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Merath K, Tiwari A, Parikh AA, Pawlik TM. Molecular targeted and systemic therapy for intrahepatic cholangiocarcinoma: a multi-disciplinary approach. Future Oncol 2023; 19:2607-2621. [PMID: 38108100 DOI: 10.2217/fon-2023-0098] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Most patients with intrahepatic cholangiocarcinoma (ICC) are diagnosed with advanced disease. For individuals with resectable tumors, R0 resection with lymphadenectomy is the best potentially curative-intent treatment. After resection, adjuvant therapy with capecitabine is the current standard of care. For patients with unresectable or distant metastatic disease, doublet chemotherapy with gemcitabine and cisplatin is the most utilized first-line regimen, but recent studies using triplet regimens and even the addition of immunotherapy have begun to shift the paradigm of systemic therapy. Molecular therapies have recently received US FDA approval for second-line treatment for patients harboring actionable genomic alterations. This review focuses on the multidisciplinary approach to the treatment of ICC with an emphasis on molecular targeted and systemic therapy.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Ankur Tiwari
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center & James Comprehensive Cancer Center, Columbus, OH 43210, USA
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Merath K, Tiwari A, Court C, Parikh A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Postoperative Liver Failure: Definitions, Risk factors, Prediction Models and Prevention Strategies. J Gastrointest Surg 2023; 27:2640-2649. [PMID: 37783906 DOI: 10.1007/s11605-023-05834-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Liver resection is the treatment for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique, and perioperative management, post hepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. METHODS A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in May of 2023. The MESH terms "liver failure," "liver insufficiency," and "hepatic failure" in combination with "liver surgery," "liver resection," and "hepatectomy" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications. RESULTS PHLF can have devastating physiological consequences. In general, risk factors can be categorized as patient-related, primary liver function-related, or perioperative factors. Currently, no effective treatment options are available and the management of PHLF is largely supportive. Therefore, identifying risk factors and preventative strategies for PHLF is paramount. Ensuring an adequate future liver remnant is important to mitigate risk of PHLF. Dynamic liver function tests provide more objective assessment of liver function based on the metabolic capacity of the liver and have the advantage of easy administration, low cost, and easy reproducibility. CONCLUSION Given the absence of randomized data specifically related to the management of PHLF, current strategies are based on the principles of management of acute liver failure from any cause. In addition, goal-directed therapy for organ dysfunction, as well as identification and treatment of reversible factors in the postoperative period are critical.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Ankur Tiwari
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Colin Court
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Alexander Parikh
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Moro A, Ejaz A, Dillhoff M, Cloyd J, Tsung A, Pawlik TM. Quality of Care Among Medicare Patients Undergoing Pancreatic Surgery: Safety Grade, Magnet Recognition, and Leapfrog Minimum Volume Standards-Which Quality Benchmark Matters? J Gastrointest Surg 2021; 25:269-277. [PMID: 32040811 DOI: 10.1007/s11605-019-04504-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 11/21/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The association of national quality benchmarking metrics with postoperative outcomes following complex surgery remains unknown. We assessed the relationship between the "quality trifactor" of Leapfrog minimum volume standards, Hospital Safety Grade A, and Magnet Recognition with outcomes of Medicare patients undergoing pancreatectomy. METHODS The Standard Analytic Files (SAF) merged with Leapfrog Hospital Survey and Leapfrog Safety Scores Denominator Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013 and 2015. Primary outcomes were overall and serious complications, as well as 30- and 90-day mortality. Multivariable logistic regression analyses were conducted to evaluate possible associations among hospitals meeting the quality trifactor and short-term outcomes. RESULTS Among 4853 Medicare patients, 909 (18.7%) underwent pancreatectomy at hospitals meeting the quality trifactor. Among 260 hospitals, 7.3% (n = 19) met the quality trifactor. Safety Grade A (48.8%, n = 127) was the most commonly met criterion followed by Magnet Recognition (36.2%, n = 94); the Leapfrog minimum volume standards were achieved by 25% (n = 65) of hospitals. Patients undergoing surgery at hospitals that were only Safety Grade A and Magnet designated, but did not meet Leapfrog criteria, had higher odds of serious complications (OR 1.59, 95% CI 1.00-2.51). In contrast, patients undergoing treatment at hospitals having all three designations (i.e., the quality trifactor) had 40% and 39% lower odds of both serious complications (OR 0.60, 95% CI 0.37-0.97) and 90-day mortality (OR 0.61, 95% CI 0.42-0.89), respectively. In turn, patients undergoing pancreatectomy at quality trifactor hospitals had higher odds of experiencing the composite quality measure textbook outcome (OR 1.28, 95% CI 1.03-1.59) versus patients undergoing pancreatectomy at non-trifactor hospitals. CONCLUSION While Safety Grade A and Magnet designation alone were not associated with higher odds of an optimal composite outcome following pancreatectomy, compliance with Leapfrog criteria to achieve the "quality trifactor" metric was associated with lower odds of serious complications and mortality.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Farooq A, Paredes AZ, Merath K, Hyer JM, Mehta R, Sahara K, Tsilimigras DI, Moro A, Wu L, Cloyd J, Ejaz A, Pawlik TM. How Safe Are Safety-Net Hospitals? Opportunities to Improve Outcomes for Vulnerable Patients Undergoing Hepatopancreaticobiliary Surgery. J Gastrointest Surg 2020; 24:2570-2578. [PMID: 31792898 DOI: 10.1007/s11605-019-04428-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 07/19/2019] [Accepted: 09/30/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined. METHODS Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined. RESULTS Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001). CONCLUSION Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.
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Affiliation(s)
- Ayesha Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Columbus, OH, USA. .,Oncology, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Sahara K, Merath K, Hyer JM, Paredes AZ, Tsilimigras DI, Mehta R, Farooq SA, Moro A, Wu L, White S, Endo I, Pawlik TM. Impact of Preoperative Cholangitis on Short-term Outcomes Among Patients Undergoing Liver Resection. J Gastrointest Surg 2020; 24:2508-2516. [PMID: 31745898 DOI: 10.1007/s11605-019-04430-7] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes. METHODS Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC. RESULTS Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality. CONCLUSION Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda A Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Merath K, Cerullo M, Farooq A, Canner JK, He J, Tsilimigras DI, Mehta R, Paredes AZ, Sahara K, Dillhoff M, Tsung A, Cloyd J, Ejaz A, Pawlik TM. Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition? J Gastrointest Surg 2020; 24:2491-2499. [PMID: 31630368 DOI: 10.1007/s11605-019-04408-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission. METHODS Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed. RESULTS In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively). CONCLUSION Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jen He
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Farooq A, Paredes AZ, Merath K, Mehta R, Moro A, Wu L, Sahara K, Hyer JM, Tsilimigras DI, Diaz A, Pawlik TM. Hepatopancreatobiliary Surgery: the Role of Clinical Resources and Variation in Performance of Hospitals Located in "Distressed" Communities. J Gastrointest Surg 2020; 24:2277-2285. [PMID: 31621025 DOI: 10.1007/s11605-019-04401-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/14/2019] [Accepted: 09/05/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The USA has one of the largest known income-based health disparities, with low-income adults being up to five times more likely to report being in poor health. We evaluated the association of hospital zip-code-based distressed communities index (DCI) with post-surgical outcomes following hepatopancreatobiliary (HPB) surgery. METHODS Adults undergoing HPB surgery were identified in the National Inpatient Sample. The association between hospital socioeconomic distress and outcomes including complications, mortality, failure to rescue (FTR), and never events were compared between high-distress facilities (HDF) and low-distress facilities (LDF). RESULTS A total of 11,119 (37.8%) patients underwent an operation at an HDF. Patients treated at HDF were younger (18-39 years, HDF: n = 1261, 11.3% vs. LDF: n = 966, 9.0%; p < 0.001), Black/Hispanic (HDF: n = 2060, 18.5% vs. LDF: n = 1440, 11.4%; p < 0.001) and in the lowest income quartile (HDF: n = 2825, 25.4% vs. LDF: n = 1116, 10.8%; p < 0.001). While complications were comparable at HDF versus LDF (HDF: n = 2483, 22.3% vs. LDF: n = 2370, 22.0%; p = 0.28), patients treated at HDF had higher odds of in-hospital mortality (OR, 1.31; 95% CI, 1.07-1.59), FTR (OR, 1.24; 95% CI, 1.02-1.52), and a never event (OR, 1.76; 95% CI, 1.29-2.39; all p < 0.001). Hospitals having advanced internal medicine services had reduced odds of mortality (OR, 0.61; 95% CI, 0.47-0.80) whereas high nurse-to-patient ratio was associated with reduced odds of a complication (OR, 0.89; 95% CI, 0.81-0.98). CONCLUSION Approximately 40% of patients were admitted to HDF. These patients were more likely to be Black/Hispanic and underinsured. Perioperative outcomes were worse at HDF following HPB surgery.
