Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study

Social inequalities in health: How do they influence the natural history of colorectal cancer?

As regards colorectal cancer (CRC) in France, social inequalities in health (SIH) exist. Underprivileged patients are characterized by reduced incidence of CRC and, conversely, by excess mortality. The explanatory mechanisms of the SIHs influencing survival are complex, multidimensional and variable according to healthcare system. Among the most deprived compared to the least deprived patients, SIHs are reflected by lower participation in screening campaigns, and CRC diagnosis is more frequently given at a later stage in an emergency context. During treatment, disadvantaged patients are more at risk of having to undergo open surgery and of enduring severe postoperative complications and belated chemotherapy (when recommended). Study of SIHs poses unusual challenges, as it is necessary not only to pinpoint social deprivation, but also to locate the different treatment facilities existing in a given territorial expanse. In the absence of individualized socioeconomic information, research in France on the social determinants of health is based on duly constituted cancer registries, in which an ecological index of social deprivation, the European Deprivation Index (EDI), provides an aggregate measure of the socioeconomic environment of a given individual in a given geographical setting at a given point in time. All in all, studies on SIHs are justified as means of identification and comprehension of the mechanisms underlying social deprivation, the objective being to more precisely orient programs and practices aimed at combating SIH.

Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease

Background:

Due to its prevalence, gallstone disease is a major public health issue. It affects diverse patient populations across various socioeconomic levels. Socioeconomic and geographic deprivation may impact both morbidity and mortality associated with digestive diseases, such as biliary tract disease.

Aim:

The aim of this systematic review was to review the available data on the impact of socioeconomic determinants and geographic factors on gallstone disease and its complications.

Methods:

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Web of Science databases were searched by two investigators to retrieve studies about the impact of income, insurance status, hospital status, education level, living areas, and deprivation indices on gallstone disease. Thirty-seven studies were selected for this review.

Results:

Socially disadvantaged populations appear to be more frequently affected by complicated or severe forms of gallstone disease. The prognosis of biliary tract disease is poor in these populations regardless of patient status, and increased morbidity and mortality were observed for acute cholangitis or subsequent cholecystectomy. Limited or delayed access and low-quality therapeutic interventions could be among the potential causes for this poor prognosis.

Conclusions:

This systematic review suggests that socioeconomic determinants impact the management of gallstone disease. Enhanced knowledge of these parameters could contribute to improved public health policies to manage these diseases.

Structured presurgery prehabilitation for aged patients undergoing elective surgery significantly improves surgical outcomes and reduces cost: A nonrandomized sequential comparative prospective cohort study

Background

With increasing global life expectancy, the number of major surgeries performed on aged adults invariably increases. This study aimed to examine the effectiveness of a structured prehabilitative program for aged colorectal cancer patients in improving short‐term surgical outcomes.

Methods

A prospective philanthropically sponsored Programme for Enhanced Elderly Recovery at Sengkang General Hospital (PEERS) was initiated in February 2017 for patients ≥70‐years‐old who were due to undergo elective colectomies. These patients were put through a 2‐ to 4‐week‐long program before surgery, which included geriatric assessment, nutrition supplementation, and resistance training. They were compared with patients from a similar age group before PEERS was introduced (non‐PEERS).

Results

Fifty‐eight patients, with a median age of 78.5 (70–93) years, were recruited from a single institution to undergo PEERS. Baseline characteristics between the groups were similar. There was no significant improvement of anthropometric and functional characteristics before and after PEERS. Duration of hospitalization was shorter in the PEERS group (9 vs 11 days, P = 0.01). Both groups had similar 30‐days’ morbidity rates (8.6% vs 17.4%, P = 0.26). The PEERS group had significant improvement in their median EuroQol‐5 Dimension score (0.70 presurgery to 0.80 6‐months’ postsurgery, P = 0.01). After multivariate analysis, the average duration of hospitalization in the PEERS group was 6.8 days shorter (P = 0.018; CI, 1.2–12.4) after adjusting for modality of surgery and complications. This represented a cost saving of USD$11,838.80.

Conclusion

A standardized prehabilitation program for aged adults reduced the duration of hospitalization, improved the quality of life after surgery, and reduced costs.

Q-Finder: An Algorithm for Credible Subgroup Discovery in Clinical Data Analysis - An Application to the International Diabetes Management Practice Study

Addressing the heterogeneity of both the outcome of a disease and the treatment response to an intervention is a mandatory pathway for regulatory approval of medicines. In randomized clinical trials (RCTs), confirmatory subgroup analyses focus on the assessment of drugs in predefined subgroups, while exploratory ones allow a posteriori the identification of subsets of patients who respond differently. Within the latter area, subgroup discovery (SD) data mining approach is widely used-particularly in precision medicine-to evaluate treatment effect across different groups of patients from various data sources (be it from clinical trials or real-world data). However, both the limited consideration by standard SD algorithms of recommended criteria to define credible subgroups and the lack of statistical power of the findings after correcting for multiple testing hinder the generation of hypothesis and their acceptance by healthcare authorities and practitioners. In this paper, we present the Q-Finder algorithm that aims to generate statistically credible subgroups to answer clinical questions, such as finding drivers of natural disease progression or treatment response. It combines an exhaustive search with a cascade of filters based on metrics assessing key credibility criteria, including relative risk reduction assessment, adjustment on confounding factors, individual feature's contribution to the subgroup's effect, interaction tests for assessing between-subgroup treatment effect interactions and tests adjustment (multiple testing). This allows Q-Finder to directly target and assess subgroups on recommended credibility criteria. The top-k credible subgroups are then selected, while accounting for subgroups' diversity and, possibly, clinical relevance. Those subgroups are tested on independent data to assess their consistency across databases, while preserving statistical power by limiting the number of tests. To illustrate this algorithm, we applied it on the database of the International Diabetes Management Practice Study (IDMPS) to better understand the drivers of improved glycemic control and rate of episodes of hypoglycemia in type 2 diabetics patients. We compared Q-Finder with state-of-the-art approaches from both Subgroup Identification and Knowledge Discovery in Databases literature. The results demonstrate its ability to identify and support a short list of highly credible and diverse data-driven subgroups for both prognostic and predictive tasks.