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Vitello DJ, Shah D, Ko B, Brajcich BC, Peters XD, Merkow RP, Pitt HA, Bentrem DJ. Establishing the clinical relevance of grade A post-hepatectomy liver failure. J Surg Oncol 2024; 129:745-753. [PMID: 38225867 PMCID: PMC10922784 DOI: 10.1002/jso.27570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/09/2023] [Indexed: 01/17/2024]
Abstract
INTRODUCTION The International Study Group of Liver Surgery's criteria stratifies post-hepatectomy liver failure (PHLF) into grades A, B, and C. The clinical significance of these grades has not been fully established. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hepatectomy-targeted database was analyzed. Outcomes between patients without PHLF, with grade A PHLF, and grade B or C PHLF were compared. Univariate and multivariable logistic regression were performed. RESULTS Six thousand two hundred seventy-four adults undergoing elective major hepatectomy were included in the analysis. The incidence of grade A PHLF was 4.3% and grade B or C was 5.3%. Mortality was similar between patients without PHLF (1.2%) and with grade A PHLF (1.1%), but higher in those with grades B or C PHLF (25.4%). Overall morbidities rates were 19.3%, 41.7%, and 72.8% in patients without PHLF, with grade A PHLF, and with grade B or C PHLF, respectively (p < 0.001). Grade A PHLF was associated with increased morbidity (grade A: odds ratios [OR] 2.7 [95% CI: 2.0-3.5]), unplanned reoperation (grade A: OR 3.4 [95% CI: 2.2-5.1]), nonoperative intervention (grade A: OR 2.6 [95% CI: 1.9-3.6]), length of stay (grade A: OR 3.1 [95% CI: 2.3-4.1]), and readmission (grade A: OR 1.8 [95% CI: 1.3-2.5]) compared to patients without PHLF. CONCLUSIONS Although mortality was similar between patients without PHLF and with grade A PHLF, other postoperative outcomes were notably inferior. Grade A PHLF is a clinically distinct entity with relevant associated postoperative morbidity.
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Affiliation(s)
- Dominic J Vitello
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dhavan Shah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bona Ko
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian C Brajcich
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xane D Peters
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago Prizker School of Medicine, Chicago, Illinois, USA
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Jesse Brown Veterans Administration Medical Center, Chicago, Illinois, USA
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Ellis RJ, Brajcich BC, Bertens KA, Chan CH, Castillo CFD, Karanicolas PJ, Maithel SK, Reames BN, Weber SM, Vidri RJ, Pitt HA, Thompson VM, Gonen M, Seo SK, Yopp AC, Ko CY, D’Angelica MI. Association Between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula: Results of a Randomized Trial of Perioperative Antibiotic Prophylaxis in Patients Undergoing Pancreatoduodenectomy. Ann Surg 2023; 278:310-319. [PMID: 37314221 PMCID: PMC10838195 DOI: 10.1097/sla.0000000000005955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. BACKGROUND Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. METHODS Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. RESULTS Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888). CONCLUSIONS Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
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Affiliation(s)
- Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, NY
- American College of Surgeons, Chicago, IL
- Indiana University Health, Indianapolis, IN
| | | | | | | | | | | | | | | | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Roberto J. Vidri
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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D’Angelica MI, Ellis RJ, Liu JB, Brajcich BC, Gönen M, Thompson VM, Cohen ME, Seo SK, Zabor EC, Babicky ML, Bentrem DJ, Behrman SW, Bertens KA, Celinski SA, Chan CHF, Dillhoff M, Dixon MEB, Fernandez-del Castillo C, Gholami S, House MG, Karanicolas PJ, Lavu H, Maithel SK, McAuliffe JC, Ott MJ, Reames BN, Sanford DE, Sarpel U, Scaife CL, Serrano PE, Smith T, Snyder RA, Talamonti MS, Weber SM, Yopp AC, Pitt HA, Ko CY. Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA 2023; 329:1579-1588. [PMID: 37078771 PMCID: PMC10119777 DOI: 10.1001/jama.2023.5728] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood. Objective To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics. Design, Setting, and Participants Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment. Intervention The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care). Main Outcomes and Measures The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program. Results The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32). Conclusions and Relevance In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy. Trial Registration ClinicalTrials.gov Identifier: NCT03269994.
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Affiliation(s)
| | - Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, New York
- American College of Surgeons, Chicago, Illinois
| | - Jason B. Liu
- American College of Surgeons, Chicago, Illinois
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Mithat Gönen
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily C. Zabor
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | | | | | | | | | | | | | - Paul J. Karanicolas
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harish Lavu
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Umut Sarpel
- Mount Sinai Medical Center, New York, New York
| | | | | | | | | | | | | | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas
| | - Henry A. Pitt
- American College of Surgeons, Chicago, Illinois
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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Brajcich BC, Johnson JK, Holl JL, Bilimoria KY, Ager MS, Chung J, Joung RHS, Iroz CB, Odell DD, Bentrem DJ, Yang AD, Franklin PD, Slota JM, Silver CM, Skolarus T, Merkow RP. Evaluation of emergency department treat-and-release encounters after major gastrointestinal surgery. J Surg Oncol 2023. [PMID: 37126379 DOI: 10.1002/jso.27292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. METHODS Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. RESULTS Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. CONCLUSIONS ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.
