal EW, Dalmacy D, Paro A, Hyer JM, Cloyd J, Dillhoff M, Ejaz A, Pawlik TM. Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis. J Gastrointest Surg 2022; 26:1697-1704. [PMID: 35705834 DOI: 10.1007/s11605-022-05380-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/03/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach. METHODS Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission. RESULTS Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14). CONCLUSIONS MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Alessandro Paro
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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16
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Paro A, Rice DR, Hyer JM, Palmer E, Ejaz A, Shaikh CF, Pawlik TM. Telehealth Utilization Among Surgical Oncology Patients at a Large Academic Cancer Center. Ann Surg Oncol 2022; 29:7267-7276. [PMID: 35896926 PMCID: PMC9331038 DOI: 10.1245/s10434-022-12259-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/05/2022] [Indexed: 01/24/2023]
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth within medicine. Data on sociodemographic and clinical characteristics associated with telehealth utilization among cancer surgical patients have not been well-defined. Methods Cancer patients who had a surgical oncology visit at the James Cancer Hospital in March 2020–May 2021 were included. Patient demographic and clinical characteristics were recorded; access to modern information technology was measured using the Digital Divide Index (DDI). A logistic regression model was used to assess odds of receiving a telehealth. Results Among 2942 patients, median DDI was 18.2 (interquartile range 17.4–22.1). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–0.98 per 10-year increase), sex (male vs. female: OR 1.83, 95% CI 1.45–2.32), cancer type (pancreatic vs. breast: OR 9.19, 95% CI 6.38–13.23; colorectal vs. breast: OR 5.31, 95% CI 3.71–7.58), insurance type (Medicare vs. Medicaid: OR 1.58, 95% CI 1.04–2.41) and county of residence (distant vs. neighboring: OR 1.33, 95% CI 1.06–1.66) were associated with increased odds of receiving a telehealth visit. Patients from high DDI counties were not less likely to receive telehealth visits versus patients from low DDI counties (OR 1.15, 95% CI 0.85–1.57). Conclusions Several patient sociodemographic and clinical characteristics had an impact on the likelihood of receiving a telehealth visit versus an in-person visit, suggesting that telehealth may not be equally accessible to all surgical oncology patients. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-12259-9.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Daniel R Rice
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Elizabeth Palmer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Chanza Fahim Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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17
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Benzing C, Haiden LM, Krenzien F, Mieg A, Wolfsberger A, Atik CF, Nevermann N, Fehrenbach U, Schöning W, Schmelzle M, Pratschke J. Textbook outcome after major hepatectomy for perihilar cholangiocarcinoma - definitions and influencing factors. Langenbecks Arch Surg 2022; 407:1561-1573. [PMID: 35246771 PMCID: PMC9283152 DOI: 10.1007/s00423-022-02467-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
Purpose The concept of “textbook outcome” (TO) as composite quality measure depicting the ideal surgical has not yet been defined for patients undergoing major hepatectomy (MH) for perihilar cholangiocarcinoma (PHC). This study sought to propose a uniform definition through a systematic literature review as well as to identify patient- or procedure-related factors influencing TO. Methods In this retrospective study, we analyzed all patients undergoing MH for PHC at our department between January 2005 and August 2019. After conducting a systematic literature search, we defined TO as the absence of 90-day mortality and major complications, no hospital readmission within 90 days after discharge, and no prolonged hospital stay (<75. percentile). A binary logistic regression analysis was performed to identify factors influencing TO. Results Of 283 patients, TO was achieved in 67 (24%) patients. Multivariate analysis revealed that preoperative biliary drainage was associated with a decreased (OR= 0.405, 95% CI: 0.194–0.845, p=0.016) and left-sided-resection (OR= 1.899, 95% CI: 1.048–3.440, p=0.035) with increased odds for TO. Overall survival (OS) and DFS (disease-free survival) did not differ significantly between the outcome groups (OS: p=0.280, DFS: p=0.735). However, there was a trend towards better overall survival, especially in the late course with TO. Conclusion Our analysis proposed a uniform definition of TO after MH for PHC. We identified left hepatectomy as an independent factor positively influencing TO. In patients where both right- and left-sided resections are feasible, this underlines the importance of a careful selection of patients who are scheduled for right hepatectomy. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02467-y.
