Telemedicine Implementation Trends in Surgical Specialties Before and After COVID-19 Shelter in Place: Adjusting to a Changing Landscape

Background

The COVID-19 pandemic caused a shift from in-person care to telemedicine, providing a unique opportunity to evaluate trends and efficiency of telemedicine usage within surgical subspecialties in a large, integrated health care system before and after shelter in place mandates.

Methods

This retrospective cohort study included all of the Kaiser Permanente Northern California members referred to surgical services from January 1, 2019 to June 13, 2020 and receiving a surgical procedure. We compared the patient referrals (categorized as benign, urgent, or cancer) before and after shelter in place mandates, and we examined rates of telemedicine (video or telephone) usage for preoperative consultations, postoperative visits, time from referral to first surgical encounter, and to surgery or procedure. In multivariate analyses, we assessed the patient and provider characteristics associated with telemedicine usage.

Results

There was a total of 34,875 surgical referrals resulting in a procedure, with a significant decline in referral after shelter in place mandates. Preoperative encounter types shifted from 89.8% in-person before shelter in place mandates to 70.2% telemedicine after shelter in place mandates (P < .0001). The median time from referral to first encounter decreased after shelter in place mandates, as did median time to procedure. After shelter in place mandates, postoperative encounters were mainly telemedicine (65.8%) compared with before shelter in place mandates (41.7%) (P < .0001). Overall, there was a comparable uptake of telemedicine usage in almost all evaluated categories of patient characteristics after shelter in place mandates.

Conclusion

Within a health care system with prior telemedicine capability, surgical specialties were able to shift to telemedicine rapidly, equitably, and efficiently in the preoperative and postoperative encounters of benign, urgent, and cancer diagnosis during mandated COVID-19 restrictions.

Racial parity in rectal cancer treatment and outcomes within an integrated healthcare system

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Background: This study evaluates survival outcomes of rectal adenocarcinoma patients treated at a large, integrated health system and whether there are differences in survival based on race. Methods: We conducted a retrospective study of patients at Kaiser Permanente Northern California (KPNC) who were treated between 2010-2019. Self-reported racial ethnic groups included Caucasian, African American, Hispanic, Asian, and Other. Kaplan Meier and Cox regression analyses were used to evaluate differences in race, age, stage, and treatment utilization in relation to overall survival. Results: A total of 3,589 patients were diagnosed with rectal adenocarcinoma from 2010-2019. There was a significant difference between race groups in stage at the time of diagnosis (p < .001) with more African Americans having localized disease (58.4%) compared to Hispanics (45.5%). Overall survival was longest for African American at 70.9 months but shortest for Hispanic at 60.6 months (p = 0.007). Hispanic patients were more likely to be male, younger, and with nodal disease. Conclusions: This study identified racial parity in survival outcomes for rectal cancer patients who were treated at a large, integrated healthcare system where patients have equal access to care. Improvement in outreach and screening should be tailored to the ethnic groups at higher risk for earlier age and more advanced disease at presentation.

Multidisciplinary Approach to the Management and Treatment of Anal Dysplasia

The incidence of anal intraepithelial neoplasia (AIN) has been increasing over the years. AIN acts as a precursor lesion for anal squamous cell cancer. Factors leading to progression of AIN into malignancy are complex and involve grade of the lesion, human papillomavirus and HIV coinfection, as well as patient-related risk factors such as immunocompromised state and men who have sex with men. The multifaced aspects of this disease make its management challenging, as it involves several disciplines including pathology, primary care, infectious disease, and colorectal specialties. Each of these fields brings its own expertize to the management of AIN, and their collaborative, coordinated work culminates into best practice and optimized outcomes in the care of the AIN patient.

Predictors of adequate lymph node harvest during colectomy for colon cancer

BACKGROUND

Consensus guidelines recommend a yield of 12 lymph nodes in resections for colon cancer. Factors affecting this yield are not well defined.

METHODS

Retrospective study using the colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program for years 2014-2016. Primary outcome was resection of at least 12 nodes. Univariate and multivariate analyses determined factors associated with ≥12 LN yield.

RESULTS

17,612 colectomies for colon cancer were extracted from the NSQIP database. 7.26% of cases did not reach a 12 LN harvest. Harvesting ≥12 LN was 74% more likely (p = 0.001) if the resection was laparoscopic and 72% more likely (p < 0.0001) if hand-assisted. Advanced T and N stage had a higher likelihood of reaching 12 LN harvest. Older age, female gender and smoking history decreased the likelihood of ≥12 LN harvest.

