Modern Trends for Primary Hyperparathyroidism: Intervening on Less Biochemically Severe Disease

INTRODUCTION

Primary hyperparathyroidism (PHPT) is defined by autonomous parathyroid hormone secretion, which has broad physiologic effects. Parathyroidectomy is the only cure and is recommended for patients demonstrating symptomatic disease and/or end organ damage. However, there may be a benefit to intervening before the development of complications. We sought to characterize institutional trends in the biochemical and symptomatic presentation of PHPT and the associated cure and complication rates.

METHODS

We performed a retrospective cohort study of 1087 patients undergoing parathyroidectomy for PHPT, evaluating patients at 2-year intervals between 2002 and 2019. We identified signs and symptoms of PHPT based on the 2016 American Association of Endocrine Surgery Guidelines. Trends were evaluated with Kruskal Wallis, Chi-square tests, and Fisher's exact tests.

RESULTS

Patients with PHPT are presenting with lower parathyroid hormone (P = 0.0001) and calcium (P = 0.001) in the current era. Parathyroidectomy is more commonly performed for borderline guideline concordant patients with osteopenia (40.2%) and modest calciuria (median 246 mg/dL/24 h). 93.7% are cured, with no difference over time or between groups by guideline concordance.

CONCLUSIONS

Parathyroidectomy is increasingly performed for patients who demonstrate modest bone and renal dysfunction. Patients experience excellent cure rates and rarely experience postoperative hypocalcemia, suggesting a role for broader surgical indications.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care

OBJECTIVE

Thyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy.

METHODS

We identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy.

RESULTS

A total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000.

CONCLUSIONS

Overall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions

OBJECTIVE

Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time.

BACKGROUND

EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition.

METHODS

This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days.

RESULTS

Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management.

CONCLUSIONS

Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Should I See You Again Soon? A Multispecialty Assessment of the Impact and Burden of Preoperative History and Physical Update Visits

BACKGROUND

Federal regulations require a history and physical (H&P) update performed ≤30 days before a planned procedure. We evaluated the utility and burdens of H&P update visits by determining impact on operative management, suitability for telehealth, and visit time and travel burden.

STUDY DESIGN

We identified H&P update visits performed in our health system during 2019 for 8 surgical specialties. As available, up to 50 visits per specialty were randomly selected. Primary outcomes were a) interval changes in history, exam, or operative plan between the initial and updated H&P notes and b) visit suitability for telehealth, as determined by two independent physician reviewers. Clinic time was captured, and round-trip driving time and distance between patients' home and clinic ZIP codes were estimated.

RESULTS

We identified 8,683 visits and 362 were randomly selected for review. Documented changes were most commonly identified in histories (60.8%), but rarely in physical exams (11.9%) and operative plans (11.6%). 99.2% of visits were considered suitable for telehealth. Median clinic time was 52 minutes (IQR:33.8-78), driving time was 55.6 minutes (IQR:35.5-85.5), and driving distance was 20.2 miles (IQR:8.5-38.4). At the health system level, patients spent an estimated aggregate 7,000 hours (including 4,046 hours of waiting room and travel time) and drove 142,273 miles to attend in-person H&P update visits in 2019.

CONCLUSION

Given their minimal impact on operative management, regulatory requirements for in-person H&P updates should be reconsidered. Flexibility in update timing and modality might help defray the substantial burdens these visits impose on patients.

Inefficiencies of care in hub and spoke healthcare systems: A multi-state cohort study

BACKGROUND

Complex surgical care is often centralized to one high volume (hub) hospital within a system. The benefit of this centralization in common operations is unknown.

METHODS

Using the Healthcare Cost and Utilization Project's State Inpatient Databases, adult general surgical patients within hospital systems in 13 states (2016-2018) were identified. Risk-adjusted logistic regression estimated the odds of death or serious morbidity (DSM) and prolonged length of stay (LOS) at hubs relative to other system hospitals (spokes).

