Using the win ratio to compare laparoscopic versus open liver resection for colorectal cancer liver metastases

Background

We sought to assess the overall benefit of laparoscopic versus open hepatectomy for treatment of colorectal liver metastases (CRLMs) using the win ratio, a novel methodological approach.

Methods

CRLM patients undergoing curative-intent resection in 2001-2018 were identified from an international multi-institutional database. Patients were paired and matched based on age, number and size of lesions, lymph node status and receipt of preoperative chemotherapy. The win ratio was calculated based on margin status, severity of postoperative complications, 90-day mortality, time to recurrence, and time to death.

Results

Among 962 patients, the majority underwent open hepatectomy (n=832, 86.5%), while a minority underwent laparoscopic hepatectomy (n=130, 13.5%). Among matched patient-to-patient pairs, the odds of the patient undergoing laparoscopic resection "winning" were 1.77 [WR: 1.77, 95% confidence interval (CI): 1.42-2.34]. The win ratio favored laparoscopic hepatectomy independent of low (WR: 2.94, 95% CI: 1.20-6.39), medium (WR: 1.56, 95% CI: 1.16-2.10) or high (WR: 7.25, 95% CI: 1.13-32.0) tumor burden, as well as unilobar (WR: 1.71, 95% CI: 1.25-2.31) or bilobar (WR: 4.57, 95% CI: 2.36-8.64) disease. The odds of "winning" were particularly pronounced relative to short-term outcomes (i.e., 90-day mortality and severity of postoperative complications) (WR: 4.06, 95% CI: 2.33-7.78).

Conclusions

Patients undergoing laparoscopic hepatectomy had 77% increased odds of "winning". Laparoscopic liver resection should be strongly considered as a preferred approach to resection in CRLM patients.

Association of County-level Upward Economic Mobility with Stage at Diagnosis and Receipt of Treatment Among Patients Diagnosed with Pancreatic Adenocarcinoma

OBJECTIVE

Determining the impact of county-level upward economic mobility on stage at diagnosis and receipt of treatment among Medicare beneficiaries with pancreatic adenocarcinoma.

SUMMARY BACKGROUND DATA

The extent to which economic mobility contributes to socioeconomic disparities in health outcomes remains largely unknown.

METHODS

Pancreatic adenocarcinoma patients diagnosed in 2004-2015 were identified from the SEER-Medicare linked database. Information on countylevel upward economic mobility was obtained from the Opportunity Atlas. Its impact on early-stage diagnosis (stage I or II), as well as receipt of chemotherapy or surgery was analyzed, stratified by patient race/ethnicity.

RESULTS

Among 25,233 patients with pancreatic adenocarcinoma, 37.1% (n = 9349) were diagnosed at an early stage; only 16.7% (n = 4218) underwent resection, whereas 31.7% (n = 7996) received chemotherapy. In turn, 10,073 (39.9%) patients received any treatment. Individuals from counties with high upward economic mobility were more likely to be diagnosed at an earlier stage (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.25), as well as to receive surgery (OR 1.58, 95% CI 1.41-1.77) or chemotherapy (OR 1.51, 95% CI 1.39-1.63). White patients and patients who identified as neither White or Black had increased odds of being diagnosed at an early stage (OR 1.12, 95% CI 1.02-1.22 and OR 1.35, 95% CI 1.02-1.80, respectively) and of receiving treatment (OR 1.73, 95% CI 1.59-1.88 and OR 1.49, 95% CI 1.13-1.98, respectively) when they resided in a county of high vs low upward economic mobility. The impact of economic mobility on stage at diagnosis and receipt of treatment was much less pronounced among Black patients (high vs low, OR 1.28, 95% CI 0.96-1.71 and OR 1.30, 95% CI 0.99-1.72, respectively).

CONCLUSIONS

Pancreatic adenocarcinoma patients from higher upward mobility areas were more likely to be diagnosed at an earlier stage, as well as to receive surgery or chemotherapy. The impact of county-level upward mobility was less pronounced among Black patients.

