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Renshaw SM, Paredes AZ, Alzatari R, Huang LC, Phillips S, Poulose BK, Collins CE. Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias. J Surg Res 2024; 295:289-295. [PMID: 38056355 DOI: 10.1016/j.jss.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/14/2023] [Accepted: 10/28/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown. METHODS The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups. RESULTS In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013). CONCLUSIONS This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.
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Affiliation(s)
- Savannah M Renshaw
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anghela Z Paredes
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ramez Alzatari
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li-Ching Huang
- Ohio University Heritage College of Osteopathic Medicine, Dublin Campus, Dublin, Ohio
| | - Sharon Phillips
- Ohio University Heritage College of Osteopathic Medicine, Dublin Campus, Dublin, Ohio
| | - Benjamin K Poulose
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Courtney E Collins
- Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Rushing AP, Strassels SA, Ricci KB, Daniel VT, Ingraham AM, Paredes AZ, Diaz A, Oslock WM, Baselice HE, Heh VK, Santry HP. In-house intensivist presence does not affect mortality in select emergency general surgery patients. J Trauma Acute Care Surg 2021; 91:719-727. [PMID: 34238856 DOI: 10.1097/ta.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Amy P Rushing
- From the Department of Surgery-Trauma (A.P.R.), University Hospitals, Cleveland; Department of Surgery (S.A.S., A.Z.P., A.D., H.E.B., V.K.H.), Ohio State University Wexner Medical Center; Department of Surgery (K.B.R.), Johns Hopkins Medical School, Baltimore, MD; Department of Surgery (W.M.O.), University of Alabama, Birmingham, AL; Consulting Studio (H.P.S.), NBBJ Design LLC, Columbus, OH; Department of Trauma Surgery (H.P.S.), Kettering Medical Center, Kettering, OH; Center for Surgical Health Assessment, Research and Policy (S.A.S., K.B.R., A.Z.P., A.D., H.E.B., V.K.H., H.P.S.), Ohio State University, Columbus, Ohio; Department of Dermatology (V.T.D.), University of Massachusetts Medical School, Worcester MA; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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Palmer Kelly E, Hyer JM, Paredes AZ, Tsilimigras D, Meyer B, Newberry H, Pawlik TM. Provision of supportive spiritual care for hepatopancreatic cancer patients: an unmet need? HPB (Oxford) 2021; 23:1400-1409. [PMID: 33642211 DOI: 10.1016/j.hpb.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/16/2020] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Among patients with a serious cancer diagnosis, like hepatopancreatic (HP) cancer, spiritual distress needs to be addressed, as these psychosocial-spiritual symptoms are often more burdensome than some physical symptoms. The objective of the current study was to characterize supportive spiritual care utilization among patients with HP cancers. METHODS Patients with HP cancer were identified from the electronic medical record at a large comprehensive cancer center; data on patients with breast/prostate cancer (non-HP) were collected for comparison. Associations between patient characteristics and receipt of supportive spiritual care were evaluated within the overall sample and end-of-life subsample. RESULTS Among 8,961 individuals (nHP=1,419, nnon-HP =7,542), 51.7% of HP patients utilized supportive spiritual care versus 19.8% of non-HP patients (p<0.001). Younger age and religious identity were associated with receiving spiritual care (p<0.001). HP patients had higher odds of receiving spiritual care versus non-HP patients (OR 2.41, 95%CI: 2.10, 2.78). Within the end-of-life subsample, HP patients more frequently received spiritual care to "accept their illness" (39.5% vs. 22.5%, p<0.001), while non-HP patients needed support to "define their purpose in life" (13.1% vs. 4.5%, p=0.001). DISCUSSION Supportive spiritual care was important to a large subset of HP patients and should be integrated into their care.
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Affiliation(s)
- Elizabeth Palmer Kelly
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Bonnie Meyer
- The Ohio State University Wexner Medical Center Department of Chaplaincy and Clinical Pastoral Education, USA
| | - Hanci Newberry
- The Ohio State University Wexner Medical Center Department of Chaplaincy and Clinical Pastoral Education, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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Tsilimigras DI, Hyer JM, Chen Q, Diaz A, Paredes AZ, Moris D, Dillhoff M, Cloyd JM, Beane JD, Tsung A, Ejaz A, Pawlik TM. Inter-surgeon variability is associated with likelihood to undergo minimally invasive hepatectomy and postoperative mortality. HPB (Oxford) 2021; 23:840-846. [PMID: 33279403 DOI: 10.1016/j.hpb.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Minimally invasive liver surgery (MILS) has been increasingly adopted in clinical practice; yet, inter-surgeon variability in operative approach (MILS vs. open), as well as the impact of providers on the likelihood of undergoing MILS have not been well characterized. METHODS The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent hepatectomy between 2013 - 2017. The impact of patient- and procedure- related factors on the likelihood of MILS was investigated. RESULTS Overall 12,110 (91.6%) patients underwent open liver resection, while 1,112 (8.4%) patients had MILS. Based on total MILS volume, surgeons were categorized into average (1-3 cases), above average (4-7 cases) and high (>8 or more cases) MILS volume surgeons. While male patients (OR = 0.85, 95%CI 0.75-0.97) were less likely to undergo MILS, patients operated on more recently (year 2017; OR = 1.72, 95%CI 1.38-2.14) for a cancer indication (OR = 1.23, 95%CI 1.05-1.42) had a higher chance of MILS. After controlling for patient- and procedure-related characteristics, there was almost a two-fold variation in the odds that a patient underwent MILS versus open hepatectomy based on the individual surgeon provider (MOR = 1.75, 95%CI 1.48-1.99). Patients who had a MILS performed by a high-volume MILS surgeon had 36% lower odds of death within 90-days (OR = 0.64, 95%CI 0.51-0.79). CONCLUSION The likelihood of undergoing MILS, as well as post-operative mortality, was heavily influenced by the individual surgeon provider rather than patient- or procedure-related factors.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Palmer Kelly E, Hyer M, Paredes AZ, McGee J, Tsilimigras DI, Cloyd J, Ejaz A, Park KU, Pawlik TM. Comparing Surgeon Approaches to Patient-Centered Cancer Care Using Vignette Methodology. J Gastrointest Surg 2021; 25:1307-1315. [PMID: 32519248 DOI: 10.1007/s11605-020-04661-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/15/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to characterize surgeon perceptions of patient attachment-related behaviors relative to patient-centered approaches during treatment decision-making within the clinical encounter. METHODS An online survey including clinical vignettes was sent to board-certified surgeons to assess their approach to patient-centered treatment decision-making. Within these vignettes, patient behaviors associated with attachment styles (secure vs 3 insecure subtypes: avoidant, anxious, and fearful) were fixed and patient factors (age, race, occupation, and gender) were randomized. Analysis included repeated measures mixed-effects linear regression. RESULTS Among the 208 respondents, the majority were male (65.4%) and White/Caucasian (84.5%) with an average age of 51.6 years (SD = 9.9). Most surgeons had been in practice for more than 10 years (66.8%) and treated adult patients (77.4%). Surgical specializations included breast (27.2%), HPB (35.0%), and broad-based/general (21.8%). Patient race, age, and gender did not impact surgeons' patient-centered approach to treatment decision-making (all ps > 0.05). However, when the "patient" had a white collar occupation and were securely attached, surgeons reported a greater likeliness to spend equal time presenting all treatment options (p = 0.02 and p < 0.001, respectively) and believe the patient wanted an active role in decision-making (p = 0.01 and p < 0.001, respectively). Surgeons reported being least likely to agree with a patient's treatment decision (p < 0.001) and an increased likelihood of being directive (p = 0.002) when patients exhibited behaviors associated with avoidant attachment. CONCLUSION Attachment-related behaviors were associated with differences in surgeon approaches to patient-centered decision-making. Attachment styles may offer a framework for providers to understand patient behaviors and needs, thereby providing insight on how to tailor their approach and provide optimal patient-centered care.