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Affiliation(s)
- Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA. .,Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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Farooq A, Sahara K, Muneeb A, Farooq K, Tsilimigras DI, Merath K, Mehta R, Paredes A, Wu L, Hyer JM, Beal E, Pawlik TM, Dillhoff ME. Analysis of Authorship in Hepatopancreaticobiliary Surgery: Women Remain Underrepresented. J Gastrointest Surg 2020; 24:2070-2076. [PMID: 31396842 DOI: 10.1007/s11605-019-04340-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 04/29/2019] [Accepted: 07/21/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Given the need to increase female representation in hepatopancreatobiliary (HPB) surgery, as well as the need to increase the academic pipeline of women in this subspecialty, we sought to characterize the prevalence of female authorship in the HPB literature. In particular, the objective of the current study was to determine the proportion of women who published HPB research articles as first, second, or last author over the last decade. METHODS All articles pertaining to hepatopancreaticobiliary (HPB) surgery appearing in seven surgical journals (Annals of Surgery, British Journal of Surgery, JAMA Surgery, Annals of Surgical Oncology, HPB (Oxford), Surgery, and Journal of Gastrointestinal Surgery) were reviewed for the years 2008 and 2018. Information on sex of author, country of author's institution, and article type was collected and entered into a computerized database. RESULTS Among the 1473 index articles included in the final analytic cohort, 414 (28%) publications had a woman as the first or last author, while the vast majority (n = 1,059, 72%) had a man as the first or last author. The number of female first authors increased from 15.6% (n = 92/591) in 2008 to 25.7% (n = 227/882) in 2018 (p < 0.001). There were no differences in the proportion of second (n = 123/536, 23.0% vs n = 214/869, 24.6%, p = 0.47) or last (n = 44/564, 7.8% vs n = 88/875, 10.1%, p = 0.15) authors. Women were more likely to publish papers appearing in medium-impact journals (OR 1.40, 95% CI 1.04-1.88) and articles with a female author were more likely to be from a North American institution (referent: North America, Asia OR 0.43, 95% CI 0.31-0.59 vs Europe OR 0.67, 95% CI 0.51-0.87). CONCLUSION Women first/last authors in HPB research articles have increased over the past 10 years from 22 to 32%. Women as last authors remain low, however, as only 1 in 10 papers had a senior woman author. These data should prompt HPB leaders to find solutions to the gap in female authorship including mentorship of young female researchers and surgeons.
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Affiliation(s)
- Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | | | - Khadija Farooq
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Anghela Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Lu Wu
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Eliza Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA
| | - Mary E Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave., Columbus, OH, 43210, USA.
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Merath K, Hyer JM, Mehta R, Farooq A, Bagante F, Sahara K, Tsilimigras DI, Beal E, Paredes AZ, Wu L, Ejaz A, Pawlik TM. Use of Machine Learning for Prediction of Patient Risk of Postoperative Complications After Liver, Pancreatic, and Colorectal Surgery. J Gastrointest Surg 2020; 24:1843-1851. [PMID: 31385172 DOI: 10.1007/s11605-019-04338-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [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: 05/20/2019] [Accepted: 07/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. RESULTS Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). CONCLUSION Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Merath K, Palmer Kelly E, Hyer JM, Mehta R, Agne JL, Deans K, Fischer BA, Pawlik TM. Patient Perceptions About the Role of Religion and Spirituality During Cancer Care. J Relig Health 2020; 59:1933-1945. [PMID: 31482443 DOI: 10.1007/s10943-019-00907-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We sought to assess the perspectives of cancer patients relative to their spiritual well-being, as well as examine the impact of religion/spirituality during cancer care. A mixed-methods concurrent embedded online survey design was used. While 86% of participants indicated a religious/spiritual belief, respondents also reported lower overall spiritual well-being than population norms (t(73) = - 5.30, p < 0.01). Open-ended responses revealed that 22% of participants desired the healthcare team to address the topic of religion/spirituality, but the majority preferred to discuss with a family member or friend (48%). Religion/spirituality might play a central role for a subset of patients across the cancer journey.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | | | - J Madison Hyer
- Department of Surgery, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Julia L Agne
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katherine Deans
- Department of Surgery, Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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11
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Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Farooq A, Mehta R, Wu L, Beal EW, White S, Endo I, Pawlik TM. Impact of Surgeon Volume on Outcomes and Expenditure Among Medicare Beneficiaries Undergoing Liver Resection: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 2020; 24:1520-1529. [PMID: 31325139 DOI: 10.1007/s11605-019-04323-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 04/08/2019] [Accepted: 07/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR). METHODS Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined. RESULTS Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055). CONCLUSION Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Ayesha Farooq
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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12
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Farooq A, Bae J, Rice D, Moro A, Paredes AZ, Crisp AL, Windholtz M, Sahara K, Tsilimigras DI, Hyer JM, Merath K, Mehta R, Parasidis E, Pawlik TM. Inside the courtroom: An analysis of malpractice litigation in gallbladder surgery. Surgery 2020; 168:56-61. [DOI: 10.1016/j.surg.2020.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/26/2020] [Accepted: 04/07/2020] [Indexed: 01/10/2023]
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13
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Mehta R, Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Ejaz A, Cloyd JM, Dillhoff M, Tsung A, Pawlik TM. Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies. J Gastrointest Surg 2020; 24:1320-1329. [PMID: 31197689 PMCID: PMC7011949 DOI: 10.1007/s11605-019-04288-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/14/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care. METHODS Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined. RESULTS In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22-0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34-0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38-0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76-2.71). CONCLUSION Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anghela Z. Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
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14
