Emergency Department Visits Before Cancer Diagnosis Among Women at Mayo Clinic

Objective

To determine associations of incident cancer diagnoses in women with recent emergency department (ED) care.

Patients and Methods

A retrospective cohort study analyzing biological females aged 18 years and older, who were diagnosed with an incident primary cancer (12 cancer types studied) from January 1, 2015, to December 31, 2021, from electronic health records. The primary outcome was a cancer diagnosis within 6 months of a preceding ED visit. Secondary outcomes included patient factors associated with a preceding ED visit.

Results

Of 25,736 patients (median age of 62 years, range 18-101) diagnosed with an incident primary cancer, 1938 (7.5%) had an ED visit ≤6 months before a diagnosis. The ED-associated cancer cases were highest in lung cancer (n=514, 14.7%) followed by acute lymphoblastic leukemia (n=22, 13.3%). Patient factors increasing the likelihood of ED evaluation before diagnosis included 18-50 years of age (OR=1.32; 95% CI, 1.09-1.61), Elixhauser score (measure of comorbidities) >4 (OR=17.90; 95% CI, 14.21-22.76), use of Medicaid or other government insurance (OR=2.10; 95% CI, 1.63-2.69), residence within the institutional catchment areas (OR=3.18; 95% CI, 2.78-3.66), non-Hispanic Black race/ethnicity (OR=1.41; 95% CI, 1.04-1.88), and established primary care provider at Mayo Clinic (OR=1.45; 95% CI, 1.28-1.65). The ED visits were more likely in those who died within 6 months of diagnosis (n=327, 37.8%) than those who did not die (n=1611, 6.5%).

Conclusion

Patient characteristics identified in this study offer opportunities to provide cancer risk assessment and health navigation, particularly among individuals with comorbidities and limited health care access.

Distinct presentation of melanoma in Black patients may inform strategies to improve outcomes

INTRODUCTION

Melanoma guidelines stem largely from data on non-Hispanic White (NHW) patients. We aimed to identify features of melanoma within non-Hispanic Black (NHB) patients to inform strategies for earlier detection and treatment.

METHODS

From 2004 to 2019 Surveillance, Epidemiology, and End Results (SEER) data, we identified nonmetastatic melanoma patients with known TN category and race. Kaplan-Meier cancer-specific survival (CSS) estimates and multivariable Cox proportional hazard modeling analyses were performed.

RESULTS

Of 492 597 patients, 1499 (0.3%) were NHB, who were younger (21% vs. 17% age <50) and more commonly female (54% vs. 41%) than NHW, both p < 0.0005. For NHBs, lower extremity was the most common site (52% vs. 15% for NHWs, p < 0.0001), T category was higher (55% Tis-T1 vs. 82%; 27% T3-T4 vs. 8%, p < 0.0001) and stage at presentation was higher (19% Stage III, vs. 6%, p < 0.0001). Within the NHB cohort, males were older, and more often node-positive than females. Five-year Stage III CSS was 42% for NHB males versus 71% for females, adjusting for age and clinical nodal status (hazard ratio 2.48).

CONCLUSIONS

NHB melanoma patients presented with distinct tumor characteristics. NHB males with Stage III disease had inferior CSS. Focus on this high-risk patient cohort to promote earlier detection and treatment may improve outcomes.

Pregnancy-associated melanoma: characteristics and outcomes from 2002 to 2020

Melanoma diagnosed within 1 year of pregnancy is defined as pregnancy-associated melanoma (PAM). No robust data on how pregnancy influences melanoma nor guidelines for PAM management exist. With IRB approval, female patients with a pathology-confirmed melanoma diagnosis within 1 year of pregnancy treated at our institution from 2000 to 2020 were identified. Controls from the cancer registry were matched 1 : 4 when available on decade of age, year of surgery (±5), and stage. We identified 83 PAM patients with median follow-up of 86 months. Mean age at diagnosis was 31 years. 80% AJCC V8 stage I, 2.4% stage II, 13% stage III, 4.8% stage IV. Mean Breslow thickness was 0.79 mm and 3.6% exhibited ulceration. The mean mitotic rate was 0.76/mm 2 . In terms of PAM management, 98.6% of ESD patients and 86.7% of LSD patients received standard-of-care therapy per NCCN guidelines for their disease stage. No clinically significant delays in treatment were noted. Time to treatment from diagnosis to systemic therapy for LSD patients was an average of 46 days (95% CI: 34-59 days). Comparing the 83 PAM patients to 309 controls matched on age, stage, and year of diagnosis, similar 5-year overall survival (97% vs. 97%, P  = 0.95) or recurrence-free survival (96% vs. 96%, P  = 0.86) was observed. The outcomes of PAM following SOC treatment at a highly specialized center for melanoma care were comparable to non-PAM when matched by clinical-pathologic features. Specialty center care is encouraged for women with PAM.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children

BACKGROUND

The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock.

METHODS

A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths.

RESULTS

Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05).

CONCLUSION

Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship

INTRODUCTION

Arthroplasty registries often utilize traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data.

METHODS

We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation were calculated for patients who have TM. The same survivorship endpoints was re-calculated with censoring performed when a patient transitioned to a MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years.

RESULTS

From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90 and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio (HR) = 1.16, P = 0.033), and there was a trend towards higher survivorship free from any revision (95 versus 93% at 15-years; HR = 1.16, P = 0.074).

CONCLUSION

Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.

One-year Results of Minimally Invasive Sutured Fixation of the Slipped Ribs in the Pediatric Population

PURPOSE

Costal cartilage resection with or without rib resection is the gold standard surgery for slipping rib syndrome. Minimally invasive restoration of normal anatomy via nonabsorbable sutures has been described in the adult population with encouraging results. We sought to assess the efficacy of minimally invasive sutured fixation of the hypermobile rib in the pediatric population.

METHODS

A retrospective review was performed at Mayo Clinic involving 31 pediatric patients diagnosed with slipped rib syndrome. Minimally invasive sutured open reduction internal fixation was performed between 2020 and 2022. The standardized Örebro Musculoskeletal Pain Screening Questionnaire was given at dedicated time points pre- and post-operatively to assess efficacy. Significance was determined via the Wilcoxon rank sum test.

