Decision aids and health information technology: One size does not fit all

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Background: Nearly 3 million cancer survivors in the US reside in rural areas. Existing survivorship care models were developed mainly at large academic centers, and thus require adaption to meet the challenging needs of the rural community. Rural cancer survivors (RCS) face issues with coordination of care, decision-making, access to specialty services, supportive care resources, and time and resources required for travel. RCS are at greater risk for social isolation and inadequate emotional support. To address these challenges, many studies propose information technology (IT), mobile, and video solutions. We assessed the potential of online and mobile video technology applications to reduce barriers to survivorship care for RCS, families, and caregivers. Methods: We conducted 2 in-person focus groups with rural care managers, providers, and public health professionals, and one virtual cross-disciplinary focus group of patients, caregivers, and provider stakeholders to evaluate acceptability of video modules. Using a Community-Based Participatory Research approach, we worked with community partners to design and develop materials that adequately addressed their needs. Results: Focus group results indicate that video modules added little value for RCS due to sporadic internet access, limited patient IT literacy, vision and memory problems, and patient difficulty interpreting information. Therefore, we designed and piloted a paper RCS Checklist to be taken to appointments, available in waiting areas or through care managers, and to serve as a guide for shared patient-provider decision-making. The resulting checklist includes evidence-based information about survivorship care goals and approaches, care coordination strategies, information about local cancer supportive services, health insurance reimbursement, state disability policies, psychosocial support, and stress-reduction tips. Conclusions: In some special patient populations like RCS, use of health IT for patient empowerment and care coordination may be a poor choice. Engaging relevant stakeholders in the development of location-specific communication and decision aid materials is paramount to successful engagement of patients and caregivers.

A Population-Based Cohort Study of Emergency Appendectomy Performed in England and New York State

BACKGROUND

To compare selected outcomes (30-day reoperation and total length of hospital stay) following emergency appendectomy between populations from New York State and England.

METHODS

This retrospective cohort study used demographic and in-hospital outcome data from Hospital Episode Statistics (HES) and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients aged 18+ years undergoing appendectomy between April 2009 and March 2014. Univariate and adjusted multivariable logistic regression were used to test significant factors. A one-to-one propensity score matched dataset was created to compare odd ratios (OR) of reoperations between the two populations.

RESULTS

A total of 188,418 patient records, 121,428 (64.4%) from England and 66,990 (35.6%) from NYS, were extracted. Appendectomy was completed laparoscopically in 77.7% of patients in New York State compared to 53.6% in England (P < 0.001). The median lengths of hospital stay for patients undergoing appendectomy were 3 (interquartile range, IQR 2-4) days versus 2 (IQR 1-3) days (P < 0.001) in England and New York State, respectively. All 30-day reoperation rates were higher in England compared to New York State (1.2 vs. 0.6%, P < 0.001), representing nearly a twofold higher risk of 30-day reoperation (OR 1.88, 95% CI 1.64-2.14, P < 0.001). As the proportion of appendectomy completed laparoscopically increased, there was a reduction in the reoperation rate in England (correlation coefficient -0.170, P = 0.036).

CONCLUSIONS

Reoperations and total length of hospital stay is significantly higher following appendectomy in England compared to New York State. Increasing the numbers of appendectomy completed laparoscopically may decrease length of stay and reoperations.

Research priorities in cancer cachexia: The University of Rochester Cancer Center NCI Community Oncology Research Program Research Base Symposium on Cancer Cachexia and Sarcopenia

PURPOSE OF REVIEW

Cancer cachexia remains understudied and there are no standard treatments available despite the publication of an international consensus definition and the completion of several large phase III intervention trials in the past 6 years. In September 2015, The University of Rochester Cancer Center NCORP Research Base led a Symposium on Cancer Cachexia and Sarcopenia with goals of reviewing the state of the science, identifying knowledge gaps, and formulating research priorities in cancer cachexia through active discussion and consensus.

RECENT FINDINGS

Research priorities that emerged from the discussion included the implementation of morphometrics into clinical decision making, establishing specific diagnostic criteria for the stages of cachexia, expanding patient selection in intervention trials, identifying clinically meaningful trial endpoints, and the investigation of exercise as an intervention for cancer cachexia.