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Ejaz A, Pawlik TM. In-hospital Mortality Following Pancreatoduodenectomy: a Comprehensive Analysis. J Gastrointest Surg 2020; 24:1119-1126. [PMID: 31292889 DOI: 10.1007/s11605-019-04307-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 04/15/2019] [Accepted: 06/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed. METHODS Retrospective review of the National Inpatient Sample database (January 2004-December 2014) was conducted to identify patients undergoing PD. Factors associated with in-hospital mortality after PD were analyzed after adjusting for previously defined patient- and hospital-level risk factors. RESULTS A total of 9639 patients who underwent a PD at 2325 hospitals were identified. Median patient age was 57 years (IQR 66-73). Overall, mortality following PD was 3.2%. When patient- and hospital-level characteristics were analyzed in the same model, patient-level characteristic associated with increased odds of in-hospital mortality included increasing patient age (OR 1.05, 95% CI 1.03-1.06/per 5 years increase), male sex (OR 1.47, 95% CI 1.16-1.86), the presence of liver disease (OR 3.03, 95% CI 1.99-4.61), chronic kidney disease (OR 1.78, 95% CI 1.18-2.68), and congestive heart failure (OR 2.48, 95% CI 1.65-3.74). The only hospital characteristic associated with odds of mortality following PD included compliance with Leapfrog volume standards (OR 0.70, 95% CI 0.54-0.92). CONCLUSION Patient-level factors, such as advanced comorbidities, male sex, and increased age, contributed the most to increased risk of mortality after PD. Hospital volume was the only hospital-level factor contributing to risk of in-hospital mortality following PD.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Farooq A, Merath K, Paredes AZ, Wu L, Tsilimigras DI, Hyer JM, Sahara K, Mehta R, Beal EW, Pawlik TM. Outcomes of Patients with Scirrhous Hepatocellular Carcinoma: Insights from the National Cancer Database. J Gastrointest Surg 2020; 24:1049-1060. [PMID: 31243715 DOI: 10.1007/s11605-019-04282-1] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/20/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Scirrhous hepatocellular carcinoma (HCC) is a rare primary liver tumor characterized by extensive fibrosis and production of parathyroid hormone-related peptide. There have been conflicting reports on patient survival in scirrhous versus non-scirrhous HCC. The objective of the present study was to define the clinical features, practice patterns, and long-term outcomes of patients with scirrhous HCC versus non-scirrhous HCC in a propensity score-matched cohort. METHODS A propensity score-matched cohort was created using data from the National Cancer Database for 2004 to 2015. A multivariable Cox proportional hazards regression analysis was performed to assess the effect of the scirrhous HCC variant on overall survival. RESULTS Among the 70,426 patients with a diagnosis of HCC who met the inclusion criteria, 99.8% had non-scirrhous HCC (n = 70,290) whereas a small subset had scirrhous HCC (n = 136, 0.19%). While 20,330 (28.9%) patients underwent liver-directed therapy (resection, ablation, and transplantation), the majority did not (n = 50,096, 71.1%). After propensity matching, there were no difference in 1-, 3-, or 5-year overall survival among patients with scirrhous versus non-scirrhous HCC (1-year overall survival (OS), 53.7% versus 51.0%; 3-year OS, 34.6% versus 28.7%; and 5-year OS, 18.0% versus 21.0%, respectively; p = 0.52). While the scirrhous HCC variant was not associated with survival (hazard ratio [HR] 0.93, 95% CI 0.74-1.16), non-receipt of liver-directed therapy (HR 0.24, 95% CI 0.18-0.32), advanced AJCC stage (III/IV) (HR 2.14, 95% CI 1.55-2.95), and non-academic facilities (HR 0.60, 95% CI 0.49-0.73) remained associated with worse survival. CONCLUSION Patients with the scirrhous variant had a comparable overall survival compared with individuals who had non-scirrhous HCC. Failure to receive liver-directed therapy, advanced AJCC stage (III/IV), and treatment at a non-academic facility was strongly associated with a worse long-term prognosis.
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Affiliation(s)
- Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Sahara K, Paredes AZ, Merath K, Tsilimigras DI, Bagante F, Ratti F, Marques HP, Soubrane O, Beal EW, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Aklile W, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Evaluation of the ACS NSQIP Surgical Risk Calculator in Elderly Patients Undergoing Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2020; 24:551-559. [PMID: 30937717 DOI: 10.1007/s11605-019-04174-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Eliza W Beal
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Workneh Aklile
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Wu L, Merath K, Farooq A, Hyer JM, Tsilimigras DI, Paredes AZ, Mehta R, Sahara K, Shen F, Pawlik TM. Photodynamic therapy may provide a benefit over systemic chemotherapy among non-surgically managed patients with extrahepatic cholangiocarcinoma. J Surg Oncol 2020; 121:286-293. [PMID: 31742706 DOI: 10.1002/jso.25773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 08/16/2019] [Accepted: 11/11/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Systemic chemotherapy is the standard treatment for patients with unresectable extrahepatic cholangiocarcinoma (ECC), however, the survival benefit of chemotherapy is limited. Photodynamic therapy (PDT) has been associated with improved survival among patients with advanced ECC, yet utilization of PDT remains low. We sought to compare the outcomes of patients with unresectable ECC following treatment with PDT versus chemotherapy. METHODS A review of the National Cancer Database was conducted to identify patients with ECC who were nonsurgically managed between 2004 and 2013. Overall survival (OS) of patients receiving PDT vs systemic chemotherapy was compared using propensity score matching. RESULTS After propensity matching (PDT, n = 59; chemotherapy, n = 177), 5-year OS was 17.6% (95% confidence interval [CI], 9.0%-28.6%) among patients who underwent PDT vs 3.8% (95%CI, 0.4%-14.0%) among patients receiving chemotherapy (P < .001). On multivariable analysis PDT was associated with an OS benefit (hazard ratio, 0.72; 95%CI, 0.52-0.998; P = .048). Subset analysis of patients receiving PDT only (n = 45) and patients receiving chemotherapy demonstrated similar results. In subset analysis of patients undergoing PDT-only vs PDT-chemotherapy, OS was comparable. CONCLUSION PDT was associated with a survival benefit compared with chemotherapy alone among patients with unresectable ECC.
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Affiliation(s)
- Lu Wu
- Department of Hepatic Surgery, Eastern Hepato-biliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Feng Shen
- Department of Hepatic Surgery, Eastern Hepato-biliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Sahara K, Farooq SA, Tsilimigras DI, Merath K, Paredes AZ, Wu L, Mehta R, Hyer JM, Endo I, Pawlik TM. Immunotherapy utilization for hepatobiliary cancer in the United States: disparities among patients with different socioeconomic status. Hepatobiliary Surg Nutr 2020; 9:13-24. [PMID: 32140475 DOI: 10.21037/hbsn.2019.07.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Indexed: 12/18/2022]
Abstract
Background Patients with advanced hepatobiliary cancer (HBC) have a dismal prognosis and limited treatment options. Immunotherapy has been considered as a promising treatment, especially for cancers not amenable to surgery. Methods Between 2004, and 2015, patients diagnosed with hepatocellular carcinoma (HCC), intra- and extrahepatic cholangiocarcinoma and gallbladder cancer (GBC) were identified in the National Cancer Database. Results Among 249,913 patients with HBC, only 585 (0.2%) patients received immunotherapy. Among patients who received immunotherapy, most patients were diagnosed between 2012 and 2015, had private insurance, as well as an income ≥$46,000 and were treated at an academic facility. The use of immunotherapy among HBC patients varied by diagnosis (HCC, 67.7%; bile duct cancer, 14%). On multivariable analysis, a more recent period of diagnosis (OR 1.80, 95% CI: 1.44-2.25), median income >$46,000 (OR 1.43, 95% CI: 1.11-1.87), and higher tumor stage (stage III, OR 2.22, 95% CI: 1.65-3.01; stage IV, OR 3.24, 95% CI: 2.41-4.34) were associated with greater odds of receiving immunotherapy. Conclusions Overall utilization of immunotherapy in the US among patients with HBC was very low, yet has increased over time. Certain socioeconomic factors were associated with an increased likely of receiving immunotherapy, suggesting disparities in access of patients with lower socioeconomic status.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - S Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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Paredes AZ, Hyer JM, Tsilimigras DI, Merath K, Mehta R, Sahara K, Farooq SA, Wu L, White S, Pawlik TM. Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries. HPB (Oxford) 2020; 22:109-115. [PMID: 31231061 DOI: 10.1016/j.hpb.2019.05.012] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/27/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown. METHODS The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy. RESULTS Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71-80] vs. 71 [IQR 68-76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32-15.29, p = 0.016). CONCLUSION While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days.