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Affiliation(s)
- Christian Benzing
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lena Marie Haiden
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alexa Mieg
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Annika Wolfsberger
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Cecilia Filiz Atik
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nora Nevermann
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Uli Fehrenbach
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Melgar P, Rodríguez-Laiz GP, Lluís N, Alcázar-López C, Franco-Campello M, Villodre C, Pascual S, Rodríguez-Soler M, Bellot P, Miralles C, Perdiguero M, Díaz M, Mas-Serrano P, Zapater P, Ramia JM, Lluís F. Textbook outcome among patients undergoing enhanced recovery after liver transplantation stratified by risk. A single-center retrospective observational cohort study. Int J Surg 2022; 99:106266. [PMID: 35182809 DOI: 10.1016/j.ijsu.2022.106266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/01/2022] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver transplantation (LT) is one of the most complex surgical procedures. Enhanced recovery after surgery (ERAS) aims to reduce the risk of postoperative complications. When patients achieve all desirable outcomes after a procedure, they are considered to have experienced a textbook outcome (TO). METHODS Two cohorts of patients undergoing low (n = 101) or medium risk (n = 15) LT were identified. The remaining patients (n = 65) were grouped separately. The ERAS protocol included pre-, intra-, and post-operative steps. TO was defined as the absence of complications, prolonged length of hospital stays, readmission and mortality during the first 90 days. RESULTS One third of patients who underwent ERAS after LT experienced a TO. On multivariable analysis, age (OR, 1.05 [95% CI, 1.01-1.09]; P = .02), and having hepatocellular carcinoma (OR, 2.83 [95% CI, 1.37-6.03]; P = .005) were individually associated with a greater probability of achieving a TO. Belonging to the cohorts of medium risk or outside the selection criteria was associated with a lower probability of achieving a TO (OR, 0.46 [96% CI, 0.22-0.93]; P = .03). Patients less likely to experience TO required more hospital resources. Patients who achieved TO were more likely to remain free of chronic kidney disease (achieved TO, 83.8% [82.7-85.6]; failed TO, 67.9% [66.9-70.2]; P < .05). Tacrolimus dose and trough levels were similar. CONCLUSIONS A novel finding of our study is that short and medium-term kidney function is better preserved in patients who experience a TO. Better kidney function of patients who achieve TO is not due to lower tacrolimus dosage.
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Affiliation(s)
- Paola Melgar
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, General University Hospital of Alicante (HGUA), and Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA Gastroenterology and Hepatology, General University Hospital of Alicante (HGUA), and Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain Nephrology, General University Hospital of Alicante (HGUA), and Health and Biomedical Research Institut of Alicant (ISABIAL), Alicante, Spain Pharmacy and Pharmacokinetics, General University Hospital of Alicante (HGUA), and Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain Clinical Pharmacology, General University Hospital of Alicante (HGUA), and Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain
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Labiner HE, Hyer M, Cloyd JM, Tsilimigras DI, Dalmacy D, Paro A, Pawlik TM. Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery. J Gastrointest Surg 2022; 26:1171-1177. [PMID: 35023035 PMCID: PMC8754363 DOI: 10.1007/s11605-022-05245-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/01/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery. METHODS Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome. RESULTS Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4. CONCLUSION Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.
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Affiliation(s)
- Hanna E. Labiner
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Madison Hyer
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Jordan M. Cloyd
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Diamantis I. Tsilimigras
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Djhenne Dalmacy
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Alessandro Paro
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
| | - Timothy M. Pawlik
- The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH USA
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Wiseman JT, Sarna A, Wills CE, Beane J, Grignol V, Ejaz A, Pawlik TM, Ikoma N, Cloyd JM. Patient Perspectives on Defining Textbook Outcomes Following Major Abdominal Surgery. J Gastrointest Surg 2022; 26:197-205. [PMID: 34327659 PMCID: PMC8321005 DOI: 10.1007/s11605-021-05093-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The composite metric textbook outcome (TO) has recently gained interest as a novel quality measure. However, the criteria for defining a TO have not been rigorously defined and patient perspectives on the characteristics of TO are unknown. METHODS Patients who underwent major abdominal surgery at a single tertiary care center were administered a customized survey designed to ascertain their perspectives on defining TOs. The relationship between patient-reported and clinically defined TO rates was compared. RESULTS Among 79 patients who underwent gastrointestinal (51%), pancreatic (29%), hepatic (18%), or other major abdominal (3%) operations, 57% were female and 86% had an ASA class ≥3. Most patients underwent surgery for malignancy (87%) with 60% undergoing an open operation. Patients most commonly valued no mortality following surgery (96%), no reoperation (75%), and having a margin negative resection (73%) as "extremely important." In contrast, those outcomes that were most commonly valued as "not important at all" or "minimally important" were receiving a blood transfusion (24%) and not having any complications (13%). Using previously published criteria for TOs, 47 (60%) patients were classified as having a clinically defined TO; in contrast, 68 patients (86%) self-reported their outcome was textbook. Self-reported responses were concordant with clinically defined TO criteria 63% of the time (McNemar's test: S=15.2, p<0.01, evidence of disagreement). CONCLUSION There was significant discordance between patient-reported versus clinically defined measures of TOs, suggesting patients value other considerations beyond traditional factors when evaluating the success of their surgery. Future studies should delineate these relationships and incorporate these factors to refine TO definitions.