RESULTS

SRS was diagnosed clinically in 31 patients (24 females, 7 males, 1220 years-old). Symptoms were present for an average of 18.9 months and patients had seen an average of 4.7 specialists. Traumatic causes were identified in three patients and eight patients had hypermobility. At one month follow up, there were no surgical complications and patients reported significantly less pain (p < 0.001). Preoperative analgesics reduced by 80%. Ultimately, seven patients underwent a second operation; three patients underwent a third operation; one patient underwent five total operations. Recurrent pain was reported in six patients. Only nine patients followed-up at 1-year post-operation.

CONCLUSION

Pediatric patients with SRS demonstrated an early positive response to suture fixation without costal cartilage excision. Reoperation and recurrent pain, however, remain significant in this population.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Case series with no comparison group.

Evaluating the Long-term Impact of Implementing Standardized Postoperative Opioid Prescribing Recommendations Following Pelvic Organ Prolapse Surgery

IMPORTANCE

Improving opioid stewardship is important, given the common use of opioids and resultant adverse events. Evidence-based prescribing recommendations for surgeons may help reduce opioid prescribing after specific procedures.

OBJECTIVE

The aim of this study was to assess longitudinal prescribing patterns for patients undergoing pelvic organ prolapse surgery in the 2 years before and after implementing evidence-based opioid prescribing recommendations.

STUDY DESIGN

In December 2017, a 3-tiered opioid prescribing recommendation was created based on prospective data on postoperative opioid use after pelvic organ prolapse surgery. For this follow-up study, prescribing patterns, including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates, were retrospectively compared for patients undergoing prolapse surgery before (November 2015-November 2017; n = 238) and after (December 2017-December 2019; n = 361) recommendation implementation. Univariate analysis was performed using the Wilcoxon rank sum and χ2 tests. Cochran-Armitage trend tests and interrupted time-series analysis tested for significance in the change in OMEs prescribed before versus after recommendation implementation.

RESULTS

After recommendation implementation, the quantity of postoperative opioids prescribed decreased from median 225 mg OME (interquartile range, 225, 300 mg OME) to 71.3 mg OME (interquartile range, 0, 112.5 mg OME; P < 0.0001). Decreases also occurred within each subgroup of prolapse surgery: native tissue vaginal repair ( P < 0.0001), robotic sacrocolpopexy ( P < 0.0001), open sacrocolpopexy ( P < 0.0001), and colpocleisis ( P < 0.003). The proportion of patients discharged following prolapse surgery without opioids increased (4.2% vs 36.6%; P < 0.0001), and the rate of opioid refills increased (2.1% vs 6.0%; P = 0.02).

CONCLUSIONS

With 2 years of postimplementation follow-up, the use of procedure-specific, tiered opioid prescribing recommendations at our institution was associated with a significant, sustained reduction in opioids prescribed. This study further supports using evidence-based recommendations for opioid prescribing.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns.

OBJECTIVES

To compare the outcomes of patients who underwent MBS with those who underwent other common operations.

SETTING

American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality.

RESULTS

A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS.

CONCLUSIONS

MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

The Benefits of Local Anesthesia Used in Mastectomy Without Reconstruction

BACKGROUND

The opioid epidemic has driven renewed interest in local anesthesia to reduce postoperative opioid use. Our objective was to determine if local anesthesia decreased hospital pain scores, oral morphine equivalents (OME), length of stay (LOS), and nausea/vomiting.

METHODS

Single institution retrospective study of females who underwent mastectomy without reconstruction.

RESULTS

Overall, 712 patients were included; 63 (8.8%) received bupivacaine (B), 512 (72%) liposomal bupivacaine (LB), and 137 (19%) no local. 95% were discharged on POD1. Liposomal bupivacaine use increased from 2014 to 2019. Additional factors associated with use of local regimen were surgeon and extent of axillary surgery. Fewer patients used postop opioids during their hospital stay if any local was used compared to none (76 vs 88%; 0.003). Compared to none, local had shorter mean PACU LOS (95 vs 87 min; P = .02), lower mean intraoperative-OME (96 vs 106; P < .001), and lower mean postoperative OME/hr (1.4 vs 1.8 P = .001). Multivariable analysis (MVA) showed lower OME/hr with LB compared to B and none (P = .002); this translates to 22 mg and 30 mg of oxycodone in a 24-hr period, respectively. MVA showed lower POD1 pain scores with LB relative to none (P = .049). Local did not impact nausea/emesis.

CONCLUSION

Local anesthesia was superior to no local in several measures. However, a consistent benefit of a specific local anesthetic agent was not demonstrated (LB vs B). A prospective study is warranted to determine the optimal local regimen for this cohort and further inform clinical relevance.

Bariatric surgery outcomes in patients with bipolar or schizoaffective disorders

BACKGROUND

Obesity is associated with many co-morbidities and can cause harm to physical and mental well-being. While much has been studied in the general population about the outcomes of bariatric surgery, its implications in patients with bipolar/schizoaffective disorder (BSD) are less well understood.

OBJECTIVE

We aimed to describe outcomes of bariatric surgery in patients with BSD.

SETTING

Referral center for bariatric surgery.

METHODS

We conducted a retrospective chart review analysis of bariatric surgical procedures in patients with BSD between 2008 and 2021 at Mayo Clinic. Patients with BSD (cases) were matched via propensity score matching (1:2) with non-BSD controls based on surgical procedure, age, sex, body mass index, and type 2 diabetes. Hierarchical logistic regression model was performed using SAS software.

RESULTS

We matched 71 patients with BSD with 142 controls in a 1:2 ratio. After adjusting for baseline preoperative weight, patients with BSD had a 3.4% greater total weight loss compared with controls over 24 months (P = .02 [95% CI, .65-6.08]). Remission in obesity-related diseases, such as diabetes, hypertension, dyslipidemia, and sleep apnea, was similar in both groups. Perioperative complication rates were similar other than deep venous thrombosis, which showed a higher rate in patients with BSD (P = .04). Patients with long-term BSD were at increased risk of alcohol use compared with controls.

CONCLUSIONS

When compared with the general bariatric population, weight loss was similar to slightly improved, with a comparable risk and complication profile. Patients with BSD have increased alcohol use after bariatric surgery, highlighting the need for psychological care before and after surgery in this population.

Cryopreserved arterial allografts vs rifampin-soaked Dacron for the treatment of infected aortic and iliac grafts

OBJECTIVE

Aortic and iliac graft infections remain complex clinical problems with high mortality and morbidity. Cryopreserved arterial allografts (CAAs) and rifampin-soaked Dacron (RSD) are options for in situ reconstruction. This study aimed to compare the safety and effectiveness of CAA vs RSD in this setting.