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Affiliation(s)
- Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - James Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda Ayesha Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Beal EW, Mehta R, Tsilimigras DI, Hyer JM, Paredes AZ, Merath K, Dillhoff ME, Cloyd JM, Ejaz A, Pawlik TM. Travel to a high volume hospital to undergo resection of gallbladder cancer: does it impact quality of care and long-term outcomes? HPB (Oxford) 2020; 22:41-49. [PMID: 31186198 DOI: 10.1016/j.hpb.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 03/21/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relationship of volume and travel distance to patient outcomes after resection of gallbladder cancer (GBC) remains poorly defined. METHODS The 2004-2015 National Cancer Database was used to identify GBC resection patients and examine the impact of travel distance, hospital volume and both on overall survival (OS) and quality of care indicators. RESULTS Among 10,174 patients undergoing surgery for GBC, the majority of patients were Caucasian (N = 8,175, 80%) and had a Charlson-Deyo comorbidity score of 0 (N = 6,785, 67%). On unadjusted survival analysis increasing travel distance and hospital volume were associated with improved OS (both p < 0.001). After controlling for competing risk factors, the 4th quartile of hospital volume was associated with a decreased hazard of death (HR 0.831, 95% CI 0.751-0.920, p < 0.001). When both hospital volume and travel distance were included, the association with improved OS persisted only for hospital volume (4th quartile HR 0.835, 95% CI 0.753-0.925, p < 0.001), whereas there was no independent association of increasing travel distance with OS. CONCLUSIONS Both increasing travel distance and hospital volume were associated with improved OS; however, adjusted models demonstrated that the impact of travel distance was mediated through hospital volume.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Mehta R, Paredes AZ, Tsilimigras DI, Farooq A, Sahara K, Merath K, Hyer JM, White S, Ejaz A, Tsung A, Dillhoff M, Cloyd JM, Pawlik TM. CMS Hospital Compare System of Star Ratings and Surgical Outcomes Among Patients Undergoing Surgery for Cancer: Do the Ratings Matter? Ann Surg Oncol 2019; 27:3138-3146. [PMID: 31792714 DOI: 10.1245/s10434-019-08088-y] [Citation(s) in RCA: 5] [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: 06/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) Hospital Compare star rating system has been proposed as a means to assess hospital quality performance. The current study aimed to investigate outcomes and payments among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer across hospital star rating groups. METHODS The Medicare Standard Analytic Files (SAF) from 2013 to 2015 were used to derive the analytic cohort. The association of star ratings to perioperative outcomes and expenditures was examined. RESULTS Among 119,854 patients, the majority underwent surgery at a 3-star (n = 34,901, 29.1%) or 4-star (n = 30,492, 25.4%) hospital. Only 12.2% (n = 14,732) were treated at a 5-star hospital. Across all procedures examined, patients who underwent surgery at a 1-star hospital had greater odds of death within 90 days than patients who had surgery at a 5-star hospital (colorectal, 1.41 [95% confidence interval {CI}, 1.25-1.60]; lung, 1.97 [95% CI 1.56-2.48]; esophagectomy, 1.83 [95% CI 0.81-4.16]; pancreatectomy, 1.70 [95% CI 1.20-2.41]; hepatectomy, 1.63 [95% CI 0.96-2.77]). A similar trend was noted for failure to rescue (FTR), with the greatest odds of FTR associated with 1-star hospitals. The median expenditure associated with an abdominal operation was $1661 more at a 1-star hospital than at a 5-star hospital (1-star: $17,399 vs 5-star: $15,738). A similar trend was noted for thoracic operations. CONCLUSION The risk of FTR, 90-day mortality, and increased hospital expenditure were all higher at a 1-star hospital. Further research is needed to investigate barriers to care at 5-star-rated hospitals and to target specific interventions to improve outcomes at 1-star hospitals.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Susan White
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH, USA.
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Tsilimigras DI, Bagante F, Moris D, Merath K, Paredes AZ, Sahara K, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Defining the chance of cure after resection for hepatocellular carcinoma within and beyond the Barcelona Clinic Liver Cancer guidelines: A multi-institutional analysis of 1,010 patients. Surgery 2019; 166:967-974. [DOI: 10.1016/j.surg.2019.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/30/2019] [Accepted: 08/23/2019] [Indexed: 02/08/2023]
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23
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Sahara K, Paredes AZ, Tsilimigras DI, Hyer JM, Merath K, Wu L, Mehta R, Beal EW, White S, Endo I, Pawlik TM. Impact of Liver Cirrhosis on Perioperative Outcomes Among Elderly Patients Undergoing Hepatectomy: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 2019; 23:2346-2353. [PMID: 30719676 DOI: 10.1007/s11605-019-04117-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 11/21/2018] [Accepted: 01/09/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of cirrhosis on perioperative outcomes for elderly patients undergoing hepatectomy remains not well defined. We sought to determine the influence of underlying cirrhosis and minimally invasive surgery (MIS) on postoperative outcomes among elderly patients who underwent a hepatectomy. METHODS Patients who underwent hepatectomy between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after hepatectomy, stratified by the presence of cirrhosis and MIS, were examined. RESULTS Among 7452 patients who underwent a hepatectomy, a minority had cirrhosis (n = 481, 6.5%) whereas the vast majority did not (n = 6971, 93.5%). Overall, median patient age was 72 years (IQR 68-76) and preoperative Charlson comorbidity score was 6 (IQR 2-8). Patients with cirrhosis were more likely to be younger (median age 71 [67-76] vs 72 [IQR 68-76] years), male (64.4% vs 50%), African American (8.1% vs 6.4%) and have a malignant diagnosis (87.1% vs 78.7%) compared to non-cirrhotic patients (all p < 0.001). There was no difference among patients with and without cirrhosis regarding type of hepatectomy or surgical approach (open vs MIS) (both p > 0.05). Patients with versus without cirrhosis had similar complication rates (24.1% vs 22.3%, p = 0.36), as well as 30-day (6.2% vs 5%, p = 0.25) and 90-day (10.4% vs 8.5%, p = 0.15) mortality. MIS reduced the length-of-stay in non-cirrhotic patients (OR 0.79, 95% CI 0.62-0.99, p < 0.05), yet was not associated with morbidity or mortality (both p > 0.05). CONCLUSION The presence of cirrhosis did not generally impact outcomes in elderly patients undergoing hepatectomy for benign and malignant diseases. MIS hepatectomy in the elderly Medicare beneficiary population reduced LOS among patients without cirrhosis, yet was not associated with differences in morbidity or mortality.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Mehta R, Merath K, Farooq A, Sahara K, Tsilimigras DI, Ejaz A, Hyer JM, Paredes AZ, Dillhoff M, Cloyd JM, Pawlik TM. U.S. News and World Report hospital ranking and surgical outcomes among patients undergoing surgery for cancer. J Surg Oncol 2019; 120:1327-1334. [DOI: 10.1002/jso.25751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Kota Sahara
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Anghela Z. Paredes
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical CenterColumbus Ohio
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Merath K, Chen Q, Diaz A, Johnson M, Mehta R, Dillhoff M, Cloyd J, Pawlik TM. Local referrals as a strategy for increasing value of surgical care among medicare patients undergoing liver and pancreatic surgery. HPB (Oxford) 2019; 21:1552-1562. [PMID: 31000338 DOI: 10.1016/j.hpb.2019.03.371] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The focus of the current Medicare payment reform is to increase value - i.e. improve health care quality while lowering costs. This study sought to define cost variation and surgical quality among hospitals within small geographic areas typical of work commute patterns. METHODS Medicare Provider Analysis and Review (MEDPAR) Inpatient Files was used to identify patients undergoing elective liver and pancreatic surgery between 2013 and 2015. Hospitals were assigned to combined statistical areas (CSAs) based on zip codes. Average price-standardized Medicare payments were used to identify highest- and lowest-cost hospitals within CSAs, and clinical outcomes were compared. RESULTS The study included 12,016 patients. Medicare payments for index hospitalization were 45% ($12,580), 42% ($16,831), 44% ($12,901) and 50% ($18,605) higher for the highest-vs. lowest-cost hospitals for non-complex pancreatic procedures, complex pancreatic procedures, non-complex liver procedures, and complex liver procedures, respectively. Surgical quality was worse at highest-vs. lowest-cost hospitals, demonstrated by higher rates of complications, prolonged LOS and 90-day mortality. CONCLUSION There was a significant variation in surgical cost for each procedure between CSAs, and within CSAs. Highest-cost hospitals demonstrated worse quality metrics than the lowest-cost hospitals. Local referrals to low-cost hospitals represent an opportunity for increasing value of surgical care.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Morgan Johnson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Wu L, Tsilimigras DI, Farooq A, Hyer JM, Merath K, Paredes AZ, Mehta R, Sahara K, Shen F, Pawlik TM. Potential survival benefit of radiofrequency ablation for small solitary intrahepatic cholangiocarcinoma in nonsurgically managed patients: A population‐based analysis. J Surg Oncol 2019; 120:1358-1364. [DOI: 10.1002/jso.25736] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/07/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Lu Wu