Burnout Assessment Among Surgeons and Surgical Trainees During the COVID-19 Pandemic: A Systematic Review

BACKGROUND

The objective of the current study was to summarize current research on burnout among surgical trainees and surgeons during the COVID-19 pandemic.

METHODS

PubMed, SCOPUS, Embase, and Psych INFO were systematically searched for studies that evaluated burnout during the COVID-19 pandemic among surgical trainees and surgeons.

RESULTS

A total of 29 articles met inclusion criteria, most of which originated from the United States (n = 18, 62.1%). Rates of burnout ranged from 6.0% to 86.0%. Personal factors responsible for burnout were fear of contracting/transmitting COVID-19 (8 studies, 27.6%), female gender (8, 27.6%), and younger age (5, 17.2%). Professional factors contributing to burnout included increased COVID-19 patient clinical load (6, 20.7%), limited work experience (6, 20.7%), reduction in operative cases (5, 17.2%) and redeployment to COVID-19 wards (4, 13.8%). The COVID-19 pandemic negatively impacted surgical education due to reduced number of operative cases (11, 37.9%), decreased hands-on experience (4, 13.8%), and not being able to complete case requirements (3, 10.34%). The shift of didactics to virtual formats (3, 10.3%), increased use of telemedicine (2, 6.9%), and improved camaraderie among residents (1, 3.4%) were viewed as positive consequences.

CONCLUSION

COVID-19 related burnout was reported in as many as 1 in 2 surgical trainees and attending surgeons. Intrinsic- (i.e., gender, age), family- (i.e., family/being married/having children or being single/not having children), as well as work-related extrinsic- (i.e., work-force deployment, risk of infection/spread, changes in educational format) factors were strongly associated with risk of burnout. These factors should be considered when designing interventions to ameliorate burnout among surgical trainees and surgeons.

Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis

INTRODUCTION

Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach.

METHODS

Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission.

RESULTS

Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14).

CONCLUSIONS

MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.

Telehealth Utilization Among Surgical Oncology Patients at a Large Academic Cancer Center

Background

The coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth within medicine. Data on sociodemographic and clinical characteristics associated with telehealth utilization among cancer surgical patients have not been well-defined.

Methods

Cancer patients who had a surgical oncology visit at the James Cancer Hospital in March 2020–May 2021 were included. Patient demographic and clinical characteristics were recorded; access to modern information technology was measured using the Digital Divide Index (DDI). A logistic regression model was used to assess odds of receiving a telehealth.

Results

Among 2942 patients, median DDI was 18.2 (interquartile range 17.4–22.1). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–0.98 per 10-year increase), sex (male vs. female: OR 1.83, 95% CI 1.45–2.32), cancer type (pancreatic vs. breast: OR 9.19, 95% CI 6.38–13.23; colorectal vs. breast: OR 5.31, 95% CI 3.71–7.58), insurance type (Medicare vs. Medicaid: OR 1.58, 95% CI 1.04–2.41) and county of residence (distant vs. neighboring: OR 1.33, 95% CI 1.06–1.66) were associated with increased odds of receiving a telehealth visit. Patients from high DDI counties were not less likely to receive telehealth visits versus patients from low DDI counties (OR 1.15, 95% CI 0.85–1.57).

Conclusions

Several patient sociodemographic and clinical characteristics had an impact on the likelihood of receiving a telehealth visit versus an in-person visit, suggesting that telehealth may not be equally accessible to all surgical oncology patients.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-12259-9.

Association of County-Level Upward Economic Mobility with Stage at Diagnosis and Receipt of Curative-Intent Treatment among Patients with Hepatocellular Carcinoma

BACKGROUND

Upward economic mobility represents the ability of children to surpass their parents financially and improve their economic status. The extent to which it contributes to socioeconomic disparities in health outcomes remains largely unknown.