SUMMARY

Standardizing how we define and measure cancer cachexia, targeting its complex biologic mechanisms, enrolling patients early in their disease course, and evaluating exercise, either alone or in combination, were proposed as initiatives that may ultimately result in the improved design of cancer cachexia therapeutic trials.

Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection

OBJECTIVE

To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery.

BACKGROUND

Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients.

METHODS

The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival.

RESULTS

Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival.

CONCLUSIONS

Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.

Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team

OBJECTIVE

To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.

SUMMARY BACKGROUND DATA

Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies.

METHODS

Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions.

RESULTS

Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32).

CONCLUSIONS

This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.

Impact of marital status on colorectal cancer (CRC) disease-specific survival in New York state

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Background: CRC is the second leading cause of cancer death in the US. Social support and financial resources vary by marital status. This study analyzes the impact of marital status by sex on survival after resection for CRC. Methods: The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for 2004-2013 colectomy or proctectomy Stage I-III CRC patients and categorized by marital status: single/never married (single), married/domestic partner (married), and widowed/separated/divorced (previously married). Competing risk analysis of 5-year mortality was executed adjusting for patient (age at diagnosis, sex, race, Medicaid, income, marital status, smoking history, comorbidities, year of diagnosis, and stage), treatment (scheduled surgery and complications, chemotherapy, radiation), surgeon (colorectal board, volume), and hospital factors (volume, academic, rural). Results: 38,020 (colon 32,451, rectal 5,569) met inclusion criteria, of which 28% died within 5 years. Single patients were more likely than married to be current smokers (17 vs 12%), be on Medicaid (42 vs 27%) and present emergently (38 vs 25%), and less likely to be treated by high volume surgeons (32 vs 40%). Married patients had decreased risk of 5-year CRC-specific mortality (hazard ratio [HR] 0.86, confidence interval [CI] 0.80-0.94) vs single. When stratified by sex, married males had a decreased risk of death but married females did not and this persists if stratified by colon vs rectum (Table). Income was not significantly associated with survival and previously married patients did not significantly differ from single. Conclusions: Marital status impacts CRC-specific survival in males and females differently. Married men have a protective effect from marriage, whereas married females do not and may benefit from additional support throughout their cancer care. [Table: see text]

Racial disparities in ovarian cancer survival in New York state

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Background: Disparities between black and white patients are well documented in gynecologic cancers but information on the contributions of social factors and medical comorbidities is sparse. We examined differences in outcomes amongst black and white women with ovarian cancer in New York State. Methods: Patients with incident ovarian cancer in the New York State Cancer Registry and the Statewide Planning and Research Cooperative System from 2006-2013 were included. Differences in social and demographic factors, comorbidities and tumor characteristics between black and white women were examined with bivariate analysis. Multivariable analyses were used to examine factors associated with specific treatments and survival. Results: Of 5969 patients, 87% were white and 13% black. Age, Hispanic ethnicity and median income were similar between groups. Black women were less likely to be married (27 vs 48%, p < 0.01); and less likely to be privately insured (20 vs 50%, p < 0.01). More black women had comorbidities by Charlson Comorbidity Index (CCI) (63 vs 51%, p < 0.01). Black women were more likely to have Stage IV disease and non-serous histology (p < 0.01). More black women were treated at academic medical centers (67 vs 50%, p < 0.01). Marital status, insurance, CCI, stage, histology and treatment site correlated to the type of treatment received (p < 0.01). Black women received different treatment and had higher odds of receiving no treatment 1.63 (1.24, 2.14); chemotherapy without surgery 1.26 (1.00, 1.59); lower odds of undergoing primary surgical management 0.71 (0.58, 0.86) or chemotherapy following surgery 0.79 (0.66, 0.96; and similar rates of neoadjuvant chemotherapy. The risk of 5 year mortality was 1.14 (1.02, 1.27) times higher for black women compared with whites. Marital status, CCI, stage and histology correlated with overall and disease specific survival among both black and white women (p < 0.01). Conclusions: Multiple factors, including race, are associated with receipt of treatment and survival in ovarian cancer. Treatment for ovarian cancer was significantly different amongst black women than white in New York State. Understanding modifiable influences on racial disparities is imperative to reducing race based differences in outcomes.