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery HospitalSecond Military Medical University Shanghai China
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Anghela Z. Paredes
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Rittal Mehta
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Kota Sahara
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
| | - Feng Shen
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery HospitalSecond Military Medical University Shanghai China
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute Columbus Ohio
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Farooq SA, Muneeb A, Farooq K, Sahara K, Tsilimigras D, Merath K, Mehta R, Paredes A, Pawlik TM, Dillhoff ME. Female Authorship in Hepatopancreatobiliary Surgery. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.385] [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: 11/16/2022]
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Merath K, Cerullo M, Farooq SA, Tsilimigras DI, Canner JK, Sahara K, Mehta R, Paredes A, He J, Pawlik TM. Routine ICU Admission after Hepatectomy for Cancer Does Not Decrease Rates of Failure-to-Rescue. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.405] [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: 11/26/2022]
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Sahara K, Merath K, Tsilimigras DI, Hyer JM, Guglielmi A, Aldrighetti L, Weiss M, Fields RC, Poultsides GA, Maithel SK, Endo I, Pawlik TM, other members of the U.S. Neuroendo. Conditional disease‐free survival after curative‐intent liver resection for neuroendocrine liver metastasis. J Surg Oncol 2019; 120:1087-1095. [DOI: 10.1002/jso.25713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
- Department of Gastroenterological SurgeryYokohama City University School of MedicineYokohama Japan
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | - Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | | | | | - Matthew Weiss
- Department of SurgeryJohns Hopkins HospitalBaltimore Maryland
| | - Ryan C. Fields
- Department of SurgeryWashington University School of MedicineSt Louis Missouri
| | | | | | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University School of MedicineYokohama Japan
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
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Ruzzenente A, Bagante F, Ratti F, Beal EW, Alexandrescu S, Merath K, Makris EA, Poultsides GA, Margonis GA, Weiss MJ, Popescu I, Aldrighetti L, Guglielmi A, Pawlik TM. Response to preoperative chemotherapy: impact of change in total burden score and mutational tumor status on prognosis of patients undergoing resection for colorectal liver metastases. HPB (Oxford) 2019; 21:1230-1239. [PMID: 30792047 DOI: 10.1016/j.hpb.2019.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 10/10/2018] [Revised: 12/29/2018] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Progression of colorectal liver metastasis (CRLM) on preoperative chemotherapy has been associated with a worse prognosis compared with patients who have responsive disease. Defining response can be challenging as traditional criteria largely assess only tumor size. METHODS Patients who underwent hepatectomy between 2010 and 2017 were identified using a multi-centric database. This study aimed to define the impact of preoperative chemotherapy response relative to initial tumor burden score (TBS) and determine impact of clinico-pathological variables on overall survival (OS). RESULTS Among 784 patients who received preoperative chemotherapy, the regimen was oxaliplatin- (66%) or irinotecan-based (34%). Among patients with a TBS<6 at diagnosis, genetic status was the most important prognostic variable. Patients with a TBS<6, 5-year OS was 55%, 35%, and 0% for patients with KRAS/NRAS/BRAF wild-type, KRAS/NRAS, and BRAF mutations, respectively. Among patients who presented with CRLM with a TBS≥6, only Δ-TBS was prognostically important and patients with a Δ-TBS ≥ -10% had a 5-year OS of 27% compared with 49% for patients with a Δ-TBS < -10%. CONCLUSIONS Prognostic stratification of patients with CRLM receiving preoperative chemotherapy should be multi-faceted and include consideration of initial tumor burden, change in tumor burden due to chemotherapy, and tumor genetic status.
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Affiliation(s)
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Georgios A Margonis
- Department of Surgery, The Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Akgul O, Merath K, Mehta R, Hyer JM, Chakedis J, Wiemann B, Johnson M, Paredes A, Dillhoff M, Cloyd J, Pawlik TM. Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy-Stratification of Patient Risk. J Gastrointest Surg 2019; 23:1817-1824. [PMID: 30478529 DOI: 10.1007/s11605-018-4045-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). We sought to develop and validate a risk score system that utilized preoperative computed tomography (CT) measurements, laboratory values, and intraoperative pancreatic texture to estimate risk of developing POPF after PD. METHODS Patients who underwent PD between 2014 and 2017 were identified. Pre- and intraoperative risk factors associated with POPF were identified. Three separate risk models were developed and assessed using multivariable analyses and receiver operating curves. RESULTS Among the 150 patients who underwent a PD, mean age was 64 years and the majority of the patients were male (59.3%, n = 89). Overall, the incidence of BL/POPF following PD was 22%. On multivariable analysis, factors associated with POPF included preoperative total serum protein < 6 g/dL (OR 3.35, 95% CI 1.04-10.34, p = 0.04), radiologic pancreatic duct diameter (OR 0.72, 95% CI 0.53-0.97, p = 0.03), intraoperative pancreatic gland texture estimated by surgeon (OR 0.17, 95% CI 0.05-0.62, p = 0.006), as well as intraoperative pancreatic duct diameter measured by surgeon (OR 0.77, 95% CI 0.61-0.98, p = 0.030). Each risk factor was assigned a weighted score (CT pancreatic duct diameter < 5 mm: 8 points; soft pancreatic gland texture: 5 points; total serum protein < 6 g/dL: 3 points; CT visceral abdominal fat ≥ 230 cm2: 2 points). Patients scoring 4-5 were at low risk of POPF, while patients with a score of 6-18 had a high risk for POPF. The Harrell's c-index for the scoring system was 0.71 (standard error [SD] 0.094) for the training set and 0.67 (SD 0.034) for the test set (with n = 1000 bootstrapping resamples). CONCLUSION A simple risk score for POPF that utilized preoperative radiologic and clinical variables combined with specific intra-operative factors was able to stratify patients relative to POPF risk with good discriminatory ability.
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Affiliation(s)
- Ozgur Akgul
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jeffery Chakedis
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Brianne Wiemann
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Morgan Johnson
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Paredes
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Mary Dillhoff
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- The Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Oncology, Health Services Management and Policy, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Bagante F, Ruzzenente A, Beal EW, Campagnaro T, Merath K, Conci S, Akgül O, Alexandrescu S, Marques HP, Lam V, Shen F, Poultsides GA, Soubrane O, Martel G, Iacono C, Guglielmi A, Pawlik TM. Complications after liver surgery: a benchmark analysis. HPB (Oxford) 2019; 21:1139-1149. [PMID: 30718185 DOI: 10.1016/j.hpb.2018.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 09/20/2018] [Revised: 11/25/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The best achievable short-term outcomes after liver surgery have not been identified. Several factors may influence the post-operative course of patients undergoing hepatectomy increasing the risk of post-operative complications. We sought to identify risk-adjusted benchmark values [BMV] for liver surgery. METHODS The National Surgery Quality Improvement Program (NSQIP) database was used to develop Bayesian models to estimate risk-adjusted BMVs for overall and liver related (post-hepatectomy liver failure [PHLF], biliary leakage [BL]) complications. A separate international multi-institutional database was used to validate the risk-adjusted BMVs. RESULTS Among the 11,243 patients included in the NSQIP database, the incidence of complications, PHLF, and BL was 36%, 5%, and 8%, respectively. The risk-adjusted BMVs for complication (range, 16-72%), PHLF (range, 1%-20%), and BL (range, 4%-22%) demonstrated a high variability based on patients characteristics. When tested using an international database including nine institutes, the risk-adjusted BMVs for complications ranged from 26% (Institute-4) to 43% (Institute-1), BMVs for PHLF between 3% (Institute-3) and 12% (Institute-5), while BMVs for BL ranged between 5% (Institute-4) and 9% (Institute-7). CONCLUSIONS Multiple factors influence the risk of complications following hepatectomy. Risk-adjusted BMVs are likely much more applicable and appropriate in assessing "acceptable" benchmark outcomes following liver surgery.
