Who Benefits? An Assessment of Resident Benefits at Top 50 Academic Institutions

OBJECTIVE

Residency serves as a crucial time in the professional and personal development of young physicians. Extensive effort is devoted to the clinical training of residents across the country. However, many residents report concerns with compensation, quality of life, and benefits during their clinical training. We sought to evaluate the benefits packages of resident physicians in comparison with other full-time employees at their institutions.

SETTING

"Top 50" Residency programs in Medicine, Surgery, and Pediatrics in the United States.

DESIGN

To accomplish this task we selected the, "Top-50," institutions for medicine, pediatrics, and surgery using Doximity's Residency Navigator and compared the benefits of residents at these institutions with full-time employees by accessing benefits offerings listed on institutional websites.

RESULTS

We found that residents were more likely to receive parking benefits and gym memberships, while full-time employees were more likely to be offered flexible spending accounts, retirement benefits, and tuition support.

CONCLUSIONS

Residents receive different benefits packages than their colleagues employed in full time positions at the same institutions. Further discussion regarding the benefits offered to physicians, and the role that benefits play in resident wellbeing is warranted in light of these findings.

Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds

INTRODUCTION

Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma.

METHODS

Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition.

RESULTS

Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001).

CONCLUSIONS

Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.

Rates of price disclosure associated with the surgical treatment of early-stage breast cancer one year after implementation of federal regulations

PURPOSE

Mastectomy, breast reconstruction (BR) and breast conserving therapy (BCT) are core components of the treatment paradigm for early-stage disease but are differentially associated with significant financial burdens. Given recent price transparency regulations, we sought to characterize rates of disclosure for breast cancer-related surgery, including mastectomy, BCT, and BR (oncoplastic reconstruction, implant, pedicled flap and free flap) and identify associated factors.

METHODS

For this cross-sectional analysis, cost reports were obtained from the Turquoise Health price transparency platform for all U.S. hospitals meeting national accreditation standards for breast cancer care. The Healthcare Cost Report Information System was used to collect facility-specific data. Addresses were geocoded to identify hospital referral and census regions while data from CMS was also used to identify the geographic practice cost index. We leveraged a Poisson regression model and relevant Medicare billing codes to analyze factors associated with price disclosure and the availability of an OOP price estimator.

RESULTS

Of 447 identified hospitals, 221 (49.4%) disclosed prices for mastectomy and 188 42.1%) disclosed prices for both mastectomy and some form of reconstruction including oncoplastic reduction (n = 184, 97.9%), implants (n = 187, 99.5%), pedicled flaps (n = 89, 47.3%), and free flaps (n = 81, 43.1%). Non-profit status and increased market competition were associated with price nondisclosure. 121 hospitals (27.1%) had an out-of-pocket price estimator that included at least one breast surgery.

CONCLUSIONS

Most eligible hospitals did not disclose prices for breast cancer surgery. Distinct hospital characteristics were associated with price disclosure. Breast cancer patients face persistent difficulty in accessing costs.

Lung Cancer Screening in Clinical Practice: A 5-Year Review of Frequency and Predictors of Lung Cancer in the Screened Population

PURPOSE

The aims of this study were to evaluate (1) frequency, type, and lung cancer stage in a clinical lung cancer screening (LCS) population and (2) the association between patient characteristics and Lung CT Screening Reporting & Data System (Lung-RADS®) with lung cancer diagnosis.

METHODS

This retrospective study enrolled individuals undergoing LCS between January 1, 2015, and June 30, 2020. Individuals' sociodemographic characteristics, Lung-RADS scores, pathology-proven lung cancers, and tumor characteristics were determined via electronic health record and the health system's tumor registry. Associations between the outcome of lung cancer diagnosis within 1 year after LCS and covariates of sociodemographic characteristics and Lung-RADS score were determined using logistic regression.

RESULTS

Of 3,326 individuals undergoing 5,150 LCS examinations, 102 (3.1%) were diagnosed with lung cancer within 1 year of LCS; most of these cancers were screen detected (97 of 102 [95.1%]). Over the study period, there were 118 total LCS-detected cancers in 113 individuals (3.4%). Most LCS-detected cancers were adenocarcinomas (62 of 118 [52%]), 55.9% (65 of 118) were stage I, and 16.1% (19 of 118) were stage IV. The sensitivity, specificity, positive predictive value, and negative predictive value of Lung-RADS in diagnosing lung cancer within 1 year of LCS were 93.1%, 83.8%, 10.6%, and 99.8%, respectively. On multivariable analysis controlling for sociodemographic characteristics, only Lung-RADS score was associated with lung cancer (odds ratio for a one-unit increase in Lung-RADS score, 4.68; 95% confidence interval, 3.87-5.78).

CONCLUSIONS

The frequency of LCS-detected lung cancer and stage IV cancers was higher than reported in the National Lung Screening Trial. Although Lung-RADS was a significant predictor of lung cancer, the positive predictive value of Lung-RADS is relatively low, implying opportunity for improved nodule classification.

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

INTRODUCTION

Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation.

MATERIALS AND METHODS

We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size.

RESULTS

A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism.

CONCLUSIONS

There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

Rural For-Profit Hospitals Are Associated With Higher Commercial Prices for 3 Common Urological Procedures

INTRODUCTION

Rural patients lack access to urological services, and high local prices may dissuade underinsured patients from surgery. We sought to describe commercially insured prices for 3 urological procedures at rural vs metropolitan and for-profit vs nonprofit hospitals.