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Affiliation(s)
- Jason T. Wiseman
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Angela Sarna
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Celia E. Wills
- College of Nursing, The Ohio State University, Columbus, OH USA
| | - Joal Beane
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Valerie Grignol
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Jordan M. Cloyd
- Division of Surgical Oncology, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, OH Columbus, USA
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21
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Spolverato G, Paro A, Capelli G, Dalmacy D, Poultsides GA, Fields RC, Weber SM, Votanopoulos KI, He J, Maithel SK, Pucciarelli S, Pawlik TM. Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients? J Surg Oncol 2021; 125:621-630. [PMID: 34964983 DOI: 10.1002/jso.26778] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients. METHODS Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy. RESULTS Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p < 0.05). The odds of achieving a TOO improved over time (p-trend < 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45). CONCLUSIONS Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.
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Affiliation(s)
- Gaya Spolverato
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Alessandro Paro
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Giulia Capelli
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Salvatore Pucciarelli
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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22
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Chen Q, Ning Z, Liu Z, Zhou Y, He Q, Tian Y, Hao H, Lin W, Jiang L, Zhao G, Li P, Zheng C, Huang C. Textbook Outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis. Chin J Cancer Res 2021; 33:433-446. [PMID: 34584369 PMCID: PMC8435827 DOI: 10.21147/j.issn.1000-9604.2021.04.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/16/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Quality assurance is crucial for oncological surgical treatment assessment. For rare diseases, single-quality indicators are not enough. We aim to develop a comprehensive and reproducible measurement, called the "Textbook Outcome" (TO), to assess the quality of surgical treatment and prognosis of gastric neuroendocrine carcinoma (G-NEC) patients. METHODS Data from patients with primary diagnosed G-NEC included in 24 high-volume Chinese hospitals from October 2005 to September 2018 were analyzed. TO included receiving a curative resection, ≥15 lymph nodes examined, no severe postoperative complications, hospital stay ≤21 d, and no hospital readmission ≤30 d after discharge. Hospital variation in TO was analyzed using a case mix-adjusted funnel plot. Prognostic factors of survival and risk factors for non-Textbook Outcome (non-TO) were analyzed using Cox and logistic models, respectively. RESULTS TO was achieved in 56.6% of 860 G-NEC patients. TO patients had better overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) than non-TO patients (P<0.05). Moreover, TO patients accounted for 60.3% of patients without recurrence. Multivariate Cox analysis revealed non-TO as an independent risk factor for OS, DFS, and RFS of G-NEC patients (P<0.05). Increasing TO rates were associated with improved OS for G-NEC patients, but not hospital volume. Multivariate logistic regression revealed that non-lower tumors, open surgery, and >200 mL blood loss were independent risk factors for non-TO patients (P<0.05). CONCLUSIONS TO is strongly associated with multicenter surgical quality and prognosis for G-NEC patients. Factors predicting non-TO are identified, which may help guide strategies to optimize G-NEC outcomes.