CONCLUSIONS

Laparoscopic and robotic colectomies were 1.5-2.5 times more likely to achieve adequate LN harvest compared to open surgery. Several non-modifiable patient and disease related factors may render adequate LN yield challenging.

Colorectal cancer-global burden, trends, and geographical variations

BACKGROUND

The aim of this study is to describe the trends and variations in the global burden of colorectal cancer (CRC).

METHODS

Data (2012-2030) relating to CRC was extracted from GLOBOCAN 2012 database and analyzed.

RESULTS

The results of our study demonstrate a rising global burden of colorectal cancer which persists until the year 2035 and likely beyond. The rise in the global burden is not uniform with significant variations influenced by geographic location, socio-economic status, age, and gender. Although the EURO region has the highest burden, Asia as a continent continues to bear the heaviest brunt of the disease. Although the burden of disease is higher in more developed regions, mortality is considerably higher in less developed regions and this gap widens over the next two decades. The disease predominantly affects the male gender across all regions of the world. Age has a complex relation with the burden of CRC and is affected by the cross-influences relating to socio-economic status.

CONCLUSIONS

The results of our study demonstrate a rising global burden of CRC with some unique variations. Knowledge of this data can increase awareness and help strategic targeting of efforts and resources.

Differences in Perioperative Outcomes Between Right and Left Hepatic Lobectomy

The safety of hepatic resection is well documented, but outcome studies comparing right and left hepatic lobectomy are sparse, especially in the context of malignancy. This study analyzes the differences in outcomes between right and left hepatic lobectomy in patients with malignant diagnoses. All patients undergoing right and left hepatic lobectomies for malignancy were extracted from the National Surgical Quality Improvement Program (NSQIP) database (2005-2010). The data was analyzed to determine differences in perioperative mortality and morbidity between the two groups. A total of 1680 patients who underwent right or left hepatic lobectomy for malignant diagnoses were identified. Patients undergoing right hepatic lobectomy had a four-fold increase in perioperative mortality, compared to left lobectomy (p < 0.0001). Mortality in right lobectomy patients increased incrementally with age, with a 12-fold increase in patients > 81 years of age. Patients undergoing right lobectomy also experienced a statistically significant increase in morbidity involving several systems (infectious, pulmonary, cardiac and renal). The results of our study demonstrate that patients undergoing right hepatic lobectomy for malignancy experience a significantly higher incidence of mortality and multi-system morbidity when compared to left lobectomy. This information will be crucial for pre-operative risk-stratification of patients undergoing hepatic resection for malignancy.

Influence of providers and nurses on completion of non-targeted HIV screening in an urgent care setting

Introduction

Despite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic.

Methods

We collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing.

Results

Visit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses.

Conclusions

Visit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates.

Development of mast cells and importance of their tryptase and chymase serine proteases in inflammation and wound healing

Mast cells (MCs) are active participants in blood coagulation and innate and acquired immunity. This review focuses on the development of mouse and human MCs, as well as the involvement of their granule serine proteases in inflammation and the connective tissue remodeling that occurs during the different phases of the healing process of wounded skin and other organs. The accumulated data suggest that MCs, their tryptases, and their chymases play important roles in tissue repair. While MCs initially promote healing, they can be detrimental if they are chronically stimulated or if too many MCs become activated at the same time. The possibility that MCs and their granule serine proteases contribute to the formation of keloid and hypertrophic scars makes them potential targets for therapeutic intervention in the repair of damaged skin.

Catechol-O-methyltransferase val158met polymorphism predicts placebo effect in irritable bowel syndrome

Identifying patients who are potential placebo responders has major implications for clinical practice and trial design. Catechol-O-methyltransferase (COMT), an important enzyme in dopamine catabolism plays a key role in processes associated with the placebo effect such as reward, pain, memory and learning. We hypothesized that the COMT functional val158met polymorphism, was a predictor of placebo effects and tested our hypothesis in a subset of 104 patients from a previously reported randomized controlled trial in irritable bowel syndrome (IBS). The three treatment arms from this study were: no-treatment (“waitlist”), placebo treatment alone (“limited”) and, placebo treatment “augmented” with a supportive patient-health care provider interaction. The primary outcome measure was change from baseline in IBS-Symptom Severity Scale (IBS-SSS) after three weeks of treatment. In a regression model, the number of methionine alleles in COMT val158met was linearly related to placebo response as measured by changes in IBS-SSS (p = .035). The strongest placebo response occurred in met/met homozygotes treated in the augmented placebo arm. A smaller met/met associated effect was observed with limited placebo treatment and there was no effect in the waitlist control. These data support our hypothesis that the COMT val158met polymorphism is a potential biomarker of placebo response.