METHODS

A cross-sectional analysis of commercially insured prices from the Turquoise Health Transparency data set was performed for ureteroscopy with laser lithotripsy, transurethral resection of bladder tumor, and transurethral resection of prostate. Hospital characteristics were linked using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Linear modeling analyzed median hospital price and its association with hospital characteristics.

RESULTS

Overall, 1,532 hospitals reported urological prices in Turquoise. Median prices for each procedure were higher at rural for-profits (ureteroscopy $16,522, transurethral resection of bladder tumor $5,393, transurethral resection of prostate $9,999) vs rural nonprofits (ureteroscopy $4,512, transurethral resection of bladder tumor $2,788, transurethral resection of prostate $3,881) and metropolitan for-profits (ureteroscopy $5,411, transurethral resection of bladder tumor $3,420, transurethral resection of prostate $4,874). Rural for-profit status was independently associated with 160% higher price for ureteroscopy (relative cost ratio 2.60, P < .001), 50% higher for transurethral resection of bladder tumor (relative cost ratio 1.50, P = .002), and 113% higher for transurethral resection of prostate (relative cost ratio 2.13, P < .001).

CONCLUSIONS

Prices are higher for 3 common urological surgeries at rural for-profit hospitals. Differential pricing may contribute to disparities for underinsured rural residents who lack access to nonprofit facilities. Interventions that facilitate transportation and price shopping may improve access to affordable urological care.

Association Between Hospital Monopoly Status, Patient Socioeconomic Disadvantage, and Total Joint Arthroplasty Price Disclosure

INTRODUCTION

In recent years, healthcare institutions and regulatory bodies have enacted cost transparency mandates for routine interventions such as total hip arthroplasty and total knee arthroplasty. However, disclosure rates remain low. This study examined the effect of financial characteristics of hospitals and the socioeconomic status of patients on price disclosure.

METHODS

Hospitals conducting total hip arthroplasty/total knee arthroplasty, their quality ratings, and procedural volumes were identified using the Leapfrog Hospital Survey and linked to procedure-specific prices. Financial performance and the Area Deprivation Index (ADI) were used to correlate disclosure rates with hospital and patient characteristics. Hospital financial, operational, and patient summary statistics were compared by price-disclosure status using two-sample t -tests for continuous variables and Pearson chi-square test for categorical variables. The association between total joint arthroplasty price disclosure and hospital ADI was further evaluated using modified Poisson regression.

RESULTS

A total of 1,425 hospitals certified by the Centers for Medicare & Medicaid Services were identified in the United States. 50.5% (n = 721) of hospitals had no published payer-specific price information. Hospitals in an area of higher socioeconomic disadvantage were more likely to disclose prices of total joint arthroplasty (incidence rate ratio = 0.966, 95% CI: 0.937 to 0.995, P = 0.024). Hospitals that were considered monopolies or were for-profit were less likely to disclose prices (IRR = 1.15, 95% CI: 1.030 to 1.280, P = 0.01; IRR = 1.256, 95% CI: 0.986 to 1.526, P = 0.038, respectively). When accounting for both ADI and monopoly status, hospitals with patients who had a higher ADI were more likely to disclose costs for a total joint arthroplasty, whereas for-profit hospitals or hospitals considered monopolies in their HSA were less likely to disclose prices.

DISCUSSION

For nonmonopoly hospitals, a higher ADI correlated with a higher likelihood of price disclosure. However, for monopoly hospitals, there was no significant association between ADI and price disclosure.

LEVEL OF EVIDENCE

II.

Surgical Evaluation in Patients Undergoing Radiation Therapy for Early-Stage Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is used to treat stage I non-small cell lung cancer (NSCLC) in nonsurgical candidates, although guidelines specify that inoperability be determined in multidisciplinary fashion. We characterized NSCLC patients treated with SBRT undergoing thoracic surgical evaluation (TSUe) and quantified TSUe's impact on time to treatment, receipt of diagnostic staging procedures, and health care costs.

METHODS

Adults with newly diagnosed NSCLC undergoing SBRT were identified in the MarketScan all-payer claims database (2014-2018). TSUe was defined as an outpatient encounter with a thoracic surgeon or multispecialty group. Time to treatment and total costs in the 6 months preceding treatment were examined using multivariable regression by receipt of TSUe, adjusting for demographic and clinical factors.

RESULTS

Of 1894 patients, 36.3% (n = 687) underwent TSUe. Compared with patients without TSUe, these patients were younger (mean age, 73.6 vs 76.3 years) and more likely to undergo invasive biopsy/staging procedures (90% vs 82%) or pulmonary function testing (80.6% vs 69.5%). Patients undergoing TSUe had a median time to treatment of 64 days (interquartile range, 43-98 days), compared with 44 days (interquartile range, 29-70 days) for no TSUe. Adjusted time to treatment was 43% longer (incident rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001) with TSUe. Patients undergoing TSUe also incurred 30% higher costs (adjusted cost ratio, 1.30; 95% CI, 1.20-1.41; P < .001).

CONCLUSIONS

Among patients with early-stage NSCLC undergoing SBRT as primary treatment, a minority are evaluated by a thoracic surgeon. Because they have a longer time to treatment, more invasive diagnostic procedures, and higher costs, this represents a targetable gap to make workup protocols more efficient.

Association of Rural Hospital For-Profit Status With Higher Publicly Reported Prices for the Components of Inpatient Hematuria Evaluation Among Commercially Insured Patients

INTRODUCTION

Rural patients have limited access to urological care and are vulnerable to high local prices. Little is known about price variation for urological conditions. We aimed to compare reported commercial prices for the components of inpatient hematuria evaluation between for-profit vs not-for-profit and rural vs metropolitan hospitals.