Surgeon and hospital variation in adjuvant chemotherapy delivery to patients with stage III colon cancer

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Background: It is well established that age and comorbidities have significant impact on adjuvant chemotherapy delivery to stage III colon cancer patients. This study examines differences in the hospital and surgeon-specific probabilities of adjuvant therapy delivery to stage III colon cancer patients by comorbidity burden and age. Methods: Patients who underwent surgery for stage III colon cancer from 2004-2013 were included from the New York State Cancer Registry and the Statewide Planning and Research Cooperative System. Comorbidity burden was defined with the Charlson Comorbidity Index (CCI). Multilevel logistic regressions characterized variation in adjuvant chemotherapy delivery among individual hospitals and surgeons by CCI and age. Results: 11575 patients met inclusion criteria, of which 59% received adjuvant therapy. Younger age, lower CCI, and high volume surgeons/hospitals were associated with delivery of adjuvant therapy (p < 0.01). Median time to chemotherapy was 43 days among CCI = 0 vs 48 among CCI≥2. The risk adjusted hospital and surgeon-specific probabilities of adjuvant delivery decreased with increasing CCI and age. The proportion of variation attributable to surgeons, vs hospitals, increased with CCI and age. Hospital variation between the highest and lowest hospitals increased from a 6-fold difference among CCI = 0 to an 11 fold difference among CCI≥2. Surgeon variation increased from a 14-fold difference among CCI = 0 to a 40 fold difference among CCI≥2. Conclusions: Variation in adjuvant chemotherapy delivery to stage III colon cancer patients increased with higher comorbidity burden and age. While a larger proportion of variation is attributable to surgeons among patients with the highest CCI and the most elderly, the vast majority of the variation is related to hospital factors. Even taking into account that some patients may be unfit for adjuvant therapy, this variation in treatment is alarmingly high. [Table: see text]

Comorbidity and cause of death after surgery for early stage colorectal cancer (CRC)

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Background: Early stage (I/II) CRC is traditionally associated with relatively good prognosis at 90% relative survival. The probability of non-cancer death in CRC patients is associated with comorbidity burden; however, there is paucity of data evaluating this association in colon versus rectal cancer. This study examines the impact of comorbdity on 5-year mortality and cause of death after resection for early stage CRC. Methods: Linked patient-level data from the New York State Cancer Registry & Statewide Planning and Research Cooperative System was queried for 2004-2013 patients who underwent colectomy or proctectomy for Stage I-II CRC who survived beyond 30 days. Comorbidity burden was defined as the sum of Elixhauser Comorbidites plus steroid use, MI history, CVD (cardiovascular disease), and dementia to capture maximum number of unique comorbidities and characterized as low (0-1 comorbidity), moderate (2-3 comorbidities), and high (4+ comorbidities). Causes of death were evaluated according to comorbidity group and colon versus rectal cancer. Results: 24,643 (colon 21,384, rectal 3,250) met inclusion criteria, of which 5,464 (22%) died within 5 years. While both colon cancer (CC) and rectal cancer patients (RC) had identical overall mortality (22%), significant differences existed in the proportion of deaths due to the primary cancer with disease-specific mortality of 7% for CC and 11% for RC. Deaths due to CC decreased while CVD causes increased with escalating comorbidity burden. Deaths due to RC accounted for nearly 50% of all deaths even with increasing comorbidity burden (Table). Conclusions: CC is the predominant cause of 5-year mortality in early stage patients with low comorbidity burden while CVD drives mortality in high comorbidity burden patients. In contrast, RC drives early stage mortality regardless of the comorbidity burden; thus, emphasizing the importance of tailored survivorship programs to each cancer. [Table: see text]

Effect of older age and comorbitities on outcomes with neoadjuvant chemotherapy (NAC) for epithelial ovarian cancer (EOC)