RESULTS

We identified 122,895 patients across 43 hub-and-spoke systems. Hubs completed 83.2 ​% of complex and 59.6 ​% of common operations. For complex operations, odds of DSM were significantly lower in hubs (OR: 0.80; 95 ​% CI [0.65, 0.98]). For common operations, odds of DSM were similar between hubs and spokes, while odds of prolonged LOS were greater at hubs (OR 1.19; 95 ​% CI [1.16,1.24]).

CONCLUSIONS

While hub hospitals had lower odds of DSM for complex operation, they had higher odds of prolonged length of stay for common operations. This finding shows an opportunity for improved system efficiency.

Predictive Risk Score for Postparathyroidectomy Hungry Bone Syndrome in Patients With Secondary Hyperparathyroidism

PURPOSE

Secondary hyperparathyroidism (SHPT) frequently affects patients with end-stage renal disease. Hungry bone syndrome (HBS) is a common complication among patients who undergo parathyroidectomy for SHPT and may cause prolonged hospitalization or require intensive care. The objective of this study is to develop a scoring system to stratify patients according to their risk of developing HBS.

METHODS

A retrospective cohort study was performed using the US Renal Data System (2010-2021). Univariable and multivariable logistic regression models were developed and weighted β-coefficients from the multivariable model were used to construct a risk score for the development of HBS. Positive and negative predictive values were assessed.

RESULTS

Of 17 074 patients who underwent parathyroidectomy for SHPT, 19.4% developed HBS. Intensive care unit admission was more common in patients who developed HBS (33.5% vs 24.6%, P < .001). On multivariable logistic regression analysis, younger age, renal osteodystrophy, longer duration of dialysis, longer duration of kidney transplant, and higher Elixhauser score were significantly associated with HBS. A risk score based on these clinical factors was developed, with a total of 6 possible points. Rates of HBS ranged from 8% in patients with 0 points to 44% in patients with 6 points. The risk score had a poor positive predictive value (20.3%) but excellent negative predictive value (89.3%) for HBS.

CONCLUSION

We developed a weighted risk score that effectively stratifies patients by risk for developing HBS after parathyroidectomy. This tool can be used to counsel patients and to identify patients who may not require postoperative hospitalization.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer

BACKGROUND

This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC).

METHODS

Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity.

RESULTS

Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 ​cm were more likely in men (vs. women: OR 2.47, p ​< ​0.001) and Hispanic patients (vs. White patients: OR 1.52, p ​= ​0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p ​= ​0.002; Hispanic: OR 1.44, p ​= ​0.038) and experienced longer time to surgery (Black: HR 0.66, p ​< ​0.001; Hispanic: HR 0.71, p ​< ​0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p ​= ​0.022).

CONCLUSIONS

Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis

BACKGROUND

Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort.

METHODS

We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort.

RESULTS

Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001).

CONCLUSION

Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons

Importance

Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons.

Objective

To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender.

Design, Setting, and Participants

A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience.

Main Outcomes and Measures

Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons.

Results

A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals.

Conclusions and Relevance

The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

The effect of Section 1557 of the Affordable Care Act on surgical outcomes in non-English primary language speakers

BACKGROUND

In 2016, Section 1557 mandated use of qualified language interpreter services. We examined the effect of Section 1557 on surgical outcomes.

METHODS

Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2013-2020), we performed a difference-in-differences analysis of adult surgical patients (Maryland, New Jersey). The exposure was implementation of Section 1557 (pre-period: 2013-2015; post-period: 2017-2020). The treatment group was non-English primary language speakers (n-EPL). The comparison group was English primary language speakers (EPL). Outcomes included length-of-stay, postoperative complications, mortality, discharge disposition, and readmissions.

RESULTS

Among 2,298,584 patients, 198,385 (8.6%) were n-EPL. After implementation of Section 1557, n-EPL saw no difference in readmission rates but did experience significantly higher rates of mortality (+0.43%, p ​= ​0.049) and non-routine discharges (+1.81%, p ​= ​0.031) in Maryland, and higher rates of post-operative complications (+0.31%, p ​= ​0.001) in both states, compared to pre-Section 1557.

