Race-based differences in length of stay among patients undergoing pancreatoduodenectomy

A Comparison of Whipple Outcomes Between a Safety-Net Hospital and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) in African Americans

Purpose The aim of this study was to compare 30-day adverse events following pancreaticoduodenectomy between our safety-net hospital and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) in a matched cohort of Black/African American (AA) patients. Methods We retrospectively reviewed consecutive Black/AA patients undergoing pancreaticoduodenectomies from 2015 to 2020 at our safety-net institution. The corresponding patients from the ACS-NSQIP (2015-2019) were queried. Propensity-score matching was performed between safety-net and ACS-NSQIP Black/AA cohorts to equate baseline characteristics, and 30-day outcomes were compared between propensity-matched cohorts. Results Thirty-two Black/AAs (16 females; 62.1±10.7 years) were identified from 128 patients undergoing pancreaticoduodenectomies at our safety-net institution and were propensity-score matched to 32 ACS-NSQIP patients. After matching, baseline characteristics did not significantly differ between cohorts. Postoperatively, surgical site infections, wound disruptions, respiratory events, cardiovascular events, urinary tract infections, acute renal failure, sepsis, delayed gastric emptying, and pancreatic fistulas were not significantly different between our safety-net and ACS-NSQIP cohorts. Our length of stay (LOS) was longer (17.0(12.3-27.0) versus 10.0(7.0-16.0) days); however, patients with a LOS>30 days were comparable. Furthermore, 30-day readmissions were similar, and 30-day reoperations were lower (p=0.03) at our safety-net institution. Conclusions Black/AA patients who underwent pancreatectomies at a safety-net hospital had similar outcomes and fewer reoperations compared to a corresponding national cohort. Although we illustrate comparable outcomes, clinical pathways to mitigate and alleviate health disparities in marginalized populations at a safety-net hospital should be emphasized to continue improving outcomes.

Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study

BACKGROUND AND PURPOSE

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center.

METHODS

We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition.

RESULTS

194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions.

CONCLUSION

Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Contemporary outcomes of pancreaticoduodenectomy for benign and precancerous cystic lesions

BACKGROUND

The decision to undertake pancreaticoduodenectomy for benign and precancerous lesions has historically relied on outcomes data from operations for cancer. We aimed to describe risks for these specific patients and identify the highest risk groups.

METHODS

The ACS-NSQIP pancreatic targeted data was queried for pancreaticoduodenectomies for benign and pre-cancerous neoplasms from 2014 to 2018. Baseline characteristics, operative techniques and outcomes were examined. Multivariate regression was performed to identify predictors of major complications.

RESULTS

748 patients underwent pancreaticoduodenectomy for (n = 541,72.3%) IPMN, (n = 87,11.6%) MCN, (n = 78,10.4%) serous cystadenoma, and (n = 42,5.6%) solid pseudopapillary neoplasm. Median LOS was 8 days. Major complications (n = 135,18.0%), non-home discharges (n = 83,11.1%) and readmissions (n = 153,20.5%) occurred frequently. In patients ≥ 80 years of age (n = 37), major complications (n = 11,29.7%) and non-home discharge (n = 9,24.3%) were quite common. 5-item modified frailty index ≥ 0.4 (OR 1.84,95%CI 1.06-3.19,p = 0.030), Male sex (OR 1.729,95%CI 1.152-2.595,p = 0.008), Age ≥ 65 (OR 1.63,95%CI 1.05-2.54,p = 0.29) and African-American race (OR 2.50,95%CI 1.22-5.16,p = 0.013) were independent predictors of major morbidity.

CONCLUSIONS

Pancreaticoduodenectomies in this setting have high rates of major complications. Morbidity extends beyond the index hospitalization, with frequent readmission and non-home discharge. Patient specific factors, rather than technical or disease factors predicted outcomes. In certain patients, particularly those older than 80, the morbidity of this operation may exceed the cancer prevention benefits.

Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume?

BACKGROUND

How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.

METHODS

A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.

RESULTS

We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).

CONCLUSIONS

This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.

In-hospital survival after pancreatoduodenectomy is greater in high-volume hospitals versus lower-volume hospitals: a meta-analysis

BACKGROUND

Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values.

METHOD

PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432.

RESULTS

From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes.

CONCLUSION

In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

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

BACKGROUND

Pancreaticoduodenectomy (PD) has a high rate of readmission, and racial disparities in care could be an important contributor.

METHODS

Patients undergoing PD were prospectively followed, and their complications graded using the Modified Accordion Grading System (MAGS). Patient factors and perioperative outcomes for patients with and without postoperative readmission were compared in univariate and multivariate analysis by severity.

RESULTS

837 patients underwent PD, the overall 90-day readmission rate was 27.5%. Non-white race was independently associated with readmission (OR 1.83, p = 0.007). 51.3% of readmissions were for non-severe complications (MAGS <3). Non-white race was independently associated with MAGS non-severe readmission (OR 2.13, p = 0.006), but not MAGS severe readmission.

CONCLUSIONS

Non-white patients are more likely to be readmitted, particularly for non-severe complications. Follow up protocols should be tailored to address race disparities in the rates of readmission as readmission for less severe complications could potentially be avoidable.

Do high-volume centers mitigate complication risk and reduce costs associated with performing pancreaticoduodenectomy in ethnic minorities?

INTRODUCTION

Few studies examine the impact of ethnicity on post-operative outcomes and costs associated with pancreaticoduodenectomy (PD).

METHODS

Multivariable regression (MVR) was used to perform a risk-adjusted comparison of patients within the Healthcare Cost and Utilization Project Databases undergoing PD.

RESULTS

4742 patients underwent PD. 3871 (81%) were white, 456 (10%) black, and 415 (9%) Hispanic. Black and Hispanics were less likely than whites to undergo PD in high volume centers. Blacks and Hispanics had a higher risk of select post-operative complications, prolonged lengths of stay, and high-cost outliers. When PDs done in high volume centers were evaluated separately, blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR 0.44, 95% CI [0.33, 0.57], OR 0.56, 95% CI [0.43, 0.73]) than whites but costs for PD among the three ethnic groups were statistically identical.

CONCLUSION

Racial and ethnic minorities undergoing PD are less likely to receive care at high-volume centers, are at an increased risk of post-operative morbidity, and have higher odds of being high-cost outliers than NHW.

Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies

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.