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Background: Although a survival benefit for NAC has not been shown in the overall population of EOC, some patients may benefit from NAC. This analysis evaluates the role of age and comorbidities on the effect of NAC compared to upfront surgery on survival among EOC patients in New York. Methods: Patients who underwent surgery for stage II-IV EOC from 2006-2013 were included from the New York State Cancer Registry and the Statewide Planning and Research Cooperative System. Elderly age was defined as >70 years. Comorbidity burden was defined with the Charlson Comorbidity Index (CCI). Cox models were used to examine the effect of NAC on 5 year overall survival. The analysis was then stratified by age and comorbidity score to evaluate the role of NAC in specific subgroups. Results: 4617 patients met inclusion criteria of which 25% were elderly and 11% received NAC. Factors associated with receipt of NAC included age > 70, advanced stage, serous histology and high hospital volume (p<0.01). After adjustment for patient, hospital, and surgeon characteristics, NAC was associated with a 27% (p<0.01) increase in 5 year overall mortality in all EOC patients. Among the elderly, NAC did not have a significant effect on overall (p=0.47) or EOC-specific survival (p=0.24). Elderly and non-elderly women without comorbidities had a higher risk of death with NAC than primary surgery. There was a trend towards improved survival among elderly patients with higher comorbidity scores. (Table) Conclusions: The impact of NAC on EOC survival differs dependent on age and comorbidities. Patients with no comorbidities may have better prognosis with upfront surgery. Counterintuitively, those with more comorbidities, particularly the elderly, may derive survival benefit from upfront neoadjuvant therapy. [Table: see text]

Explaining variation in ventral and inguinal hernia repair outcomes: A population-based analysis

BACKGROUND

No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair.

METHODS

The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003-2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence.

RESULTS

Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models.

CONCLUSION

The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.

Patterns and Yearly Time Trends in the Use of Radiation Therapy During the Last 30 Days of Life Among Patients With Metastatic Rectal Cancer in the United States From 2004 to 2012

PURPOSE

Although radiation therapy (RT) can provide palliative benefits for patients with metastatic rectal cancer, its role at the end of life remains unclear. The objective of this study was to assess sociodemographic and clinical factors associated with the use of RT during the last 30 days of life and to evaluate yearly time trends in RT utilization among stage IV patients with rectal cancer.

METHODS

The 2004 to 2012 National Cancer DataBase was queried for patients with metastatic rectal cancer who had a documented death during follow-up. A Bayesian multilevel logistic regression model was used to characterize predictive factors and yearly time trends associated with RT use in the last 30 days of life.

RESULTS

Among 10 431 patients who met inclusion criteria, 345 (3%) received RT during the last 30 days of life. Factors independently associated with RT use included older age, female sex, African American race, nonprivate insurance, higher comorbidity burden, and worse grade. The odds of RT use at the end of life decreased by 28% between 2007 and 2009 (odds ratio [OR] = 0.72, 95% Credible Interval (CI) = 0.58-0.93), but then increased by 16% from 2010 to 2012 (OR = 1.16, 95% CI = 1.13-1.33), relative to 2004 to 2006.

CONCLUSION

Radiation therapy use for patients with metastatic rectal cancer is beneficial, and efforts to optimize its appropriate use are important. Several factors associated with RT use during the last 30 days of life included disparities in sociodemographic and clinical subgroups. Research is needed to understand the underlying causes of these inequalities and the role of predictive models in clinical decision-making.

Outcomes for critical limb ischemia are driven by lower extremity revascularization volume, not distance to hospital

OBJECTIVE

The objective of this study was to identify relationships among geographic access to care, vascular procedure volume, limb preservation, and survival in patients diagnosed with critical limb ischemia (CLI).

METHODS

Using New York State administrative data from 2000 to 2013, we identified a patient's first presentation with CLI defined by International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Distance from the patient's home to the index hospital was calculated using the centroids of the respective ZIP codes. A multivariable logistic regression model was employed to estimate the impact of distance, major lower extremity amputation (LEA) volume, and lower extremity revascularization (LER) volume on major amputation and 30-day mortality. Volumes and distances were analyzed in quintiles. The farthest distance quintile and the highest procedure volume quintiles were used as references for generating odds ratios (ORs).