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Affiliation(s)
| | - Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Julia McGee
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Ko Un Park
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Pawlik TM. Preoperative Medical Referral Prior to Hepatopancreatic Surgery-Is It Worth it? J Gastrointest Surg 2021; 25:954-961. [PMID: 32314229 DOI: 10.1007/s11605-020-04590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/30/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Many patients who present for complex surgery have underlying medical comorbidities. While surgeons often refer these patients to medical appointments for preoperative "optimization" or "clearance," the actual impact of these visits remains poorly examined. The objective of the current study was to define the potential benefit of preoperative medical appointments on outcomes and costs associated with hepatopancreatic (HP) surgery. METHODS Patients with modifiable comorbidities undergoing HP surgery were identified in the Medicare claims data. The association of preoperative non-surgical visit and postoperative outcomes and expenditures was assessed using inverse propensity treatment weighting analysis and multivariable logistic regression. RESULTS Among the 5574 Medicare beneficiaries who underwent a hepatopancreatic surgery, one in seven patients (n = 830, 14.9%) was "optimized" preoperatively. On multivariable logistic regression analysis, age (OR 1.02; 95% CI 1.01-1.03; p = 0.006) and higher comorbidity burden (OR 1.03; 95% CI 1.01-1.05; p = 0.007) were associated with modest increased odds of being referred in the preoperative period for a non-surgical evaluation; the factor most associated with preoperative non-surgical visit was male patient sex (OR 1.33; 95% CI 1.14-1.56; p < 0.001). After adjustment for competing risk factors and random site effect, patients with an "optimization" visit had 28% lower odds (OR 0.72; 95% CI 0.59-0.86; p < 0.001) of experiencing an operative complication. Additionally, patients who had a non-surgical visit had 13% higher median total expenditures compared with individuals who did not undergo an "optimization" visit (p < 0.05). CONCLUSION In conclusion, roughly one in seven Medicare beneficiaries who underwent HP surgery may have been risk stratified by a non-surgical provider prior to surgery. Preoperative evaluation was associated with modestly lower odds of complications following HP surgery and higher Medicare expenditures. Further research is needed to determine its routine utility as a means to decrease the morbidity surrounding HP surgery.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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Sahara K, Tsilimigras DI, Moro A, Mehta R, Hyer JM, Paredes AZ, Beane JD, Endo I, Pawlik TM. Variation in Drain Management Among Patients Undergoing Major Hepatectomy. J Gastrointest Surg 2021; 25:962-970. [PMID: 32342262 DOI: 10.1007/s11605-020-04610-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection. METHODS The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3. RESULTS Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R2 = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3). CONCLUSIONS Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Palmer E, Lustberg MB, Dillhoff ME, Cloyd JM, Tsung A, Ejaz A, Wells-Di Gregorio S, Pawlik TM. Association of pre-existing mental illness with all-cause and cancer-specific mortality among Medicare beneficiaries with pancreatic cancer. HPB (Oxford) 2021; 23:451-458. [PMID: 32843275 DOI: 10.1016/j.hpb.2020.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Among patients with pancreatic cancer, the association of pre-existing mental illness with long-term outcomes remains unknown. METHODS Individuals diagnosed with pancreatic adenocarcinoma were identified in the SEER-Medicare database. Patients were classified as having mental illness if an ICD9/10CM code for anxiety, depression, bipolar disorder, schizophrenia or other psychotic disorder was recorded. RESULTS Among the 54,234 Medicare beneficiaries with pancreatic cancer, roughly 1 in 12 (n = 4793, 8.83%) individuals had a diagnosis of a mental illness. The majority (n = 4029, 84.1%) had anxiety or depression, while 16% (n = 764) had bipolar/schizophrenic disorders. On multivariable analysis, among patients with early stage cancer, individuals with pre-existing anxiety/depression and bipolar/schizophrenic disorders had 22% (OR 0.78, 95% CI 0.69-0.86) and 46% (OR 0.54, 95% CI 0.42-0.70) reduced odds, respectively, to undergo cancer-directed surgery. Furthermore, patients with a pre-existing history of bipolar/schizophrenic disorders had a 20% (HR 1.20, 95% CI 1.21-1.40) higher risk of all-cause mortality and 27% (HR 1.27, 95% CI 1.17-1.37) higher risk of pancreatic cancer-specific mortality compared to individuals without a history of mental illness. CONCLUSION One in twelve patients with pancreatic cancer had a pre-existing mental illness. Individuals with mental illness were more likely to have worse overall and cancer-specific long-term outcomes.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Elizabeth Palmer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Maryam B Lustberg
- Division of Medical Oncology, Supportive Care Services, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 1250 Lincoln Tower, Columbus, OH 43210, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA
| | - Sharla Wells-Di Gregorio
- Department of Internal Medicine, Division of Palliative Medicine, College of Medicine, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 504 McCampbell Hall North, 1581 Dodd Drive, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Dillhoff ME, Ejaz A, Cloyd JM, Tsung A, Pawlik TM. Wide variation in inpatient opioid utilization following hepatopancreatic surgery. HPB (Oxford) 2021; 23:212-219. [PMID: 32561176 DOI: 10.1016/j.hpb.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inpatient opioid utilization following major surgery remains relatively unknown. We sought to characterize inpatient opioid consumption following hepatopancreatic surgery and determine factors associated with the variability in opioid utilization. METHODS Adult patients who underwent hepatopancreatic surgery at a single institution were identified. Multimodal pain management strategies assessed included opioids (oral morphine equivalents, OME), acetaminophen, ibuprofen and ketorolac. RESULTS Among 2,054 patients, the median total OME utilized was 465 (129-815) during a patient's hospitalization following hepatopancreatic surgery. The interquartile range for total OMEs administered following hepatopancreatic surgery was as high as 940 OMEs (125 oxycodone-5mg pills) following a pancreaticoduodenectomy versus 520 OMEs (69 oxycodone-5mg pills) following a hemi-hepatectomy. Despite relatively high use of acetaminophen post-operatively (n = 1,588, 77.0%), multimodal pain control with acetaminophen and ibuprofen was infrequent (n = 175, 8.5%). Furthermore, individuals with high opioid utilization used on average 147 OMEs (20 oxycodone-5mg pills) the day before discharge versus 44 OME (6 oxycodone-5mg pills) among patients with expected opioid utilization. CONCLUSIONS Marked variability in inpatient opioid consumption following hepatopancreatic surgery was noted. Future work is necessary to decrease the variability in inpatient opioid prescribing practices to promote the safe and effective management of pain.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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10
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Azap RA, Hyer JM, Diaz A, Paredes AZ, Pawlik TM. Association of County-Level Vulnerability, Patient-Level Race/Ethnicity, and Receipt of Surgery for Early-Stage Hepatocellular Carcinoma. JAMA Surg 2021; 156:197-199. [PMID: 33355639 DOI: 10.1001/jamasurg.2020.5554] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus.,Deputy Editor, JAMA Surgery
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11
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Sahara K, Paredes AZ, Tsilimigras DI, Sasaki K, Moro A, Hyer JM, Mehta R, Farooq SA, Wu L, Endo I, Pawlik TM. Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery. Hepatobiliary Surg Nutr 2021; 10:20-30. [PMID: 33575287 DOI: 10.21037/hbsn.2019.11.30] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/12/2019] [Indexed: 12/26/2022]
Abstract