METHODS

Data from patients with aortic and iliac graft infections undergoing in situ reconstruction with either CAA or RSD from January 2002 through August 2022 were retrospectively analyzed. Our primary outcomes were freedom from graft-related reintervention and freedom from reinfection. Secondary outcomes included comparing trends in the use of CAA and RSD at our institution, overall survival, perioperative mortality, and major morbidity.

RESULTS

A total of 149 patients (80 RSD, 69 CAA) with a mean age of 68.9 and 69.1 years, respectively, were included. Endovascular stent grafts were infected in 60 patients (41 CAA group and 19 RSD group; P ≤ .01). Graft-enteric fistulas were more common in the RSD group (48.8% RSD vs 29.0% CAA; P ≤ .01). Management included complete resection of the infected graft (85.5% CAA vs 57.5% RSD; P ≤ .01) and aortic reconstructions were covered in omentum in 57 (87.7%) and 63 (84.0%) patients in the CAA and RSD group, respectively (P = .55). Thirty-day/in-hospital mortality was similar between the groups (7.5% RSD vs 7.2% CAA; P = 1.00). One early graft-related death occurred on postoperative day 4 due to CAA rupture and hemorrhagic shock. Median follow-up was 20.5 and 21.5 months in the CAA and RSD groups, respectively. Overall post-discharge survival at 5 years was similar, at 59.2% in the RSD group and 59.0% in the CAA group (P = .80). Freedom from graft-related reintervention at 1 and 5 years was 81.3% and 66.2% (CAA) vs 95.6% and 92.5% (RSD; P = .02). Indications for reintervention in the CAA group included stenosis (n = 5), pseudoaneurysm (n = 2), reinfection (n = 2), occlusion (n = 2), rupture (n = 1), and graft-limb kinking (n = 1). In the RSD group, indications included reinfection (n = 3), occlusion (n = 1), endoleak (n = 1), omental coverage (n = 1), and rupture (n = 1). Freedom from reinfection at 1 and 5 years was 98.3% and 94.9% (CAA) vs 92.5% and 87.2% (RSD; P = .11). Two (2.9%) and three patients (3.8%) in the CAA and RSD group, respectively, required graft explantation due to reinfection.

CONCLUSIONS

Aorto-iliac graft infections can be managed safely with either CAA or RSD in selected patients for in situ reconstruction. However, reintervention was more common with CAA use. Freedom from reinfection rates in the RSD group was lower, but this was not statistically significant. Conduit choice is associated with long-term surveillance needs and reinterventions.

Racial disparities in surgical treatment of oropharyngeal cancer: A Surveillance, Epidemiology, and End Results review

OBJECTIVES

Oropharyngeal squamous cell carcinoma (OPSCC) has been rising. This manuscript looks to explore racial disparities in the surgical management of OPSCC.

METHODS

A cancer database was queried for patients with OPSCC diagnosed from 2004 to 2017. Univariate and multivariable logistic regressions were used to evaluate associations between patient race/ethnicity, surgical treatment, and reasons for lack of surgery.

RESULTS

37 306 (74.3%) patients did not undergo surgery, while 12 901 (25.7%) patients did. Non-Hispanic black (NHB) patients were less likely to undergo surgery than other races (17.9% vs. 26.5%; p < 0.0001). In clinical discussions, the Asian, Native American, Hawaiian, Pacific Islander (ANAHPI), and unknown race group was more likely to directly refuse surgery when recommended (2.5% vs. 1.5%; p = 0.015).

CONCLUSION

Racial differences exist in treatment for OPSCC. NHB patients are less likely to actually undergo surgical management for OPSCC, while other patients are more likely to directly "refuse" surgery outright when offered.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis

OBJECTIVE

This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI.

METHODS

This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses.

RESULTS

There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010).

CONCLUSION

Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Impact of a High-Risk, Ambulatory COVID-19 Remote Patient Monitoring Program on Utilization, Cost, and Mortality

OBJECTIVE

To evaluate care utilization, cost, and mortality among high-risk patients enrolled in a coronavirus disease 2019 (COVID-19) remote patient monitoring (RPM) program.

METHODS

This retrospective analysis included patients diagnosed with COVID-19 at risk for severe disease who enrolled in the RPM program between March 2020 and October 2021. The program included in-home technology for symptom and physiologic data monitoring with centralized care management. Propensity score matching established matched cohorts of RPM-engaged (defined as ≥1 RPM technology interactions) and non-engaged patients using a logistic regression model of 59 baseline characteristics. Billing codes and the electronic death certificate system were used for data abstraction from the electronic health record and reporting of care utilization and mortality endpoints.

RESULTS

Among 5796 RPM-enrolled patients, 80.0% engaged with the technology. Following matching, 1128 pairs of RPM-engaged and non-engaged patients comprised the analysis cohorts. Mean patient age was 63.3 years, 50.9% of patients were female, and 81.9% were non-Hispanic White. Patients who were RPM-engaged experienced significantly lower rates of 30-day, all-cause hospitalization (13.7% vs 18.0%, P=.01), prolonged hospitalization (3.5% vs 6.7%, P=.001), intensive care unit admission (2.3% vs 4.2%, P=.01), and mortality (0.5% vs 1.7%; odds ratio, 0.31; 95% CI, 0.12 to 0.78; P=.01), as well as cost of care ($2306.33 USD vs $3565.97 USD, P=0.04), than those enrolled in RPM but non-engaged.

CONCLUSION

High-risk COVID-19 patients enrolled and engaged in an RPM program experienced lower rates of hospitalization, intensive care unit admission, mortality, and cost than those enrolled and non-engaged. These findings translate to improved hospital bed access and patient outcomes.

Management and Outcomes of Severe Hypoglycemia Treated by Emergency Medical Services in the U.S. Upper Midwest

OBJECTIVE

To examine factors associated with emergency department (ED) transport after hypoglycemia treated by emergency medical services (EMS) and assess the impact of ED transport on severe hypoglycemia recurrence.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed electronic health records of a multistate advanced life support EMS provider and an integrated healthcare delivery system serving an overlapping geographic area in the upper Midwest. For adults with diabetes treated by EMS for hypoglycemia between 2013 and 2019, we examined rates of ED transport, factors associated with it, and its impact on rates of recurrent hypoglycemia requiring EMS, ED, or hospital care within 3, 7, and 30 days.