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Affiliation(s)
- Brian C Brajcich
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, Illinois, USA
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Jeanette Chung
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Hae Soo Joung
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - Cassandra B Iroz
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - David D Odell
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - David J Bentrem
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
- Surgical Service, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Anthony D Yang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer M Slota
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - Casey M Silver
- Department of Surgery, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern Medicine, Chicago, Illinois, USA
| | - Ted Skolarus
- Department of Surgery, Biological Sciences Division, The University of Chicago, Chicago, Illinois, USA
| | - Ryan P Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, Biological Sciences Division, The University of Chicago, Chicago, Illinois, USA
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5
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Iroz CB, Johnson JK, Ager MS, Joung RHS, Brajcich BC, Cella D, Franklin PD, Holl JL, Bilimoria KY, Merkow RP. Barriers and Facilitators to Implementing Patient-Reported Outcome Monitoring in Gastrointestinal Surgery. J Surg Res 2023; 288:341-349. [PMID: 37060860 DOI: 10.1016/j.jss.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/13/2023] [Accepted: 03/09/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION More than 30% of patients experience complications after major gastrointestinal (GI) surgery, many of which occur after discharge when patients and families must assume responsibility for monitoring. Patient-reported outcomes (PROs) have been proposed as a tool for remote monitoring to identify deviations in recovery, and recognize and manage complications earlier. This study's objective was to characterize barriers and facilitators to the use of PROs as a patient monitoring tool following GI surgery. METHODS We conducted semistructured interviews with GI surgery patients and clinicians (surgeons, nurses, and advanced practitioners). Patients and clinicians were asked to describe their experience using a PRO monitoring system in three surgical oncology clinics. Using a phenomenological approach, research team dyads independently coded the transcripts using an inductively developed codebook and the constant comparative approach with differences reconciled by consensus. RESULTS Ten patients and five clinicians participated in the interviews. We identified four overarching themes related to functionality, workflow, meaningfulness, and actionability. Functionality refers to barriers faced by clinicians and patients in using the PRO technology. Workflow represents problematic integration of PROs into the clinical workflow and need for setting expectations with patients. Meaningfulness refers to lack of patient and clinician understanding of the impact of PROs on patient care. Finally, actionability reflects barriers to follow-up and practical use of PRO data. CONCLUSIONS While use of PRO systems for postoperative patient monitoring have expanded, significant barriers persist for both patients and clinicians. Implementation enhancements are needed to optimize functionality, workflow, meaningfulness, and actionability.
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Affiliation(s)
- Cassandra B Iroz
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Hae-Soo Joung
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian C Brajcich
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan P Merkow
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Biological Sciences Division, The University of Chicago, Chicago, Illinois; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
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Melucci AD, Liu JB, Brajcich BC, Collins CE, Kazaure HS, Ko CY, Pusic AL, Temple LK. Scaling and spreading the electronic capture of patient-reported outcomes using a national surgical quality improvement programme: a feasibility study protocol. BMJ Open Qual 2022; 11:e001909. [PMID: 36375858 PMCID: PMC9664302 DOI: 10.1136/bmjoq-2022-001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Patient-reported outcomes (PROs) are important for research, patient care and quality assessment; however, large-scale collection among the US surgical patient population has been limited. A structured implementation and dissemination programme focused on electronic PRO collection could improve the use of PROs data to improve surgical care. This study aims to (1) evaluate the feasibility of PRO collection among a larger volume of surgical patients through the stepwise implementation of PRO collection processes in a sample of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals; (2) identify best practices and barriers to PRO collection through qualitative study of participating hospitals and patients; and (3) evaluate the utility of PROs at detecting differences in the quality of care among surgical patients. METHODS AND ANALYSIS ACS NSQIP-participating hospitals are being recruited, and patients at participating hospitals who undergo elective surgical procedures receive invitations via e-mail or short message service 'text'message to complete PROs after surgery. Validated PRO measures which evaluate physical and mental health-related quality of life, pain, fatigue, physical function and shared decision-making were selected. The scalability of PRO collection will be assessed by site enrolment, patient accrual and response rates. Qualitative interviews and focus groups will be performed with patients and hospital personnel to identify best practices and barriers to successful enrolment and PRO collection. Multivariable hierarchical regression models will be used to evaluate the distinctness of PROs from clinical outcomes captured in ACS NSQIP and the ability of PROs to detect differences in hospital performance. ETHICS AND DISSEMINATION This study was reviewed by the Advarra Institutional Review Board (IRB) and deemed to be exempt from IRB oversight. Findings will be disseminated through peer-reviewed manuscripts, reports and presentations.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason B Liu
- Department of Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Brian C Brajcich
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern Medicine, Chicago, Illinois, USA
| | - Courtney E Collins
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Hadiza S Kazaure
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Andrea L Pusic
- Department of Surgery, Brigham Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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7
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Li RD, Joung RHS, Brajcich BC, Schlick CJR, Yang AD, McGee MF, Bentrem D, Bilimoria KY, Merkow RP. Comprehensive Evaluation of the Trends in Length of Stay and Post-discharge Complications After Colon Surgery in the USA. J Gastrointest Surg 2022; 26:2184-2192. [PMID: 35819663 DOI: 10.1007/s11605-022-05391-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION With widespread adoption of enhanced recovery protocols and a push toward shorter length of stay (LOS) following colon surgery, the extent to which complications have shifted to the post-discharge setting is unknown. The objectives of this study were to (1) characterize changes in LOS and post-discharge complications over time and (2) evaluate risk factors associated with post-discharge complications. METHODS Patients who underwent elective colon resection from 2012 to 2018 were identified from the ACS NSQIP Colectomy-Targeted Dataset. Changes in LOS and the proportion of post-discharge complications were evaluated over time, and predictors of post-discharge complications were assessed using multivariable logistic regression. RESULTS Of the 98,136 patients who underwent colon resection, median LOS decreased from 5 days in 2012 to 4 days in 2018. Overall, 30-day complication rate was 21.5%, which decreased during the study period (25.8 to 19.1%, p < 0.001). Of the 13 individual complications evaluated, 4 demonstrated a significant increase in the proportion of post-discharge events including overall SSI (55.8 to 63.3%, p = 0.002), superficial SSI (57.3 to 75.7%, p < 0.001), wound disruption (46.0 to 62.1%, p = 0.047), and UTI (41.5 to 62.7%, p < 0.001). Factors associated with the development of any post-discharge complication included female sex, ASA III/IV/V, dependent functional status, and higher BMI. Intraoperative factors included wound class, operation time, and approach. CONCLUSIONS Although LOS and 30-day complications decreased over time, the proportion of events occurring post-discharge increased for several complications. We identified specific factors associated with post-discharge complications which emphasize the importance of a patient monitoring program to early identify and manage post-discharge complications.