METHODS

We abstracted commercial prices for the components of intermediate- and high-risk hematuria evaluation from a price transparency data set. We compared hospital characteristics between those that do and do not report prices for a hematuria evaluation using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Generalized linear modelling evaluated the association between hospital ownership and rural/metropolitan status with prices of intermediate- and high-risk evaluations.

RESULTS

Of all hospitals, 17% of for-profits and 22% of not-for-profits report prices for hematuria evaluation. For intermediate-risk, median price at rural for-profit hospitals was $6,393 (interquartile range [IQR] $2,357-$9,295) compared to $1,482 (IQR $906-$2,348) at rural not-for-profits and $2,645 (IQR $1,491-$4,863) at metropolitan for-profits. For high-risk, rural for-profit hospitals' median price was $11,151 (IQR $5,826-$14,366) vs $3,431 (IQR $2,474-$5,156) at rural not-for-profits and $4,188 (IQR $1,973-$8,663) at metropolitan for-profits. Rural for-profit status was associated with an additional higher price for intermediate- (relative cost ratio 1.62, 95% CI 1.16-2.28, P = .005) and high-risk evaluations (relative cost ratio 1.50, 95% CI 1.15-1.97, P = .003).

CONCLUSIONS

Rural for-profit hospitals report high prices for components of inpatient hematuria evaluation. Patients should be aware of prices at these facilities. These differences may dissuade patients from undergoing evaluation and lead to disparities.

Association Between Cancer Center Accreditation and Compliance With Price Disclosure of Common Oncologic Surgical Procedures

BACKGROUND

Cancer center accreditation status is predicated on several factors that measure high-value healthcare. However, price transparency, which is critical in healthcare decisions, is not a quality measure included for accreditation. We reported the rates of price disclosure of surgical procedures for 5 cancers (breast, lung, cutaneous melanoma, colon, and prostate) among hospitals ranked by the American College of Surgeon's Commission on Cancer (ACS-CoC).

METHODS

We identified nonfederal, adult, and noncritical access ACS-CoC accredited hospitals and used the commercial Turquoise Health database to perform a cross-sectional analysis of hospital price disclosures for 5 common oncologic procedures (mastectomy, lobectomy, wide local excision for cutaneous melanoma, partial colectomy, prostatectomy). Publicly available financial reporting data were used to compile facility-specific features, including bed size, teaching status, Centers for Medicare & Medicaid wage index, and patient revenues. Modified Poisson regression evaluated the association between price disclosure and ACS-CoC accreditation after adjusting for hospital financial performance.

RESULTS

Of 1,075 total ACS-CoC accredited hospitals, 544 (50.6%) did not disclose prices for any of the surgical procedures and only 313 (29.1%) hospitals reported prices for all 5 procedures. Of the 5 oncologic procedures, prostatectomy and lobectomy had the lowest price disclosure rates. Disclosing and nondisclosing hospitals significantly differed in ACS-CoC accreditation, ownership type, and teaching status. Hospitals that disclosed prices were more likely to receive Medicaid disproportionate share hospital payments, have lower average charge to cost ratios (4.53 vs 5.15; P<.001), and have lower net hospital margins (-2.03 vs 0.44; P=.005). After adjustment, a 1-point increase in markup was associated with a 4.8% (95% CI, 2.2%-7.4%; P<.001) higher likelihood of nondisclosure.

CONCLUSIONS

More than half of the hospitals did not disclose prices for any of the 5 most common oncologic procedures despite ACS-CoC accreditation. It remains difficult to obtain price transparency for common oncologic procedures even at centers of excellence, signaling a discordance between quality measures visible to patients.

Improved Survival and Higher Rates of Surgical Resection Associated with Hepatocellular Carcinoma in Children as Compared to Young Adults

Hepatocellular adenocarcinoma (HCC) is the second most common primary hepatic malignancy in children with a 5-year overall survival of 30%. Few studies have examined the similarities and differences between pediatric and adult HCC. This paper aims to examine the relationship between tumor characteristics, treatments, and outcomes in pediatric and adult patients with HCC. The 2019 National Cancer Database was queried for patients with HCC. Patients were stratified by age: pediatric <21 years (n = 214) and young adults 21-40 (n = 1102). Descriptive statistics and chi square were performed. The mean age at diagnosis was 15.5 years (SD 5.6) in the pediatric and 33 years (5.3) in the adult group. Children had a comparable rate of metastasis (30% vs 28%, P = 0.47) and increased fibrolamellar histology (32% vs 9%). Surgical resection was more common in children compared with adults (74% vs 62%, P < 0.001), children also had more lymph nodes examined (39% vs 19%, P < 0.001), positive lymph nodes (35% vs 17%, P = 0.02), and surgical resection when metastasis were present at diagnosis (46% vs 18%, P < 0.001). The 1, 3, and 5-year overall survival was higher for pediatric patients than adults (81%, 65%, 55%, vs 70%, 54%, 48%,) Despite higher prevalence of fibrolamellar histology, greater number of positive lymph nodes, and comparable rates of metastasis at diagnosis, children with HCC have improved overall survival compared with adults. Age did not significantly contribute to survivorship, so it is likely that the more aggressive surgical approach contributed to the improved overall survival in pediatric patients. This article is protected by copyright. All rights reserved.

Surgical resection is associated with improved long-term survival of patients with resectable pancreatic head cancer compared to multiagent chemotherapy

BACKGROUND

Standard of care for resectable pancreatic cancer is a combination of surgical resection (SR) and multiagent chemotherapy (MCT). We aim to determine whether SR or MCT is associated with superior survival for patients receiving only single-modality therapy.