Background Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined. We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program (NSQIP) estimated probability (EP), as well as develop a machine learning model to identify individuals at risk for "unpredicted death" (UD) among patients undergoing hepatopancreatic (HP) procedures. Methods The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017. The risk of morbidity and mortality was stratified into three tiers (low, intermediate, or high estimated) using a k-means clustering method with bin sorting. A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation. C statistics were used to compare model performance. Results Among 63,507 patients who underwent an HP procedure, median patient age was 63 (IQR: 54-71) years. Patients underwent either pancreatectomy (n=38,209, 60.2%) or hepatic resection (n=25,298, 39.8%). Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP: low (n=36,923, 58.1%), intermediate (n=23,609, 37.2%) and high risk (n=2,975, 4.7%). Among 36,923 patients with low estimated risk of morbidity and mortality, 237 patients (0.6%) experienced a UD. According to the classification tree analysis, age was the most important factor to predict UD (importance 16.9) followed by preoperative albumin level (importance: 10.8), disseminated cancer (importance: 6.5), preoperative platelet count (importance: 6.5), and sex (importance 5.9). Among patients deemed to be low risk, the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP. Conclusions A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda A Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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12
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Ricci KB, Oslock WM, Ingraham AM, Rushing AP, Diaz A, Paredes AZ, Daniel VT, Collins CE, Heh VK, Baselice HE, Strassels SA, Caterino JM, Santry HP. Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen. J Surg Res 2021; 261:361-368. [PMID: 33493888 DOI: 10.1016/j.jss.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/06/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.
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Affiliation(s)
- Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | | | | | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Courtney E Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Victor K Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Jeffrey M Caterino
- Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio.
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13
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Paredes AZ, Hyer JM, Tsilimigras DI, Pawlik TM. Hepatopancreatic Surgery in the Rural United States: Variation in Outcomes at Critical Access Hospitals. J Surg Res 2021; 261:123-129. [PMID: 33422902 DOI: 10.1016/j.jss.2020.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/03/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. MATERIALS AND METHODS Medicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). RESULTS Patients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). CONCLUSIONS Only a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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14
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Moro A, Ejaz A, Dillhoff M, Cloyd J, Tsung A, Pawlik TM. Quality of Care Among Medicare Patients Undergoing Pancreatic Surgery: Safety Grade, Magnet Recognition, and Leapfrog Minimum Volume Standards-Which Quality Benchmark Matters? J Gastrointest Surg 2021; 25:269-277. [PMID: 32040811 DOI: 10.1007/s11605-019-04504-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The association of national quality benchmarking metrics with postoperative outcomes following complex surgery remains unknown. We assessed the relationship between the "quality trifactor" of Leapfrog minimum volume standards, Hospital Safety Grade A, and Magnet Recognition with outcomes of Medicare patients undergoing pancreatectomy. METHODS The Standard Analytic Files (SAF) merged with Leapfrog Hospital Survey and Leapfrog Safety Scores Denominator Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013 and 2015. Primary outcomes were overall and serious complications, as well as 30- and 90-day mortality. Multivariable logistic regression analyses were conducted to evaluate possible associations among hospitals meeting the quality trifactor and short-term outcomes. RESULTS Among 4853 Medicare patients, 909 (18.7%) underwent pancreatectomy at hospitals meeting the quality trifactor. Among 260 hospitals, 7.3% (n = 19) met the quality trifactor. Safety Grade A (48.8%, n = 127) was the most commonly met criterion followed by Magnet Recognition (36.2%, n = 94); the Leapfrog minimum volume standards were achieved by 25% (n = 65) of hospitals. Patients undergoing surgery at hospitals that were only Safety Grade A and Magnet designated, but did not meet Leapfrog criteria, had higher odds of serious complications (OR 1.59, 95% CI 1.00-2.51). In contrast, patients undergoing treatment at hospitals having all three designations (i.e., the quality trifactor) had 40% and 39% lower odds of both serious complications (OR 0.60, 95% CI 0.37-0.97) and 90-day mortality (OR 0.61, 95% CI 0.42-0.89), respectively. In turn, patients undergoing pancreatectomy at quality trifactor hospitals had higher odds of experiencing the composite quality measure textbook outcome (OR 1.28, 95% CI 1.03-1.59) versus patients undergoing pancreatectomy at non-trifactor hospitals. CONCLUSION While Safety Grade A and Magnet designation alone were not associated with higher odds of an optimal composite outcome following pancreatectomy, compliance with Leapfrog criteria to achieve the "quality trifactor" metric was associated with lower odds of serious complications and mortality.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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15
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Paredes AZ, Hyer JM, Palmer E, Lustberg MB, Pawlik TM. Racial/Ethnic Disparities in Hospice Utilization Among Medicare Beneficiaries Dying from Pancreatic Cancer. J Gastrointest Surg 2021; 25:155-161. [PMID: 32193849 DOI: 10.1007/s11605-020-04568-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to define the incidence and characterize the timing of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. METHODS The Medicare Standard Analytic Files from 2013 to 2017 were used to identify patients with pancreatic cancer who underwent a pancreatectomy. Logistic regression was utilized to identify the association between race and patterns of hospice utilization among deceased individuals. RESULTS Among the 14,495 individuals (median age 73; 52.3% female; 6.8% racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 47% (n = 6859) died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 4978, 72.6%) used hospice leading up to the time of death. Racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities n = 301, 67% vs. whites: n = 4677, 73%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 22% less likely than whites to initiate hospice services prior to death (OR 0.78, 95% CI 0.63-0.96). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e., within 3 days of death) versus white patients (OR 1.5, 95% CI 0.73-1.50). DISCUSSION While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, racial/ethnic minorities were less likely to use hospice services than whites.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Elizabeth Palmer
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Maryam B Lustberg
- Division of Medical Oncology, Medical Director, Supportive Care Services, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1250 Lincoln Tower, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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16
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Palmer Kelly E, Hyer M, Paredes AZ, Pawlik TM. A mixed-methods approach to comparing perceptions of cancer patients' and cancer care providers' religious and spiritual beliefs, behaviours, and attitudes. Eur J Cancer Care (Engl) 2020; 30:e13390. [PMID: 33368724 DOI: 10.1111/ecc.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/05/2020] [Accepted: 11/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the perceptions of cancer patients' and cancer care providers' religious and spiritual (R&S) beliefs, behaviours, and attitudes. METHODS A concurrent, nested, quantitative dominant, mixed-methods design was utilised. Data were collected from patient and provider groups via online survey. Analyses include chi-square tests of independence and independent t-tests for quantitative data and content analysis for qualitative data. RESULTS The final analytic cohort for the study included 576 participants (npatients = 236, nproviders = 340) with an average age of 47.4 years (SD = 15.0). Over half of participants were partnered (n = 386, 70.1%), female (n = 317, 57.3%) and had an advanced degree (n = 284, 51.2%). The most common diagnosis for patients was breast cancer (n = 103, 43.2%). The most common provider role was nurse (n = 220; 64.7%), while a smaller subset included physicians (n = 61; 17.9%) and "other" providers (n = 59; 17.4%). There was no difference between patients and providers in relation to R&S identity (p = 0.49) or behaviour (p = 0.28). Providers more frequently indicated that patients should receive R&S resources in the hospital (n = 281, 89.7% vs. n = 111, 49.6%, p < 0.001). For resource type, patients most frequently endorsed written resources (n = 93, 83.8%) while providers endorsed relational resources (n = 281, 97.9%). CONCLUSION Aligning patient and provider expectations of spiritual care will contribute to provision of optimal patient-centred cancer care.