RESULTS

We identified 1,977 hypoglycemia-related EMS encounters among 1,028 adults with diabetes (mean age 63.5 years [SD 17.7], 55.2% male, 87.4% non-Hispanic White, 42.4% rural residents, and 25.6% with type 1 diabetes), of which 46.4% resulted in ED transport (31.1% of calls by patients with type 1 diabetes and 58.0% of calls by patients with type 2 diabetes). Odds of ED transport were lower in patients with type 1 diabetes (odds ratio [OR] 0.44 [95% CI 0.31-0.62] vs. type 2 diabetes) and higher in patients with prior ED visits (OR 1.38 [95% CI 1.03-1.85]). Within 3, 7, and 30 days, transported patients experienced recurrent severe hypoglycemia 2.8, 5.2, and 10.6% of the time, respectively, compared with 7.4, 11.2, and 22.8% of the time among nontransported patients (all P < 0.001). This corresponds to OR 0.58 (95% CI 0.42-0.80) for recurrent severe hypoglycemia within 30 days for transported versus nontransported patients. When subset by diabetes type, odds of recurrent severe hypoglycemia among transported patients were 0.64 (95% CI 0.43-0.96) and 0.42 (95% CI 0.24-0.75) in type 1 and type 2 diabetes, respectively.

CONCLUSIONS

Transported patients experienced recurrent hypoglycemia requiring medical attention approximately half as often as nontransported patients, reinforcing the importance of engaging patients in follow-up to prevent recurrent events.

Underreporting and Underrepresentation of Race and Ethnicity in Head and Neck Cancer Trials, 2010-2020: A Systematic Review

Importance

There is substantial evidence demonstrating racial disparities in the survival outcomes of patients with head and neck cancer. The reporting and representation of race and ethnicity in cancer trials is crucial for generalizability of trial results to patient care and reduction of racial health disparities in head and neck cancers. Racial disparities in oncologic outcomes across various therapeutic interventions may only manifest when diverse races are appropriately represented in trials.

Objective

To characterize the reporting and representation of race and ethnicity in head and neck cancer clinical trials.

Evidence Review

A systematic search of published trials and those available on ClinicalTrials.gov was conducted to identify 3973 studies from 2010 to 2020. Title, abstract, and full-text review yielded 155 trials for data extraction of patient demographics. Year of publication, type of intervention, publication source, and funding source were also collected. Race and ethnicity data were compared with Surveillance, Epidemiology, and End Results (SEER) Program cancer registry data.

Findings

Of the 155 included studies, only 89 (57%) reported race or ethnicity. Only 81 (52%) of the studies reported detailed classification of race or ethnicity per the US Census Bureau classification scheme. Race and ethnicity reporting varied considerably with year of publication, type of intervention, data source, and funding source. Studies in the latter half of the decade were more likely to report race or ethnicity (odds ratio, 2.78; 95% CI, 1.33-5.80), with the highest number in 2019 (24 of 30 [80%] trials), followed by 2020 (20 of 29 [69%] trials). Among the possible interventions, trials on therapeutic chemoradiation most frequently reported race or ethnicity (11 of 12 [92%]), followed by supportive drug trials (22 of 31 [71%]), and then therapeutic chemotherapy trials (28 of 48 [58%]). When compared with SEER data, race and ethnicity distribution in clinical trials showed fewer Black patients (10% vs 8%) and Asian or Pacific Islander patients (6% vs 2%).

Conclusions and Relevance

In this systematic review, nearly half of head and neck cancer trials in the past decade did not report the race or ethnicity of participants. Participation of Black and Asian or Pacific Islander patients does not adequately reflect the US population's head and neck cancer demographics, limiting the generalizability of trial results and adding to racial health disparities in patients with head and neck cancers.

Patient Telemedicine Perceptions During the COVID-19 Pandemic within a Multi-State Medical Institution: A Qualitative Study

Background

During the COVID-19 pandemic, to prevent the spread of the virus, federal regulatory barriers around telemedicine were lifted, and health care institutions encouraged patients to use telemedicine, including video appointments. Many patients, however, still chose face-2-face (f2f) appointments for nonemergent clinical care.

Objective

We explored patients’ personal and environmental barriers to the use of video appointments from April 2020 to December 2020.

Methods

We conducted qualitative telephone interviews of Mayo Clinic patients who attended f2f appointments at the Mayo Clinic from April 2020 to December 2020 but did not utilize Mayo Clinic video appointment services during that time frame.

Results

We found that, although most patients were concerned about preventing COVID-19 transmission, they trusted Mayo Clinic to keep them safe when attending f2f appointments. Many expressed that a video appointment made it difficult to establish rapport with their providers. Other common barriers to video appointments were perceived therapeutic benefits of f2f appointments, low digital literacy, and concerns about privacy and security.

Conclusions

Our study provides an in-depth investigation into barriers to engaging in video appointments for nonemergent clinical care in the context of the COVID-19 pandemic. Our findings corroborate many barriers prevalent in the prepandemic literature and suggest that rapport barriers need to be analyzed and problem-solved at a granular level.

Informing therapeutic lymphadenectomy: Location of regional metastatic lymph nodes in adrenocortical carcinoma

BACKGROUND

The anatomic boundaries of lymphadenectomy for adrenocortical carcinoma (ACC) are not defined.

METHODS

Adults undergoing resection of ACC were included. Locations were categorized based on positive LN locations on final pathology.

RESULTS

Of 231 resected ACC, 6% had positive LN during initial resection. Positive LN in left ACC (n = 7) were: 2 para-aortic, 2 left renal-hilar, 1 para-aortic and left renal-hilar and 1 unknown, while for right ACC (n = 7): 2 para-caval, 1 para-caval and right renal-hilar, 1 inter-aortocaval, 1 celiac, 1 para-aortic, and 1 unknown. Of 55 resections for recurrent ACC, positive LN in left ACC (n = 2) were: 1 para-aortic, and 1 para-aortic with left renal-hilar, while LN for right ACC (n = 7): 2 inter-aortocaval, 2 right renal-hilar, 2 para-caval and one retrocrural.

CONCLUSION

The most common LN metastases are para-caval for right, and para-aortic and left renal-hilar for left ACC. Further studies are necessary to determine the boundaries of lymphadenectomy in ACC resection.

Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

OBJECTIVES

This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states.

DESIGN

This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018.

METHODS

Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum t tests for OMEs and χ2 t tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).

RESULTS

In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (p < 0.0001). The opioid refill rate remained unchanged at 7.4% (p = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (p < 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; p = 0.739).

LIMITATIONS

Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design.

CONCLUSIONS

Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

Implementation of a multisite, interdisciplinary remote patient monitoring program for ambulatory management of patients with COVID-19

Established technology, operational infrastructure, and nursing resources were leveraged to develop a remote patient monitoring (RPM) program for ambulatory management of patients with COVID-19. The program included two care-delivery models with different monitoring capabilities supporting variable levels of patient risk for severe illness. The primary objective of this study was to determine the feasibility and safety of a multisite RPM program for management of acute COVID-19 illness. We report an evaluation of 7074 patients served by the program across 41 US states. Among all patients, the RPM technology engagement rate was 78.9%. Rates of emergency department visit and hospitalization within 30 days of enrollment were 11.4% and 9.4%, respectively, and the 30-day mortality rate was 0.4%. A multisite RPM program for management of acute COVID-19 illness is feasible, safe, and associated with a low mortality rate. Further research and expansion of RPM programs for ambulatory management of other acute illnesses are warranted.

Impact of Opioid Prescribing Guidelines on Postoperative Opioid Prescriptions Following Elective Spine Surgery: Results From an Institutional Quality Improvement Initiative

BACKGROUND

With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic.

OBJECTIVE

To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery.

METHODS

Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d.

RESULTS

A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78).

CONCLUSION

Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.

Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis

OBJECTIVE

To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.

PATIENTS AND METHODS

Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ² tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation.

RESULTS

The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001).

CONCLUSION

In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

Barriers to Obtaining a Timely Diagnosis in Human Papillomavirus-Associated Oropharynx Cancer

OBJECTIVE

Failure to recognize symptoms of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care center.

METHODS

Patients with HPV(+)OPSCC receiving intent-to-cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations.

RESULTS

Of 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine-needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis (P < .01, all). Treatment with antibiotics and a suspicion for HPV(+)OPSCC at first presentation were associated with decreased delays in diagnosis (P < .01, both).

CONCLUSIONS

Patient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.

Liposomal bupivacaine during subcutaneous implantable cardioverter defibrillator implantation for pain management

BACKGROUND

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has a larger generator and its implantation involves more dissection and tunneling compared to traditional transvenous defibrillator system. Liposomal bupivacaine, an extended-release bupivacaine with 72 h of duration has been used for postoperative pain management in patients undergoing S-ICD implantation. Our aim was to compare postoperative pain and opioid prescription patterns among patients undergoing S-ICD implantation who received intraprocedural liposomal bupivacaine and those who did not.

METHODS

We performed a retrospective analysis of all patients who underwent subcutaneous ICD implantation from January 1, 2013 to March 30, 2018 at the Mayo Clinic in Rochester, Minnesota. Patients were categorized into those who received liposomal bupivacaine and those who did not. Data on inpatient pain score, outpatient opioid prescription rates at discharge, and doses based on oral morphine equivalents (OME) were collected.

RESULTS

A total of 104 patients underwent S-ICD implantation. Intraprocedural liposomal bupivacaine was used in 69% of patients. Patients who received intraprocedural liposomal bupivacaine had similar mean inpatient pain scores (2.9 vs. 2.9, p = .786). There was also no difference in the rate of inpatient opioid administration (79.2% vs. 87.5%, p = .4139), outpatient opioid prescription (23.6% vs. 12.5%, p = .29), or mean OME (41.7-mg vs. 16.6-mg, p = .188) when comparing patients those who received intraprocedural liposomal bupivacaine and those who did not.

CONCLUSION

Intraprocedural liposomal bupivacaine administration was not associated with any significant impact on postoperative pain scores, inpatient opioid administration, and outpatient opioid prescription rates or OME amounts at discharge.

Malignant Insulinoma: A Rare Form of Neuroendocrine Tumor

INTRODUCTION

Due to the rarity of malignant insulinoma, a lack of the literature describing factors affecting outcomes exists. Our aim was to review malignant insulinoma incidence, characteristics and survival trends.

METHODS

We identified all patients with malignant insulinoma in the SEER registries from 1973 to 2015. Incidence, neoplasm characteristics and factors affecting cancer-specific survival (CSS) were described.

RESULTS

A total of 121 patients were identified. The crude annual overall incidence was low (range 0.0-0.27 cases per million person years). The largest proportion had localized disease (40%), while 16% had regional disease, 39% distant metastatic disease, and stage was unreported in 5%. Most neoplasms were in the body/tail of the pancreas, followed by the head of the pancreas. Grade was reported in 40% of patients; only a single patient reported as having grade IV with the remainder all grades I/II. Surgical resection was performed in 64% of patients. Within surgical patients, the median primary neoplasm size was 1.8 cm. Regional lymph nodes were examined in 57.1% of surgical patients, while 34% of examined nodes were positive. The median CSS was 183 months. On multivariable analysis, surgical resection, male sex and absence of metastatic disease were associated with superior survival.

CONCLUSION

While the greatest proportion of patients with malignant insulinoma present with localized disease, regional lymph node involvement was found in 34% of whose nodes were tested. Further studies are needed to assess the role of lymph node dissection in improving survival and preventing recurrence given the observed frequency of lymph node involvement.

Positive Lymph Nodes in Adrenocortical Carcinoma: What Does It Mean?

BACKGROUND

The role of lymphadenectomy in adrenocortical carcinoma resection is controversial. Therefore, we conducted a population-based study to assess the association between positive lymph nodes (LN) and survival.

METHODS

The Surveillance, Epidemiology, and End Results set of cancer registries were utilized. The associations between positive lymph nodes and tumor size, grade and laterality were assessed. Cancer specific survival (CSS) trends and factors affecting survival were analyzed.

RESULTS

A total of 2170 adult patients were identified; 60% underwent resection. Among those resected, LN were examined in 23% and were positive in 25% of patients with LN examined. Patients with positive LN tended to have smaller tumors compared to those with negative LN (12 ± 5 vs 15 ± 11 cm, p = 0.02). The rate of positive LN was higher in right ACC, p = 0.03. Median overall CSS was 21 months, with significant differences between resection (42 months) and no resection (4 months), p < 0.01. Median CSS did not change over time when comparing ACC patients who underwent surgery before 2000, 2000-2009, and 2010-2016. On multivariable analysis including resection group, advanced age, grades III and IV, regional and distant stage, in addition to positive LN were associated with worse survival, p < 0.05.