METHODS

Patients with stage I-IIb pancreatic head adenocarcinoma who received either MCT or SR were identified in the NCDB (2013-2015). Following a piecewise approach to estimating hazards over the course of follow-up, conditional overall survival (OS) at 30, 60, and 90 days after treatment initiation was estimated using landmark analyses.

RESULTS

3103 patients received MCT alone (60.3%) and 2043 underwent SR alone (39.7%). SR had an OS disadvantage at 30 (HR 3.99, 95% CI 3.12-5.11) and 60 days (HR 1.85, 95% CI 1.4-2.45), but an OS advantage after 90 days (HR 0.59, 95% CI 0.55-0.64). In a landmark analysis conditioned on 90 days survival post treatment initiation, median OS was improved for SR (17.0 vs. 12.2 months, p < 0.0001); SR improved 3-year OS by 21.3% (p < 0.05), despite patients being older (median 72 vs. 67 years, p < 0.0001) with higher Charlson-Deyo comorbidity scores (≥2: 11.2 vs. 8.6%, p = 0.006).

CONCLUSION

For patients with resectable pancreatic cancer, SR is associated with superior long-term survival compared to MCT.

Financial Impacts And Operational Implications Of Private Equity Acquisition Of US Hospitals

Although private equity acquisition of short-term acute care hospitals purportedly improves efficiency and cost-effectiveness, financial performance after acquisition remains unexamined. We compared changes in the financial performance of 176 hospitals acquired during 2005-14 versus changes in matched control hospitals. Acquisition was associated with a $432 decrease in cost per adjusted discharge and a 1.78-percentage-point increase in operating margin. The majority of acquisitions-134 members of the Hospital Corporation of America, acquired in 2006-were associated with a $559 decrease in cost per adjusted discharge but no change in operating margin. Conversely, non-HCA hospitals exhibited a 3.27-percentage-point increase in operating margin without a concomitant change in cost per adjusted discharge. When we examined markers of hospital capacity, operational efficiency, and costs, we found that private equity acquisition was associated with decreases in total beds, ratio of outpatient to inpatient charges, and staffing (total personnel and nursing full-time equivalents and total full-time equivalents per occupied bed). Therefore, financial performance improved after acquisition, whereas patient throughput and inpatient utilization increased and staffing metrics decreased. Future research is needed to identify any unintended trade-offs with safety and quality.

Association Between Hospital Private Equity Acquisition and Outcomes of Acute Medical Conditions Among Medicare Beneficiaries

IMPORTANCE

As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored.

OBJECTIVE

To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia.

EXPOSURES

Acquisition of hospitals by PE firms.

MAIN OUTCOMES AND MEASURES

Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments.

RESULTS

Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI.

Empiric nasogastric decompression after pancreaticoduodenectomy is not necessary

BACKGROUND

The aim of the present study was to evaluate the impact of routine NGT decompression after PD on postoperative outcomes in the era of an enhanced recovery after surgery (ERAS) protocol.

MATERIALS AND METHODS

A retrospective review of all patients undergoing PD between January 2015 and October 2017 at our institution was performed comparing routine post-operative NGT decompression versus omission. The incidence of delayed gastric emptying, post-operative pancreatic fistula, hospital length of stay, operative time, 30-day readmission rate as well the time to first oral intake were evaluated.

RESULTS

Out of 149 patients who underwent PD, 65 maintained post-operative NGT decompression while post-operative NGT decompression was omitted in 84 patients. No differences were noted in delayed gastric emptying rates (both p>0.05). The median length of stay (9 days for NGT group versus 8.5 days for no NGT group) and 30-day readmission rates (13.8% versus 15.5%, respectively) were similar (p=0.781). Compared with patients who had routine post-operative NGT placed, those who had omission of a post-operative NGT had a lower need for reinsertion, shorter time to PO intake, and a lower likelihood of extended length of stay.

CONCLUSIONS

In the era of ERAS protocols, we observed no association between routine post-operative NGT decompression after PD and improved postoperative outcomes.

Private Equity Acquisition And Responsiveness To Service-Line Profitability At Short-Term Acute Care Hospitals

As private equity firms continue to increase their ownership stake in various health care sectors in the US, questions arise about potential impacts on the organization and delivery of care. Using a difference-in-differences approach, we investigated changes in service-line provision in private equity-acquired hospitals. Relative to nonacquired hospitals, private equity acquisition was associated with a higher probability of adding specific profitable hospital-based services (interventional cardiac catheterization, hemodialysis, and labor and delivery), profitable technologies (robotic surgery and digital mammography), and freestanding or satellite emergency departments. Moreover, private equity acquisition was associated with an increased probability of providing services that were previously categorized as unprofitable but that have more recently become areas of financial opportunity (for example, mental health services). Finally, private equity-acquired hospitals were less likely to add or continue services that have unreliable revenue streams or that may face competition from nonprofit hospitals (for example, outpatient psychiatry), although fewer shifts were noted among unprofitable services. This may reflect a prevailing shift by acute care hospitals toward outpatient settings for appropriate procedures and synergies with existing holdings by private equity firms.

Private Equity Investments In Health Care: An Overview Of Hospital And Health System Leveraged Buyouts, 2003-17

Private equity firms have increased their participation in the US health care system, raising questions about incentive alignment and downstream effects on patients. However, there is a lack of systematic characterization of private equity acquisition of short-term acute care hospitals. We present an overview of the scope of private equity-backed hospital acquisitions over the course of 2003-17, comparing the financial and operational differences between those hospitals and hospitals that remained unacquired through 2017. A total of 42 private equity deals occurred, involving 282 unique hospitals across 36 states. In unadjusted analyses, hospitals that were acquired had larger bed sizes, more discharges, and more full-time-equivalent staff positions in 2003 relative to nonacquired hospitals; private equity-acquired hospitals also had higher charge-to-cost ratios and higher operating margins, and this gap widened during our study period. These findings motivate evaluations by policy makers and researchers on the impact, if any, of private equity acquisition on health care access, spending, and risk-adjusted outcomes.