METHODS

Patients diagnosed with hepatocellular carcinoma (HCC) in 2004-2015 were identified from the SEER-Medicare linked database. Information on county-level upward economic mobility was obtained from the Opportunity Atlas, and its impact on early-stage diagnosis (tumor size ≤ 5 cm, no nodal involvement or distant metastases, no major vascular invasion or extrahepatic extension) and receipt of curative-intent treatment (resection, transplantation, or ablation) was examined.

RESULTS

Among 9190 Medicare beneficiaries diagnosed with HCC, the majority were White (64.9%, n = 5965). Overall, 44.7% (n = 4105) of patients were diagnosed with early-stage HCC and 29.7% (n = 2731) underwent curative-intent treatment. While higher upward economic mobility was not associated with HCC diagnosis at an early stage (OR 0.94, 95% CI 0.83-1.06), patients with early-stage HCC from areas of high upward economic mobility had increased odds of undergoing curative-intent treatment (OR 1.25, 95% CI 1.03-1.51). Upward economic mobility had no impact on the likelihood to undergo curative-intent treatment for early-stage HCC among White (OR 1.15, 95% CI 0.91-1.45), Black (OR 1.94, 95% CI 0.85-4.45) or Asian patients (OR 0.77, 95% CI 0.44-1.36). In contrast, non-White patients other than Blacks or Asians diagnosed with early-stage HCC had markedly higher odds of receiving curative-intent treatment if the individual resided in an area characterized by higher versus lower upward economic mobility (OR 2.58, 95% CI 1.50-4.46).

CONCLUSIONS

While community-level economic mobility was not associated with stage of diagnosis, it affected the likelihood of undergoing curative-intent treatment for early-stage HCC, especially among minority patients other than Black or Asian patients.

Financial Impact of Out-of-Pocket Costs Among Patients Undergoing Resection for Colorectal Carcinoma

Introduction

Little is known about the societal burden of cancer surgical care in terms of out-of-pocket (OOP) costs. The current study sought to define OOP costs incurred by patients undergoing colorectal cancer resection.

Methods

Privately insured patients undergoing colorectal cancer resection between 2013 and 2017 were identified from the IBM MarketScan database. Total and OOP costs were calculated within 1 year prior to and 1 year post surgery. A multivariable linear regression model was used to estimate total OOP costs relative to patient demographic and clinical characteristics.

Results

Among 10,935 patients, 7289 (66.7%) had primary colon cancer while 3643 (33.3%) had rectal cancer. Median total costs were US$93,967 (IQR US$51027–168,251). Median OOP costs were US$4417 (IQR US$2519–6943), or 4.5% (IQR 2.2–8.1%) of total costs. OOP costs varied over the course of patient care; specifically, median OOP costs in the preoperative period were US$432 (IQR US$130–1452) versus US$2146 (IQR US$851–3525) in the perioperative period and US$969 (IQR US$327–2239) in the postoperative period. On multivariable analysis, receipt of chemotherapy (+US$1368, 95%CI +US$1211 to +US$1525) or radiotherapy (+US$842, 95% CI +US$626 to +US$1059) was associated with higher total OOP costs. Patients with a health maintenance organization (HMO) (−US$2119, 95% CI −US$2550 to −US$1689) or a point-of-service plan (−US$938, 95% CI −US$1385 to −US$491) had lower total OOP costs than patients with comprehensive insurance. In contrast, patients with a consumer-driven or a high-deductible health plan had considerably higher total OOP costs than patients with comprehensive insurance (+US$1400, 95% CI +US$972 to +US$1827 and +US$3243, 95% CI +US$2767 to +US$3717, respectively).

Conclusions

Privately insured colorectal cancer patients undergoing surgical resection pay a median of US$4417 in OOP costs, or 4.5% of total costs. OOP costs varied with receipt of chemotherapy or radiotherapy, region of residence, and insurance plan type.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11755-2.

