Characterizing the impact of verbal communication and health literacy in the patient-surgeon encounter

BACKGROUND

Patients with limited health literacy (HL) have difficulty understanding written/verbal information. The quality of verbal communication is not well understood. Therefore, our aim was to characterize patient-surgeon conversations and identify opportunities for improvement.

METHODS

New colorectal patient-surgeon encounters were audio-recorded and transcribed. HL was measured. Primary outcomes were rates-of-speech, understandability of words, patient-reported understanding, and usage of medical jargon/statistics. Secondary outcomes included length-of-visit (LOV), conversation possession time, patient-surgeon exchanges, and speech interruptions.

RESULTS

Significant variations existed between surgeons in rates-of-speech and understandability of words (p < 0.05). Faster rates-of-speech were associated with significantly less understandable words (p < 0.05). Patient-reported understanding varied by HL and by surgeon. Conversation possession time and usage of medical jargon/statistics varied significantly by surgeon (p < 0.05) in addition to patient-surgeon exchanges and interruptions. Patients with limited HL had shorter LOV.

CONCLUSIONS

Significant variations exist in how surgeons talk to patients. Opportunities to improve verbal communication include slowing speech and using more understandable words.

Multidisciplinary clinics for colorectal cancer may not provide more efficient coordination of care

BACKGROUND

This retrospective study compares a multidisciplinary clinic (MDC) to standard care for time to treatment of colorectal cancer.

METHODS

We queried our institutional ACS-NSQIP database for patients undergoing surgery for colorectal cancer from 2017 to 2020. Patients were stratified by initial clinic visit (MDC vs control). Primary endpoint was the time to start treatment (TST), either neoadjuvant therapy or surgery, from the date of diagnosis by colonoscopy.

RESULTS

A total of 405 patients were evaluated (115 MDC, 290 Control). TST from diagnosis was not significantly shorter for the MDC cohort (MDC 30 days, Control 37 days; p = 0.07) even when stratified by type of initial treatment of neoadjuvant therapy (MDC 30, Control 34 days; p = 0.28) or surgery (MDC 32.5 days, Control 38 days; p = 0.35).

CONCLUSION

Implementation of an MDC provides insignificant reduction in delay to start treatment for colorectal cancer patients as compared to standard care colorectal surgery clinics.

CLASSIFICATION

Colorectal.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery

BACKGROUND

Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system.

METHODS

Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs).

RESULTS

616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs.

CONCLUSIONS

Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.

Assessment of a circular powered stapler for creation of anastomosis in left-sided colorectal surgery: A prospective cohort study

BACKGROUND

Circular staplers perform a critical function for creation of anastomoses in colorectal surgeries. Powered stapling systems allow for reduced force required by surgeons to fire the device and may provide advantages for creating a secure anastomosis. The objective of this study was to evaluate the clinical performance of a novel circular powered stapler in a post-market setting, during left-sided colectomy procedures.

MATERIALS AND METHODS

Consecutive subjects underwent left-sided colorectal resections that included anastomosis performed with the ECHELON CIRCULAR™ Powered Stapler (ECP). The primary endpoint was the frequency in which a stapler performance issue was observed. Secondary endpoints included evaluation of ease of use of the device via a surgeon satisfaction questionnaire, and monitoring/recording of procedure-related adverse events (AEs).

RESULTS

A total of 168 anastomoses were performed with the ECP. Surgical approaches included robotic-assisted (n = 74, 44.0%), laparoscopic (n = 71, 42.3%), open (n = 20, 11.9%), and hand-assisted minimally invasive (n = 3, 1.8%) procedures. There were 22 occurrences of device performance issues in 20 (11.9%) subjects during surgery. No positive intraoperative leak tests were observed, and only 1 issue was related to a procedure-related AE or surgical complication, which was an instance of incomplete surgical donut necessitating re-anastomosis. Postoperative anastomotic leaks were experienced in 4 (2.4%) subjects. Clavien-Dindo classification of all AEs indicated that 92.0% were Grades I or II. Participating surgeons rated the ECP as easier to use compared to previously used manual circular staplers in 85.7% of procedures.