CONCLUSIONS

Contrary to our hypothesis, Section 1557 did not improve surgical outcomes for n-EPL.

An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment

BACKGROUND

This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT).

METHODS

Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy.

RESULTS

Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p ​= ​0.03; 90d readmission:+7.1%, p ​= ​0.776).

CONCLUSIONS

In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.

Perceived Implications of Compensation Structure for Academic Surgical Practice: A Qualitative Study

This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.

Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study

OBJECTIVE

To compare hospital surgical performance in older and younger patients.

SUMMARY BACKGROUND DATA

In-hospital mortality after surgical procedures varies widely between hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown.

METHODS

We performed a retrospective cohort study of patients ≥18 years undergoing one of ten common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into two populations: Medicare ≥65 (older adult) and non-Medicare <65 (younger adult) patients. Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population.

RESULTS

We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs. 29.8%; P=0.059) and significantly higher failure-to-rescue rates (16.0% vs. 4.0%; P<0.001). Among younger adults, high- relative to low-mortality hospitals had higher complication (15.4% vs. 12.1%; P<0.001) and failure-to-rescue rates (8.3% vs. 0.7%; P<0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 (P<0.001).

CONCLUSIONS

High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

BACKGROUND

We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

OBJECTIVE

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

DESIGN

A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

MAIN MEASURES

30-day (primary) and 90-day (secondary) all-cause mortality.

KEY RESULTS

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

LIMITATIONS

The study used claims-based data.

CONCLUSIONS

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

Non-English Primary Language: A Growing Population's Access to Cholecystectomy

OBJECTIVE

To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients.

BACKGROUND

The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy.

METHODS

We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes.

RESULTS

Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken.

CONCLUSIONS

Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

Importance

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition.

Objective

To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition.

Design, Setting, and Participants

This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023.

Exposure

Follow-up with a PCP within 30 days after hospital discharge for the index admission.

Main Outcomes and Measures

The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission.

Results

The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups.

Conclusions and Relevance

In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study

INTRODUCTION

Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively.

METHODS

EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal-Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models.

RESULTS

Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001).

CONCLUSIONS

HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion

BACKGROUND

Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection.

METHODS

We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication.

RESULTS

Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states.

CONCLUSIONS

Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

The Pursuing Excellence Collaborative: Engaging First-Year Residents and Fellows in Patient Safety Event Investigations

OBJECTIVES

Resident and fellow engagement in patient safety event investigations (PSEIs) can benefit both the clinical learning environment's ability to improve patient care and learners' problem-solving skills. The goals of this collaborative were to increase resident and fellow participation in these investigations and improve PSEI quality.

METHODS

This collaborative involved 18 sites-8 sites that had participated in a similar previous collaborative (cohort I) and 10 "new" sites (cohort II). The 18-month collaborative included face-to-face and virtual learning sessions, check-ins, and coaching calls. A validated assessment tool measured PSEI quality, and sites tracked the percentage of first-year residents and fellows included in a PSEI.

RESULTS

Sixteen of the 18 sites completed the 18-month collaborative. Baseline was no first-year resident or fellow participation in a PSEI. Among these 16 clinical learning environments, 1237 early learners participated in a PSEI by the end of the collaborative. Six of these 16 sites (38%) reached the goal of 100% participation of first-year residents and fellows. As a percentage of total first-year residents and fellows, larger institutions had less resident and fellow participation. Six of the 9 cohort II sites submitted PSEIs for independent review at 6 months and again at the end of the collaborative. The PSEI quality scores increased from 5.9 ± 1.8 to 8.2 ± 0.8 ( P ≤ 0.05).

CONCLUSIONS

It is possible to include all residents and fellows in PSEIs. Patient safety event investigation quality can improve through resident and fellow participation, use of standardized processes during training and investigations, and review of PSEI quality scores with a validated tool.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis

OBJECTIVE

To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions.

BACKGROUND

EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity.

METHODS

Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions.

RESULTS

Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients.