Machine Learning Approach to Stratifying Prognosis Relative to Tumor Burden after Resection of Colorectal Liver Metastases: An International Cohort Analysis

BACKGROUND

Assessing overall tumor burden on the basis of tumor number and size may assist in prognostic stratification of patients after resection of colorectal liver metastases (CRLM). We sought to define the prognostic accuracy of tumor burden by using machine learning (ML) algorithms compared with other commonly used prognostic scoring systems.

STUDY DESIGN

Patients who underwent hepatectomy for CRLM between 2001 and 2018 were identified from a multi-institutional database and split into training and validation cohorts. ML was used to define tumor burden (ML-TB) based on CRLM tumor number and size thresholds associated with 5-year overall survival. Prognostic ability of ML-TB was compared with the Fong and Genetic and Morphological Evaluation scores using Cohen's d.

RESULTS

Among 1,344 patients who underwent resection of CRLM, median tumor number (2, interquartile range 1 to 3) and size (3 cm, interquartile range 2.0 to 5.0) were comparable in the training (n = 672) vs validation (n = 672) cohorts; patient age (training 60.8 vs validation 61.0) and preoperative CEA (training 10.2 ng/mL vs validation 8.3 ng/mL) was also similar (p > 0.05). ML empirically derived optimal cutoff thresholds for number of lesions (3) and size of the largest lesion (1.3 cm) in the training cohort, which were then used to categorize patients in the validation cohort into 3 prognostic groups. Patients with low, average, or high ML-TB had markedly different 5-year overall survival (51.6%, 40.9%, and 23.1%, respectively; p < 0.001). ML-TB was more effective at stratifying patients relative to 5-year overall survival (low vs high ML-TB, d = 2.73) vs the Fong clinical (d = 1.61) or Genetic and Morphological Evaluation (d = 0.84) scores.

CONCLUSIONS

Using a large international cohort, ML was able to stratify patients into 3 distinct prognostic categories based on overall tumor burden. ML-TB was noted to be superior to other CRLM prognostic scoring systems.

Patterns of health care utilization among Medicare beneficiaries diagnosed with pancreatic adenocarcinoma

BACKGROUND

Care patterns among patients diagnosed with pancreatic adenocarcinoma remain poorly defined.

METHODS

Cluster analysis was performed on patients with pancreatic adenocarcinoma to assess time from diagnosis to death spent in different care settings (home self-care-dominant[HSC], acute in-hospital care-dominant[ACS], hospice care-dominant[HC] or mixed home and hospice care[MHH]).

RESULTS

Among 32,816 patients, most belonged to the HSC group (n = 13,459, 41%), followed by MHH (n = 9,091, 28%), ACS (n = 5,737, 18%) and HC (n = 4,529, 14%). Only about 1 in 3 patients in the HSC (n = 4,028, 30%) or ACS (n = 2,206, 35%) received hospice services for at least one week before death. 16% of patients (n = 5,188) died in the hospital, which was most common among ACS patients (n = 1,640, 29%). Median daily expenditures varied according to health care utilization (HSC, $44.6, IQR 12.3-130.1 vs MHH, $162.3, IQR 60.5-351.9 vs ACS, $489.7, IQR 243.2-856.8 vs HC, $306.1, IQR 132.3-580.0; p < 0.001).

CONCLUSIONS

Pancreatic adenocarcinoma patients differed with regards to health care utilization, hospice use and expenditures following diagnosis.

Fragmentation of practice: The adverse effect of surgeons moving around

BACKGROUND

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.

METHOD

Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

RESULTS

Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05).

CONCLUSION

Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery

BACKGROUND

There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery.

METHODS

Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome.

RESULTS

Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4.

CONCLUSION

Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.

Trends in Textbook Outcomes over Time: Are Optimal Outcomes Following Complex Gastrointestinal Surgery for Cancer Increasing?

BACKGROUND

The use of composite measures like "textbook outcome" (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer.

METHODS

Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time.