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Affiliation(s)
| | - Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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17
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Tsilimigras DI, Hyer JM, Paredes AZ, Moris D, Sahara K, Guglielmi A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Soubrane O, Koerkamp BG, Endo I, Sasaki K, Aucejo F, Zhang XF, Pawlik TM. Tumor Burden Dictates Prognosis Among Patients Undergoing Resection of Intrahepatic Cholangiocarcinoma: A Tool to Guide Post-Resection Adjuvant Chemotherapy? Ann Surg Oncol 2020; 28:1970-1978. [PMID: 33259043 DOI: 10.1245/s10434-020-09393-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/04/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION While tumor burden (TB) has been associated with outcomes among patients with hepatocellular carcinoma, the role of overall TB in intrahepatic cholangiocarcinoma (ICC) remains poorly defined. METHODS Patients undergoing curative-intent resection of ICC between 2000 and 2017 were identified from a multi-institutional database. The impact of TB on overall (OS) and disease-free survival (DFS) was evaluated in the multi-institutional database and validated externally. RESULTS Among 1101 patients who underwent curative-intent resection of ICC, 624 (56.7%) had low TB, 346 (31.4%) medium TB, and 131 (11.9%) high TB. OS incrementally worsened with higher TB (5-year OS; low TB: 48.3% vs medium TB: 29.8% vs high TB: 17.3%, p < 0.001). Similarly, patients with low TB had better DFS compared with medium and high TB patients (5-year DFS: 38.3% vs 18.7% vs 6.9%, p < 0.001). On multivariable analysis, TB was independently associated with OS (medium TB: HR = 1.40, 95% CI 1.14-1.71; high TB: HR = 1.89, 95% CI 1.46-2.45) and DFS (medium TB, HR = 1.61, 95% CI 1.33-1.96; high TB: HR = 2.03, 95% CI 1.56-2.64). Survival analysis revealed an excellent prognostic discrimination using the TB among the external validation cohort (3-year OS; low TB: 44.8%, medium TB: 29.3%; high TB: 23.3%, p = 0.03; 3-year DFS: low TB: 32.7%, medium TB: 10.7%; high TB: 0%, p < 0.001). While neoadjuvant chemotherapy was not associated with survival across the TB groups, receipt of adjuvant chemotherapy was associated with increased survival among patients with high TB (5-year OS: 24.4% vs 13.4%, p = 0.02). CONCLUSION Overall TB dictated prognosis among patients with resectable ICC. TB may be used as a tool to help guide post-resection treatment strategies.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Federico Aucejo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Collins C, Pawlik TM. The association of Hospital Medicare beneficiary payer-mix, national quality rankings and outcomes following hepatopancreatic surgery. Am J Surg 2020; 221:492-496. [PMID: 33198957 DOI: 10.1016/j.amjsurg.2020.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/19/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We sought to determine the impact of payer-mix on post-operative outcomes among Medicare beneficiaries following hepatopancreatic surgery. METHODS Medicare beneficiaries who underwent hepatopancreatic surgery were identified. Hospital quality markers were obtained from the Hospital General Information dataset. Hospitals were dichotomized (low/average vs. high) based on Medicare patient days versus all patient days irrespective of payer type. RESULTS High Medicare patient-mix hospitals were more likely to be ranked higher than the national average relative to safety of care (29.4% vs. 38.1%) and timeliness of care (15.4% vs. 26.3%) versus low burden Medicare hospitals (both p < 0.001). However, Medicare beneficiaries who had hepatopancreatic surgery at a high Medicare patient-mix hospital were at higher risk of a complication (OR = 1.13, 95%CI 1.04-1.22), and death within 30-days (OR = 1.37, 95%CI 1.23-1.53) following surgery. CONCLUSION While hospitals caring for higher numbers of Medicare beneficiaries generally performed better on CMS quality indicators, these rankings did not equate to improved post-operative outcomes.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Courtney Collins
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Hyer JM, Paredes AZ, Tsilimigras DI, Azap R, White S, Ejaz A, Pawlik TM. Preoperative continuity of care and its relationship with cost of hepatopancreatic surgery. Surgery 2020; 168:809-815. [DOI: 10.1016/j.surg.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 01/20/2023]
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Azap RA, Paredes AZ, Diaz A, Hyer JM, Pawlik TM. The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery. Surgery 2020; 168:868-875. [DOI: 10.1016/j.surg.2020.06.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
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Paredes AZ, Hyer JM, Tsilimigras DI, Sahara K, White S, Pawlik TM. Interaction of Surgeon Volume and Nurse-to-Patient Ratio on Post-operative Outcomes of Medicare Beneficiaries Following Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:2551-2559. [PMID: 31745895 DOI: 10.1007/s11605-019-04449-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume. METHODS Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated. RESULTS Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86). CONCLUSION Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Farooq A, Paredes AZ, Merath K, Hyer JM, Mehta R, Sahara K, Tsilimigras DI, Moro A, Wu L, Cloyd J, Ejaz A, Pawlik TM. How Safe Are Safety-Net Hospitals? Opportunities to Improve Outcomes for Vulnerable Patients Undergoing Hepatopancreaticobiliary Surgery. J Gastrointest Surg 2020; 24:2570-2578. [PMID: 31792898 DOI: 10.1007/s11605-019-04428-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/30/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined. METHODS Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined. RESULTS Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001). CONCLUSION Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.
