Inability to manage non-severe complications on an outpatient basis increases non-white patient readmission rates after pancreaticoduodenectomy: A large metropolitan tertiary care center experience

A Culturally Adapted Perioperative Mental Health Intervention for Older Black Surgical Patients

OBJECTIVES

Perioperative mental health of older Black surgical patients is associated with poor surgical outcomes; however, evidence-based perioperative interventions are lacking. Our two study objectives included: first, examine factors affecting perioperative care experiences of older Black surgical patients with mental health problems, and second, ascertain design and implementation requirements for a culturally-adapted perioperative mental health intervention.

DESIGN SETTING AND PARTICIPANTS

We conducted six focus groups with older Black patients (n = 15; ≥50 years; surgery within the past 5 years and/or interest in mental health research; history of distress, anxiety, or depression coping with surgery/hospitalization/) from a large academic medical center. We engaged study partners, including interventionists and community members, to gather insights on intervention and implementation needs. We followed a hybrid inductive-deductive thematic approach using open coding and the National Institute on Minority Health and Health Disparities Research Framework.

RESULTS

Patients reported that their psychological well-being and long-term mental health outcomes were not appropriately considered during perioperative care. Perceived stressors included interpersonal and structural barriers to using mental healthcare services, clinician treatment biases and ageism in care, and lack of healthcare professional connections/resources. Patients utilized various coping strategies, including talk therapy, faith/spirituality, and family and friends.

CONCLUSION

This study offers valuable insights into the experiences of older Black surgical patients and the critical elements for developing a personalized perioperative mental health intervention to support their well-being before, during, and after surgery. Our findings demonstrated a need for a patient-centered and culturally adapted intervention targeting the individual/behavioral and interpersonal levels. Informed by the cultural adaptation framework, we propose a multi-component intervention that integrates psychological and pharmacological components.

Race and Odds of Surgery Offer in Small Bowel and Pancreas Neuroendocrine Neoplasms

BACKGROUND

Despite existing society guidelines, management of pancreatic (PanNEN) and small bowel (SBNEN) neuroendocrine neoplasms remains inconsistent. The purpose of this study was to identify patient- and/or disease-specific characteristics associated with increased odds of being offered surgery for PanNEN and SBNEN.

PATIENTS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) Program database and the National Cancer Database (NCDB) were queried for patients with PanNEN/SBNEN. Demographic and pathologic data were compared between patients who were offered surgery and those who were not. Multivariate logistic regression was performed to identify factors independently associated with being offered surgery.

RESULTS

In SEER, there were 3641 patients with PanNEN (54.7% were offered surgery) and 5720 with SBNEN (86.0% were offered surgery). On multivariate analysis of SEER, non-white race was associated with decreased odds of surgery offer for SBNEN [odds ratio (OR) 0.58, p < 0.001], but not PanNEN (p = 0.187). In NCDB, there were 28,483 patients with PanNEN (57.5% were offered surgery) and 42,675 with SBNEN (86.9% were offered surgery). On multivariate analysis of NCDB, non-white race was also associated with decreased odds of surgery offer for SBNEN (OR 0.61, p < 0.001) but not PanNEN (p = 0.414).

CONCLUSIONS

This study's findings suggest that, in addition to previously reported disparities in surgical resection and surgery refusal rates, racial/ethnic disparities also exist earlier in the course of treatment, with non-white patients being less likely to be offered surgery for SBNEN but not for PanNEN; this is potentially due to discrepancies in rates of referral to academic centers for pancreas and small bowel malignancies.

Preoperative levels of physical activity can be increased in pancreatectomy patients via a remotely monitored, telephone-based intervention: A randomized trial

Background

Higher levels of preoperative physical activity are associated with improved outcomes after pancreatectomy, but it remains unclear if preoperative activity levels are modifiable.

Methods

Patients undergoing pancreatectomy were randomized 1:1 to a telephone-based intervention at least one week before surgery or to control. All patients wore wearable devices to remotely collect physical activity and clinical data.

Results

In total, 152 patients were enrolled and 83 completed the study (41 intervention and 42 control). The intervention group walked 4568 (SD 2522) average daily steps pre-intervention, which increased to 5071 (SD 3055) post-intervention (p = 0.042) (11.0% increase). The control group walked 5260 (SD 2795) average daily steps. There were no differences in the rate of severe complications between groups (intervention 22.9% vs control 20.5%, p = 0.807).

Conclusions

A telephone-based intervention increased average daily step count in patients scheduled to undergo pancreatectomy, demonstrating physical activity is a modifiable target for surgical prehabilitation protocols.

Social vulnerability is associated with more stomas after surgery for uncomplicated diverticulitis

Background

Previous research has demonstrated disparities in surgical management of diverticulitis based on various patient characteristics, including race. Recent investigation suggests environmental factors may also play a prominent role in patient outcomes. The Center for Disease Control and Prevention's Social Vulnerability Index (SVI) is emerging as a useful tool for studying this effect and may better characterize social determinants of health among colorectal pathology.

Methods

This was a retrospective review of patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database (2006-2014), matched by ZIP code to their corresponding SVI. Patients admitted through the emergency department with a primary diagnosis of diverticulitis were included. The rate of stoma creation amongst patients undergoing non-elective surgery for uncomplicated diverticulitis was compared by SVI.

Results

Of the 4,212 patients in this study who underwent colectomy, 2,310 (54.8%) received a stoma. Compared to those with low vulnerability, highly vulnerable patients were more likely to receive a stoma (p = 0.014). In multivariable logistic analysis, increasing vulnerability was independently associated with increased odds of stoma creation (OR 1.08, p<0.001). Female sex (OR 0.86, p = 0.027), nonwhite race (OR 0.63, p<0.001), and minimally invasive surgical approach (OR 0.41, p<0.001) were associated with decreased odds of stoma creation.

Conclusions

High social vulnerability was associated with stoma creation amongst patients who underwent non-elective surgery for uncomplicated diverticulitis. Contrarily, nonwhite race was associated with decreased rate of stoma creation, highlighting the importance of using more comprehensive metrics of patient vulnerability such as SVI, rather than race, in disparities research.