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Affiliation(s)
- Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Surgery, University of Verona, Verona, Italy
| | | | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Simone Conci
- Department of Surgery, University of Verona, Verona, Italy
| | - Ozgür Akgül
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, AP-HP, Beaujon Hospital, Clichy, France
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Sahara K, Paredes AZ, Mehta R, Hyer JM, Tsilimigras DI, Merath K, Farooq SA, Wu L, Moro A, Beal EW, Endo I, Pawlik TM. Potential disease burden of patients with substance abuse undergoing major abdominal surgery: A propensity score-matched analysis. Surgery 2019; 166:1181-1187. [PMID: 31378476 DOI: 10.1016/j.surg.2019.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/08/2019] [Accepted: 06/22/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Over 19 million Americans have a substance abuse disorder. The current study sought to characterize the relationship between substance abuse with in-hospital outcomes following major, elective abdominal surgery. METHODS The Nationwide Inpatient Sample was used to identify patients who underwent major abdominal surgery between 2007 to 2014. Patients with preoperative substance abuse, including alcohol, opioids, and non-opioid drugs, were identified. Propensity score matching was used to examine the association of substance abuse with perioperative outcomes. RESULTS Among 301,659 patients, 7,925 patients (2.6%) had a history of substance abuse. Pancreatectomy was the surgical procedure with the highest proportion of patients with substance abuse history (n = 844, 4.7%). Compared with patients without a substance abuse history, patients with a substance abuse history were more likely to be younger (median age, 60 years [interquartile range (IQR) 52-69] vs 63 years [IQR 52-72]), male (n = 5,438, 67.5% vs n = 132,961, 54.7%), and be in the lowest income category (n = 2,062, 26% vs n = 64,345, 21.9%) (all P < .001). On propensity score matching, substance abuse was associated with increased odds ratio of experiencing a complication (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.55-1.82), non-home discharge (OR 1.95, 95% CI 1.76-2.16), extended length of stay (OR 1.88, 95% CI 1.76-2.02), and higher expenditure (OR 1.62, 95% CI 1.49-1.77). Stratified by the type of substance abuse, patients with history of alcohol (OR 1.57, 95% CI 1.44-1.71) and drug abuse (OR 1.26, 95% CI 1.14-1.39) were more likely to experience a complication, whereas only history of alcohol abuse was associated with higher odds ratio of in-hospital mortality (OR 1.38, 95% CI 1.07-1.79) (all P < .05). CONCLUSION Up to 1 in 50 patients undergoing complex abdominal surgery had a substance abuse history. History of substance abuse was associated with an increased risk of adverse perioperative outcomes and higher healthcare expenditures.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Gastroenterological Surgery Division, Yokohama City University School of Medicine, Japan
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Syeda A Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Mehta R, Ejaz A, Hyer JM, Tsilimigras DI, White S, Merath K, Sahara K, Bagante F, Paredes AZ, Cloyd JM, Dillhoff M, Tsung A, Pawlik TM. The Impact of Dedicated Cancer Centers on Outcomes Among Medicare Beneficiaries Undergoing Liver and Pancreatic Cancer Surgery. Ann Surg Oncol 2019; 26:4083-4090. [DOI: 10.1245/s10434-019-07677-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Indexed: 12/28/2022]
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Idrees JJ, Merath K, Gani F, Bagante F, Mehta R, Beal E, Cloyd JM, Pawlik TM. Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma. HPB (Oxford) 2019; 21:981-989. [PMID: 30591307 DOI: 10.1016/j.hpb.2018.11.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [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: 09/15/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS). METHODS Using the National Cancer Database (NCDB) 2004-2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS. RESULTS Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%-44%, p < 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%-15%, p < 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88-0.97, p < 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83-0.91, p < 0.001) were independently associated with improved OS. CONCLUSIONS Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Bagante
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Wu L, Tsilimigras DI, Farooq A, Hyer JM, Merath K, Paredes AZ, Mehta R, Sahara K, Shen F, Pawlik TM. Management and outcomes among patients with sarcomatoid hepatocellular carcinoma: A population-based analysis. Cancer 2019; 125:3767-3775. [PMID: 31299092 DOI: 10.1002/cncr.32396] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 05/03/2019] [Revised: 06/04/2019] [Accepted: 06/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Few data are available regarding the management and outcomes among patients with sarcomatoid hepatocellular carcinoma (HCC) due to its rarity. METHODS Patients diagnosed with sarcomatoid HCC from 2004 through 2015 were identified in the National Cancer Data Base. Overall survival (OS) was calculated among patients with sarcomatoid versus conventional HCC using a 1:3 propensity score matching based on sex, age, and American Joint Committee on Cancer (AJCC) stage of disease. RESULTS The final analytic cohort included 104 patients with sarcomatoid HCC and 312 patients with conventional HCC. Patients with sarcomatoid HCC more often had a larger median tumor size (8.5 cm vs 5.4 cm; P < .001) and poorly or undifferentiated tumors (52.9% vs 13.8%; P < .001) compared with patients who had conventional HCC. 5-year OS was worse among patients with sarcomatoid versus conventional HCC (5.7% vs 30.1%; P < .001). Subgroup analysis demonstrated worse 5-year OS among patients with sarcomatoid versus conventional HCC among patients treated with either curative-intent or palliative therapies. Stage-specific subgroup analysis indicated a worse OS among patients with AJCC stage I, stage II, or stage III sarcomatoid HCC. On multivariable analysis, uninsured status, advanced AJCC stage (stage III/stage IV), and histological sarcomatoid subtype were independently associated with worse outcomes (all P < .05). CONCLUSIONS Sarcomatoid HCC is a very rare variant of HCC, which was associated with larger tumor size and worse tumor grade on presentation. On propensity score matched analyses that controlled for known confounding factors, patients with sarcomatoid HCC had a worse stage-for-stage long-term survival compared with patients who had conventional HCC.