RESULTS

Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p < 0.001). The proportion of patients achieving a textbook outcome increased over time for all patients (2004-2007, 53.3% vs. 2008-2011, 56.5% vs. 2012-2016, 60.1%) (5-year increase: OR 1.16 95%CI 1.13-1.18) (p < 0.001). Survival at 1-year following pancreatic, liver, or colon resection for cancer had improved over time among both patients who did and did not achieve a postoperative TO. TO was independently associated with a marked reduction in hazard of death (HR 0.44, 95%CI 0.43-0.45). The association of TO and survival was consistent among patients stratified by procedure.

CONCLUSION

Less than two-thirds of patients undergoing complex gastrointestinal surgery for a malignant indication achieved a TO. The likelihood of achieving a TO increased over time and was associated with improved survival.

Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients?

BACKGROUND AND OBJECTIVES

Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients.

METHODS

Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy.

RESULTS

Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p < 0.05). The odds of achieving a TOO improved over time (p-trend < 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45).

CONCLUSIONS

Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.

Dynamic Prediction of Survival after Curative Resection of Gastric Adenocarcinoma: A landmarking-based analysis

BACKGROUND

Accurate estimation of survival and recurrence are important to inform decisions regarding therapy and surveillance. We sought to design and validate a dynamic prognostic model for patients undergoing resection for gastric adenocarcinoma.

METHODS

Patients who underwent curative-intent surgery for gastric adenocarcinoma between 2000 and 2020 were identified using a multi-institutional database. Landmark analysis was used to create dynamic OS and DFS prediction models. Model performance was internally cross-validated via bootstrap resampling.

RESULTS

Among 895 patients, 507 (57.2%) patients underwent partial gastrectomy (n = 507, 57.2%) while 380 (42.8%) had total gastrectomy. Median tumor size was 40 mm (IQR: 25-65), most tumors were located in the antrum (n = 344, 39.5%) and infiltrated the subserosa (T3 tumors: n = 283, 31.9%) or serosa (T4 tumors: n = 253, 28.5%); lymph node metastasis occurred in 528 (59.1%) patients. Median OS and DFS were 17.5 (IQR: 7.5-42.8) and 14.3 months (IQR: 6.5-39.9), respectively. The impact of age, sex, preoperative comorbidities, tumor size and location, extent of lymphadenectomy and total number of lymph nodes examined, Lauren class, T and N category, postoperative complications, and tumor recurrence varied over time (all p < 0.05). An online tool to predict dynamic OS and DFS based on patient survival relative to time survived was developed and made available for clinical use. Discrimination ability of OS and DFS was excellent (C-index: 0.84 and 0.86, respectively) and calibration plots revealed good prediction.

CONCLUSIONS

An online dynamic prognostic tool was developed and validated to predict OS and DFS following resection of gastric adenocarcinoma. Landmark analysis to predict long-term outcomes based on follow-up time may be helpful to surgeons and patients.

Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery

BACKGROUND

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined.

METHODS

The Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined.

RESULTS

Among 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194-1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04-6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39-30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11-1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04-1.13), nonelective surgery (HR 1.19, 95%CI 1.14-1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05-1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29-6.61) and non-cancer patients (HR 6.98, 95%CI 6.37-7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08-28.02), as well as non-cancer (HR 30.81, 95%CI 27.01-35.15) patients.

CONCLUSIONS

Patients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1-2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.

Emergency Department Utilization Following Hepatopancreatic Surgery Among Medicare Beneficiaries

BACKGROUND

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge.

METHODS

The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated.

RESULTS

Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07-1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32-1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10-1.23) and patients not discharged home (OR 1.41, 95%CI 1.33-1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87-0.97 and OR 0.22, 95%CI 0.20-0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days.