RESULTS

There were 49,576 patients identified with an initial presentation of CLI. The median age was 73 years, 35,829 (73.2%) had Medicare as a primary insurer, 11,395 (23.0%) had a major amputation, and 4249 (8.6%) died within 30 days of admission. Patients in the closest distance quintile were more likely to undergo amputation (OR, 1.53 [1.39-1.68]; P < .0001). Patients who visited hospitals in the lowest LER volume quintile with at least one procedure per year faced higher 30-day mortality rates (OR, 2.05 [1.67-2.50]; P < .0001) and greater odds of amputation (OR, 9.94 [8.5-11.63]; P < .0001). Patients who visited hospitals in the lowest LEA volume quintile had lower odds of 30-day mortality (OR, 0.66 [0.50-0.87]; P = .0033) and lower odds of amputation (OR, 0.180 [0.142-0.227]; P < .0001).

CONCLUSIONS

Rates of major amputation are inversely associated with distance from the index hospital, whereas rates of both major amputation and mortality are inversely associated with LER volume. Rates of major amputation and mortality are directly associated with LEA volume. We believe that unless it is otherwise contraindicated, these data support consideration for selective referral of CLI patients to high-volume centers for LER regardless of distance. Within the context of value-based health care delivery, policy supporting regionalization of CLI care into centers of excellence may improve outcomes for these patients.

Emergent Colectomy Is Independently Associated with Decreased Long-Term Overall Survival in Colon Cancer Patients

BACKGROUND

The purpose of this study was to examine the long-term overall survival (OS) of colon cancer patients who underwent emergent resection versus patients who were resected electively.

METHODS

The 2006-2012 National Cancer Data Base was queried for colon cancer patients who underwent surgical resection. Emergent resection was defined as resection within 24 h of diagnosis. A mixed-effects logistic regression was used to estimate the effect of emergent resection on 30- and 90-day mortality. A propensity score-matched mixed-effects Cox proportional-hazards model was used to estimate the effect of emergent resection on 5-year OS.

RESULTS

Two hundred fourteen thousand one hundred seventy-four patients met inclusion criteria, 30% of the cohort had an emergent resection. After controlling for patient and hospital factors, pathological stage, lymph node yield, margin status, and adjuvant chemotherapy, emergent resection was associated with increased odds of 30-day mortality (OR = 1.69, 95% CI = 1.60, 1.78) and hazard of death at 5 years (HR = 1.13, 95% CI = 1.09, 1.15) compared to elective resections.

CONCLUSION

Emergent resection for colon cancer is independently associated with poor short-term outcomes and decreased 5-year OS compared to elective resection. With 30% of cases in this study emergent, these findings underlie the importance of adherence to colon cancer screening guidelines to limit the need for emergent resections.

Nonelective colon cancer resection: A continued public health concern

BACKGROUND

Little is known regarding recent trends in the rate of nonelective colon cancer resection in the United States and its impact on both short-term and long-term outcomes.

METHODS

The New York State Cancer Registry and Statewide Planning & Research Cooperative System identified stage I-III colon cancer resections from 2004-2011. Propensity-matched analyses assessed differences in short-term adverse outcomes and 5-year disease-specific and overall survival between elective and nonelective colon cancer operations. Further analyses assessed the association among patient, surgeon, and hospital-level factors and outcomes within the nonelective operation group.

RESULTS

Among 26,420 patients, 26.5% underwent nonelective operations. There was no significant change in the rate of nonelective resection from 2004-2011 (P = .25). Nonelective operations were independently associated with greater odds of 30-day mortality (odds ratio [OR] = 3.42, 95% confidence interval [CI] = 2.87-4.06), stoma creation (OR = 4.49, 95% CI = 3.95-5.09), intensive care unit admission (OR = 1.68, 95% CI = 1.53-1.84), complications (OR = 2.34, 95% CI = 2.18-2.52), and discharge to another health care facility (OR = 2.46, 95% CI = 2.26-2.68), longer duration of stay (incidence rate ratio = 1.79, 95% CI = 1.76-1.83), and worse disease-specific (hazard ratio = 1.74, 95% CI = 1.61-1.88) and overall survival (hazard ratio = 1.64, 95% CI = 1.55-1.75). Other than an association among high-volume surgeons, adequate lymph node yield, and receipt of adjuvant chemotherapy and lower mortality, no other potentially modifiable factors were associated with survival after nonelective operations.