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Affiliation(s)
- Lu Wu
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.,Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Ayesha Farooq
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - J Madison Hyer
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Katiuscha Merath
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Anghela Z Paredes
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Rittal Mehta
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Kota Sahara
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Feng Shen
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Paredes AZ, Hyer JM, Beal EW, Bagante F, Merath K, Mehta R, White S, Pawlik TM. Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery. Surgery 2019; 166:1-7. [DOI: 10.1016/j.surg.2018.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 01/06/2023]
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Farooq A, Merath K, Hyer JM, Paredes AZ, Tsilimigras DI, Sahara K, Mehta R, Wu L, Cloyd JM, Ejaz A, Pawlik TM. Financial toxicity risk among adult patients undergoing cancer surgery in the United States: An analysis of the National Inpatient Sample. J Surg Oncol 2019; 120:397-406. [DOI: 10.1002/jso.25605] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/07/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Ayesha Farooq
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Katiuscha Merath
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - J. Madison Hyer
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Anghela Z. Paredes
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | | | - Kota Sahara
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Rittal Mehta
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Lu Wu
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Jordan M. Cloyd
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Aslam Ejaz
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Timothy M. Pawlik
- Department of SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
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Merath K, Chen Q, Bagante F, Alexandrescu S, Marques HP, Aldrighetti L, Maithel SK, Pulitano C, Weiss MJ, Bauer TW, Shen F, Poultsides GA, Soubrane O, Martel G, Koerkamp BG, Guglielmi A, Itaru E, Cloyd JM, Pawlik TM. A Multi-institutional International Analysis of Textbook Outcomes Among Patients Undergoing Curative-Intent Resection of Intrahepatic Cholangiocarcinoma. JAMA Surg 2019; 154:e190571. [PMID: 31017645 DOI: 10.1001/jamasurg.2019.0571] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Composite measures may be superior to individual measures for the analysis of hospital performance and quality of surgical care. Objective To determine the incidence of a so-called textbook outcome, a composite measure of the quality of surgical care, among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. Design, Setting, and Participants This cohort study involved an analysis of a multinational, multi-institutional cohort of patient from 15 major hepatobiliary centers in North America, Europe, Australia, and Asia who underwent curative-intent resection of intrahepatic cholangiocarcinoma between 1993 and 2015. Data analysis was conducted from April 2018 to May 2018. Main Outcomes and Measures Hospital variation in the composite end point of textbook outcome, defined as negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no 30-day readmissions, and no 30-day mortality. Secondary end points were factors associated with achieving textbook outcomes. Results Among 687 patients (of whom 370 [53.9%] were men; median patient age, 61 [range, 18-86] years) undergoing curative-intent resection of intrahepatic cholangiocarcinoma, a textbook outcome was achieved in 175 patients (25.5%). Being 60 years or younger (odds ratio [OR], 1.61 [95% CI, 1.04-2.49]; P = .03), absence of preoperative jaundice (OR, 4.40 [95% CI, 1.28-15.15]; P = .02), no neoadjuvant chemotherapy (OR, 2.57 [95% CI, 1.05-6.29]; P = .04), T1a/T1b-stage disease (OR, 1.58 [95% CI, 1.01-2.49]; P = .049), N0 status (OR, 3.89 [95% CI, 1.77-8.54]; P = .001), and no bile duct resection (OR, 2.46 [95% CI, 1.25-4.84]; P = .009) were independently associated with achieving a textbook outcome after resection. A prolonged length of stay had the greatest negative association with a textbook outcome. A nomogram to assess the probability of textbook outcome was developed and had good accuracy in both the training data set (area under the curve, 0.755) and validation data set (area under the curve, 0.763). Conclusions and Relevance In this study, while hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome was achieved in only approximately 26% of patients. A textbook outcome may be useful for the reporting of patient-level hospital performance and hospital variation, leading to quality improvement efforts after resection of intrahepatic cholangiocarcinoma.
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Affiliation(s)
| | - Qinyu Chen
- The Ohio State University Wexner Medical Center, Columbus
| | - Fabio Bagante
- The Ohio State University Wexner Medical Center, Columbus.,University of Verona, Verona, Italy
| | | | | | | | | | | | | | - Todd W Bauer
- University of Virginia, Charlottesville, Virginia
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | | | | | | | | | - Endo Itaru
- Yokohama City University, Yokohama, Japan
| | - Jordan M Cloyd
- The Ohio State University Wexner Medical Center, Columbus
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Merath K, Chen Q, Johnson M, Mehta R, Beal EW, Dillhoff M, Cloyd J, Pawlik TM. Hot spotting surgical patients undergoing hepatopancreatic procedures. HPB (Oxford) 2019; 21:765-772. [PMID: 30497897 DOI: 10.1016/j.hpb.2018.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 08/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The burden of health care spending in the United States is a major concern, as health care costs have exponentially increased during the last three decades. The objective of the current study was to investigate the degree of cost-concentration among Medicare patients undergoing liver and pancreatic surgery. METHODS Medicare claims data from 2013 to 2015 were used to identify patients undergoing elective liver and pancreatic resections. Patients were divided into four groups: 1) non-complex pancreatic procedures; 2) complex pancreatic procedures; 3) non-complex liver procedures; and 4) complex liver procedures. Unadjusted price-standardized Medicare payments were calculated and payments were divided into quintiles. Patient-level factors associated with payments were analyzed by multivariable linear regression. RESULTS A total of 17,125 patients were included in the study. Patients in the top quintile of spending accounted for over 40% of payments for all liver and pancreatic procedures. Patients with comorbidity scores ≥5, male sex, open surgical approach and a diagnosis of congestive heart failure were associated with higher costs. CONCLUSION Patients undergoing liver and pancreatic resections on the top 20% of payments were responsible for a disproportionate share of Medicare payments - over 40% of total expenditures. Overall hospital surgical volume was lower among the highest quintile of payments.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Morgan Johnson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Bagante F, Beal EW, Merath K, Mehta R, Pawlik TM. Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery. Surgery 2019; 165:1128-1135. [DOI: 10.1016/j.surg.2019.02.020] [Citation(s) in RCA: 8] [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: 12/14/2018] [Revised: 02/21/2019] [Accepted: 02/27/2019] [Indexed: 12/14/2022]
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Sahara K, Tsilimigras DI, Merath K, Bagante F, Guglielmi A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Soubrane O, Koerkamp BG, Matsuyama R, Endo I, Pawlik TM. Therapeutic Index Associated with Lymphadenectomy Among Patients with Intrahepatic Cholangiocarcinoma: Which Patients Benefit the Most from Nodal Evaluation? Ann Surg Oncol 2019; 26:2959-2968. [DOI: 10.1245/s10434-019-07483-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Indexed: 12/16/2022]
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Idrees JJ, Bagante F, Gani F, Rosinski BF, Chen Q, Merath K, Dillhoff M, Cloyd J, Pawlik TM. Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer. HPB (Oxford) 2019; 21:456-464. [PMID: 30266492 DOI: 10.1016/j.hpb.2018.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 05/08/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR. METHODS Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR. RESULTS Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (Δ = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7-12] vs. 14 days [IQR: 10-21]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were $13,093 lower for patients undergoing CR + LR (median costs: $36,775 [IQR: 26,416-54,245] vs. $23,682 [IQR: 16,299-32,996]). CONCLUSION CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faiz Gani
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Beal EW, Bagante F, Paredes A, Chen Q, Akgul O, Merath K, Dillhoff ME, Cloyd JM, Pawlik TM. Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted? J Gastrointest Surg 2019; 23:702-711. [PMID: 30039444 DOI: 10.1007/s11605-018-3882-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 05/06/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission. METHODS The National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90 days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals. RESULTS A total of 49,080 patients underwent HPB surgery (liver n = 27,081, 55%; pancreas n = 14,787, 30%; biliary n = 7212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90 days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90 days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥ 3 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay > 7 days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all p < 0.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, p = 0.010). CONCLUSIONS Roughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Tsilimigras DI, Hyer JM, Paredes AZ, Moris D, Beal EW, Merath K, Mehta R, Ejaz A, Cloyd JM, Pawlik TM. The optimal number of lymph nodes to evaluate among patients undergoing surgery for gallbladder cancer: Correlating the number of nodes removed with survival in 6531 patients. J Surg Oncol 2019; 119:1099-1107. [DOI: 10.1002/jso.25450] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/22/2019] [Accepted: 02/23/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Anghela Z. Paredes
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Dimitrios Moris
- Department of SurgeryDuke University Medical CenterDurham North Carolina
| | - Eliza W. Beal
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Rittal Mehta
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbus Ohio
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Merath K, Mehta R, Hyer JM, Bagante F, Sahara K, Alexandrescu S, Marques HP, Aldrighetti L, Maithel SK, Pulitano C, Weiss MJ, Bauer TW, Shen F, Poultsides GA, Soubrane O, Martel G, Koerkamp BG, Guglielmi A, Itaru E, Ejaz A, Pawlik TM. Impact of body mass index on tumor recurrence among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma- a multi-institutional international analysis. Eur J Surg Oncol 2019; 45:1084-1091. [PMID: 30871884 DOI: 10.1016/j.ejso.2019.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The association between body mass index (BMI) and long-term outcomes of patients with ICC has not been well defined. We sought to define the presentation and oncologic outcomes of patients with ICC undergoing curative-intent resection, according to their BMI category. METHODS Patients who underwent resection of ICC were identified in a multi-institutional database. Patients were categorized as normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2) and obese (BMI≥30 kg/m2) according to the World Health Organization (WHO) definition. Impact of clinico-pathological factors on recurrence-free survival (RFS) was assessed using Cox proportional hazards model among patients in the three BMI categories. RESULTS Among a total of 790 patients undergoing curative-intent resection of ICC in the analytic cohort, 399 (50.5%) had normal weight, 274 (34.7%) were overweight and 117 (14.8%) were obese. Caucasian patients were more likely to be obese (66.7%, n = 78) and overweight (47.1%, n = 129) compared with Asian (obese: 18.8%, n = 22; overweight: 46%, n = 126) and other races (obese: 14.5%, n = 17; overweight: 6.9%, n = 19)(p < 0.001). There were no differences in the presence of cirrhosis (10.9%, vs. 12.8%, vs. 12.9%), preoperative jaundice (8.6% vs. 9.5% vs. 12.0%), or levels of CA 19-9 (75, IQR 24.6-280 vs. 50.9, IQR 17.9-232 vs. 43, IQR 16.9-192.7) among the BMI groups (all p > 0.05). On multivariable analysis, increased BMI was an independent risk factor for tumor recurrence (OR 1.16, 95% CI 1.02-1.32, for every 5 unit increase). CONCLUSION Increasing BMI was associated with incremental increases in the risk of recurrence following curative-intent resection of ICC. Future studies should aim to achieve a better understanding of BMI-related factors relative to prognosis of patients with ICC.