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Affiliation(s)
- Ruojia Debbie Li
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA
| | - Rachel Hae-Soo Joung
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael F McGee
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Bentrem
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, 633 N St Clair St 20th Floor, Chicago, IL, 60611, USA. .,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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8
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Cotler JH, Nogueira L, McCabe R, Nelson H, Brajcich BC, Boffa DJ, Lum SS, Harris JB, Hawhee V, Mullett TW, Bilimoria KY, Palis BE. Evaluating information loss in the National Cancer Database from cases lost to follow-up. J Surg Oncol 2022; 126:1123-1132. [PMID: 36029288 DOI: 10.1002/jso.26977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/17/2022] [Accepted: 05/21/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Cancer registries must focus on data capture which returns value while reducing resource burden with minimal loss of data. Identifying the optimum length of follow-up data collection for patients with cancer achieves this goal. METHODS A two-step analysis using entropy calculations to assess information gain for each follow-up year, and second-order differences to compare survival outcomes between the defined follow-up periods and lifetime follow-up. A total of 391 567 adult cases, deidentified in the National Cancer Database and diagnosed in 1989. Comparisons examined a subset of 61 908 lung cancer cases, 48 387 colon and rectal cancer cases, and 64 134 breast cancer cases in adults. A total of 4133 pediatric cases were diagnosed in 1989 examining 1065 leukemia cases and 494 lymphoma cases. RESULTS Annual increases in information gain fell below 1% after 16 years of follow-up for adult cases and 9 years for pediatric cases. Comparison of second-order differences showed 62% of the comparisons were similar between 15 years and lifetime follow-up when examining restricted mean survival time. In addition, 90% of the comparisons were statistically similar when comparing hazard ratios. CONCLUSIONS Survival analysis using 15 years postdiagnosis follow-up showed minimal differences in information gain compared to lifetime follow-up.
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Affiliation(s)
- Joseph H Cotler
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Leticia Nogueira
- Health Services Research, American Cancer Society, Atlanta, Georgia, USA
| | - Ryan McCabe
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Daniel J Boffa
- Department of Thoracic Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sharon S Lum
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - James B Harris
- Department of Surgery, University of Nevada School of Medicine, Reno, Nevada, USA
| | - Vicki Hawhee
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Timothy W Mullett
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Bryan E Palis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
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9
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Brajcich BC, Platoff RM, Thompson VM, Hall B, Ko CY, Pitt HA. Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes? HPB (Oxford) 2022; 24:1252-1260. [PMID: 35034836 DOI: 10.1016/j.hpb.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1). METHODS Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1. RESULTS POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039). CONCLUSION POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.
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Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | | | | | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University in Saint Louis School of Medicine, and BJC Healthcare, St Louis, MO USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA; The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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10
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Schlick CJR, Huang R, Brajcich BC, Halverson AL, Yang AD, Kreutzer L, Bilimoria KY, McGee MF. Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative. Dis Colon Rectum 2022; 65:1052-1061. [PMID: 34840291 PMCID: PMC9124224 DOI: 10.1097/dcr.0000000000002223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN This was a post-hoc analysis of a prospective cohort study. SETTING This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. PATIENTS Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. INTERVENTIONS The intervention was a 16-element colorectal surgical site infection reduction bundle. MAIN OUTCOME MEASURES Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . DESEMPAQUETANDO PAQUETES EVALUACIN DE LA ASOCIACIN DE ELEMENTOS INDIVIDUALES DEL PAQUETE DE REDUCCIN DE INFECCIONES DEL SITIO QUIRRGICO COLORRECTAL CON LAS TASAS DE INFECCIN EN UNA COLABORACIN ESTATAL ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).