Hepatic vascular malignancies in children are associated with increased rates of surgical resection and improved overall survival compared with adults

BACKGROUND

Hepatic vascular malignancies (HVMs) are rare malignancies, with no standardized treatment regimens. The most common HVMs, angiosarcoma and malignant epithelioid hemangioendothelioma (EHE), are often grouped together in the literature complicating our ability to achieve reliable survival data and treatment strategies.

OBJECTIVE

To compare the disease characteristics of HVMs, with a subanalysis on pediatric patients.

METHODS

The 2016 National Cancer Database was queried for patients with HVMs using international classification of diseases-oncology-3 (ICD-O-3) codes yielding 699 patients. Descriptive statistics, chi-square, Kaplan-Meier, and log-rank analyses were performed.

RESULTS

We found 478 patients (68%) with angiosarcoma and 221 (32%) with EHE. The median (Q1, Q3) age for angiosarcoma patients was 65 years (56, 75) versus 54 years (37, 65) in EHE patients (P < .001). The rate of resection was lower in patients with angiosarcoma than EHE (13% vs 32%, P < .001). The mean 1-, 3-, and 5-year overall survival for angiosarcoma patients was 17%, 8%, and 6%, respectively, versus 80%, 65%, and 62% in EHE patients (P < .0001). A subgroup analysis was performed on pediatric patients demonstrating six with angiosarcoma and 10 with EHE. The mean 1-, 3-, and 5-year overall survival for pediatric angiosarcoma patients was 67%, 50%, and 50%, respectively, and 90%, 90%, and 90% for pediatric EHE patients.

CONCLUSION

In the largest study of HVMs to date, we found angiosarcoma has significantly worse overall survival than EHE. Pediatric patients appear to have improved survival and higher rates of resection. Larger studies of HVMs are needed to clearly differentiate tumor types, standardize care, and improve survivorship.

Donor-Recipient Height Mismatch Is Associated With Decreased Survival in Pediatric-to-Adult Liver Transplant Recipients

Liver grafts from pediatric donors represent a small fraction of grafts transplanted into adult recipients, and their use in adults requires special consideration of donor size to prevent perioperative complications. In the past, graft weight or volume ratios have been adopted from the living donor liver transplant literature to guide clinicians; however, these metrics are not regularly available to surgeons accepting deceased donor organs. In this study, we evaluated all pediatric-to-adult liver transplants in the United Network for Organ Sharing Standard Transplant Analysis and Research database from 1987 to 2019, stratified by donor age and donor-recipient height mismatch ratio (HMR; defined as donor height/recipient height). On multivariable regression controlling for cold ischemia time, age, and transplantation era, the use of donors from ages 0 to 4 and 5 to 9 had increased risk of graft failure (hazard ratio [HR], 1.81 [P < 0.01] and HR, 1.16 [P < 0.01], respectively) compared with donors aged 15 to 17. On Kaplan-Meier survival analysis, a HMR < 0.8 was associated with inferior graft survival (mean, 11.8 versus 14.6 years; log-rank P < 0.001) and inferior patient survival (mean, 13.5 versus 14.9 years; log-rank P < 0.01) when compared with pairs with similar height (HMR, 0.95-1.05; ie, donors within 5% of recipient height). This study demonstrates that both young donor age and low HMR confer additional risk in adult recipients of pediatric liver grafts.

Development and Performance of a Clinical Decision Support Tool to Inform Resource Utilization for Elective Operations

IMPORTANCE

Hospitals ceased most elective procedures during the height of coronavirus disease 2019 (COVID-19) infections. As hospitals begin to recommence elective procedures, it is necessary to have a means to assess how resource intensive a given case may be.

OBJECTIVE

To evaluate the development and performance of a clinical decision support tool to inform resource utilization for elective procedures.

DESIGN, SETTING, AND PARTICIPANTS

In this prognostic study, predictive modeling was used on retrospective electronic health records data from a large academic health system comprising 1 tertiary care hospital and 2 community hospitals of patients undergoing scheduled elective procedures from January 1, 2017, to March 1, 2020. Electronic health records data on case type, patient demographic characteristics, service utilization history, comorbidities, and medications were and abstracted and analyzed. Data were analyzed from April to June 2020.

MAIN OUTCOMES AND MEASURES

Predicitons of hospital length of stay, intensive care unit length of stay, need for mechanical ventilation, and need to be discharged to a skilled nursing facility. These predictions were generated using the random forests algorithm. Predicted probabilities were turned into risk classifications designed to give assessments of resource utilization risk.

RESULTS

Data from the electronic health records of 42 199 patients from 3 hospitals were abstracted for analysis. The median length of stay was 2.3 days (range, 1.3-4.2 days), 6416 patients (15.2%) were admitted to the intensive care unit, 1624 (3.8%) received mechanical ventilation, and 2843 (6.7%) were discharged to a skilled nursing facility. Predictive performance was strong with an area under the receiver operator characteristic ranging from 0.76 to 0.93. Sensitivity of the high-risk and medium-risk groupings was set at 95%. The negative predictive value of the low-risk grouping was 99%. We integrated the models into a daily refreshing Tableau dashboard to guide decision-making.