CONCLUSION

More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Trends in Discharge Disposition Following Hepatectomy for Hepatocellular Carcinoma Among Medicare Beneficiaries

BACKGROUND

Post-acute care (PAC) services can include home healthcare, long-term care hospitals, and skilled nursing facilities. We sought to define factors associated with PAC discharge disposition among Medicare beneficiaries who underwent hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Data for Medicare beneficiaries with a diagnosis of HCC and who underwent a hepatectomy between 2004 and 2015 were retrieved from the SEER-Medicare database. Discharge disposition was defined as routine (HSC: discharged to home) or non-routine (SNF/ICF, discharged to skilled nursing/intermediate care facilities, or HHA, discharge to home with home health agency). The Cochran-Mantel-Haenszel test and multivariable logistic regression were used to assess trends in discharge disposition.

RESULTS

Among 1305 patients, the median patient age at diagnosis was 72 years (IQR: 68-76). Approximately 4 in 5 patients were discharged to HSC (77.4%; n = 1010). The odds of a non-routine discharge decreased by 7.0% annually from 2004 to 2015 (OR_trend, 0.93; 95%CI, 0.89-0.97; p_trend = 0.001). Several factors were associated with non-routine discharge, including patient age (OR 1.06, 95%CI 1.04-1.09) and longer LOS (OR 1.07, 95%CI 1.05-1.10). In contrast, patients who had a minor hepatectomy (OR 0.69, 95%CI 0.52-0.93) at a teaching hospital (OR 0.63, 95%CI 0.45-0.89) had lower odds of a non-routine discharge (all P < 0.05). HSC discharge increased over time (2004-2007 (n = 205, 68.1%) vs. 2008-2011 (n = 330, 77.8%) vs. 2012-2015 (n = 475, 81.9%); p_trend < 0.001). Over the same time period, there was a decreasing trend in 90-day readmission (2004-2007 (n = 91, 30.2%) vs. 2008-2011 (n = 107, 25.2%) vs. 2012-2015 (n = 129, 22.2%); p_trend = 0.03).

CONCLUSION

Utilization of PAC services following hepatic resection of HCC decreased by 57.0% between 2004 and 2015. These data highlight that decreased PAC utilization was not generally associated with higher readmission rates following resection of HCC.

Association of Community Economic Distress and Breast and Colorectal Cancer Screening, Incidence, and Mortality Rates Among US Counties

INTRODUCTION

Not all Americans may benefit equally from current improvements in breast and colorectal cancer screening and mortality rates.

METHODS

We performed a cross-sectional retrospective review of county-level screening, incidence, and mortality rates for breast and colon cancer utilizing three publicly available data sources from the Centers for Disease Control and Prevention (CDC), and their association with the Distressed Communities Index (DCI), a measure of local economic prosperity across communities.

RESULTS

After controlling for other factors, DCI was associated with county-level screening, incidence, and death rates per 100,000 for breast and colorectal cancer. There was an absolute increase of 0.77 (95% confidence interval [CI] 0.67-0.85, p < 0.001) in the proportion of women aged 40 years or older who had a screening mammogram for every 10-point decrease in DCI, which in turn correlated with an increase in the age-adjusted incidence by 1.68 per 100,000 (95% CI 1.37-2.00, p < 0.001). While the age-adjusted death rate for breast cancer was highest in the most distressed communities, the overall incidence of age-adjusted death decreased by 0.28 per 100,000 (95% CI -0.37 to -0.19, p < 0.001) with every 10-point decrease in DCI. For colorectal cancer, every 10-point decrease in DCI was similarly associated with an absolute 0.60 (95% CI 0.52-0.69, p < 0.001) increase in the proportion of individuals who had screening endoscopy. Increased colorectal screening in low-DCI counties was associated with a lower age-adjusted incidence rate (-0.80 per 100,000; 95% CI -0.94 to -0.65) and age-adjusted death rate (-0.55 per 100,000; 95% CI -0.62 to -0.49) of colorectal cancer per every 10-point decrease in DCI (p < 0.001).

CONCLUSION

The association of county-level socioeconomic and healthcare factors with breast and colorectal cancer outcomes was notable, with level of community distress impacting cancer screening, incidence, and mortality rates.