CONCLUSION

The circular powered stapler exhibited few clinically relevant performance issues, an overall favorable safety profile, and ease of use for creation of left-sided colon anastomoses.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans

BACKGROUND

Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy.

METHODS

Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses.

RESULTS

Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels.

CONCLUSIONS

Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Genetic/Familial High-Risk Assessment: Colorectal Version 1.2016, NCCN Clinical Practice Guidelines in Oncology

This is a focused update highlighting the most current NCCN Guidelines for diagnosis and management of Lynch syndrome. Lynch syndrome is the most common cause of hereditary colorectal cancer, usually resulting from a germline mutation in 1 of 4 DNA mismatch repair genes (MLH1, MSH2, MSH6, or PMS2), or deletions in the EPCAM promoter. Patients with Lynch syndrome are at an increased lifetime risk, compared with the general population, for colorectal cancer, endometrial cancer, and other cancers, including of the stomach and ovary. As of 2016, the panel recommends screening all patients with colorectal cancer for Lynch syndrome and provides recommendations for surveillance for early detection and prevention of Lynch syndrome-associated cancers.

Evaluation, Diagnosis, and Medical Management of Rectal Prolapse

Full-thickness rectal prolapse, or procidentia, is the passage of the full-thickness wall of the rectum beyond the anal sphincters. This condition results in pain and fecal incontinence which greatly impairs the quality of life of those afflicted. It is associated with several anatomic abnormalities, including decreased anal sphincter tone, levator muscle diastasis, and a deep anterior cul-de-sac. The diagnosis of rectal prolapse is made based on physical examination, although several other modalities are used to provide additional information about the patients' condition. While medical management of rectal prolapse can be effective in some cases, the mainstay of management of rectal prolapse is surgical correction.

Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery

INTRO

Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.

METHODS

Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.

RESULTS

Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).

CONCLUSION

These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.

Colorectal Cancer Screening, Version 1.2015

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colorectal Cancer Screening provide recommendations for selecting individuals for colorectal cancer screening, and for evaluation and follow-up of colon polyps. These NCCN Guidelines Insights summarize major discussion points of the 2015 NCCN Colorectal Cancer Screening panel meeting. Major discussion topics this year were the state of evidence for CT colonography and stool DNA testing, bowel preparation procedures for colonoscopy, and guidelines for patients with a positive family history of colorectal cancer.

Biomaterials: so many choices, so little time. What are the differences?

The use of biologic mesh has increased greatly in recent years in response to the need for a solution in managing contaminated hernias. Multiple different meshes are commercially available, and are derived from a variety of sources, including human dermis as well as animal sources. For a mesh to be effective, it must be resistant to infection, have adequate tensile strength for hernia repair, and be well tolerated by the host. To achieve this end, biologic meshes go through an intense processing that varies from one product to the next. In this article, the authors review the types of mesh available, how they are processed, and examine these characteristics in terms of their strengths and weaknesses in application to surgical technique.

Colorectal cancer screening

Mortality from colorectal cancer can be reduced by early diagnosis and by cancer prevention through polypectomy. These NCCN Guidelines for Colorectal Cancer Screening describe various colorectal screening modalities and recommended screening schedules for patients at average or increased risk of developing colorectal cancer. In addition, the guidelines provide recommendations for the management of patients with high-risk colorectal cancer syndromes, including Lynch syndrome. Screening approaches for Lynch syndrome are also described.

Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery

BACKGROUND

Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery.

STUDY DESIGN

This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission.

RESULTS

Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38).

CONCLUSIONS

Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.