CONCLUSION

Lymphadenectomy is infrequently performed during ACC resection, and when performed, regional LN involvement tends to be associated with worse survival. Neoplasm size and grade were not associated with LN involvement and therefore, do not inform lymphadenectomy need. Further studies are needed to assess the indications for, and value of lymphadenectomy in ACC.

Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery

INTRODUCTION

In 2018, our institution implemented opioid prescribing guidelines for endocrine surgery.

METHODS

We evaluated prescribing trends before and after the guidelines (60 MME following adrenal procedures and 37.5 MME for thyroid/parathyroid procedures) using chi-squared and Wilcoxon Rank-Sum tests.

RESULTS

We identified 357 patients in the pre-guideline and 397 in the post-guideline period. The proportion discharged with any opioid prescription decreased from 96.1% to 77.3%, p < 0.01, and the median (IQR) prescribed amount decreased from 150.0 (100.0, 200.0) to 50.0 (25.0, 75.0), p < 0.01 overall and within each category. The proportion receiving prescription above the upper guidelines limit also decreased, while opioid refills within 30-day of discharge remained stable (2.8% before and 4.5% after the guidelines, p = 0.21).

CONCLUSION

Opioid prescribing guidelines for endocrine surgical procedures decreased both the proportion of patients receiving opioids and the amount when prescribed, therefore further supporting the utility of opioid prescribing guidelines in decreasing over-prescription.

Comparison of benign and malignant insulinoma

BACKGROUND

How malignant insulinomas present relative to benign insulinomas is unknown.

METHODS

A single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used.

RESULTS

A total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01.

CONCLUSIONS

Larger size of insulinoma and increased serum β-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.

Intraoperative Pathologic Margin Analysis and Re-Excision to Minimize Reoperation for Patients Undergoing Breast-Conserving Surgery

BACKGROUND

Reoperation rates following breast-conserving surgery (BCS) range from 10 to 40%, with marked surgeon and institutional variation.

OBJECTIVE

The aim of this study was to identify factors associated with intraoperative margin re-excision, evaluate for any differences in local recurrence based on margin re-excision and determine reoperation rates with use of intraoperative margin analysis.

PATIENTS AND METHODS

We analyzed consecutive patients with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent BCS at our institution between 1 January 2005 and 31 December 2016. Routine intraoperative frozen section margin analysis was performed and positive or close margins were re-excised intraoperatively. Univariate analysis was used to compare margin status and the Kaplan-Meier method was used to compare recurrence. Multivariable logistic regression was utilized to analyze factors associated with re-excision.

RESULTS

We identified 3201 patients who underwent BCS-688 for DCIS and 2513 for invasive carcinoma. Overall, 1513 (60.2%) patients with invasive cancer and 434 (63.1%) patients with DCIS had close or positive margins that underwent intraoperative re-excision. Margin re-excision was associated with larger tumor size in both groups. The permanent pathology positive margin rate among all patients was 1.2%, and the 30-day reoperation rate for positive margins was 1.1%. Five-year local recurrence rates were 0.6% and 1.2% for patients with DCIS and invasive cancer, respectively. There was no difference in recurrence between patients with and without intraoperative margin re-excision (p = 0.92).

CONCLUSION

Both DCIS and invasive carcinoma had similar rates of intraoperative margin re-excision. Although intraoperative margin re-excision was common, the reoperation rate was extremely low and there was no difference in recurrence between those with or without intraoperative re-excision.

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

OBJECTIVES

To describe pain experience and opioid use after major head and neck reconstructive surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0-10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank-sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

The study population comprised 445 patients. Median age was 60 years (interquartile range 50-68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One-quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one-half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33-0.84), whereas surgical defect volume ≥ 100 cm³ (aOR = 1.92, 95% CI = 1.21-3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07-1.32 per 1 point increase) increased the odds of refill.

CONCLUSION

Continued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population.

LEVEL OF EVIDENCE

IV Laryngoscope, 130: E469-E478, 2020.

Monoclonal Gammopathy of Undetermined Significance: Indications for Prediagnostic Testing, Subsequent Diagnoses, and Follow-up Practice at Mayo Clinic

OBJECTIVES

To determine the indications for prediagnostic testing, subsequent diagnoses found, and follow-up practices in patients who were incidentally diagnosed with monoclonal gammopathy of undetermined significance (MGUS).

PATIENTS AND METHODS

From our prospective MGUS database, we identified 329 patients residing in southeastern Minnesota who were diagnosed from January 1, 2011, through December 31, 2014, and followed up at Mayo Clinic.

RESULTS

Most test orders came from nonhematologists (n=310, 94.2%). The top 5 indications were neuropathy (n=65, 19.8%), renal disease (n=45, 13.7%), anemia (n=42, 12.8%), bone disorder or connective tissue pain (n=42, 12.8%), and cutaneous disease (n=19, 5.8%). Hypercalcemia was an infrequent indication (n=9, 2.7%). The final diagnosis for all neuropathy evaluations was sensory/motor neuropathy-not otherwise specified, with 18.7% having IgM MGUS. Chronic kidney disease-not otherwise specified, iron deficiency, and osteoporosis/osteopenia were the most common subsequent diagnoses for test indications of renal disease, anemia, and bone disorder or connective tissue pain, respectively. Most patients (n=213, 64.7%) had 1 or more follow-up visit during the study period. A minority were followed by hematologists (43.5%, n=143). Patients with low-risk MGUS comprised 45.0% (n=148) of the cohort. Male patients and younger patients were more likely to be followed up than their counterparts (P<.01). About one-third (n=27, 32.1%) of patients 80 years or older (n=84) continued to have regular follow-up visits. Hematologists were more likely to follow patients with MGUS more closely than nonhematologists (P<.001). However, the intensity of follow-up was not based on MGUS risk.

CONCLUSION

Monoclonal protein testing is commonly performed for signs and symptoms not typically associated with lymphoplasmacytic malignancies. There is a significant variation in MGUS follow-up between hematologists and nonhematologists (P<.001) that is not based on risk factors or clinical practice guidelines.