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Affiliation(s)
- Cary Jo R. Schlick
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Reiping Huang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Brian C. Brajcich
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Amy L. Halverson
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Anthony D. Yang
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Lindsey Kreutzer
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
| | - Karl Y. Bilimoria
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
- Center for Healthcare Studies, Institute for Public Health
and Medicine, Feinberg School of Medicine, Northwestern University, Chicago,
Illinois
| | - Michael F. McGee
- Illinois Surgical Quality Improvement Collaborative,
Chicago, Illinois
- Surgical Outcomes and Quality Improvement Center (SOQIC),
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago,
Illinois
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11
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Joung RHS, Nelson H, Mullett TW, Kurtzman SH, Shafir S, Harris JB, Yao KA, Brajcich BC, Bilimoria KY, Cance WG. A national quality improvement study identifying and addressing cancer screening deficits due to the COVID-19 pandemic. Cancer 2022; 128:2119-2125. [PMID: 35307815 PMCID: PMC9086125 DOI: 10.1002/cncr.34157] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/21/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cancer-related deaths over the next decade are expected to increase due to cancer screening deficits associated with the coronavirus disease 2019 (COVID-19) pandemic. Although national deficits have been quantified, a structured response to identifying and addressing local deficits has not been widely available. The objectives of this report are to share preliminary data on monthly screening deficits in breast, colorectal, lung, and cervical cancers across diverse settings and to provide online materials from a national quality improvement (QI) study to help other institutions to address local screening deficits. METHODS This prospective, national QI study on Return-to-Screening enrolled 748 accredited cancer programs in the United States from April through June 2021. Local prepandemic and pandemic monthly screening test volumes (MTVs) were used to calculate the relative percent change in MTV to describe the monthly screening gap. RESULTS The majority of facilities reported monthly screening deficits (colorectal cancer, 80.6% [n = 104/129]; cervical cancer, 69.0% [n = 20/29]; breast cancer, 55.3% [n = 241/436]; lung cancer, 44.6% [n = 98/220]). Overall, the median relative percent change in MTV ranged from -17.7% for colorectal cancer (interquartile range [IQR], -33.6% to -2.8%), -6.8% for cervical cancer (IQR, -29.4% to 1.7%), -1.6% for breast cancer (IQR, -9.6% to 7.0%), and 1.2% for lung cancer (IQR, -16.9% to 19.0%). Geographic differences were not observed. There were statistically significant differences in the percent change in MTV between institution types for colorectal cancer screening (P = .02). CONCLUSION Cancer screening is still in need of urgent attention, and the screening resources made available online may help facilities to close critical gaps and address screenings missed in 2020. LAY SUMMARY Question: How can the effects of the coronavirus disease 2019 pandemic on cancer screening be mitigated? FINDINGS When national resources were provided, including methods to calculate local screening deficits, 748 cancer programs promptly enrolled in a national Return-to-Screening study, and the majority identified local screening deficits, most notably in colorectal cancer. Using these results, 814 quality improvement projects were initiated with the potential to add 70,000 screening tests in 2021. Meaning: Cancer screening is still in need of urgent attention, and the online resources that we provide may help to close critical screening deficits.
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Affiliation(s)
- Rachel Hae-Soo Joung
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, IL, USA
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, IL, USA
| | - Timothy W. Mullett
- American College of Surgeons Cancer Programs, Chicago, IL, USA
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Scott H. Kurtzman
- National Accreditation Program for Breast Centers, Chicago, IL, USA
- Waterbury Hospital, Waterbury, CT, USA
| | | | - James B. Harris
- American College of Surgeons Cancer Programs, Chicago, IL, USA
- University of Nevada Reno School of Medicine, Reno, Nevada
| | - Katharine A. Yao
- National Accreditation Program for Breast Centers, Chicago, IL, USA
- NorthShore University Health System, Evanston, IL, USA
| | - Brian C. Brajcich
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, IL, USA
| | - Karl Y. Bilimoria
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, IL, USA
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12
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Brajcich BC, Schlick CJR, Halverson AL, Huang R, Yang AD, Love R, Bilimoria KY, McGee MF. Association between Patient and Hospital Characteristics and Adherence to a Surgical Site Infection Reduction Bundle in a Statewide Surgical Quality Improvement Collaborative. J Am Coll Surg 2022; 234:783-792. [PMID: 35426391 DOI: 10.1097/xcs.0000000000000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative. STUDY DESIGN A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation. RESULTS Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements. CONCLUSION Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers.
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Affiliation(s)
- Brian C Brajcich
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Cary Jo R Schlick
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Amy L Halverson
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Reiping Huang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Anthony D Yang
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Remi Love
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Karl Y Bilimoria
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
| | - Michael F McGee
- From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
- the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL (Brajcich, Schlick, Halverson, Huang, Yang, Love, Bilimoria, McGee)
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13
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Brajcich BC, Palis BE, McCabe R, Nogueira L, Boffa DJ, Lum SS, Harris JB, Hawhee V, Mullett TW, Bilimoria KY, Nelson H. Twenty-Five Years of Cancer Follow-Up; Is the Data Worth the Effort? Ann Surg Oncol 2022. [PMID: 34689251 DOI: 10.1245/s10434-021-10668-w:10.1245/s10434-021-10668-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Substantial resources are dedicated to long-term follow-up within cancer registries; however, the completeness of these data is poorly characterized. Our objectives were to quantify long-term cancer follow-up data completeness and the effort required to collect these data using the National Cancer Database (NCDB). METHODS To quantify data completeness, patients diagnosed with cancer in 1989 were identified in the NCDB and loss to follow-up rates were assessed for 25 years after diagnosis. To quantify data collection effort, patients diagnosed from 1989 to 2014 who were alive and eligible for follow-up in 2014 were identified and the effort to perform patient follow-up was obtained via a survey of tumor registrars. The effort to perform follow-up beyond various intervals after diagnosis was calculated. RESULTS In total, 484,201 patients at 958 hospitals were diagnosed with cancer in 1989. After 5 years, 6.5% of patients were lost to follow-up (13.1% of living patients), 50.3% were deceased, and 43.2% had ongoing follow-up. After 15 years, 22.9% were lost to follow-up (68.7% of living patients), 66.7% were deceased, and 10.5% had ongoing follow-up. By 25 years, loss to follow-up increased to 28.6% (93.7% of living patients), 69.5% were deceased, and 1.9% had ongoing follow-up. In 2014, 522,838 h were spent performing follow-up for 2,091,353 patients at 1456 hospitals who were >15 years from their initial cancer diagnosis. CONCLUSIONS While 5-year follow-up is excellent in the NCDB, loss to follow-up increases over time. The impact of curtailing data collection is under investigation and follow-up duration requirements will be re-evaluated.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Bryan E Palis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan McCabe
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Leticia Nogueira
- Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Daniel J Boffa
- Department of Thoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sharon S Lum
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - James B Harris
- Department of Surgery, University of Nevada School of Medicine, Reno, NV, USA
| | - Vicki Hawhee
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Timothy W Mullett
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.