CONCLUSIONS AND RELEVANCE

The clinical decision support tool is currently being used by surgical leadership to inform case scheduling. This work shows the importance of a learning health care environment in surgical care, using quantitative modeling to guide decision-making.

Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Adjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma.

METHODS

Patients with stage I-III pancreatic head adenocarcinoma in the 2006-2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6-12-weeks, and 12-24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy.

RESULTS

Of 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6-12 weeks, and 1194 (8.9%) within 12-24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6-12-weeks: 0.744, and 12-24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens.

CONCLUSIONS

For patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.

Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition?

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.

Defining a textbook surgical outcome for patients undergoing surgical resection of intermediate and high-grade soft tissue sarcomas of the extremities

BACKGROUND

Quality measures for the surgical management soft tissue sarcoma of the extremity are limited. The purpose of this study was to define a textbook surgical outcome (TO) for soft tissue sarcoma of the extremities (STS-E) and to examine its associations with hospital volume and overall survival.

METHODS

All patients in the National Cancer Database undergoing resection of primary STS-E between 2004 and 2015 were identified. The primary outcome was a TO, defined as: hospital length of stay (LOS) <75th percentile, survival >90 days from the date of surgery, no readmission within 30 days of discharge, and negative surgical margins (R0 resection).

RESULTS

Overall, 7658 patients met criteria for inclusion; a TO was achieved in 4291 (56%) patients. Of patients who did not achieve TOs, 51.9% (n = 1748) had an extended LOS, and 47.3% (n = 1591) did not have negative margins. Older age, more medical comorbidities, and non-white or black race were independently associated with not receiving a TO (P = .034). With respect to tumor and treatment characteristics, larger tumor size, lower extremity location and higher grade were independently associated with not receiving a TO (P < .001). Hospital volume was not associated with a TO. TOs conferred a significant survival benefit (hazrds ratio = 0.71 [0.65-0.78], P < .001). A TO was associated with a 27.5% longer survival time (P < .001).

CONCLUSIONS

This study defined a TO in intermediate and high-grade STS-E and demonstrated that this outcome measure is associated with overall survival. Facility volume was not associated with a TO.

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection

BACKGROUND/AIM

Recently, the concept of textbook outcome (TO) has emerged as a novel effort to develop a benchmark that reflects multiple domains of quality. The aims of the current study were to define TO for retroperitoneal sarcoma (RPS), evaluate the relationship of TO with hospital volume and assess the association of TO with overall survival.

PATIENTS AND METHODS

Patients who underwent resection for RPS diagnosed between 2004 and 2015 were identified in the National Cancer Database. The primary outcome was TO that was defined as: hospital length of stay<75^th percentile, survival>90 days from surgery, no readmission within 30 days and grossly negative margins.

RESULTS

Of the 11,032 patients analyzed, 54.0% had a TO. Among patients who had a TO, 57.8% were treated in high-volume hospitals. Undergoing surgery at high-volume centers was associated with a higher probability of a TO (p=0.009). TO were associated with significantly longer overall survival (p<0.001). In a subgroup analysis with grossly negative margins and no 90-day mortality, the association of TO with improved survival persisted (p<0.001).

CONCLUSION

The concept of TO is a promising tool for measuring patient-level hospital performance and may be useful for identifying important variations in care for patients with RPS.

Anal Cancer Screening Attitudes and Practices in Maryland Healthcare Providers: Implications for National Trends

Background: Anal cancer incidence is increasing in the US. Though formally established national anal cancer screening guidelines are nonexistent, many providers advocate screening to avoid late disease presentation. This study assesses the knowledge, attitudes, and practices of anal cancer screening among providers to identify the degree of variation and barriers to screening. Methods: Healthcare providers from two academic medical centers and a statewide community primary care group were surveyed using a questionnaire adapted from the National Survey of Primary Care Physicians’ Recommendations and Practice for Cancer Screening. Descriptive statistics were performed to explore providers’ responses and Fisher’s exact test to explore variation. Results: 86 providers completed the questionnaire (response rate 24.2%): 81.4% physicians, 18.6% advanced practitioners. 48.2% of respondents perform anal cancer screening. 5.8% correctly identified all high-risk patient factors. “HIV+ patient” was identified most frequently as high-risk (93.5%), “organ transplant recipient” (42.9%) least frequently. Anal pap test was the most recommended first-line screening test (76.6%) followed by digital anorectal exam (19.2%), HPV test (8.5%), and high-resolution anoscopy (HRA) (6.4%). Clinical evidence (72.3%) and national guidelines (70.2%) were most influential in guiding providers’ screening recommendations. Lack of qualified screening providers (34.1%), lack of patient follow-up after positive test results (22.7%), and patient non-compliance to initial screening (15.9%) were identified as “usual” barriers. Conclusions: Anal cancer screening attitudes and practices vary among providers. Development of national practice guidelines that define a multidisciplinary team approach from primary care anal cancer screening to specialist referral for HRA may reduce screening variability.

Reliability of Glasgow Coma Score in pediatric trauma patients

BACKGROUND

Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS.

METHODS

We conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearson's correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates.

RESULTS

We identified 5306 patients. Pearson's correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score.

CONCLUSIONS

GCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients.

LEVEL OF EVIDENCE

III, Prognostic.

The Effect of Frailty Index on Early Outcomes after Combined Colorectal and Liver Resections

BACKGROUND

Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections.

METHODS

Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005-2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed.

RESULTS

A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02-1.96, p = 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47-3.04, p < 0.001).

CONCLUSIONS

The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.