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Affiliation(s)
- Qiyue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou 350004, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou 350004, China
| | - Zhongliang Ning
- Department of Gastrointestinal Surgery, West District of the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - Zhiyu Liu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Qingliang He
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Yantao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hankun Hao
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Wei Lin
- Department of Gastrointestinal Surgery and Gastrointestinal Surgery Research Institute, the Affiliated Hospital of Putian University, Putian 351106, China
| | - Lixin Jiang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital, Yantai 264099, China
| | - Gang Zhao
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiaotong University, Shanghai 200127, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou 350004, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou 350004, China
| | - Chaohui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou 350004, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou 350004, China
| | - Changming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou 350004, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou 350004, China
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Fuchs J, Hoffmann K, Murtha-Lemekhova A, Kessler M, Günther P, Frongia G, Probst P, Mehrabi A. Establishing a Standardized Measure of Quality in Pediatric Liver Surgery: Definition and Validation of Textbook Outcome With Associated Predictors. Front Surg 2021; 8:708351. [PMID: 34368218 PMCID: PMC8333609 DOI: 10.3389/fsurg.2021.708351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose: To establish comparable reporting of surgical results in pediatric liver surgery, the recently introduced composite outcome measures Textbook Outcome (TO) and Comprehensive Complication Index (CCI) are applied and validated in a pediatric surgery context for the first time. In a representative cohort of pediatric patients undergoing liver resection, predictive factors for TO and CCI are investigated, and outcomes are compared to available literature on surgical outcomes of pediatric liver resection. Methods: All liver resections for patients under 21 years of age performed at the Department of General, Visceral, Transplantation and Pediatric Surgery of the University of Heidelberg between 2009 and 2020 were included in the analysis. Criteria for TO were defined prior to the analysis. Univariate and Multivariate regression was applied to identify factors associated with TO and CCI. Results: Fifty-three pediatric patients underwent liver resections during the observation period. No 30- or 90-day mortality occurred. Twenty-three patients (43.4%) had a TO. CCI and TO showed highly significant correlation (b = −30.33, 95% CI [−37.44; −23.22], p < 0.001). Multivariate analyses revealed significant association between intraoperative blood loss (adjusted for circulating blood volume) and CCI (b = 0.70, 95%CI [0.22; 1.32], p = 0.008) and failure to achieve TO (OR = 0.85, 95%CI [0.69; 0.97], p = 0.048). Conclusion: TO and CCI are suited outcome measures in pediatric surgical studies and offer objective comparability of results. Their application in clinical studies will be a major step forward to establish evidence-based therapies in pediatric surgery. Systematic utilization of TO and CCI can aid in generating comparable studies on surgical techniques and outcomes in pediatric liver resection.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Frongia
- Department of General, Visceral, Thorax, Pediatric and Endocrine Surgery, Johannes Wesling Hospital Minden, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Tsilimigras DI, Hyer JM, Chen Q, Diaz A, Paredes AZ, Moris D, Dillhoff M, Cloyd JM, Beane JD, Tsung A, Ejaz A, Pawlik TM. Inter-surgeon variability is associated with likelihood to undergo minimally invasive hepatectomy and postoperative mortality. HPB (Oxford) 2021; 23:840-846. [PMID: 33279403 DOI: 10.1016/j.hpb.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Minimally invasive liver surgery (MILS) has been increasingly adopted in clinical practice; yet, inter-surgeon variability in operative approach (MILS vs. open), as well as the impact of providers on the likelihood of undergoing MILS have not been well characterized. METHODS The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent hepatectomy between 2013 - 2017. The impact of patient- and procedure- related factors on the likelihood of MILS was investigated. RESULTS Overall 12,110 (91.6%) patients underwent open liver resection, while 1,112 (8.4%) patients had MILS. Based on total MILS volume, surgeons were categorized into average (1-3 cases), above average (4-7 cases) and high (>8 or more cases) MILS volume surgeons. While male patients (OR = 0.85, 95%CI 0.75-0.97) were less likely to undergo MILS, patients operated on more recently (year 2017; OR = 1.72, 95%CI 1.38-2.14) for a cancer indication (OR = 1.23, 95%CI 1.05-1.42) had a higher chance of MILS. After controlling for patient- and procedure-related characteristics, there was almost a two-fold variation in the odds that a patient underwent MILS versus open hepatectomy based on the individual surgeon provider (MOR = 1.75, 95%CI 1.48-1.99). Patients who had a MILS performed by a high-volume MILS surgeon had 36% lower odds of death within 90-days (OR = 0.64, 95%CI 0.51-0.79). CONCLUSION The likelihood of undergoing MILS, as well as post-operative mortality, was heavily influenced by the individual surgeon provider rather than patient- or procedure-related factors.