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14
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Brajcich BC, Yuce TK, Merkow RP, Bilimoria KY, McGee MF, Zhan T, Odell DD. Association of preoperative smoking with complications following major gastrointestinal surgery. Am J Surg 2022; 223:312-317. [PMID: 34119328 PMCID: PMC8648850 DOI: 10.1016/j.amjsurg.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery. METHODS Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes. RESULTS A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]). CONCLUSIONS Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA.
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA; American College of Surgeons, Chicago, IL, USA
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Tiannan Zhan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
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15
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Ecker BL, Brajcich BC, Ellis RJ, Ko CY, D’Angelica MI. Registry-based randomized clinical trials in surgery: Working with ACS-NSQIP and the AHPBA to conduct pragmatic trials. J Surg Oncol 2022; 125:89-92. [PMID: 34897710 PMCID: PMC8787438 DOI: 10.1002/jso.26742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 01/03/2023]
Abstract
Randomized controlled trials (RCTs) represent the gold standard for evidence in clinical medicine because of their ability to account for the effects of unmeasured confounders and selection bias by indication. However, their complexity and immense costs limit their application, and thus the availability of high-quality data to guide clinical care. Registry-based RCTs are a type of pragmatic trial that leverages existing registries as a platform for data collection, providing a low-cost alternative for randomized studies. Herein, we describe the tenets of registry RCTs and the development of the first AHPBA/ACS-NSQIP-based registry trial.
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Affiliation(s)
- Brett L. Ecker
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Brian C. Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Ryan J. Ellis
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, Department of Surgery, University of California Los Angeles, Los Angeles, CA,Department of Surgery, University of California Los Angeles David Geffen School of Medicine, 10833 LeConte Avenue., 72-215 CHS, Los Angeles, CA,VA Greater Los Angeles Healthcare System, 11301 Wiltshire Blvd., Los Angeles, CA
| | - Michael I. D’Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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16
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Brajcich BC, Shallcross ML, Johnson JK, Joung RHS, Iroz CB, Holl JL, Bilimoria KY, Merkow RP. Barriers to Post-Discharge Monitoring and Patient-Clinician Communication: A Qualitative Study. J Surg Res 2021; 268:1-8. [PMID: 34274626 PMCID: PMC8822471 DOI: 10.1016/j.jss.2021.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION As postoperative length of stay has decreased for many operations, the proportion of complications occurring post-discharge is increasing. Early identification and management of these complications requires overcoming barriers to effective post-discharge monitoring and communication. The aim of this study was to identify barriers to post-discharge monitoring and patient-clinician communication through a qualitative study of surgical patients and clinicians. MATERIALS AND METHODS Semi-structured interviews and focus groups were held with gastrointestinal surgery patients and clinicians. Participants were asked about barriers to post-discharge monitoring and communication. Each transcript was coded by 2 of 4 researchers, and recurring themes related to communication and care barriers were identified. RESULTS A total of 15 patients and 17 clinicians participated in interviews and focus groups. Four themes which encompassed barriers to post-discharge monitoring and communication were identified from patient interviews, and 4 barriers were identified from clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences, while clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency. CONCLUSIONS Multiple barriers exist to effective post-discharge monitoring and patient-clinician communication among surgical patients. These barriers must be addressed to develop an effective system for post-discharge care after surgery.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Meagan L Shallcross
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Julie K Johnson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Rachel Hae-Soo Joung
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Cassandra B Iroz
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.