Impact of Angiotensin Receptor Blocker Use on Overall Survival Among Patients Undergoing Resection for Pancreatic Cancer

BACKGROUND

Pancreatic cancer has higher concentrations of angiotensin II compared with other cancers. This study sought to assess the effect of angiotensin II receptor blockers (ARBs) on survival of patients undergoing resection using a large, nationally representative dataset.

METHODS

Patients undergoing pancreatic cancer resection were identified in the Truven Health MarketScan database. Multivariable Cox proportional hazards regression was used to assess the effect of ARB use on overall survival.

RESULTS

A total of 4299 patients were identified, among whom 479 (11.1%) filled a prescription for an ARB. Mean patient age was 54.5 years (SD = 8.6 years); 2187 (51.1%) were female. Exactly 49.4% (n = 2125) of patients had a Charlson comorbidity index >2 at the time of surgery (n = 2125, 49.4%) and 59.6% (n = 2563) underwent a pancreaticoduodenectomy. Kaplan-Meier estimates of survival at 1, 2, and 4 years were 62.8% (95% CI: 61.3-64.2%), 38.2% (95% CI: 36.6-39.8%), and 19.0% (95% CI: 17.1-21.0%), respectively. On multivariable analysis, ARB use was associated with a 24% decreased risk of death over the 5-year period in which patients were under observation (HR = 0.76, 95% CI: 0.67-0.87, p < 0.001).

CONCLUSIONS

ARB use was associated with improved survival in patients undergoing resection of pancreatic cancer. Further research is required into the differential effect of ARBs in the treatment of pancreatic cancer.

Self-Directed Interactive Video-Based Instruction Versus Instructor-Led Teaching for Myanmar House Surgeons: A Randomized, Noninferiority Trial

OBJECTIVE

To compare self-directed interactive video-based instruction (IVBI) with instructor-led teaching in the acquisition of basic surgical skills by House Surgeons at University of Medicine 1, Yangon.

DESIGN

A prospective, 1:1 randomized controlled trial was conducted. Participants were randomized into 2 teaching arms: (1) self-directed IVBI or (2) instructor-led teaching. Self-directed IVBI participants were provided with a portable DVD player that could play, fast forward, rewind, and skip through skills modules. Participants in the instructor-led teaching group were taught in small groups by standardized instructors. Pretesting and posttesting of 1-handed knot tie, 2-handed knot tie, vertical mattress suture, and instrument tie was performed using the Objective Structured Assessment of Technical Skills (OSATS). Students randomized to self-directed IVBI completed an exit survey to assess satisfaction. Demographic data were collected of all participants.

SETTING

University of Medicine 1, Yangon, Myanmar.

PARTICIPANTS

Fifty participants were randomly selected from 78 eligible House Surgeons who were enrolled in their basic surgery rotation.

RESULTS

Demographic characteristics and baseline skills were comparable in participants randomized to IVBI and instructor-led teaching. Mean OSATS score increased from pretest to posttest in both groups (p < 0.001). The mean posttest OSATS score of the IVBI group was 0.72 points below that of the instructor-led teaching group (90% CI: -3.8 to 5.2), with the 90% CI falling below the a priori noninferiority margin, satisfying criteria for noninferiority. More than 90% of students marked either "agree" or "strongly agree" to the following statements on the exit survey: further expansion of IVBI into other skills modules and integration of IVBI into training curriculum.

CONCLUSION

IVBI is noninferior to instructor-led teaching of surgical skills based on OSATS scores. House Surgeons highly rated self-directed IVBI. Self-directed IVBI has the potential to significantly reduce the personnel required for skills teaching and may serve as a long-term learning adjunct in low-resource settings.

Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery

IMPORTANCE

Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges.

OBJECTIVE

To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017.

INTERVENTIONS

Hepatic or pancreatic resection.

MAIN OUTCOMES AND MEASURES

Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection.

RESULTS

Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets.

CONCLUSIONS AND RELEVANCE

Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.

Defining payments associated with the treatment of colorectal cancer

BACKGROUND

While bundled payments aim to reduce variations in health care spending across the continuum of care, data reporting on variations in payments for privately insured patients undergoing treatment for colon cancer (CC) are lacking. The current study sought to characterize variations in payments received for the treatment of CC using a cohort of commercially insured patients.

METHODS

Patients who underwent a colectomy for CC were identified using the MarketScan Database for 2010-2014. Multivariable regression analysis was used to calculate and compare risk-adjusted payments between patients.

RESULTS

A total of 18,337 patients were identified who met inclusion criteria. The median risk-adjusted payment for surgery was $26,408 (IQR: $19,193-$38,037) ranging from $19,762 (IQR: $15,595-$25,636) among patients in the lowest quartile of payments to $33,809 (IQR: $24,783-$48,254) for patients in the highest (+△71.1%). The median risk-adjusted payment for chemotherapy was $70,090 (IQR: $57,813-$83,216); compared with patients in the lowest quartile of payments, payments associated with chemotherapy were 40.4% higher among patients in the highest quartile of payments (Q1 versus Q4: $56,827 [IQR: 49,173-65,353] versus $79,801 [IQR: 67,270-90,999]). When stratified by treatment type, patients in the highest two quartiles of risk-adjusted payments accounted for a total of 58.5% of all payments, whereas patients in the lower two quartiles of risk-adjusted payments accounted for only 41.5% of all payments. A younger patient age, increasing patient comorbidity and undergoing an open operation were associated with higher overall payments.

CONCLUSIONS

Wide variations in payments exist for the treatment for colon cancer. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CC.

Physiologic correlates of intraoperative blood transfusion among patients undergoing major gastrointestinal operations

BACKGROUND

Guidelines for transfusion focus on nadir levels of hemoglobin. Hemoglobin triggers may not be helpful, however, in defining appropriate intraoperative use of packed red blood cells. We sought to define the use of intraoperative packed red blood cells relative to quantitative physiologic factors at the time of operation.