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Mehta R, Tsilimigras DI, Pawlik TM. Assessment of Magnet status and Textbook Outcomes among medicare beneficiaries undergoing hepato-pancreatic surgery for cancer. J Surg Oncol 2021; 124:334-342. [PMID: 33961716 DOI: 10.1002/jso.26521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The relationship between hospital Magnet status recognition and postoperative outcomes following complex cancer surgery remains ill-defined. We sought to characterize Textbook Outcome (TO) rates among patients undergoing (HP) surgery for cancer in Magnet versus non-Magnet centers. METHODS Medicare beneficiaries undergoing HP surgery between 2015 and 2017 were identified. The association of postoperative TO (no complications/extended length-of-stay/90-day mortality/90-day readmission) with Magnet designation was examined after adjusting for competing risk factors. RESULTS Among 10,997 patients, 21.3% (n = 2337) patients underwent surgery at Magnet hospitals (non-Magnet centers: 78.7%, n = 8660). On multivariable analysis, patients undergoing HP surgery had comparable odds of achieving a TO at Magnet versus non-Magnet hospitals (hepatectomy: odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.94-1.17; pancreatectomy-OR: 0.88, 95% CI: 0.74-1.06). Patients treated at hospitals with a high nurse-to-bed ratio had higher odds of achieving a TO irrespective of whether they received surgery at Magnet (high vs. low nurse-to-bed ratio; OR: 1.38; 95% CI: 1.01-1.89) or non-Magnet centers (OR: 1.26; 95% CI: 1.10-1.45). Similarly, hospital HP volume was strongly associated with higher odds of TO following HP surgery in both Magnet (Leapfrog compliant vs. noncompliant; OR: 1.24, 95% CI: 1.06-1.44) and non-Magnet centers (OR: 1.18; 95% CI: 1.11-1.26). CONCLUSION Hospital Magnet designation was not an independent factor of superior outcomes after HP surgery. Rather, hospital-level factors such as nurse-to-bed ratio and HP procedural volume drove outcomes.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Tsilimigras DI, Pawlik TM, Moris D. Textbook outcomes in hepatobiliary and pancreatic surgery. World J Gastroenterol 2021; 27:1524-1530. [PMID: 33958840 PMCID: PMC8058657 DOI: 10.3748/wjg.v27.i15.1524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
The concept of textbook outcome (TO) has recently gained popularity in surgical research and has been used to evaluate the quality or success of different surgical procedures, including hepatopancreatobiliary (HPB) operations. TO consists of individual outcome parameters that each reflect different domains of care including structure, process, and individual outcomes; in turn, the composite TO metric represents the optimal course after a surgical episode. TO can be used to assess patient-level outcomes, hospital performance, center designation and quality metrics. In addition to being an outcome measurement, TO may also be linked to healthcare costs. Future efforts should be directed towards establishing a universal definition of TO in HPB surgery so that surgeons and hospitals can assess and compare outcomes, identify shortcomings and improve real world patient outcomes.
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Affiliation(s)
| | | | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27710, United States
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Paro A, Hyer JM, Pawlik T. Association of Depression with In-Patient and Post-Discharge Disposition and Expenditures Among Medicare Beneficiaries Undergoing Resection for Cancer. Ann Surg Oncol 2021; 28:6525-6534. [PMID: 33748892 DOI: 10.1245/s10434-021-09838-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of depression on utilization of post-discharge care and overall episode of care expenditures remains poorly defined. We sought to define the impact of depression on postoperative outcomes, including discharge disposition, as well as overall expenditures associated with the global episode of surgical care. METHOD The Medicare 100% Standard Analytic Files were used to identify patients undergoing resection for esophageal, colon, rectal, pancreatic, and liver cancer between 2013 and 2017. The impact of depression on inpatient outcomes, as well as home health care and skilled nursing facilities utilization and expenditures, was analyzed. RESULTS Among 113,263 patients, 14,618 (12.9%) individuals had depression. Patients with depression were more likely to experience postoperative complications (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.31-1.42), extended length of stay (LOS) (OR 1.41, 95% CI 1.36-1.47), readmission within 90 days (OR 1.20, 95% CI 1.14-1.25), as well as 90-day mortality (OR 1.35, 95% CI 1.27-1.42) (all p < 0.05). In turn, the proportion of patients who achieved a textbook outcome following cancer surgery was lower among patients with depression (no depression: 53.3% vs. depression: 45.3%; OR 0.70, 95% CI 0.68-0.73). Patients with a preexisting diagnosis of depression had higher odds of additional post-discharge expenditures compared with individuals without a diagnosis of depression (OR 1.42; 95% CI 1.35-1.50); patients with a preexisting diagnosis of depression ($10,500, IQR $3,200-$22,500) had higher median post-discharge expenditures versus patients without depression ($6600, IQR $2100-$17,400) (p < 0.001). On multivariable analysis, after controlling for other factors, depression remained associated with a 19.0% (95% confidence interval [CI] 15.7-22.3%) increase in post-discharge expenditures. CONCLUSIONS Patients with depression undergoing resection for cancer had worse in-patient outcomes and were less likely to achieve a TO. Patients with depression were more likely to require post-discharge care and had higher post-discharge expenditures.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Timothy Pawlik
- Department of Surgery, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, Columbus, USA.