Impact of Tumor Burden Score on Conditional Survival after Curative-Intent Resection for Hepatocellular Carcinoma: A Multi-Institutional Analysis

BACKGROUND

The impact of tumor burden score (TBS) on conditional survival (CS) among patients undergoing curative-intent resection of hepatocellular carcinoma (HCC) has not been examined to date.

METHODS

Patients who underwent liver resection of HCC between 2000 and 2017 were identified from a multi-institutional database. The impact of TBS and other clinicopathologic factors on 3-year conditional survival (CS₃) was examined.

RESULTS

Among 1,040 patients, 263 (25.3%) patients had low TBS, 668 (64.2%) had medium TBS and 109 (10.5%) had high TBS. TBS was strongly associated with OS; 5-year OS was 39.0% among patients with high TBS compared with 61.1% and 79.4% among patients with medium and low TBS, respectively (p < 0.001). While actuarial survival decreased as time elapsed from resection, CS increased over time irrespective of TBS. The largest differences between 3-year actuarial survival and CS₃ were noted among patients with high TBS (5-years postoperatively; CS₃: 78.7% vs. 3-year actuarial survival: 30.7%). The effect of adverse clinicopathologic factors including high TBS, poor/undifferentiated tumor grade, microvascular invasion, liver capsule involvement, and positive margins on prognosis decreased over time.

CONCLUSIONS

CS rates among patients who underwent resection for HCC increased as patients survived additional years, irrespective of TBS. CS estimates can be used to provide important dynamic information relative to the changing survival probability after resection of HCC.

Profiles in social vulnerability: The association of social determinants of health with postoperative surgical outcomes

BACKGROUND

The association of different social vulnerability subthemes (ie, socioeconomic status, household composition and disability, minority status and language, and housing and transportation) with surgical outcomes remains poorly defined. The current study aimed to identify distinct profiles of social vulnerability among Medicare beneficiaries and define the association of these profiles with postoperative outcomes.

METHODS

The Medicare 100% Standard Analytic Files were used to identify patients undergoing lung resection, coronary artery bypass grafting, abdominal aortic aneurysm repair, and colectomy between 2013 and 2017. A cluster analysis was performed based on ranked scores across the 4 subthemes of the Centers for Disease Control and Prevention social vulnerability index. The likelihood of complications, extended length of stay, readmission, and mortality were assessed relative to cluster vulnerability profiles.

RESULTS

Among 852,449 Medicare beneficiaries undergoing surgery, median social vulnerability index among patients in the cohort was 49 (interquartile range: 24-74); cluster analysis revealed 5 vulnerability profiles that had heterogeneity in the vulnerability subthemes, even among patients with similar overall social vulnerability index scores. Postoperative outcomes differed across the 5 vulnerability profiles, with patients in the profiles characterized by higher overall vulnerability having worse postoperative outcomes. In particular, risk of complications (profile 1, 31.9% vs profile 5, 34.0%), extended length of stay (profile 1, 21.7% vs profile 5, 24.3%), 30-day readmission (profile 1, 12.6% vs profile 5, 13.2%), and 30-day mortality (profile 1, 4.0% vs profile 5, 4.7%) was greater among patients with the highest vulnerability (all P < .01). Of note, surgical outcomes varied among patients who resided in communities with similar average social vulnerability index scores (social vulnerability index 49-54). In particular, patients in social vulnerability profile 4 had 26% increased odds of 30-day mortality compared to social vulnerability profile 2 patients (odds ratio 1.26, 95% confidence interval 1.21-1.30). Additionally, profile 3 patients had 15% higher odds of 30-day mortality versus profile 2 patients (odds ratio 1.15, 95% confidence interval 1.10-1.20).

CONCLUSION

Postoperative outcomes differed across patients based on cluster vulnerability profiles. Despite similar overall aggregate social vulnerability index scores, cluster analysis was able to discriminate various social determinants of health subthemes among patients who resided in "average" vulnerability communities that stratified patients relative to risk of adverse postoperative events.

Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer

INTRODUCTION

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined.

OBJECTIVE

The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery.

METHODS

The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined.

RESULTS

Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities.

CONCLUSION

Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.

Association of Depression with In-Patient and Post-Discharge Disposition and Expenditures Among Medicare Beneficiaries Undergoing Resection for Cancer

BACKGROUND

The impact of depression on utilization of post-discharge care and overall episode of care expenditures remains poorly defined. We sought to define the impact of depression on postoperative outcomes, including discharge disposition, as well as overall expenditures associated with the global episode of surgical care.

METHOD

The Medicare 100% Standard Analytic Files were used to identify patients undergoing resection for esophageal, colon, rectal, pancreatic, and liver cancer between 2013 and 2017. The impact of depression on inpatient outcomes, as well as home health care and skilled nursing facilities utilization and expenditures, was analyzed.

RESULTS

Among 113,263 patients, 14,618 (12.9%) individuals had depression. Patients with depression were more likely to experience postoperative complications (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.31-1.42), extended length of stay (LOS) (OR 1.41, 95% CI 1.36-1.47), readmission within 90 days (OR 1.20, 95% CI 1.14-1.25), as well as 90-day mortality (OR 1.35, 95% CI 1.27-1.42) (all p < 0.05). In turn, the proportion of patients who achieved a textbook outcome following cancer surgery was lower among patients with depression (no depression: 53.3% vs. depression: 45.3%; OR 0.70, 95% CI 0.68-0.73). Patients with a preexisting diagnosis of depression had higher odds of additional post-discharge expenditures compared with individuals without a diagnosis of depression (OR 1.42; 95% CI 1.35-1.50); patients with a preexisting diagnosis of depression ($10,500, IQR $3,200-$22,500) had higher median post-discharge expenditures versus patients without depression ($6600, IQR $2100-$17,400) (p < 0.001). On multivariable analysis, after controlling for other factors, depression remained associated with a 19.0% (95% confidence interval [CI] 15.7-22.3%) increase in post-discharge expenditures.

CONCLUSIONS

Patients with depression undergoing resection for cancer had worse in-patient outcomes and were less likely to achieve a TO. Patients with depression were more likely to require post-discharge care and had higher post-discharge expenditures.

Postoperative imaging surveillance for hepatocellular carcinoma: How much is enough?

BACKGROUND

The objective of the current study was to define trends in postoperative surveillance imaging following liver-directed treatment of hepatocellular carcinoma (HCC), and characterize the impact of high-intensity surveillance on long-term survival.

METHODS

Patients who underwent liver- directed therapy for HCC between 2004 and 2016 were identified using the SEER-Medicare database. Trends in surveillance intensity over time, factors associated with high surveillance intensity and the impact of surveillance on long-term outcomes were examined.

RESULTS

Utilization of high-intensity surveillance abdominal imaging (≥6 scans over 2 years) following liver-directed therapy of HCC decreased over time (2004-2007: n = 130, 36.1% vs. 2008-2011: n = 181, 29.5% vs. 2012-2016: n = 111, 24.5%; p_trend  < 0.001). History of chronic viral hepatitis (hepatitis B: odds ratio [OR], 1.98; 95% confidence interval [CI]: 1.15-3.43; hepatitis C: OR, 1.79; 95% CI: 1.32-2.43), presence of regional (vs. local-only) disease (OR, 1.47; 95% CI: 1.09-1.98) and receipt of transplantation (OR, 2.23; 95% CI: 1.57-3.17) were associated with higher odds of high intensity surveillance. Intensity of surveillance imaging was not associated with long-term survival (5-year overall survival: low-intensity, 48.1% vs. high-intensity, 48.9%; hazards ratio, 0.94; 95% CI: 0.78-1.13).

CONCLUSION

Utilization of posttreatment surveillance imaging decreased over time following liver-directed therapy for HCC. While utilization of high-intensity screening varied by HCC procedure performed, intensity of surveillance had no effect on survival.