CONCLUSIONS

The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures

Importance

Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown.

Objective

To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults.

Design, Setting, and Participants

This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race.

Exposure

Primary care utilization in the year prior to presentation for an EGS operation.

Main Outcome and Measures

In-hospital, 30-day, 60-day, 90-day, and 180-day mortality.

Results

A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different.

Conclusions and Relevance

In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions

INTRODUCTION

Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken.

METHODS

Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes.

RESULTS

One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation.

CONCLUSIONS

Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

Disparities in Presentation, Treatment, and Survival in Anaplastic Thyroid Cancer

BACKGROUND

Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC).

METHODS

We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes.

RESULTS

Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups.

CONCLUSIONS

There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions

INTRODUCTION

Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially.

METHODS

We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients.

RESULTS

A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes.

CONCLUSIONS

The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults

Background

Older patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia.

Methods

We conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators.

Results

The primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18-69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001).

Conclusion

Provider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients.

Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair

OBJECTIVE

Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair.

METHODS

A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type.

RESULTS

We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients.

CONCLUSIONS

Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.

Thyroid cancer pathologic upstaging: Frequency and related factors

INTRODUCTION

Histopathologic assessment of thyroid tumors can lead to stage migration. We assessed frequency of pathologic upstaging, and associations with patient and tumor factors.

METHODS

Primary thyroid cancers treated between 2013 and 2015 were included from our institutional cancer registry. For tumor, nodal, and summary stage, upstaging was present when final pathologic stage was greater than clinical staging. Multivariate logistic regression and Chi-squared tests were performed.

RESULTS

5,351 resected thyroid tumors were identified. Upstaging rates for tumor, nodal, and summary stage were 17.5% (n = 553/3156), 18.0% (n = 488/2705), and 10.9% (n = 285/2607), respectively. Age, Asian race, days to surgery, lymphovascular invasion, and follicular histology were significantly associated. Upstaging was significantly more common after total vs partial thyroidectomy, for tumor (19.4% vs 6.2%, p < 0.001), nodal (19.3% vs 6.4%, p < 0.001), and summary stages (12.3% vs 0.7%, p < 0.001).

CONCLUSIONS

Pathologic upstaging occurs in a considerable proportion of thyroid tumors, most commonly after total thyroidectomy. These findings can inform patient counseling.

Barriers and facilitators to surgical access in underinsured and immigrant populations

BACKGROUND

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.

METHODS

A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.

RESULTS

Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.

CONCLUSIONS

Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Primary Hyperparathyroidism in Young Adult Patients

BACKGROUND

Primary hyperparathyroidism (PHPT) affects 2% of Americans over 55 years of age, and is less common in younger patients. Pediatric PHPT patients have higher rates of multigland disease (MGD). We studied young adult patients to determine whether they have similarly elevated rates of MGD and would benefit from routine bilateral neck exploration.

METHODS

Retrospective chart review was performed on patients who underwent parathyroidectomy for PHPT (2000-2019). Cohorts were defined by age: Group A (18-40 years) and Group B (> 40 years). Univariate and multivariate logistic regression analyses were performed.

RESULTS

Of 3889 patients with PHPT, 9.1% (n = 352) were included in Group A. On multivariate analysis, multiple endocrine neoplasia (odds ratio [OR] 6.3, 95% confidence interval [CI] 3.1-12.7), male sex (OR 1.3, 95% CI 1.0-1.5), family history of PHPT (OR 2.7, 95% CI 1.6-4.8), prior parathyroidectomy (OR 2.2, 95% CI 1.6-3.0), and non-localizing imaging (OR 1.8, 95% CI 1.5-2.1) were associated with MGD; younger age was not an independent risk factor. In patients with sporadic PHPT (n = 3833), family history was most strongly associated with MGD (OR 4.0, 95% CI 2.2-7.3).

CONCLUSIONS

In our population of patients with sporadic PHPT, a positive family history of PHPT was strongly associated with MGD; additional associations were found with prior parathyroidectomy, non-localizing imaging, and male sex. Younger age was not an independent risk factor. Age alone in the absence of a family history should not raise suspicion for MGD nor determine the need for bilateral neck exploration.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable

OBJECTIVE

To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.