METHODS

Prospective intraoperative data on patients undergoing a major gastrointestinal operation between 2010 and 2014 were analyzed. Risk of intraoperative transfusion was assessed with multivariable extended Cox models using baseline clinical covariates and time-varying intraoperative covariates.

RESULTS

Among 2,316 patients, the mean preoperative hemoglobin was 12.6 g/dL (standard deviation = 2.0 g/dL), while the median estimated blood loss was 200 mL (interquartile range: 100-55 mL). Overall, 357 (15.4%) patients received a transfusion intraoperatively. A greater hazard of transfusion was associated with a greater American Society of Anesthesiologists class (ref: American Society of Anesthesiologists class I-II; American Society of Anesthesiologists class III-IV; hazard ratio = 1.44, 95% confidence interval, 1.18-1.77, P < .001), and a lesser preoperative hemoglobin level (per 1 g/dL increase; hazard ratio = 0.70, 95% confidence interval, 0.65-0.74, P < .001). In addition, an increase in heart rate of 10 beats/min above the cumulative average at any measurement was associated with up to a 30% increased probability of transfusion (hazard ratio = 1.30, 95% confidence interval, 1.15-1.47, P < .001); similarly, an increase in mean arterial pressure of 10 mm Hg was associated with an 8% decreased likelihood of transfusion (hazard ratio = 0.92, 95% confidence interval, 87-0.99, P = .017). In contrast, nadir hemoglobin was not associated with the risk of receiving a transfusion (hazard ratio = 1.10, 95% confidence interval, 0.97-1.23, P = .129). Among patients who received an intraoperative transfusion, 9.2% (n = 33) never had a hemoglobin nadir below 10 g/dL, nor an average mean arterial pressure less than 65 mm Hg or a heart rate greater than 100 beats/min around the time of transfusion.

CONCLUSION

Among the intraoperative factors, heart rate, and mean arterial pressure were strongly associated with the likelihood of receiving a transfusion, despite the observation that 9.2% of patients never had a physiologic indicator for transfusion or a nadir hemoglobin below 10 g/dL, suggesting a subset of patients could benefit from a decrease in intraoperative rate of transfusion.

Metformin Use Is Associated with Improved Survival in Patients Undergoing Resection for Pancreatic Cancer

Preclinical evidence has demonstrated anti-tumorigenic effects of metformin. The effects of metformin following pancreatic cancer, however, remain undefined. We sought to assess the association between metformin use and survival using a large, nationally representative sample of patients undergoing surgery for pancreatic cancer. Patients undergoing a pancreatic resection between January 01, 2010, and December 31, 2012, were identified using the Truven Health MarketScan database. Clinical data, including history of metformin use, as well as operative details and information on long-term outcomes were collected. Multivariable Cox proportional hazards regression analysis was performed to assess the effect of metformin use on overall survival (OS). A total of 3393 patients were identified. The mean age of patients was 54.2 years (SD = 9.1 years). Roughly one half of patients were female (n = 1735, 51.1 %); 49.1 % (n = 1665) presented with a Charlson comorbidity index of 3 or greater (CCI ≥3); and 19.6 % (n = 664) had diabetes. At the time of surgery, 60.0 % (n = 2034) of patients underwent a pancreaticoduodenectomy, 35.7 % (n = 1212) a partial/distal pancreatectomy, while 4.3 % (n = 147) had a total pancreatectomy. On pathology, 1057 (31.2 %) had lymph node metastasis. Metformin use was identified in 456 patients (13.4 %) and was more commonly administered among patients without locally advanced disease (14.3 vs. 11.6 %, p = 0.038). While OS was comparable between patients within the first year of surgery (OS at 1 year 65.4 % [95 % confidence interval (CI) 63.4-67.3 %] vs. 69.2 % [95 % CI 64.2-73.4 %]), patients who received metformin demonstrated an improved OS beginning at 18 months following surgery. On multivariable analysis adjusting for patient and clinicopathologic characteristics, metformin use was independently associated with a decreased risk of mortality (hazard ratio [HR] = 0.79, 95 % CI 0.67-0.93, p = 0.005). Metformin use was associated with an improved overall survival among patients undergoing pancreatic surgery for pancreatic cancer. Further work is necessary to better understand its role in modifying cancer-specific and overall health outcomes.

Awareness of racial/ethnic disparities in surgical outcomes and care: factors affecting acknowledgment and action

BACKGROUND

Studies have demonstrated racial/ethnic disparities in surgical outcomes and care. Surgeon awareness and its association with institutional action remain unclear. The study sought to assess surgeons' awareness of racial/ethnic disparities, ascertain whether demographic and practice factors influence acknowledgement of disparities, and determine whether surgeons are seeking to mitigate disparities.

METHODS

Anonymous online survey was administered to a random sample of American College of Surgeons (ACS) general surgeons (July 2013 to March 2014). Responses were weighted for nonresponse and risk-adjusted using logistic regression.

RESULTS

172 surgeons completed the survey. Levels of acknowledged disparities were low. Less than one half reported institutional efforts to address disparities, and less than one fourth had taken efforts to investigate disparities in their personal practice. Several respondent factors including Academic Medical Center affiliation, awareness of the ACS statement on optimal access, and year of medical school graduation significantly associated with expressed acknowledgment of disparities.

CONCLUSIONS

Such associations speak to the need for continued efforts to promote enhanced provider awareness and participation. As the field of surgical disparities moves from understanding to action, we must acknowledge the contributing role that providers play.