Sex-Based Differences in Melanoma Survival in a Contemporary Patient Cohort

Background: A female survival advantage in cutaneous melanoma has been long recognized. However, whether this extends across all age groups, with risk stratification using the latest prognostic staging system or in the current era of efficacious systemic therapies is unknown. Therefore, we evaluated whether sex-based differences in melanoma survival persisted within a recent population-based patient cohort with consideration of these factors. Materials and Methods: We identified stage II-IV cutaneous melanoma patients from 2010 to 2014 Surveillance, Epidemiology, and End Results cancer registries data. We recalculated stage per American Joint Committee on Cancer 8th edition guidelines. Cancer-specific survival (CSS) was estimated by using the Kaplan-Meier method and multivariable Cox proportional hazards regression. Results: Of 16,807 patients (39.8% female), 8,990 were stage II, 4,826 stage III, and 2,991 stage IV at diagnosis. Unadjusted 3-/5-year CSS estimates for females versus males were 64.2% versus 59.7%, and 53.5% versus 49.9%, respectively, p ≤ 0.0001. Five-year CSS varied within each stage and across age strata of <45, 45 - 59, and ≥60 years. Within each stage, females <45 had better CSS than all other sex/age groups (p < 0.0001). In multivariable analysis of stage II/III patients, female sex, younger age, and lower mitotic index retained favorable CSS prognostic significance (p < 0.001). Conclusions: Sex-based differences in melanoma survival persist in a contemporary patient cohort staged with the latest prognostic system. These data may guide decision marking regarding adjuvant therapy, highlight the importance of including sex as a pre-specified clinical trial variable, and suggest that investigation of underlying biologic mechanisms may drive discovery of biomarkers and therapeutic targets to improve patient care.

Characteristics of opioid users undergoing surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Understanding demographic and opioid utilization patterns of preoperative opioid users compared with opioid-naïve patients undergoing surgical treatment for pelvic organ prolapse (POP) better informs opioid prescribing.

METHODS

A cohort of preoperative opioid users undergoing surgery for POP from 1 January 2012 through 30 May 2017 was identified. Electronic medical records were utilized to obtain pain scores and prescription data. The cohort was organized by surgical approach, number of concomitant procedures, and patient age. These factors were then matched to pain scores, opioid quantity prescribed at discharge, and subsequent refills. Pain scores and opioid use were evaluated for correlation. Results were then compared with similar data previously published for opioid-naïve patients undergoing surgical treatment of POP.

RESULTS

Preoperative opioid users were younger (55.5 [14.7] vs 59.5 [12.7]; p = 0.002), of higher body mass index (BMI; 29.2 [5.4] vs 28.6 [10.3]; p = 0.04), and less likely Caucasian (90.3% vs 95.9%; p = 0.002) than opioid-naïve patients. After matching for these differences, opioid users reported higher pain scores (3.5 [2.2] vs 2.6 [1.8]; p = <0.0001), but received similar opioid quantities (324.4 [395] vs 296 [158] oral morphine equivalents [OME]; p = 0.27; 16.8% vs 10.4% refill rates; p = 0.07). In preoperative opioid users, neither surgical approach nor the number of concomitant procedures influenced pain scores. Increasing mean pain scores (1.8 [2.0] to 4.2 [2.4]; p < 0.002) and OME prescribed (226 [170.2] to 541 [902.5] p = 0.056; 0% to 22.2% refill rates; p = 0.02), were seen with decreasing patient age. Pain scores correlated directly with the opioid amount prescribed.

CONCLUSIONS

Patient age and preoperative opioid utilization should be factored into urogynecological postoperative opioid-prescribing protocols.

Trauma registry data as a tool for comparison of practice patterns and outcomes between low- and middle-income and high-income healthcare settings

PURPOSE

There is a lack of data-driven, risk-adjusted mortality estimates for injured children outside of high-income countries (HIC). To inform injury prevention and quality improvement efforts, an upper middle-income country (UMIC) pediatric trauma registry was compared to that of a HIC.

METHODS

Clinical data, injury details, and mortality of injured children (< 18 years) hospitalized in two centers (USA and South African (SA)) from 2013 to 2017 were abstracted. Univariate and multivariable analyses evaluated risk of mortality and were expressed as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Of 2089 patients, SA patients had prolonged transfer times (21.1 vs 3.4 h) and were more likely referred (78.2% vs 53.9%; both p < 0.001). Penetrating injuries were more frequent in SA (23.2% vs 7.4%, p < 0.001); injury severity (9 vs 4) and shock index (0.90 vs 0.80) were greater (both p < 0.001). SA utilized cross-sectional imaging more frequently (66.4% vs 37.3%, p < 0.001). In-hospital mortality was similar (1.9% SA, 1.3% USA, p = 0.31). Upon multivariable analysis, ISS > 25 [210.50 (66.0-671.0)] and penetrating injury [5.5 (1.3-23.3)] were associated with mortality, while institution [1.7 (0.7-4.2)] was not.

CONCLUSIONS

Despite transfer time, the centers demonstrated comparable survival rates. Comparison of registry data can alert clinicians to problematic practice patterns, assisting initiatives to improve trauma systems.

Returns to Operating Room After Neurosurgical Procedures in a Tertiary Care Academic Medical Center: Implications for Health Care Policy and Quality Improvement

BACKGROUND

Return to the operating room (ROR) has been put forth by the National Quality Forum and the American College of Surgeons as a surgical quality indicator. However, current quality metrics fail to consider the nature and etiology of the ROR.

OBJECTIVE

To provide a comprehensive description of all reoperations after neurosurgical procedures and assess the validity of ROR as a quality measure in neurosurgery.

METHODS

We retrospectively analyzed all neurosurgical procedures performed in a high-volume, tertiary care academic medical center between June 1, 2014 and December 31, 2016. Based on a system constructed and validated at our institution, we classified RORs into (a) unplanned related, (b) planned return due to complications, (c) planned-staged return, or (d) unrelated return.

RESULTS

A total of 9200 unique neurosurgical cases were identified, of which 788 had an ROR within 45 d (8.6%). Median time to ROR (interquartile range) was 9 d (4-15). Specifically, 4.2% were planned-staged returns, 3.4% were unplanned related, 0.3% were unrelated, and 0.6% were planned because of previous complications. Cranial procedures had the highest unplanned ROR rate (4.2%), followed by spinal (2.8%) and peripheral nerve (0.4%). The most common reason for an unplanned ROR was wound complication/surgical site infection (34.3%), followed by hematoma evacuation (13.9%) and cerebrospinal fluid (CSF) leak (11.3%).

