1
|
Ali D, Syed M, Gamboa AC, Hawkins AT, Regenbogen SE, Holder-Murray J, Silviera M, Ejaz A, Balch GC, Khan A. Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer. J Surg Oncol 2024; 129:930-938. [PMID: 38167808 DOI: 10.1002/jso.27572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database. METHODS Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association. RESULTS A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [β = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]. CONCLUSIONS Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.
Collapse
Affiliation(s)
- Danish Ali
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Maria Syed
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Alexander T Hawkins
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Glen C Balch
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Aimal Khan
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Hrebinko K, Anto VP, Reitz KM, Gamboa AC, Regenbogen SE, Hawkins AT, Hopkins MB, Ejaz A, Bauer PS, Wise PE, Balch GC, Holder-Murray J. Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium. Int J Colorectal Dis 2024; 39:39. [PMID: 38498217 PMCID: PMC10948474 DOI: 10.1007/s00384-024-04600-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. METHODS This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. RESULTS Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models. CONCLUSION Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.
Collapse
Affiliation(s)
- Katherine Hrebinko
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Vincent P Anto
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, MD Anderson Cancer Center, University of Texas, Austin, USA
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, USA
| | - Philip S Bauer
- Department of Surgery, Allegheny Health Network, Pittsburgh, USA
| | - Paul E Wise
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Glen C Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University, Atlanta, USA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Office Building, Suite 603, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
3
|
Kankotia RJ, Kwon RS, Philips GM, Regenbogen SE, Zacur GM, Wamsteker EJ, Schulman AR, Machicado JD. Comparison of lumen apposing metal stents versus endoscopic balloon dilation for the management of benign colorectal anastomotic strictures. Gastrointest Endosc 2024:S0016-5107(24)00161-5. [PMID: 38462058 DOI: 10.1016/j.gie.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/07/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND AIMS Limited data exist evaluating lumen apposing metal stents (LAMS) with endoscopic balloon dilation (EBD) for the treatment of benign colorectal anastomotic strictures (BCAS). This study compares outcomes of both interventions. METHODS Patients with left-sided BCAS treated with LAMS vs. EBD were identified retrospectively. The primary outcome was a composite of crossover to another intervention to achieve clinical success or recurrence requiring reintervention. RESULTS Twenty-nine patients (11 LAMS; 18 EBD) were identified, with longer follow-up in the EBD group (734 vs. 142 days, p=0.003). No significant differences were found in the composite outcome, technical success, clinical success, or components of composite outcome. With LAMS, there was a nonsignificant trend toward fewer procedures (2.4 vs. 3.3, p=0.06) and adverse events (0 vs. 16.7%, p=0.26). CONCLUSIONS LAMS appears to be as effective as EBD for the treatment of BCAS but may require fewer procedures and may be safer than EBD.
Collapse
Affiliation(s)
- Ravi J Kankotia
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - George M Philips
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | | | - George M Zacur
- Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI.
| |
Collapse
|
4
|
Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
Collapse
|
5
|
Hider AM, Gomez-Rexrode AE, Agius J, MacEachern MP, Ibrahim AM, Regenbogen SE, Berlin NL. Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review. Am J Surg 2024; 229:83-91. [PMID: 38148257 DOI: 10.1016/j.amjsurg.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions. BACKGROUND SUMMARY Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear. METHODS A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion. RESULTS Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited. CONCLUSIONS Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.