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Affiliation(s)
- Ayesha Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Columbus, OH, USA. .,Oncology, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Sahara K, Merath K, Hyer JM, Paredes AZ, Tsilimigras DI, Mehta R, Farooq SA, Moro A, Wu L, White S, Endo I, Pawlik TM. Impact of Preoperative Cholangitis on Short-term Outcomes Among Patients Undergoing Liver Resection. J Gastrointest Surg 2020; 24:2508-2516. [PMID: 31745898 DOI: 10.1007/s11605-019-04430-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes. METHODS Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC. RESULTS Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality. CONCLUSION Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda A Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Merath K, Cerullo M, Farooq A, Canner JK, He J, Tsilimigras DI, Mehta R, Paredes AZ, Sahara K, Dillhoff M, Tsung A, Cloyd J, Ejaz A, Pawlik TM. Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition? J Gastrointest Surg 2020; 24:2491-2499. [PMID: 31630368 DOI: 10.1007/s11605-019-04408-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission. METHODS Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed. RESULTS In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively). CONCLUSION Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jen He
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Hyer JM, Kelly EP, Paredes AZ, Tsilimigras DI, Diaz A, Pawlik TM. Mental illness is associated with increased risk of suicidal ideation among cancer surgical patients. Am J Surg 2020; 222:126-132. [PMID: 33268055 DOI: 10.1016/j.amjsurg.2020.10.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/01/2020] [Accepted: 10/19/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mental illness and depression can be associated with increased risk of suicidal ideation (SI). We sought to determine the association between mental illness and SI among cancer surgical patients. METHODS Medicare beneficiaries who underwent resection of lung, esophageal, pancreatic, colon, or rectal cancer were analyzed. Patients were categorized as no mental illness, anxiety and/or depression disorders or bipolar/schizophrenic disorders. RESULTS Among 211,092 Medicare beneficiaries who underwent surgery for cancer, the rate of suicidal ideation was 270/100,000 patients. Antecedent mental health diagnosis resulted in a marked increased SI. On multivariable analysis, patients with anxiety alone (OR 1.49, 95%CI 1.04-2.14), depression alone (OR 2.60, 95%CI 1.92-3.38), anxiety + depression (OR 4.50, 95%CI 3.48-5.86), and bipolar/schizophrenia (OR 7.30, 95%CI 5.27-10.30) had increased odds of SI. CONCLUSIONS Roughly 1 in 370 Medicare beneficiaries with cancer who underwent a wide range of surgical procedures had SI. An antecedent mental health diagnosis was a strong risk factor for SI.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Elizabeth Palmer Kelly
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
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Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
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Farooq A, Paredes AZ, Merath K, Mehta R, Moro A, Wu L, Sahara K, Hyer JM, Tsilimigras DI, Diaz A, Pawlik TM. Hepatopancreatobiliary Surgery: the Role of Clinical Resources and Variation in Performance of Hospitals Located in "Distressed" Communities. J Gastrointest Surg 2020; 24:2277-2285. [PMID: 31621025 DOI: 10.1007/s11605-019-04401-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/05/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The USA has one of the largest known income-based health disparities, with low-income adults being up to five times more likely to report being in poor health. We evaluated the association of hospital zip-code-based distressed communities index (DCI) with post-surgical outcomes following hepatopancreatobiliary (HPB) surgery. METHODS Adults undergoing HPB surgery were identified in the National Inpatient Sample. The association between hospital socioeconomic distress and outcomes including complications, mortality, failure to rescue (FTR), and never events were compared between high-distress facilities (HDF) and low-distress facilities (LDF). RESULTS A total of 11,119 (37.8%) patients underwent an operation at an HDF. Patients treated at HDF were younger (18-39 years, HDF: n = 1261, 11.3% vs. LDF: n = 966, 9.0%; p < 0.001), Black/Hispanic (HDF: n = 2060, 18.5% vs. LDF: n = 1440, 11.4%; p < 0.001) and in the lowest income quartile (HDF: n = 2825, 25.4% vs. LDF: n = 1116, 10.8%; p < 0.001). While complications were comparable at HDF versus LDF (HDF: n = 2483, 22.3% vs. LDF: n = 2370, 22.0%; p = 0.28), patients treated at HDF had higher odds of in-hospital mortality (OR, 1.31; 95% CI, 1.07-1.59), FTR (OR, 1.24; 95% CI, 1.02-1.52), and a never event (OR, 1.76; 95% CI, 1.29-2.39; all p < 0.001). Hospitals having advanced internal medicine services had reduced odds of mortality (OR, 0.61; 95% CI, 0.47-0.80) whereas high nurse-to-patient ratio was associated with reduced odds of a complication (OR, 0.89; 95% CI, 0.81-0.98). CONCLUSION Approximately 40% of patients were admitted to HDF. These patients were more likely to be Black/Hispanic and underinsured. Perioperative outcomes were worse at HDF following HPB surgery.
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Affiliation(s)
- Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA. .,Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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Tsilimigras DI, Chen Q, Hyer JM, Paredes AZ, Mehta R, Dillhoff M, Cloyd JM, Ejaz A, Beane JD, Tsung A, Pawlik TM. The impact of individual surgeon on the likelihood of minimal invasive surgery among Medicare beneficiaries undergoing pancreatic resection. Surgery 2020; 169:550-556. [PMID: 32948338 DOI: 10.1016/j.surg.2020.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/07/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The objective of the current study was to evaluate the impact of the individual surgeon on the use of minimally invasive pancreatic resection. METHODS The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent pancreatic resection between 2013 and 2017. The impact of patient- and procedure-related factors on the likelihood of minimally invasive pancreatic resection was investigated. RESULTS A total of 12,652 (85.4%) patients underwent open pancreatic resection, whereas minimally invasive pancreatic resection was performed in 2,155 (14.6%) patients. Unadjusted rates of minimally invasive pancreatic resection ranged from 0% in the bottom volume tertile to 35.3% in the top tertile. Although patients with emergency admission were less likely to undergo minimally invasive pancreatic resection (odds ratio = 0.43, 95% confidence interval 0.32-0.58), patients operated on more recently had a higher chance of minimally invasive pancreatic resection (year 2017; odds ratio = 1.51, 95% confidence interval 1.28-1.79). On multivariable analysis, there was over a 3-fold variation in the odds that a patient underwent minimally invasive versus open pancreatic resection based on the individual surgeon (median odds ratio = 3.27, 95% confidence interval 2.98-3.56). Patients who underwent pancreatectomy by a low-volume, minimally invasive pancreatic resection surgeon had higher odds of 90-day mortality after surgery (odds ratio = 1.33, 95% confidence interval: 1.16-1.59), as well as higher observed/expected mortality compared with individuals treated by high-volume surgeons. CONCLUSION The likelihood of undergoing minimally invasive pancreatic resection among Medicare beneficiaries was markedly influenced by the individual treating surgeon rather than patient- or procedure-level factors.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Qinyu Chen
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Joal D Beane
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Paredes AZ, Hyer JM, Diaz A, Tsilimigras DI, Pawlik TM. Examining healthcare inequities relative to United States safety net hospitals. Am J Surg 2020; 220:525-531. [DOI: 10.1016/j.amjsurg.2020.01.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 11/30/2022]
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McCarty AR, Villarreal ME, Tamer R, Strassels SA, Schubauer KM, Paredes AZ, Santry H, Wisler JR. Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States. J Surg Res 2020; 257:107-117. [PMID: 32818779 DOI: 10.1016/j.jss.2020.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/05/2020] [Accepted: 06/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking. METHODS Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05. RESULTS 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location. CONCLUSIONS In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.