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Affiliation(s)
- Katiuscha Merath
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- The Ohio State University Wexner Medical Center, Columbus, OH, USA; University of Verona, Verona, Italy
| | - Kota Sahara
- The Ohio State University Wexner Medical Center, Columbus, OH, USA; Yokohama City University, Yokohama, Japan
| | | | | | | | | | | | | | - Todd W Bauer
- University of Virginia, Charlottesville, VA, USA
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | | | | | | | | | - Endo Itaru
- Yokohama City University, Yokohama, Japan
| | - Aslam Ejaz
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Merath K, Chen Q, Bagante F, Sun S, Akgul O, Idrees JJ, Dillhoff M, Schmidt C, Cloyd J, Pawlik TM. Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery. HPB (Oxford) 2019; 21:310-318. [PMID: 30266495 DOI: 10.1016/j.hpb.2018.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 03/12/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality. METHODS A retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue). RESULTS A total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16-1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51-2.09), 30-day readmission (RR 1.21 95% CI 1.06-1.39), 90-day mortality (RR, 1.29, 95% CI 1.01-1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14-1.97). CONCLUSION Highest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Qinyu Chen
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA; Department of Surgery, University of Verona, Verona, Italy
| | - Steven Sun
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ozgur Akgul
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jay J Idrees
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Idrees JJ, Rosinski BF, Merath K, Chen Q, Bagante F, Pawlik TM. Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database. HPB (Oxford) 2019; 21:291-300. [PMID: 30201297 DOI: 10.1016/j.hpb.2018.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 03/26/2018] [Revised: 05/22/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. METHODS We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. RESULTS The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6-1.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by $9,293 with cost-savings of $6.98 million/year. CONCLUSION HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Bagante F, Gani F, Beal EW, Merath K, Chen Q, Dillhoff M, Cloyd J, Pawlik TM. Prognosis and Adherence with the National Comprehensive Cancer Network Guidelines of Patients with Biliary Tract Cancers: an Analysis of the National Cancer Database. J Gastrointest Surg 2019; 23:518-528. [PMID: 30112703 DOI: 10.1007/s11605-018-3912-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 05/14/2018] [Accepted: 08/01/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) guidelines recommend chemotherapy for patients with inoperable biliary tract cancers (BTC), as well as patients following resection of BTC with lymph node metastasis (N1)/positive margins (R1). We sought to define overall adherence, as well as long-term outcomes, with the NCCN guidelines for BTC using the National Cancer Database (NCDB). METHODS A total of 176,536 patients diagnosed with BTC at a hospital participating in the NCDB between 2004 and 2015 were identified. RESULTS Among all patients, 63% of patients received medical therapy (chemotherapy or best supportive care), 11% underwent surgical palliation, and 26% underwent curative-intent surgery. According to the NCCN guidelines, 86% (n = 152,245) of patients were eligible for chemotherapy, yet, only 42.2% (n = 64,615) received chemotherapy. Factors associated with a lower adherence with NCCN guidelines included patient age (> 65 years: OR = 1.02), ethnicity (Black: OR = 1.14, Hispanic: OR = 1.21, Asian: OR = 1.24), and insurance status (non-private: OR = 1.45, all p < 0.001). A smaller subset of patients was either recommended chemotherapy but refused (n = 9269, 10.6%) or had medical factors that contraindicated chemotherapy (n = 8275, 9.4%). On multivariable analysis, adjusting for clinical and tumor-specific factors, adherence with NCCN guidelines was associated with a survival benefit for patients receiving medical therapies (HR = 0.74) or undergoing curative-intent surgery (HR = 0.73, both p < 0.001). CONCLUSION Less than half of patients with BTC received systemic chemotherapy in adherence with NCCN guidelines. While a subset of patients had contraindications or refused chemotherapy, other factors such as insurance status and ethnicity were associated with adherence. Adherence with chemotherapy guidelines may influence long-term outcomes.
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Affiliation(s)
- Fabio Bagante
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eliza W Beal
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Qinyu Chen
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Mary Dillhoff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Jordan Cloyd
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair in Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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Onuma AE, Palmer Kelly E, Chakedis J, Paredes AZ, Tsilimigras DI, Wiemann B, Johnson M, Merath K, Akgul O, Cloyd J, Pawlik TM. Patient preferences on the use of technology in cancer surveillance after curative surgery: A cross-sectional analysis. Surgery 2019; 165:782-788. [PMID: 30770135 DOI: 10.1016/j.surg.2018.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/21/2018] [Accepted: 12/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advances in communication technology have enabled new methods of delivering test results to cancer survivors. We sought to determine patient preferences regarding the use of newer technology in delivering test results during cancer surveillance. METHODS A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication versus phone call or office visit) to receive surveillance test results was undertaken. RESULTS Among 257 respondents, the average age was 59.1 years (SD 13.5) and 61.8% were female. Common malignancies included melanoma/sarcoma (29.5%), thyroid (25.7%), breast (22.8%), and gastrointestinal (22.0%) cancer. Although patients expressed a relative preference to receive normal surveillance results via MyChart or secure e-mail, the majority preferred abnormal imaging (87.2%) or blood results (85.9%) to be communicated by in-office appointments or phone calls irrespective of age or cancer type. Patients with a college degree or higher were more likely to prefer electronic means of communication of abnormal blood results compared with a telephone call or in-person visit (odds ratio 2.18, 95% confidence interval: 1.01-4.73, P < .05). In contrast, patients >65 years were more likely to express a preference for telephone or in-person communication of normal imaging results (odds ratio: 2.03, 95% CI: 1.16-3.56, P < .05) versus patients ≤65 years. Preference also varied according to malignancy type. CONCLUSION Although many cancer patients preferred to receive "normal" surveillance results electronically, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.
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Affiliation(s)
- Amblessed E Onuma
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | | | - Jeffery Chakedis
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | | | - Brianne Wiemann
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Morgan Johnson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus.
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