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17
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Brajcich BC, Benson AB, Gantt G, Eng OS, Marsh RW, Mulcahy MF, Polite BN, Shogan BD, Yang AD, Merkow RP. Management of colorectal cancer during the COVID-19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborative. J Surg Oncol 2021; 125:560-563. [PMID: 34820843 PMCID: PMC9015333 DOI: 10.1002/jso.26758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/13/2021] [Indexed: 11/09/2022]
Abstract
COVID‐19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID‐19 or other large‐scale disruptions in cancer care.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gerald Gantt
- Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Oliver S Eng
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Robert W Marsh
- Department of Medical Oncology, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois, USA
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Blase N Polite
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
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Brajcich BC, Palis BE, McCabe RM, Nogueira L, Lum SS, Harris JB, Hawhee VM, Bilimoria KY, Nelson H. Lifetime Follow-Up in the National Cancer Database: How Valuable Is It? J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Gupta AR, Brajcich BC, Merkow RP. Postoperative LAMN surveillance recommendations. J Surg Oncol 2021; 125:546-547. [PMID: 34719030 DOI: 10.1002/jso.26724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Aakash R Gupta
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
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20
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Brajcich BC, Palis BE, McCabe R, Nogueira L, Boffa DJ, Lum SS, Harris JB, Hawhee V, Mullett TW, Bilimoria KY, Nelson H. Twenty-Five Years of Cancer Follow-Up; Is the Data Worth the Effort? Ann Surg Oncol 2021; 29:828-836. [PMID: 34689251 DOI: 10.1245/s10434-021-10668-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Substantial resources are dedicated to long-term follow-up within cancer registries; however, the completeness of these data is poorly characterized. Our objectives were to quantify long-term cancer follow-up data completeness and the effort required to collect these data using the National Cancer Database (NCDB). METHODS To quantify data completeness, patients diagnosed with cancer in 1989 were identified in the NCDB and loss to follow-up rates were assessed for 25 years after diagnosis. To quantify data collection effort, patients diagnosed from 1989 to 2014 who were alive and eligible for follow-up in 2014 were identified and the effort to perform patient follow-up was obtained via a survey of tumor registrars. The effort to perform follow-up beyond various intervals after diagnosis was calculated. RESULTS In total, 484,201 patients at 958 hospitals were diagnosed with cancer in 1989. After 5 years, 6.5% of patients were lost to follow-up (13.1% of living patients), 50.3% were deceased, and 43.2% had ongoing follow-up. After 15 years, 22.9% were lost to follow-up (68.7% of living patients), 66.7% were deceased, and 10.5% had ongoing follow-up. By 25 years, loss to follow-up increased to 28.6% (93.7% of living patients), 69.5% were deceased, and 1.9% had ongoing follow-up. In 2014, 522,838 h were spent performing follow-up for 2,091,353 patients at 1456 hospitals who were >15 years from their initial cancer diagnosis. CONCLUSIONS While 5-year follow-up is excellent in the NCDB, loss to follow-up increases over time. The impact of curtailing data collection is under investigation and follow-up duration requirements will be re-evaluated.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Bryan E Palis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan McCabe
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Leticia Nogueira
- Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Daniel J Boffa
- Department of Thoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sharon S Lum
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - James B Harris
- Department of Surgery, University of Nevada School of Medicine, Reno, NV, USA
| | - Vicki Hawhee
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Timothy W Mullett
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.
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21
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Brajcich BC, Palis BE, McCabe R, Nogueira L, Boffa DJ, Lum SS, Harris JB, Hawhee V, Mullett TW, Bilimoria KY, Nelson H. ASO Visual Abstract: Twenty-Five Years of Cancer Follow-Up: Are the Data Worth the Effort? Ann Surg Oncol 2021. [PMID: 34467506 DOI: 10.1245/s10434-021-10738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N Saint Clair, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern Medicine, Surgical Outcomes and Quality Improvement Center (SOQIC), Chicago, IL, USA
| | - Bryan E Palis
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N Saint Clair, Chicago, IL, 60611, USA
| | - Ryan McCabe
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N Saint Clair, Chicago, IL, 60611, USA
| | - Leticia Nogueira
- Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Daniel J Boffa
- Department of Thoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sharon S Lum
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - James B Harris
- Department of Surgery, University of Nevada School of Medicine, Reno, NV, USA
| | - Vicki Hawhee
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Timothy W Mullett
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N Saint Clair, Chicago, IL, 60611, USA.,Department of Surgery, Northwestern Medicine, Surgical Outcomes and Quality Improvement Center (SOQIC), Chicago, IL, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N Saint Clair, Chicago, IL, 60611, USA.
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22
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Brajcich BC, Chung JW, Wood DE, Horvath KD, Tolley PD, Yates EF, Are C, Ellis RJ, Hu YY, Bilimoria KY. National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being. JAMA Netw Open 2021; 4:e2123412. [PMID: 34468754 PMCID: PMC8411294 DOI: 10.1001/jamanetworkopen.2021.23412] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/28/2021] [Indexed: 11/16/2022] Open
Abstract
Importance Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions. Objective To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US. Design, Setting, and Participants This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021. Exposures Presence of a general surgery resident labor union. Rates of labor union coverage among non-health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program. Main Outcomes and Measures The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. Results A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, -0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]). Conclusions and Relevance In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.
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Affiliation(s)
- Brian C. Brajcich
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Jeanette W. Chung
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | | | | | | | | | | | - Ryan J. Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Yue-Yung Hu
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Karl Y. Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
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23
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Gupta AR, Brajcich BC, Yang AD, Bentrem DJ, Merkow RP. Necessity of posttreatment surveillance for low-grade appendiceal mucinous neoplasms. J Surg Oncol 2021; 124:1115-1120. [PMID: 34333785 DOI: 10.1002/jso.26621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Low-grade appendiceal mucinous neoplasms (LAMNs) are generally treated by surgical resection, but posttreatment surveillance protocols are not well-established. The objectives of this study were to characterize posttreatment surveillance and determine the risk of recurrence following surgical resection of LAMN. METHODS Patients who underwent surgical resection of localized LAMNs in an 11-hospital regional healthcare system from 2000 to 2019 were identified. Posttreatment surveillance regimens were characterized, and rates of disease recurrence were evaluated. RESULTS A total of 114 patients with LAMNs were identified. T-category was pTis for 92 patients (80.7%), pT3 for 7 (6.1%), pT4a for 14 (12.3%), and pT4b for 1 (0.9%). Two patients (1.8%) had a positive resection margin. Posttreatment surveillance was performed for 39 (34.2%) patients and consisted of office visits for 32 (82%) patients, computerized tomography imaging for 30 (77%), magnetic resonance imaging for 5 (13%), colonoscopy for 15 (38%), and serum tumor marker measurement for 12 (31%). After a mean follow-up duration of 4.7 years, no patients experienced tumor recurrence. CONCLUSIONS Posttreatment surveillance is common among patients with LAMNs. However, no patients experienced tumor recurrence, regardless of T-category or margin status, suggesting that routine surveillance following surgical resection of LAMN may be unnecessary.