BACKGROUND

Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.

METHODS

We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.

RESULTS

For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.

CONCLUSIONS

The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

A study analyzing outcomes after bariatric surgery by primary language

BACKGROUND

Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language.

METHODS

This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race.

RESULTS

Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes.

CONCLUSIONS

Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Explaining racial disparities in surgical survival: a tapered match analysis of patient and hospital factors

OBJECTIVES

Evaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time.

DESIGN

Retrospective tapered-match.

SETTING

571 hospitals at two time points (Early Era 2003-2005; Recent Era 2013-2015).

PARTICIPANTS

6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era).

INTERVENTIONS

Black patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time).

OUTCOMES

30-day and 1-year mortality.

RESULTS

Before matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black-white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black-white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors.

CONCLUSIONS

Survival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.

Insurance-Based Disparities in Guideline-Concordant Thyroid Cancer Care in the Era of De-Escalation

INTRODUCTION

Prior studies have demonstrated insurance-based disparities in the treatment of well-differentiated thyroid cancer. However, it remains unclear whether these disparities have persisted in the era of the 2015 American Thyroid Association (ATA) management guidelines. The goal of this study was to assess whether insurance type is associated with the receipt of guideline-concordant and timely thyroid cancer treatment in a modern cohort.

METHODS

Patients diagnosed with well-differentiated thyroid cancer between 2016 and 2019 were identified from the National Cancer Database. Appropriateness of surgical and radioactive iodine treatment (RAI) was determined based on the 2015 ATA guidelines. Multivariable logistic regression and Cox proportional hazard regression analyses, stratified at age 65, were used to evaluate the associations between insurance type and appropriateness and timeliness of the treatment.

RESULTS

125,827 patients were included (private = 71%, Medicare = 19%, Medicaid = 10%). Compared to privately insured patients, patients with Medicaid more frequently presented with tumors >4 cm in size (11% versus 8%, P < 0.001) and regional metastases (29% versus 27%, P < 0.001). However, patients with Medicaid were also less likely to undergo appropriate surgical treatment (odds ratio 0.69, P < 0.001), less likely to undergo surgery within 90 d of diagnosis (hazard ratio 0.80, P < 0.001), and more likely to be undertreated with RAI (odds ratio 1.29, P < 0.001). There were no differences in the likelihood of guideline-concordant surgical or medical treatment by insurance type in patients ≥65 y old.

CONCLUSIONS

In the era of the 2015 ATA guidelines, patients with Medicaid remain less likely to receive guideline-concordant, timely surgery and more likely to be undertreated with RAI compared to privately insured patients.

Health System Structure: An Opportunity to Address Structural Racism and Discrimination

OBJECTIVE

To examine the role of hub-and-spoke systems as a factor in structural racism and discrimination.

BACKGROUND

Health systems are often organized in a "hub-and-spoke" manner to centralize complex surgical care to 1 high-volume hospital. Although the surgical health care disparities are well described across health care systems, it is not known how they seem across a single system's hospitals.

METHODS

Adult patients who underwent 1 of 10 general surgery operations in 12 geographically diverse states (2016-2018) were identified using the Healthcare Cost and Utilization Project's State Inpatient Databases. System status was assigned using the American Hospital Association dataset. Hub designation was assigned in 2 ways: (1) the hospital performing the most complex operations (general hub) or (2) the hospital performing the most of each specific operation (procedure-specific hub). Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of treatment at hubs by race and ethnicity.

RESULTS

We identified 122,236 patients across 133 hospitals in 43 systems. Most patients were White (73.4%), 14.2% were Black, and 12.4% Hispanic. A smaller proportion of Black and Hispanic patient underwent operations at general hubs compared with White patients (B: 59.6% H: 52.0% W: 62.0%, P <0.001). After adjustment, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (general hub B: odds ratio: 0.88 CI, 0.85, 0.91 H: OR: 0.82 CI, 0.79, 0.85).