CONCLUSION

Unplanned RORs were relatively rare and most commonly associated with wound complication, postoperative hematoma, and CSF leak. To better reflect surgical quality, ROR metrics should indicate whether the return was planned or unrelated.

Revision Total Hip Arthroplasty for the Treatment of Fracture: More Expensive, More Complications, Same Diagnosis-Related Groups: A Local and National Cohort Study

BACKGROUND

Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally.

METHODS

Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex.

RESULTS

Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001).

CONCLUSIONS

Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Returns to the operating room after breast surgery at a tertiary care medical center

BACKGROUND

Evaluation of returns to the operating room (RORs) may spur practice modifications to improve patient outcomes and hospital practices. We determined the frequency and indications for RORs after breast operations.

METHODS

We identified patients ≥18 years who underwent a breast operation at our institution 1/1/14-1/13/17 and assessed ROR within 45-days. RORs were categorized as unplanned/planned, staged/unstaged, or unrelated procedures. Univariate and multivariable analyses compared variables between patients who did and did not have an ROR.

RESULTS

2,914 patients underwent a breast operation of whom 117 (4.0%) had 121 RORs. Planned staged procedures accounted for 48 RORs (39.7%), while unplanned complications accounted for 65 (53.7%). On multivariable analysis, ROR was more common among patients undergoing total, skin-sparing, or nipple-sparing mastectomy (versus lumpectomy) all p < 0.03, while immediate breast reconstruction did not increase RORs.

CONCLUSIONS

RORs following breast operations occurred in 4% of patients, with approximately one-third for a staged oncologic procedure. Implementation of ROR documentation tools should be encouraged, as these data provide benchmarks for clinical practice improvement initiatives to improve the quality of patient care.

Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers

OBJECTIVE

To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery.

PATIENTS AND METHODS

We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables.

RESULTS

Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge.

CONCLUSION

The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.

Ileal-pouch anal anastomosis in pediatric NSQIP: Does a laparoscopic approach reduce complications and length of stay?

PURPOSE

The purpose of this study was to determine if a laparoscopic approach reduces complications and length of stay (LOS) after total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) in pediatric patients using a multicenter prospective database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project Pediatric database from 2012 to 2015 was used to identify patients with a diagnosis of chronic ulcerative colitis (CUC) or familial adenomatous polyposis (FAP) undergoing TPC-IPAA. Major complications, minor complications, and prolonged LOS were compared based on laparoscopic versus open approach.

RESULTS

195 (108 female) patients underwent TPC-IPAA at a median age of 14 years (IQR: 11-16) for CUC (N = 99) or FAP (N = 96). Two-thirds of cases were laparoscopic. A laparoscopic approach was not associated with major complications, but lower odds of minor complications were observed. A reduced LOS was seen in laparoscopic versus open surgery (median LOS 6 vs 8 days, p < 0.01). Open IPAA was independently associated with prolonged LOS (>9 days) in the FAP cohort (OR 4.0, 95% CI 1.1-14.0).

CONCLUSION

A laparoscopic approach was not associated with increased major complications but was associated with lower odds of minor complications and shorter LOS. The laparoscopic approach should continue to be preferred for pouch procedures in pediatric patients.

TYPE OF STUDY

Treatment; retrospective study.

LEVEL OF EVIDENCE

Level III.

Racial Differences in Disease Presentation and Management of Intracranial Meningioma

Objective/Hypothesis  The aim of the study was to determine the impact of race on disease presentation and treatment of intracranial meningioma in the United States. Study Design  This study comprised of the analysis of a national population-based tumor registry. Methods  Analysis of the surveillance, epidemiology, and end results (SEER) database was performed, including all patients identified with a diagnosis of intracranial meningioma. Associations between race, disease presentation, treatment strategy, and overall survival were analyzed in a univariate and multivariable model. Results  A total of 65,973 patients with intracranial meningiomas were identified. Of these, 45,251 (68.6%) claimed white, 7,796 (12%) black, 7,154 (11%) Hispanic, 4,902 (7%) Asian, and 870 (1%) patients reported "other-unspecified" or "other-unknown." The median annual incidence of disease was lowest among black (3.43 per 100,000 persons) and highest among white (9.52 per 100,000 persons) populations ( p  < 0.001). Overall, Hispanic patients were diagnosed at the youngest age and white patients were diagnosed at the oldest age (mean of 59 vs. 66 years, respectively; p  < 0.001). Compared with white populations, black, Hispanic, and Asian populations were more likely to present with larger tumors ( p  < 0.001). After controlling for tumor size, age, and treatment center in a multivariable model, Hispanic patients were more likely to undergo surgery than white, black, and Asian populations. Black populations had the poorest disease specific and overall survival rates at 5 years following surgery compared with other groups. Conclusion  Racial differences among patients with intracranial meningioma exist within the United States. Understanding these differences are of vital importance toward identifying potential differences in the biological basis of disease or alternatively inequalities in healthcare delivery or access Further studies are required to determine which factors drive differences in tumor size, age, annual disease incidence, and overall survival between races.

Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting

INTRODUCTION

Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting.

METHODS

We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016.

RESULTS

A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively).

CONCLUSION

Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.

Undertriage after severe injury among United States trauma centers and the impact on mortality

INTRODUCTION

Severely injured patients should receive definitive care at high acuity trauma centers. The purposes of this study were to determine the undertriage (UT) rate within a national sample of trauma centers and to identify characteristics of UT patients.

METHODS

Severely injured adults ≥16 years were identified from the 2010-2012 NTDB. UT was defined as those who received definitive care or died at hospitals without state or ACS level I or II verification. Risk factors for UTT and the impact of UT on mortality were determined.

RESULTS

Of 348,394 severely injured patients, 11,578 (3.3%) were UT. Older, less severely injured, and certain minority patients were most likely to be UT. After risk adjustment, predictors of UT included increased age and minority race. Increased injury severity and comorbidity were protective (all p < .05). Mortality was greater in UT patients regardless of ISS (OR = 1.32, p < .001).

CONCLUSION

The low UT rate in this study demonstrates the effectiveness of triage practices amongst ACS and state verified centers however age, race, and insurance disparities in UT should be improved.