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Affiliation(s)
- Aakash R Gupta
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA.,Surgery Service, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
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24
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Brajcich BC, Ko CY, Liu JB, Ellis RJ, D Angelica MI. A NSQIP-based randomized clinical trial evaluating choice of prophylactic antibiotics for pancreaticoduodenectomy. J Surg Oncol 2021; 123:1387-1394. [PMID: 33831250 DOI: 10.1002/jso.26402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/17/2021] [Indexed: 12/23/2022]
Abstract
Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first US randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern Medicine, Chicago, Illinois, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Jason B Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryan J Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern Medicine, Chicago, Illinois, USA
| | - Michael I D Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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25
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Saadat LV, Brajcich BC, Liu Y, Ko C, D'Angelica MI. Defining the risk of liver failure after minor hepatectomy: a NSQIP analysis of 7029 patients. HPB (Oxford) 2021; 23:551-559. [PMID: 32952033 PMCID: PMC8422033 DOI: 10.1016/j.hpb.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) remains a significant complication after hepatic resection. This study aims to determine the rate of PHLF in patients undergoing resection of 3 or fewer segments and analyze the association of PHLF with perioperative characteristics and postoperative complications. METHODS The American College of Surgeons hepatectomy-targeted National Surgical Quality Improvement Program database was queried for patients undergoing left hemi-hepatectomy or partial resection from 2014 to 2018. The primary outcome was PHLF, defined by ISGLS. Multivariable logistic regression models assessed the association between PHLF, preoperative and operative variables and postoperative complications. RESULTS Among 7029 patients, 187 (2.7%) experienced PHLF, with clinically significant (grade B/C) PHLF in 1.4%. PHLF was associated with older age, male gender, higher ASA classification, ascites, and elevated SGOT. Preoperative ascites (OR 4.94, 95%CI: 2.45-9.94, p < 0.001) had the strongest association with PHLF. There was no association between PHLF and concurrent colorectal resection, neoadjuvant therapy, or concurrent ablation. Surgical site infection (OR 3.64, 95%CI: 2.40-5.54, p < 0.001), sepsis (OR 3.78, 95%CI: 2.16-6.61, p < 0.001), postoperative invasive procedure (OR 6.92, 95%CI: 4.91-9.76, p < 0.001), and bile leak (OR 4.65, 95%CI: 3.04-7.12, p < 0.001) were associated with PHLF. CONCLUSION PHLF after minor hepatectomy is rare and associated with signs of preoperative liver dysfunction. The association with infectious complications suggests a multifactorial etiology and provides targets for quality improvement.
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Affiliation(s)
- Lily V Saadat
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Yaoming Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Clifford Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA; Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael I D'Angelica
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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26
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Nevarez NM, Brajcich BC, Liu J, Ellis R, Ko CY, Pitt HA, D'Angelica MI, Yopp AC. Cefoxitin versus piperacillin-tazobactam as surgical antibiotic prophylaxis in patients undergoing pancreatoduodenectomy: protocol for a randomised controlled trial. BMJ Open 2021; 11:e048398. [PMID: 33664081 PMCID: PMC7934720 DOI: 10.1136/bmjopen-2020-048398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Although antibiotic prophylaxis is established in reducing postoperative surgical site infections (SSIs), the optimal antibiotic for prophylaxis in pancreatoduodenectomy (PD) remains unclear. The study objective is to evaluate if administration of piperacillin-tazobactam as antibiotic prophylaxis results in decreased 30-day SSI rate compared with cefoxitin in patients undergoing elective PD. METHODS AND ANALYSIS This study will be a multi-institution, double-arm, non-blinded randomised controlled superiority trial. Adults ≥18 years consented to undergo PD for all indications who present to institutions participating in the National Surgical Quality Improvement Program Hepato-Pancreato-Biliary (NSQIP HPB) Collaborative will be included. Data collection will use the NSQIP HPB Collaborative Surgical Clinical Reviewers. Patients will be randomised to either 1-2 g intravenous cefoxitin or 3.375-4.5 g intravenous piperacillin-tazobactam within 60 min of surgical incision. The primary outcome will be 30-day postoperative SSI rate following PD. Secondary outcomes will include 30-day postoperative mortality; specific postoperative complication rate; and unplanned reoperation, length of stay, and hospital readmission. A subset of patients will have bacterial isolates and sensitivities of intraoperative bile cultures and SSIs. Postoperative SSIs and secondary outcomes will be analysed using logistic regression models with the primary predictor as the randomised treatment group. Additional adjustment will be made for preoperative biliary stent presence. Additionally, bacterial cultures and isolates will be summarised by presence of bacterial species and antibiotic sensitivities. ETHICS AND DISSEMINATION This study is approved by the Institutional Review Board at Memorial Sloan Kettering Cancer Center. This trial will evaluate the effect of piperacillin-tazobactam compared with cefoxitin as antibiotic prophylaxis on the hazard of postoperative SSIs. The results will be disseminated regardless of the effect of the intervention on study outcomes. The manuscript describing the effect of the intervention will be submitted to a peer-reviewed journal when data collection and analyses are complete. TRIAL REGISTRATION NUMBER NCT03269994.