CONCLUSIONS

When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the published advantages of high-volume care, this new finding may highlight an opportunity in the pursuit of health equity.

Redefining Multimorbidity in Older Surgical Patients

BACKGROUND

Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.

STUDY DESIGN

We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.

RESULTS

Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795).

CONCLUSIONS

Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity

BACKGROUND

Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased.

OBJECTIVE

To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs.

RESEARCH DESIGN

Matched cohort study.

SUBJECTS

Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures.

MEASURES

Seven and 30-day revisit and complication rates.

RESULTS

For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately.

CONCLUSIONS

The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.

Development of a Machine Learning Model to Identify Colorectal Cancer Stage in Medicare Claims

PURPOSE

Staging information is essential for colorectal cancer research. Medicare claims are an important source of population-level data but currently lack oncologic stage. We aimed to develop a claims-based model to identify stage at diagnosis in patients with colorectal cancer.

METHODS

We included patients age 66 years or older with colorectal cancer in the SEER-Medicare registry. Using patients diagnosed from 2014 to 2016, we developed models (multinomial logistic regression, elastic net regression, and random forest) to classify patients into stage I-II, III, or IV on the basis of demographics, diagnoses, and treatment utilization identified in Medicare claims. Models developed in a training cohort (2014-2016) were applied to a testing cohort (2017), and performance was evaluated using cancer stage listed in the SEER registry as the reference standard.

RESULTS

The cohort of patients with 30,543 colorectal cancer included 14,935 (48.9%) patients with stage I-II, 9,203 (30.1%) with stage III, and 6,405 (21%) with stage IV disease. A claims-based model using elastic net regression had a scaled Brier score (SBS) of 0.45 (95% CI, 0.43 to 0.46). Performance was strongest for classifying stage IV (SBS, 0.62; 95% CI, 0.59 to 0.64; sensitivity, 93%; 95% CI, 91 to 94) followed by stage I-II (SBS, 0.45; 95% CI, 0.44 to 0.47; sensitivity, 86%; 95% CI, 85 to 76) and stage III (SBS, 0.32; 95% CI, 0.30 to 0.33; sensitivity, 62%; 95% CI, 61 to 64).

CONCLUSION

Machine learning models effectively classified colorectal cancer stage using Medicare claims. These models extend the ability of claims-based research to risk-adjust and stratify by stage.

Racial and Ethnic Disparities in Appropriate Thyroid Cancer Treatment, Before and After the Release of the 2015 American Thyroid Association Guidelines

BACKGROUND

The 2015 American Thyroid Association (ATA) guidelines reduced the recommended extent of therapy for low-risk thyroid cancers. Little is known about the impact of these changes on overall treatment patterns and on previously described racial/ethnic disparities in guideline-concordant care. This study aimed to assess trends in thyroid cancer care before and after release of the 2015 guidelines, with particular attention to racial/ethnic disparities.

METHODS

Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2018). An interrupted time series design was used to assess trends in treatment before and after the 2015 guidelines. Appropriateness of surgical and radioactive iodine (RAI) treatment was determined based on the ATA guidelines, and the likelihood of receiving guideline-concordant treatment was compared between racial/ethnic groups.

RESULTS

The study identified 309,367 patients (White 74%, Black 8%, Hispanic 9%, Asian 6%). Between 2010 and 2015, the adjusted probability of appropriate surgery was lower for Black (- 2.1%; p < 0.001), Hispanic (- 1.0%; p < 0.001), and Asian (- 2.1%; p < 0.001) patients than for White patients. After 2015, only Hispanic patients had a lower probability of undergoing appropriate surgical therapy (- 2.6%; p = 0.040). Similarly, between 2010 and 2015, the adjusted probability of receiving appropriate RAI therapy was lower for the Hispanic (- 3.6%; p < 0.001) and Asian (- 2.4%; p < 0.001) patients than for White patients. After 2015, the probability of appropriate RAI therapy did not differ between groups.