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Affiliation(s)
- Adara R McCarty
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio.
| | - Michael E Villarreal
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Robert Tamer
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Scott A Strassels
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio; Ohio State University, Wexner Medical Center Center For Surgical Health Assessment, Research And Policy (SHARP), Columbus, Ohio
| | - Kathryn M Schubauer
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Anghela Z Paredes
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
| | - Heena Santry
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio; Ohio State University, Wexner Medical Center Center For Surgical Health Assessment, Research And Policy (SHARP), Columbus, Ohio
| | - Jon R Wisler
- Ohio State University, Wexner Medical Center Department of Surgery, Columbus, Ohio
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Hyer JM, Paredes AZ, Kelley EP, Tsilimigras D, Meyer B, Newberry H, Pawlik TM. Characterizing Pastoral Care Utilization by Cancer Patients. Am J Hosp Palliat Care 2020; 38:758-765. [PMID: 32799646 DOI: 10.1177/1049909120951082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the rate of and characterize the utilization of pastoral care (PC) among patients on their cancer treatment trajectory. METHODS Patients included in the present study were diagnosed with cancer 01/2015-08/2019 at The Ohio State Wexner Medical Center-The James. To determine which patient demographic and clinical factors were independently associated with PC utilization, a multivariable logistic regression was performed. RESULTS A total of 14,322 patients were included in the study and 5,166 (36.1%) had at least one visit with PC. Cancers such as brain (n = 232, 4.5% vs. n = 159, 1.7%), liver/pancreas (n = 733, 14.2% vs. 686, 7.5%), and lung (n = 1,288 vs. 24.9% vs. n = 1,113, 12.2%) were more commonly noted among patients who utilized PC services (all p < 0.001). Furthermore, compared with patients diagnosed with Stage 1 cancer, patients with more advanced disease stages had higher odds of utilizing PC services (Stage III: OR 2.37, 95% CI 2.07-2.70; Stage IV OR 2.31, 95% CI: 2.04-2.61; both p < 0.05). Interestingly, patients who had a DNR order had a markedly higher odds (OR 4.18, 95%CI 3.76-4.65, p < 0.001) of utilizing PC services. DISCUSSION One in three patients with cancer utilized PC services. Patients with more severe prognoses and individuals with a DNR order were more likely to utilize PC. The data suggest that PC services are an important resource for many patients and should be integrated into the treatment approach for cancer.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, 2647The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, 2647The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Elizabeth Palmer Kelley
- Department of Surgery, 2647The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Diamantis Tsilimigras
- Department of Surgery, 2647The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Bonnie Meyer
- 2647The Ohio State University Wexner Medical Center Department of Chaplaincy and Clinical Pastoral Education, OH, USA
| | - Hanci Newberry
- 2647The Ohio State University Wexner Medical Center Department of Chaplaincy and Clinical Pastoral Education, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, 2647The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
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Paredes AZ, Tsilimigras DI, Pawlik TM. ASO Author Reflections: Development and Validation of a Novel Risk Score Using Machine-Learning Methodology to Predict Recurrence After Hepatectomy for Colorectal Liver Metastases. Ann Surg Oncol 2020; 27:5148-5149. [PMID: 32776192 DOI: 10.1245/s10434-020-08995-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Moro A, Bagante F, Guglielmi A, Ruzzenente A, Alexandrescu S, Makris EA, Poultsides GA, Sasaki K, Aucejo FN, Pawlik TM. A Novel Machine-Learning Approach to Predict Recurrence After Resection of Colorectal Liver Metastases. Ann Surg Oncol 2020; 27:5139-5147. [PMID: 32779049 DOI: 10.1245/s10434-020-08991-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/11/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical resection of hepatic metastases remains the only potentially curative treatment option for patients with colorectal liver metastases (CRLM). Widely adopted prognostic tools may oversimplify the impact of model parameters relative to long-term outcomes. METHODS Patients with CRLM who underwent a hepatectomy between 2001 and 2018 were identified in an international, multi-institutional database. Bootstrap resampling methodology used in tandem with multivariable mixed-effects logistic regression analysis was applied to construct a prediction model that was validated and compared with scores proposed by Fong and Vauthey. RESULTS Among 1406 patients who underwent hepatic resection of CRLM, 842 (59.9%) had recurrence. The full model (based on age, sex, primary tumor location, T stage, receipt of chemotherapy before hepatectomy, lymph node metastases, number of metastatic lesions in the liver, size of the largest hepatic metastases, carcinoembryonic antigen [CEA] level and KRAS status) had good discriminative ability to predict 1-year (area under the receiver operating curve [AUC], 0.693; 95% confidence interval [CI], 0.684-0.704), 3-year (AUC, 0.669; 95% CI, 0.661-0.677), and 5-year (AUC, 0.669; 95% CI, 0.661-0.679) risk of recurrence. Studies analyzing validation cohorts demonstrated similar model performance, with excellent model accuracy. In contrast, the AUCs for the Fong and Vauthey scores to predict 1-year recurrence were only 0.527 (95% CI, 0.514-0.538) and 0.525 (95% CI, 0.514-0.533), respectively. Similar trends were noted for 3- and 5-year recurrence. CONCLUSION The proposed clinical score, derived via machine learning, which included clinical characteristics and morphologic data, as well as information on KRAS status, accurately predicted recurrence after CRLM resection with good discrimination and prognostic ability.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | | | | | | | | | - Kazunari Sasaki
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Federico N Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Oslock WM, Ricci KB, Ingraham AM, Rushing AP, Baselice HE, Paredes AZ, Heh VK, Byrd CA, Strassels SA, Santry HP. Role of interprofessional teams in emergency general surgery patient outcomes. Surgery 2020; 168:347-353. [DOI: 10.1016/j.surg.2020.04.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Amalia Cochran
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus.,Associate Editor, JAMA Surgery
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Sahara K, Tsilimigras DI, Paredes AZ, Farooq SA, Hyer JM, Moro A, Mehta R, Wu L, Endo I, Ejaz A, Cloyd J, Pawlik TM. Development and validation of a real-time mortality risk calculator before, during and after hepatectomy: an analysis of the ACS NSQIP database. HPB (Oxford) 2020; 22:1158-1167. [PMID: 31812552 DOI: 10.1016/j.hpb.2019.10.2446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy. METHODS Patients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data. RESULTS Among 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods. CONCLUSION A real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA; Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Syeda A Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Merath K, Hyer JM, Mehta R, Farooq A, Bagante F, Sahara K, Tsilimigras DI, Beal E, Paredes AZ, Wu L, Ejaz A, Pawlik TM. Use of Machine Learning for Prediction of Patient Risk of Postoperative Complications After Liver, Pancreatic, and Colorectal Surgery. J Gastrointest Surg 2020; 24:1843-1851. [PMID: 31385172 DOI: 10.1007/s11605-019-04338-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. RESULTS Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). CONCLUSION Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Hyer JM, Paredes AZ, Tsilimigras DI, White S, Cloyd J, Ejaz A, Pawlik TM. Variations in Healthcare Expenditures Among Medicare Beneficiaries Undergoing Resection of Pancreatic Cancer. J Gastrointest Surg 2020; 24:1863-1865. [PMID: 32472269 DOI: 10.1007/s11605-020-04660-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/15/2020] [Indexed: 01/31/2023]
Affiliation(s)
- J Madison Hyer
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- Department of Financial Services, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Mehta R, Paredes AZ, Pawlik TM. Redefining the “Honor Roll:” do hospital rankings predict surgical outcomes or receipt of quality surgical care? Am J Surg 2020; 220:438-440. [DOI: 10.1016/j.amjsurg.2019.11.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/20/2019] [Indexed: 01/26/2023]
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Christopher T Aquina
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Luke V Selby
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Stephanie DiFilippo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA.