Extracellular matrix-associated cytokines regulate CD4+ effector T-cell responses in the human intestinal mucosa

Extracellular matrix (stroma) regulation of mucosal T-cell function is incompletely understood. In this study, we uncovered a role for intestinal stromal products in the innate regulation of effector T cells. Stroma-conditioned media (S-CM) derived from the normal human intestinal stroma (transforming growth factor-β (TGF-β)(hi)/interleukin (IL)-6(lo)/IL-1β(lo)) significantly downregulated T-cell proliferation and interferon-γ (IFN-γ) production compared with S-CM derived from the inflamed Crohn's mucosa (TGF-β(hi)/IL-6(hi)/IL-1β(hi)). Antibody neutralization studies showed that TGF-β in normal S-CM inhibited T-cell proliferation and IFN-γ production, whereas IL-6 plus IL-1β in Crohn's S-CM promoted T-cell proliferation, and IL-1β alone promoted IFN-γ and IL-17 release. Importantly, normal S-CM inhibited T-bet expression, whereas Crohn's S-CM activated signal transducer and activator of transcription 3, suggesting that discordant T-cell responses are regulated at the transcription factor and signaling levels. These findings implicate stromal TGF-β in the downregulation of T-cell 2 responses in the normal intestinal mucosa, and stromal IL-6 and IL-1β in the promotion of Th1 and Th17 responses in the inflamed Crohn's mucosa, suggesting an innate regulatory function for the intestinal extracellular matrix.

GP41-specific antibody blocks cell-free HIV type 1 transcytosis through human rectal mucosa and model colonic epithelium

Monostratified epithelial cells translocate HIV type 1 (HIV-1) from the apical to the basolateral surface via vesicular transcytosis. Because acutely transmitted HIV-1 is almost exclusively CCR5-tropic and human intestinal epithelial cells preferentially transcytose CCR5-tropic virus, we established epithelial monolayers using polarized HT-29 cells transduced to express CCR5, and an explant system using normal human rectal mucosa, to characterize biological parameters of epithelial cell transcytosis of HIV-1 and assess antiviral Ab blockade of transcytosis. The amount of cell-free HIV-1 transcytosed through the epithelial monolayer increased linearly in relation to the amount of virus applied to the apical surface, indicating transcytosis efficiency was constant (r(2) = 0.9846; p < 0.0001). The efficiency of HIV-1 transcytosis ranged between 0.05 and 1.21%, depending on the virus strain, producer cell type and gp120 V1-V3 loop signature. Inoculation of HIV-1 neutralizing Abs to the immunodominant region (7B2) or the conserved membrane proximal external region (2F5) of gp41 or to cardiolipin (IS4) onto the apical surface of epithelial monolayers prior to inoculation of virus significantly reduced HIV-1 transcytosis. 2F5 was the most potent of these IgG1 Abs. Dimeric IgA and monomeric IgA, but not polymeric IgM, 2F5 Abs also blocked HIV-1 transcytosis across the epithelium and, importantly, across explanted normal human rectal mucosa, with monomeric IgA substantially more potent than dimeric IgA in effecting transcytosis blockade. These findings underscore the potential role of transcytosis blockade in the prevention of HIV-1 transmission across columnar epithelium such as that of the rectum.

Outcomes of right- compared with left-side colectomy

Right colon resections are perceived as less morbid than left colon resections. The purpose of this study was to determine the differences in outcomes between right-and left-side colon resections. We reviewed 420 consecutive open colectomies over 4 years. Patient demographics, surgical indications, intraoperative variables, and outcomes were collected. Two hundred twenty-three right colectomies (RCs) were compared with 197 left colectomies (LCs). RCs were more often required for cancer (111 vs 65, P < .001) and LCs for diverticular disease (10 vs 90, P < .001). LCs were more often performed emergently (36% vs 23%, P = .004) and required longer mean operative times (149 minutes vs 130 minutes, P = .004). Complications and mortality in the two groups were equal statistically. In the emergent colectomy subset, LCs were associated with greater intraoperative blood loss (315 vs 201 mL, P = .02) but fewer complications (11% vs 17%, P = .003).

Routine use of a shunt for carotid endarterectomy

A temporary inlying shunt used during carotid endarterectomy is the ideal method of cerebral protection. The data presented suggest that if meticulous technique is used, the potential complications of a shunt may be avoided and excellent clinical results expected. When a shunt is used properly, carotid endarterectomy may be performed in a teaching situation with a high degree of safety.

Application of electromagnetic blood flowmeter during arterial reconstruction. Results in conjunction with pavarine in 47 cases

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