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Hyer JM, Tsilimigras DI, Diaz A, Mirdad RS, Azap RA, Cloyd J, Dillhoff M, Ejaz A, Tsung A, Pawlik TM. High Social Vulnerability and "Textbook Outcomes" after Cancer Operation. J Am Coll Surg 2021; 232:351-359. [PMID: 33508426 DOI: 10.1016/j.jamcollsurg.2020.11.024] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | | | - Rosevine A Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH.
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Tsilimigras DI, Hyer JM, Diaz A, Moris D, Abbas A, Dillhoff M, Cloyd JM, Ejaz A, Beane JD, Tsung A, Pawlik TM. Impact of cancer center accreditation on outcomes of patients undergoing resection for hepatocellular carcinoma: A SEER-Medicare analysis. Am J Surg 2021; 222:570-576. [PMID: 33485619 DOI: 10.1016/j.amjsurg.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/01/2021] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We sought to assess variations in outcomes among patients undergoing resection for hepatocellular carcinoma (HCC) at centers with varied accreditation status. METHODS Patients undergoing resection for HCC from 2004 to 2016 were identified from the linked SEER-Medicare database. Short- and long-term outcomes as well as expenditures associated with receipt of surgery were examined based on cancer center accreditation. RESULTS Among 1390 patients, 46.1% (n = 641) were treated at unaccredited centers, 39.3% (n = 546) at CoC-accredited and 14.6% (n = 203) at NCI-designated centers. Patients undergoing resection of HCC at NCI-designated hospitals had lower odds of complications (OR = 0.66, 95%CI: 0.45-0.98) and 90-day mortality (OR = 0.31, 95%CI: 0.11-0.85) after major liver resection compared with individuals treated at CoC-accredited centers. Receipt of surgery at NCI-designated hospitals (ref: CoC-accredited; HR = 0.81, 95%CI: 0.66-0.99) was an independent predictor of improved survival. Medicare payments for liver resection were comparable at different accreditation status centers (NCI: $21,760 vs CoC: $24,059 vs unaccredited: $24,724, p = 0.18). CONCLUSION Patients undergoing resection of HCC at NCI-designated hospitals had improved outcomes for the same level of Medicare expenditure compared with patients treated at CoC-accredited centers.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alizeh Abbas
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer. Surgery 2020; 169:573-579. [PMID: 33189365 DOI: 10.1016/j.surg.2020.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND We sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer. METHODS Standard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition. RESULTS Among 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76-0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82-0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06-1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10-1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21-1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90-1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98-1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes. CONCLUSION Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.