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Diaz A, Chavarin D, Paredes AZ, Tsilimigras DI, Pawlik TM. Association of Neighborhood Characteristics with Utilization of High-Volume Hospitals Among Patients Undergoing High-Risk Cancer Surgery. Ann Surg Oncol 2020; 28:617-631. [PMID: 32699923 DOI: 10.1245/s10434-020-08860-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/02/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION As high-risk cancer surgery continues to become more centralized, it is important to understand the association of neighborhood characteristics relative to access to surgical care. We sought to determine the neighborhood level characteristics that may be associated with travel patterns and utilization of high-volume hospitals. METHODS The California Office of Statewide Health Planning database was used to identify patients who underwent pancreatectomy (PD), esophagectomy (ES), proctectomy (PR), or pneumonectomy (PN) for cancer between 2014 and 2016. Total minutes (m) traveled as well as whether a patient bypassed the nearest hospital that performed the operation to get to a higher-volume center was assessed. Data were merged with the Centers for Disease control social vulnerability index (SVI). RESULTS Overall, 26,937 individuals (ES: 4.7%; PN: 53.5% PD: 13.9% PR: 27.9%) underwent a complex oncologic operation. Median travel time was 16 m (interquartile range [IQR] 8.3-30.24) [ES: 21.8 m (IQR 10.6-46.9); PN: 14 m (IQR 7.8-27.0); PD: 21.2 m (IQR 10.6-42.6); PR: 15 m (IQR 8.1-28.4)]. Nearly three-quarter of patients (ES: 34%; PN: 73%; PD: 72%; LR: 81%) underwent an operation at a high-volume hospital. For all four operations, patients who resided in a county with a high overall SVI were less likely to have surgery at a high-volume hospital (ES: odds ratio [OR] 0.39, 95% confidence interval [CI] 0.24-0.65; PN: OR: 0.67, 95% CI 0.51-0.88; PD: OR 0.61, 95% CI 0.44-0.84; PR: OR 0.76, 95% CI 0.58-0.98). CONCLUSIONS Patients residing in communities of high social vulnerability were less likely to undergo high-risk cancer surgery at a high-volume hospital. The identification of society-based contextual disparities in access to complex surgical care should serve to inform targeted strategies to direct additional resources toward these vulnerable communities.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.,IHPI Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Chavarin
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Moro A, Mehta R, Tsilimigras DI, Sahara K, Paredes AZ, Bagante F, Guglielmi A, Alexandrescu S, Poultsides GA, Sasaki K, Aucejo FN, Pawlik TM. Prognostic factors differ according to KRAS mutational status: A classification and regression tree model to define prognostic groups after hepatectomy for colorectal liver metastasis. Surgery 2020; 168:497-503. [PMID: 32675031 DOI: 10.1016/j.surg.2020.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although KRAS mutation status is known to affect the prognosis of patients with colorectal liver metastasis, the hierarchical association between other prognostic factors and KRAS status is not fully understood. METHODS Patients who underwent a hepatectomy for colorectal liver metastasis were identified in a multi-institutional international database. A classification and regression tree model was constructed to investigate the hierarchical association between prognostic factors and overall survival relative to KRAS status. RESULTS Among 1,123 patients, 29.9% (n = 336) had a KRAS mutation. Among wtKRAS patients, the classification and regression tree model identified presence of metastatic lymph nodes as the most important prognostic factor, whereas among mtKRAS patients, carcinoembryonic antigen level was identified as the most important prognostic factor. Among patients with wtKRAS, the highest 5-year overall survival (68.5%) was noted among patients with node negative primary colorectal cancer, solitary colorectal liver metastases, size <4.3 cm. In contrast, among patients with mtKRAS colorectal liver metastases, the highest 5-year overall survival (57.5%) was observed among patients with carcinoembryonic antigen <6 mg/mL. The classification and regression tree model had higher prognostic accuracy than the Fong score (wtKRAS [Akaike's Information Criterion]: classification and regression tree model 3334 vs Fong score 3341; mtKRAS [Akaike's Information Criterion]: classification and regression tree model 1356 vs Fong score 1396). CONCLUSION Machine learning methodology outperformed the traditional Fong clinical risk score and identified different factors, based on KRAS mutational status, as predictors of long-term prognosis.
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Affiliation(s)
- Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | | | | | - Kazunari Sasaki
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Federico N Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Hyer JM, Ejaz A, Tsilimigras DI, Paredes AZ, Mehta R, Pawlik TM. Novel Machine Learning Approach to Identify Preoperative Risk Factors Associated With Super-Utilization of Medicare Expenditure Following Surgery. JAMA Surg 2020; 154:1014-1021. [PMID: 31411664 DOI: 10.1001/jamasurg.2019.2979] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Typically defined as the top 5% of health care users, super-utilizers are responsible for an estimated 40% to 55% of all health care costs. Little is known about which factors may be associated with increased risk of long-term postoperative super-utilization. Objective To identify clusters of patients with distinct constellations of clinical and comorbid patterns who may be associated with an elevated risk of super-utilization in the year following elective surgery. Design, Setting, and Participants A retrospective longitudinal cohort study of 1 049 160 patients who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, colectomy, total hip arthroplasty, total knee arthroplasty, or lung resection were identified from the 100% Medicare inpatient and outpatient Standard Analytic Files at all inpatient facilities performing 1 or more of the evaluated surgical procedures from 2013 to 2015. Data from 2012 to 2016 were used to evaluate expenditures in the year preceding and following surgery. Using a machine learning approach known as Logic Forest, comorbidities and interactions of comorbidities that put patients at an increased chance of becoming a super-utilizer were identified. All comorbidities, as defined by the Charlson (range, 0-24) and Elixhauser (range, 0-29) comorbidity indices, were used in the analysis. Higher scores indicated higher comorbidity burden. Data analysis was completed on November 16, 2018. Main Outcome and Measures Super-utilization of health care in the year following surgery. Results In total, 1 049 160 patients met inclusion criteria and were included in the analytic cohort. Their median (interquartile range) age was 73 (69-78) years, and approximately 40% were male. Super-utilizers comprised 4.8% of the overall cohort (n = 79 746) yet incurred 31.7% of the expenditures. Although the difference in overall expenditures per person between super-utilizers ($4049) and low users ($2148) was relatively modest prior to surgery, the difference in expenditures between super-utilizers ($79 698) vs low users ($2977) was marked in the year following surgery. Risk factors associated with super-utilization of health care included hemiplegia/paraplegia (odds ratio, 5.2; 95% CI, 4.4-6.2), weight loss (odds ratio, 3.5; 95% CI, 2.9-4.2), and congestive heart failure with chronic kidney disease stages I to IV (odds ratio, 3.4; 95% CI, 3.0-3.9). Conclusions and Relevance Super-utilizers comprised only a small fraction of the surgical population yet were responsible for a disproportionate amount of Medicare expenditure. Certain subpopulations were associated with super-utilization of health care following surgical intervention despite having lower overall use in the preoperative period.