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Affiliation(s)
- Nicole M Nevarez
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jason Liu
- American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ryan Ellis
- American College of Surgeons, Chicago, Illinois, USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam C Yopp
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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27
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Brajcich BC, Fischer CP, Ko CY. Administrative and Registry Databases for Patient Safety Tracking and Quality Improvement. Surg Clin North Am 2021; 101:121-134. [DOI: 10.1016/j.suc.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Brajcich BC, Stulberg JJ, Palis BE, Chung JW, Huang R, Nelson H, Bilimoria KY. Association Between Surgical Technical Skill and Long-term Survival for Colon Cancer. JAMA Oncol 2021; 7:127-129. [PMID: 33125472 DOI: 10.1001/jamaoncol.2020.5462] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, Illinois.,Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Jonah J Stulberg
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | | | - Jeanette W Chung
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Reiping Huang
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Heidi Nelson
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karl Y Bilimoria
- American College of Surgeons, Chicago, Illinois.,Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
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Brajcich BC, Schlick CJR, Dong Eun Yang A, Lynne Halverson A, Kreutzer L, Huang R, Bilimoria KY, Francis McGee M. The Association of Patient and Hospital Factors with Adherence to a Statewide Colorectal Surgical Site Infection Reduction Program. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ellis RJ, Brajcich BC, Ko CY, Cohen ME, Bilimoria KY, Yopp AC, D’Angelica MI, Merkow RP. Hospital variation in use of prophylactic drains following hepatectomy. HPB (Oxford) 2020; 22:1471-1479. [PMID: 32173175 PMCID: PMC8385641 DOI: 10.1016/j.hpb.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use. METHODS Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed. RESULTS Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level. CONCLUSION Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.
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Affiliation(s)
- Ryan J. Ellis
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian C. Brajcich
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL,Department of Surgery, University of Chicago Medicine, Chicago, IL,Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | - Karl Y. Bilimoria
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Adam C. Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael I. D’Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryan P. Merkow
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Affiliation(s)
- Brian C Brajcich
- Department of Surgery, Northwestern University, Chicago, Illinois
- American College of Surgeons, Chicago, Illinois
| | - Eric S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois
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Brajcich BC, Bentrem DJ, Yang AD, Cohen ME, Ellis RJ, Mahalingam D, Mulcahy MF, Lidsky ME, Allen PJ, Merkow RP. Short-Term Risk of Performing Concurrent Procedures with Hepatic Artery Infusion Pump Placement. Ann Surg Oncol 2020; 27:5098-5106. [PMID: 32740732 DOI: 10.1245/s10434-020-08938-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/14/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hepatic artery infusion pump (HAIP) chemotherapy is an advanced cancer therapy for primary and secondary hepatic malignancies. The risk of concurrent hepatic and/or colorectal operations with HAIP placement is unknown. Our objective was to characterize the short-term outcomes of concurrent surgery with HAIP placement. METHODS The 2005-2017 ACS NSQIP dataset was queried for patients undergoing hepatic and colorectal operations with or without HAIP placement. Outcomes were compared for HAIP placement with different combined procedures. Patients who underwent procedures without HAIP placement were propensity score matched with those with HAIP placement. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included infectious complications, wound complications, length of stay (LOS), and operative time. RESULTS Of 467 patients who underwent HAIP placement, 83.9% had concurrent surgery. The rate of DSM was 10.7% for HAIP placement alone, 19.2% with concurrent minor hepatic procedures, 22.1% with concurrent colorectal resection, 23.2% with concurrent minor hepatic plus colorectal procedures, 28.4% with concurrent major hepatic resection, and 41.7% with concurrent major hepatic plus colorectal resection. On matched analyses, there was no difference in DSM, infectious, or wound complications for procedures with HAIP placement compared with the additional procedure alone, but operative time (294.7 vs 239.8 min, difference 54.9, 95% CI 42.8-67.0) and LOS (6 vs 5, IRR 1.20, 95% CI 1.08-1.33) were increased. CONCLUSIONS HAIP placement is not associated with additional morbidity when performed with hepatic and/or colorectal surgery. Decisions regarding HAIP placement should consider the risks of concurrent operations, and patient- and disease-specific factors.
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Affiliation(s)
- Brian C Brajcich
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA.,American College of Surgeons, Chicago, IL, USA
| | - David J Bentrem
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA.,Department of Surgery, Jesse Brown Veterans' Affairs Medical Center, Chicago, IL, USA
| | - Anthony D Yang
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA
| | | | - Ryan J Ellis
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA.,American College of Surgeons, Chicago, IL, USA
| | - Devalingam Mahalingam
- Department of Medicine, Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mary F Mulcahy
- Department of Medicine, Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ryan P Merkow
- Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA. .,American College of Surgeons, Chicago, IL, USA.
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 12/11/2022]
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He JC, Golob JF, Brajcich BC, Clancy K, Schechtman D, Claridge JA. Benefit of TeamSTEPPS Rounding Improvement Project on Infection-Related Monitoring. Surg Infect (Larchmt) 2016; 17:530-4. [DOI: 10.1089/sur.2015.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jack C. He
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Joseph F. Golob
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Kate Clancy
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David Schechtman
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A. Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Brajcich BC, McHenry CR. The utility of intraoperative nerve monitoring during thyroid surgery. J Surg Res 2016; 204:29-33. [DOI: 10.1016/j.jss.2016.04.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/04/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
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