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Azap RA, Paredes AZ, Diaz A, Hyer JM, Pawlik TM. The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery. Surgery 2020; 168:868-875. [DOI: 10.1016/j.surg.2020.06.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
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Azap RA, Hyer JM, Diaz A, Tsilimigras DI, Mirdad RS, Pawlik TM. Sex-based differences in time to surgical care among pancreatic cancer patients: A national study of Medicare beneficiaries. J Surg Oncol 2020; 123:236-244. [PMID: 33084065 DOI: 10.1002/jso.26266] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The objective of this study was to characterize time from cancer symptoms to diagnosis and time from diagnosis to surgical treatment among patients undergoing pancreatectomy for cancer. METHODS Medicare beneficiaries who underwent pancreatectomy for cancer between 2013 and 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Mixed effects negative binomial regression models were utilized to determine which factors were associated with the number of weeks to diagnosis and pancreatic resection. RESULTS Among 7647 Medicare beneficiaries, two-thirds (n = 5127, 67%) had symptoms associated with a pancreatic cancer diagnosis before surgery. Median time from the first symptom to diagnosis was 6 weeks (IQR: 1-25) and the median time from diagnosis to surgery was 4 weeks (IQR: 2-15). In risk-adjusted models, female patients had 13% longer waiting times from identification of a related symptom to pancreatic cancer diagnosis (OR = 1.13, 95% CI: 1.05-1.21) and 12% longer waiting times from diagnosis to surgery (OR = 1.12, 95% CI: 1.07-1.18). Older age was associated with 10% longer waiting times from symptom identification to diagnosis (p < .0001). CONCLUSIONS Female and older patients had longer wait times between symptom presentation and pancreatic cancer diagnosis. Sex-based disparities in cancer care need to be recognized and addressed by policymakers and health care institutions.
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Affiliation(s)
- Rosevine A Azap
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - James M Hyer
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Adrian Diaz
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rayyan S Mirdad
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
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Azoulay D, Ramos E, Casellas-Robert M, Salloum C, Lladó L, Nadler R, Busquets J, Caula-Freixa C, Mils K, Lopez-Ben S, Figueras J, Lim C. Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension. JHEP Rep 2020; 3:100190. [PMID: 33294830 PMCID: PMC7689549 DOI: 10.1016/j.jhepr.2020.100190] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 02/08/2023] Open
Abstract
Background & Aims Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg is not encouraged. Here, we reappraised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres. Methods This was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified. Results In total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients at 3 months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively. Conclusions Patients with cirrhosis, HCC and HVPG ≥10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome. Lay summary Patients with cirrhosis, hepatocellular carcinoma, and clinically significant portal hypertension (defined as a hepatic venous pressure gradient ≥10 mmHg) can undergo resection with acceptable mortality, morbidity, liver decompensation rates, and a textbook outcome. These results can be achieved in selected patients with preserved liver function, good general status, and sufficient remnant liver volume. Patients with HCC and CSPH can undergo resection, with mortality of 6% and severe morbidity of 27%. Postoperative and persistent liver decompensation occurred in 35% and 10% of patients, respectively. Textbook outcome was achieved in 34% of patients. The laparoscopic approach was identified as a predictor of postoperative liver decompensation and textbook outcome.
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Key Words
- AFP, alpha-fetoprotein
- ASA, American Society of Anesthesiologists
- BCLC, Barcelona-Clinic Liver Cancer
- CCI, Comprehensive Complication Index
- CSPH, clinically significant portal hypertension
- CT, computed tomography
- Clinically significant portal hypertension
- EASL, European Association for the Study of the Liver
- HVPG, hepatic venous pressure gradient
- Hepatectomy
- Hepatic venous pressure gradient
- LLR, laparoscopic liver resection
- LR, liver resection
- MELD, model for end-stage liver disease
- PHT, portal hypertension
- PVE, portal vein embolisation
- Postoperative liver decompensation
- TACE, transarterial chemoembolisation
- Textbook outcome
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Affiliation(s)
- Daniel Azoulay
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France.,Department of Hepato-Biliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Emilio Ramos
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
| | - Margarida Casellas-Robert
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
| | - Chady Salloum
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France
| | - Laura Lladó
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
| | - Roy Nadler
- Department of Hepato-Biliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Juli Busquets
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
| | - Celia Caula-Freixa
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
| | - Kristel Mils
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
| | - Santiago Lopez-Ben
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
| | - Joan Figueras
- Hepato-Biliary and Pancreatic Surgery, Department of Surgery, "Sagrat Cor" Hospital University of Barcelona, Barcelona, Spain
| | - Chetana Lim