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Affiliation(s)
- J Madison Hyer
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Anghela Z Paredes
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Rittal Mehta
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, Solove Research Institute, The Ohio State University, Wexner Medical Center, James Cancer Hospital, Columbus.,Deputy Editor
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Mehta R, Tsilimigras DI, Paredes AZ, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Pawlik TM. Is Patient Satisfaction Dictated by Quality of Care Among Patients Undergoing Complex Surgical Procedures for a Malignant Indication? Ann Surg Oncol 2020; 27:3126-3135. [DOI: 10.1245/s10434-020-08788-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
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Tameron AM, Ricci KB, Oslock WM, Rushing AP, Ingraham AM, Daniel VT, Paredes AZ, Diaz A, Collins CE, Heh VK, Baselice HE, Strassels SA, Santry HP. The association between self-declared acute care surgery services and critical care resources: Results from a national survey. J Crit Care 2020; 60:84-90. [PMID: 32769008 DOI: 10.1016/j.jcrc.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/27/2020] [Accepted: 04/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. METHODS 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. RESULTS 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. CONCLUSIONS Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.
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Affiliation(s)
- Ashley M Tameron
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA
| | - Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Wendelyn M Oslock
- Ohio State University College of Medicine, 370 W 9th Avenue, Columbus, OH, USA
| | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Angela M Ingraham
- University of Wisconsin, Department of Surgery, 600 Highland Avenue, Madison, WI, USA
| | - Vijaya T Daniel
- University of Massachusetts Medical School, Department of Surgery, 55 Lake Avenue, Worcester, MA, USA
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Courtney E Collins
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Victor K Heh
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, 395 W 12th Avenue, Columbus, OH, USA; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, 395 W 12th Avenue, Columbus, OH, USA.
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Paredes AZ, Diaz A, Pawlik TM. COVID-19 pandemic and mental health: The surgeon's role in re-engaging patients. Am J Surg 2020; 220:1366-1367. [PMID: 32600843 PMCID: PMC7306103 DOI: 10.1016/j.amjsurg.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, USA
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Sahara K, Merath K, Hyer JM, Tsilimigras DI, Paredes AZ, Farooq A, Mehta R, Wu L, Beal EW, White S, Endo I, Pawlik TM. Impact of Surgeon Volume on Outcomes and Expenditure Among Medicare Beneficiaries Undergoing Liver Resection: the Effect of Minimally Invasive Surgery. J Gastrointest Surg 2020; 24:1520-1529. [PMID: 31325139 DOI: 10.1007/s11605-019-04323-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR). METHODS Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined. RESULTS Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055). CONCLUSION Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.
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Affiliation(s)
- Kota Sahara
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.,Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katiuscha Merath
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Ayesha Farooq
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Itaru Endo
- Gastroenterological Surgery Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Farooq A, Bae J, Rice D, Moro A, Paredes AZ, Crisp AL, Windholtz M, Sahara K, Tsilimigras DI, Hyer JM, Merath K, Mehta R, Parasidis E, Pawlik TM. Inside the courtroom: An analysis of malpractice litigation in gallbladder surgery. Surgery 2020; 168:56-61. [DOI: 10.1016/j.surg.2020.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/26/2020] [Accepted: 04/07/2020] [Indexed: 01/10/2023]
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Tsilimigras DI, Paredes AZ, Pawlik TM. ASO Author Reflections: Identification of Intrahepatic Cholangiocarcinoma Clusters Using Machine Learning Techniques: Should Patients be Treated Differently? Ann Surg Oncol 2020; 27:5233-5234. [PMID: 32591955 DOI: 10.1245/s10434-020-08697-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Tsilimigras DI, Hyer JM, Paredes AZ, Diaz A, Moris D, Guglielmi A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Soubrane O, Koerkamp BG, Endo I, Pawlik TM. A Novel Classification of Intrahepatic Cholangiocarcinoma Phenotypes Using Machine Learning Techniques: An International Multi-Institutional Analysis. Ann Surg Oncol 2020; 27:5224-5232. [PMID: 32495285 DOI: 10.1245/s10434-020-08696-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Patients with intrahepatic cholangiocarcinoma (ICC) generally have a poor prognosis, yet there can be heterogeneity in the patterns of presentation and associated outcomes. We sought to identify clusters of ICC patients based on preoperative characteristics that may have distinct outcomes based on differing patterns of presentation. METHODS Patients undergoing curative-intent resection of ICC between 2000 and 2017 were identified using a multi-institutional database. A cluster analysis was performed based on preoperative variables to identify distinct patterns of presentation. A classification tree was built to prospectively assign patients into cluster assignments. RESULTS Among 826 patients with ICC, three distinct presentation patterns were noted. Specifically, Cluster 1 (common ICC, 58.9%) consisted of individuals who had a small-size ICC (median 4.6 cm) and median carbohydrate antigen (CA) 19-9 and neutrophil-to-lymphocyte ratio (NLR) levels of 40.3 UI/mL and 2.6, respectively; Cluster 2 (proliferative ICC, 34.9%) consisted of patients who had larger-size tumors (median 9.0 cm), higher CA19-9 levels (median 72.0 UI/mL), and similar NLR (median 2.7); Cluster 3 (inflammatory ICC, 6.2%) comprised of patients with a medium-size ICC (median 6.2 cm), the lowest range of CA19-9 (median 26.2 UI/mL), yet the highest NLR (median 13.5) (all p < 0.05). Median OS worsened incrementally among the three different clusters {Cluster 1 vs. 2 vs. 3; 60.4 months (95% confidence interval [CI] 43.0-77.8) vs. 27.2 months (95% CI 19.9-34.4) vs. 13.3 months (95% CI 7.2-19.3); p < 0.001}. The classification tree used to assign patients into different clusters had an excellent agreement with actual cluster assignment (κ = 0.93, 95% CI 0.90-0.96). CONCLUSION Machine learning analysis identified three distinct prognostic clusters based solely on preoperative characteristics among patients with ICC. Characterizing preoperative patient heterogeneity with machine learning tools can help physicians with preoperative selection and risk stratification of patients with ICC.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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