CONCLUSIONS

Between 2010 and 2015, patients from racial/ethnic minority backgrounds were less likely than White patients to receive appropriate surgical and RAI therapy for thyroid cancer. After the 2015 guidelines, racial/ethnic disparities in treatment improved.

Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals

IMPORTANCE

Although objective data are used routinely in prescription drug recommendations, it is unclear how referring physicians apply evidence when making surgeon or hospital recommendations for surgery.

OBJECTIVE

To compare the factors associated with the hospital or surgeon referral decision-making process with that used for prescription medication recommendations.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study comprised interviews conducted between April 26 and May 18, 2021, of a purposive sample of 21 primary care physicians from a large primary care network in the Northeast US.

MAIN OUTCOMES AND MEASURES

Main outcomes were the factors considered when making prescription medication recommendations vs referral recommendations to specific surgeons or hospitals for surgery.

RESULTS

All 21 participant primary care physicians (14 women [66.7%]) reported use of evidence-based decision support tools and patient attributes for prescription medication recommendations. In contrast, for surgeon and hospital referral recommendations, primary care physicians relied on professional experience and training, personal beliefs about surgical quality, and perceived convenience. Primary care physicians cited perceived limitations of existing data on surgical quality as a barrier to the use of such data in the process of making surgical referrals.

CONCLUSIONS AND RELEVANCE

As opposed to the widespread use of objective decision support tools for guidance on medication recommendations, primary care physicians relied on subjective factors when making referrals to specific surgeons and hospitals. The findings of this study highlight the potential to improve surgical outcomes by introducing accessible, reliable data as an imperative step in the surgical referral process.

Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals

IMPORTANCE

Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.

OBJECTIVE

To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.

EXPOSURES

Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.

RESULTS

A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.

An Opportunity to Advance Workforce Equity: Surgical Referrals

Emerging literature suggests unconscious bias impacts referrals to female surgeons with downstream consequences on career advancement, compensation, and patient care. The use of structural processes, such as group referrals, along with data and objective criteria to aid in the selection of consultants will advance workforce equity.

Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis

AIM

We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort.

METHODS

We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns.

RESULTS

Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001).

CONCLUSION

We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.

How low is too low? Intraoperative parathyroid hormone decline in normohormonal primary hyperparathyroidism

BACKGROUND

In normohormonal primary hyperparathyroidism, parathyroid hormone levels are normal but inappropriately elevated for the degree of hypercalcemia. The study goals were to determine intraoperative parathyroid hormone parameters predictive of (1) cure and (2) hypocalcemia in this subgroup.

METHODS

We performed a retrospective cohort study comparing patients who underwent parathyroidectomy (2002-2019) for normohormonal and classic primary hyperparathyroidism. The primary outcomes were cure (calcium <10.3 mg/dL) and hypocalcemia (≤8.4 mg/dL) ≥6 months postoperatively.

RESULTS

In the study, 127 of 1,087 patients (11.7%) had normohormonal primary hyperparathyroidism. The groups experienced similar rates of cure (91.3% vs 94.1%, P = .23) and hypocalcemia (3.9% vs 2.9%, P = .53). However, intraoperative parathyroid hormone decline in cured patients was lower in those with normohormonal primary hyperparathyroidism (66.4% vs 84.5%, P < .0001). Receiver operating characteristic curves provided Youden's indices of 52% and 75% (cure) and 75% and 88% (hypocalcemia) for patients with normohormonal and classic primary hyperparathyroidism, respectively. Cure rates with ≥50% intraoperative parathyroid hormone decline were similar (94.1% vs 95.0%, P = .72), but hypocalcemia was more prevalent in patients with normohormonal primary hyperparathyroidism and ≥70% intraoperative parathyroid hormone decline (10.4% vs 3.3%, P = .01).

CONCLUSION

In patients with normohormonal primary hyperparathyroidism, intraoperative parathyroid hormone declines of ≥50% and ≥70% were predictive of postoperative cure and hypocalcemia, respectively. These parameters may inform intraoperative decision making and postoperative management.