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
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Ocuin LM, Hardacre JM, Ammori JB, Rothermel LD, Mohamed A, Selfridge JE, Bajor D, Winter JM. Neoadjuvant chemotherapy is associated with improved survival in patients with left-sided pancreatic adenocarcinoma. J Surg Oncol 2020; 122:1595-1603. [PMID: 32844445 DOI: 10.1002/jso.26196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy is used infrequently in the management of distal pancreatic cancers. We investigated outcomes associated with neoadjuvant chemotherapy or up-front surgery in patients undergoing distal pancreatectomy. METHODS The National Cancer Database (2004-2016) was queried for patients with pancreas cancer who underwent distal pancreatectomy. Demographics, clinical characteristics, postoperative outcomes, pathologic outcomes, and overall survival were analyzed by univariate and multivariate analysis. RESULTS Six thousand five-hundred and twenty-three patients were included, including 5,643 who underwent up-front distal pancreatectomy and 880 who received neoadjuvant therapy. Factors associated with receipt of neoadjuvant chemotherapy included care at academic/research programs, higher education level, higher clinical T stage, higher clinical N stage, and elevated carbohydrate antigen 19-9 level. Patients who received neoadjuvant therapy had fewer positive lymph nodes, higher margin-negative resection rate, lower 30-day readmission rate, and lower 90-day mortality rate. Patients who received neoadjuvant therapy had longer median overall survival (28.8 vs 22.0 months; P < .001). On multivariate analysis, neoadjuvant therapy remained independently associated with improved survival (hazards ratio, 0.72; 95% confidence inteval, 0.63-0.82; P < .001). CONCLUSIONS Neoadjuvant therapy in patients with left-sided pancreatic cancers is associated with improved pathologic outcomes as well as longer overall survival. Neoadjuvant therapy should be considered in all patients with PDAC regardless of tumor location.
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Affiliation(s)
- Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, North Carolina
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Amr Mohamed
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Jennifer E Selfridge
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - David Bajor
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
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Combined use of advanced practice providers and care pathways reduces the duration of stay after surgery for gastrointestinal malignancies. Surgery 2020; 169:852-858. [PMID: 32713756 DOI: 10.1016/j.surg.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The gastrointestinal surgical oncology service at our comprehensive cancer center sought to improve the quality of postsurgical inpatient care while increasing discharge efficiency. METHODS A stakeholder team established standard postsurgical care pathways and dedicated inpatient advanced practice provider positions. We compared postsurgical length of stay before (July 2017 to April 2018) and after (May 2018 to April 2019) the interventions using Wilcoxon rank-sum tests. We benchmarked length of stay to National Surgical Quality Improvement Project and Centers for Medicare and Medicaid Services geometric mean length of stay. We also compared readmission rates and surgeon-specific Hospital Consumer Assessment of Health Care Provider and Systems and Press-Ganey scores. RESULTS There were 462 cases before and 563 after the interventions. Postintervention, median length of stay decreased from 6.50 to 6.00 days (P = .017). There was a ≥1-day reduction for 10 of 14 case types with significant length of stay decreases for robotic esophagectomy (P = .001), liver resection (P = .023), and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (P = .030). More case types met or exceeded Centers for Medicare and Medicaid Services and National Surgical Quality Improvement Project benchmarks after the interventions. Readmission rates were stable (preintervention 9.3%, postintervention 10.3%, P = .585). Press-Ganey and HCAHPS measures were stable or improved in all evaluated domains. CONCLUSION Incorporating advanced practice providers and care pathways into gastrointestinal surgical oncology inpatient care was associated with reduced length of stay without declination in readmission rates or patient experience measures.
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Mehta R, Tsilimigras DI, Paredes AZ, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Pawlik TM. Is Patient Satisfaction Dictated by Quality of Care Among Patients Undergoing Complex Surgical Procedures for a Malignant Indication? Ann Surg Oncol 2020; 27:3126-3135. [DOI: 10.1245/s10434-020-08788-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
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Tsilimigras DI, Pawlik TM. ASO Author Reflections: Assessing the Outcomes of Liver Cancer Patients Undergoing Surgery Over the Last Decade—Are We Doing Better? Ann Surg Oncol 2020; 27:3328-3329. [DOI: 10.1245/s10434-020-08549-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 11/18/2022]
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Brajcich BC, Merkow RP. A Textbook Answer to the Debate About Medicare’s Prospective Payment System Exemption? Ann Surg Oncol 2020; 27:1730-1732. [DOI: 10.1245/s10434-020-08414-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 12/11/2022]
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Mehta R, Tsilimigras DI, Pawlik TM. ASO Author Reflections: Chance of Textbook Outcome following Hepatopancreatic Surgery Varies Based on Cancer Center Designation. Ann Surg Oncol 2020; 27:1898-1899. [PMID: 32215757 DOI: 10.1245/s10434-020-08293-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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