Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System

Impact of Operative Approach on Acute Kidney Injury Risk Prediction Models for Colectomy

INTRODUCTION

Acute kidney injury (AKI) is a serious postoperative complication associated with increased morbidity and mortality. Identifying patients at risk for AKI is important for risk stratification and management. This study aimed to develop an AKI risk prediction model for colectomy and determine if the operative approach (laparoscopic versus open) alters the influence of predictive factors through an interaction term analysis.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2005 to 2019. Patients undergoing laparoscopic and open colectomy were identified and propensity score matched. Multivariable logistic regression identified significant preoperative demographic, comorbidity, and laboratory value predictors of AKI. The predictive ability of a baseline model consisting of these variables was compared to a proposed model incorporating interaction terms between operative approach and predictor variables using the likelihood ratio test, c-statistic, and Brier score. Shapley Additive Explanations values assessed relative importance of significant predictors.

RESULTS

252,372 patients were included in the analysis. Significant AKI predictors were hypertension, age, sex, race, body mass index, smoking, diabetes, preoperative sepsis, Congestive heart failure, preoperative creatinine, preoperative albumin, and operative approach (P < 0.001). The proposed model with interaction terms had improved predictive ability per the likelihood ratio test (P < 0.05) but had no statistically significant interaction terms. C-statistic and Brier scores did not improve. Shapley Additive Explanations analysis showed hypertension had the highest importance. The importance of age and diabetes showed some variation between operative approaches.

CONCLUSIONS

While the inclusion of interaction terms collectively improved AKI prediction, no individual operative approach interaction terms were significant. Including operative approach interactions may enhance predictive ability of AKI risk models for colectomy.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Racial Disparities in Surgical Outcomes of Acute Diverticulitis: Have We Moved the Needle?

INTRODUCTION

There has been increasing national attention on reducing healthcare disparities. Prior studies cite worse surgical outcomes and less use of laparoscopy for Black patients with diverticulitis. Re-evaluation of these disparities is lacking despite national initiatives to improve health equity. This study aimed to evaluate the association of race with short-term outcomes and surgical approaches in patients with acute diverticulitis.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent nonelective surgery for acute diverticulitis from 2015 to 2019. Severity of presentation, morbidity, mortality, surgical approach, and ostomy creation were compared by race.

RESULTS

Of the 13,996 patients included in the study, 82.4% were White, 7.6% were Black, 1.1% Asian, 0.61% American Indian/Alaska Native, and 0.20% Native Hawaiian/Pacific Islander (NH/PI). Overall 30-day morbidity was 44.3% and 30-day mortality was 3.9%. In a multivariate logistic regression analysis, compared to Whites, Black race was independently associated with higher 30-day morbidity (Odds Ratio: 1.24, 95% confidence interval: 1.07-1.43, P = 0.003) and NH/PI race was independently associated with higher mortality (Odds Ratio: 5.35, 95% confidence interval: 1.32-21.6, P = 0.019). There was no difference in complicated disease (abscess or perforation), use of laparoscopy, or ostomy creation among races.

CONCLUSIONS

Despite national efforts to achieve equity in healthcare, disparities persist in surgical outcomes for those with diverticulitis. Black and NH/PI race are independently associated with increased morbidity and mortality, respectively. Use of laparoscopy, however, is no longer different by race suggesting some gaps may be closing.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Racial Disparities in Colorectal Cancer Care for Black Patients: Barriers and Solutions

Racial disparities in colorectal cancer for Black patients have led to a significant mortality difference when compared to White patients, a gap which has remained to this day. These differences have been linked to poorer quality insurance and socioeconomic status in addition to lower access to high-quality health care resources, which are emblematic of systemic racial inequities. Disparities impact nearly every point along the colorectal cancer care continuum and include barriers to screening, surgical care, oncologic care, and surveillance. These critical faults are the driving forces behind the mortality difference Black patients face. Health care systems should strive to correct these disparities through both cultural competency at the provider level and public policy change at the national level.

Are patients living far from hospital at higher risk of late adjuvant chemotherapy for colon cancer?

INTRODUCTION

Late adjuvant chemotherapy (aCT) administration after colectomy (> 56 days) is known to be associated with impaired prognosis. We aim to identify risk factors associated with late aCT, especially the travel time between patients' home and hospital.

METHOD

We performed a retrospective monocentre cohort study. Patients included had a colectomy for a stage III or "high risk" stage II colon cancer between 2009 and 2015 performed at a French university hospital. Risk factors for late aCT were identified using a fractional polynomial logistic regression.

RESULTS

Ninety-four patients were included. The risk of late aCT was associated with travel time length, emergent colectomy, the need for scheduled care before aCT, and length of time between colectomy and postoperative multidisciplinary meeting advising aCT.

CONCLUSION

Our study suggests that, in patients with colon cancer, factors unrelated to disease severity and complexity could be associated with a higher risk of late aCT.

Indications and Outcomes for Non-Trauma Emergency Laparotomy: A Comparison of Rwanda, South Africa, and the USA

BACKGROUND

Emergency conditions requiring exploratory laparotomy (EL) can be challenging. The objective of this study is to describe indications, outcomes, and risk factors for perioperative mortality (POMR) after non-trauma EL.

METHODS

This was a prospective study of patients undergoing non-trauma EL at four hospitals in Rwanda, South Africa, and the USA. Multivariate logistic regression was used to determine factors associated with POMR.

RESULTS

Over one year, there were 632 EL with the most common indications appendicitis (n = 133, 21%), peptic ulcer disease (PUD) (n = 101, 16%), and hernia (n = 74, 12%). In Rwanda, the most common indications were appendicitis (n = 41, 19%) and hernia (n = 37, 17%); in South Africa appendicitis (n = 91, 28%) and PUD (n = 60, 19%); and in the USA, PUD (n = 16, 19%) and adhesions from small bowel obstruction (n = 16, 19%). POMR was 11%, with no difference between countries (Rwanda 7%, South Africa 12%, US 16%, p = 0.173). Risk factors associated with increased odds of POMR included typhoid intestinal perforation (adjusted odds ratio (aOR): 16.48; 95% confidence interval (CI): 4.31, 62.98; p value < 0.001), mesenteric ischemia (aOR: 13.77, 95% CI: 4.21, 45.08, p value < 0.001), cancer (aOR: 5.84, 95% CI: 2.43, 14.05, p value < 0.001), other diagnoses (aOR: 3.97, 95% CI: 3.03, 5.20, p value < 0.001), high ASA score (score ≥ 3) (aOR: 3.95, 95% CI: 3.03, 5.15, p value < 0.001), peptic ulcer disease (aOR: 2.82, 95% CI: 1.64, 4.85, p value < 0.001), age > 60 years (aOR: 2.32, 95% CI: 1.41, 3.83, p value = 0.001), and ICU admission (aOR: 2.23, 95% CI: 1.24, 3.99, p value = 0.007). Surgery in the US was associated with decreased odds of POMR (aOR: 0.41, 95% CI: 0.21, 0.80, p value = 0.009).

CONCLUSIONS

Indications for EL vary between countries and POMR is high. Differences in mortality were associated with patient and disease characteristics with certain diagnoses associated with increased risk of mortality. Understanding the risk factors and outcomes for patients with EL can assist providers in judicious patient selection, both for patient counselling and resource allocation.