CONCLUSION

Nonelective colon cancer resection remains a concerning public health issue with >25% of cases being performed on a nonelective basis and an independent association with poor short-term and long-term survival compared with elective operations. Given that few potentially modifiable factors appear to have an impact on survival after nonelective operations, these findings highlight the importance of adherence to colon cancer screening guidelines to limit the number of nonelective colon cancer resections.

Surgeon-, pathologist-, and hospital-level variation in suboptimal lymph node examination after colectomy: Compartmentalizing quality improvement strategies

BACKGROUND

The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and to examine if this variation affects 5-year, disease-specific survival.

METHODS

A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I-III colon cancer from 2004-2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses.

RESULTS

The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival.

CONCLUSION

There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.

Lymph node yield is an independent predictor of survival in rectal cancer regardless of receipt of neoadjuvant therapy

AIMS

Lymph node yield (LNY) is used as a marker of adequate oncological resection. The American Joint Committee on Cancer (AJCC) currently recommends that at least 12 nodes are necessary to confirm node-negative disease for rectal cancer. A LNY of 12 is not always achieved, particularly in patients who have undergone neoadjuvant treatment. This study attempts to examine factors associated with LNY and its prognostic impact following neoadjuvant chemoradiation in rectal cancer.

METHODS

The 2006-2011 National Cancer Data Base was queried for patients with clinical stage I-III rectal cancer who underwent a proctectomy. Suboptimal LNY was defined as <12 lymph nodes examined. A mixed-effects multinomial logistic regression model was used to identify independent factors associated with LNY. Mixed-effects Cox proportional hazards models were used to estimate the adjusted effect of LNY on 5-year overall survival.

RESULTS

25 447 patients met inclusion criteria. Overall, 62% of the cohort received neoadjuvant chemoradiation and 32% had suboptimal LNY. The median LNY for patients who received neoadjuvant therapy was 13 (IQR: 9-18) and for patients who did not receive neoadjuvant therapy was 15 (IQR: 12-21). After risk adjustment, there was a 3.5-fold difference in the rate of suboptimal LNY among individual hospitals (27%-95%). Suboptimal LNY was independently associated with an 18% increased hazard of death among patients who did not receive neoadjuvant treatment and a 20% increased hazard of death among those who did receive neoadjuvant treatment when controlled for adjuvant treatment, staging, proximal/distal margins and other patient factors.

CONCLUSIONS

Suboptimal LNY is independently associated with worse overall survival regardless of neoadjuvant therapy, pathological staging and patient factors in rectal cancer. This finding underlies the importance and challenge of an optimal lymph node evaluation for prognostication, especially for patients receiving neoadjuvant therapy.

Surgical readmissions: results of integrating pre-, peri- and postsurgical care

AIMS

To explore the feasibility of recruiting surgical oncology patients and implementing a surgical integrated discharge (SID) programme led by advanced practice providers (APP).

BACKGROUND

Burden of illness and complexity of treatment regimen makes it challenging for surgical oncology patients to participate in research. Surgical oncology nurses may have the necessary expertise to overcome this problem.

DESIGN

Controlled longitudinal prospective observational study.

METHODS

The SID programme included multidisciplinary care coordination, regular communication among APPs and proactive postdischarge follow-up. Administrative databases were used to identify matching historical controls (n = 113) and evaluate programme outcomes.

RESULTS

Patient enrolment was 84%. The main challenges for the programme implementation included incompatible health information systems among care settings, variation in care processes among hospital units and need for provider behaviour change.

CONCLUSIONS

Most surgical oncology patients are willing to participate in outcomes programmes when contacted by familiar clinical personnel but programme implementation requires leadership support, communication among care teams and training and infrastructure.