Collapse
Affiliation(s)
- Ahmad M Hider
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Josh Agius
- University of Michigan, Ann Arbor, MI, USA
| | - Mark P MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
6
|
Regenbogen SE. What's the Matter With Trials Today? Dis Colon Rectum 2024; 67:345-347. [PMID: 37889945 DOI: 10.1097/dcr.0000000000003030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Scott E Regenbogen
- Division of Colorectal Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
7
|
West CT, West MA, Mirnezami AH, Drami I, Denys A, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Pape E, van Ramshorst GH, Aalbers AGJ, Abdul AN, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Angenete E, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brown K, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelen W, Chan KKL, Chang GJ, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Denost QD, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Egger E, Eglinton T, Enrique-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Flatmark K, Fleming F, Flor B, Folkesson J, Foskett K, Frizelle FA, Funder J, Gallego MA, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther N, Glover T, Goffredo P, Golda T, Gomez CM, Griffiths B, Gwenaël F, Harris C, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kaufman M, Kazi M, Kelley SR, Keller DS, Kelly ME, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Kusters M, Lago V, Lakkis Z, Lampe B, Langheinrich MC, Larach T, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Mackintosh M, Mann C, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McDermott FD, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Monson JRT, Morton JR, Mullaney TG, Navarro AS, Neeff H, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock A, Pellino G, Peterson AC, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Quyn A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Smith T, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor C, Taylor D, Tejedor P, Tekin A, Tekkis PP, Teras J, Thanapal MR, Thaysen HV, Thorgersen E, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg 2023; 110:1730-1731. [PMID: 37757457 PMCID: PMC10805575 DOI: 10.1093/bjs/znad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
|
8
|
Janda AM, Vaughn MT, Colquhoun D, Mentz G, Buehler MS RN CPPS K, Nathan H, Regenbogen SE, Syrjamaki J, Kheterpal S, Shah N. Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study. Anesth Analg 2023; 137:1093-1103. [PMID: 37678254 PMCID: PMC10592579 DOI: 10.1213/ane.0000000000006565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. METHODS In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. RESULTS We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. CONCLUSIONS Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.
Collapse
Affiliation(s)
- Allison M. Janda
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Michelle T. Vaughn
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Douglas Colquhoun
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kathryn Buehler MS RN CPPS
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hari Nathan
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | | | - John Syrjamaki
- Michigan Value Collaborative (MVC), Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Nirav Shah
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| |
Collapse
|
9
|
Thompson MP, Cain-Nielsen AH, Yost Karslake ML, Pizzo CA, Yaser JM, Syrjamaki JD, Nathan H, Norton EC, Regenbogen SE. Hospital performance in a statewide commercial insurer episode-based incentive program. Am J Manag Care 2023; 29:e250-e256. [PMID: 37616153 DOI: 10.37765/ajmc.2023.89412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVES To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.
Collapse
Affiliation(s)
- Michael P Thompson
- Michigan Medicine, 5331K Frankel Cardiovascular Center, 1500 E Medical Center Dr, SPC 5864, Ann Arbor, MI 48109.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
OBJECTIVE To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making. BACKGROUND PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making. METHODS We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool. RESULTS Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42-2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04-2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (-63.3), outpatient management (-54.9), and patient preference (-39.6). PRS was predicted to have high utility (+71). CONCLUSIONS A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making.
Collapse
Affiliation(s)
- Ana C De Roo
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Yanhua Chen
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI
| | - Xiaomeng Du
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI
| | | | - Mary Byrnes
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Elizabeth K Speliotes
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI
| | | |
Collapse
|
11
|
Roberson JL, Maguire LH, Mitchem JB, Regenbogen SE, Smith JJ, Huang E. The Specific Aims Page: A Primer. Dis Colon Rectum 2023; 66:623-625. [PMID: 36745112 DOI: 10.1097/dcr.0000000000002754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lillias H Maguire
- Division of Colon and Rectal Surgery, Department of Surgery, Corporal Michael Crescenz VA Medical Center Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John B Mitchem
- Division of General Surgery, University of Missouri, Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emina Huang
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
12
|
Vogel JD, Fleshner PR, Holubar SD, Poylin VY, Regenbogen SE, Chapman BC, Messaris E, Mutch MG, Hyman NH. High Complication Rate After Early Ileostomy Closure: Early Termination of the Short Versus Long Interval to Loop Ileostomy Reversal After Pouch Surgery Randomized Trial. Dis Colon Rectum 2023; 66:253-261. [PMID: 36627253 DOI: 10.1097/dcr.0000000000002427] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In patients with ulcerative colitis who undergo IPAA, a diverting ileostomy is used to diminish the severity of anastomotic complications. Typically, the ileostomy is closed after an interval of 2 to 4 months. The safety of earlier closure of the ileostomy after pouch surgery is unknown. OBJECTIVE This study aimed to compare postoperative outcomes in patients randomly assigned to early (7-12 days) or late (≥8 weeks) ileostomy closure after ileal pouch construction. DESIGN This was a multicenter, prospective randomized trial. SETTING The study was conducted at colorectal surgical units at select United States hospitals. PATIENTS Adults with ulcerative colitis who underwent 2- or 3-stage proctocolectomy with IPAA were included. MAIN OUTCOME MEASURES The primary outcomes included Comprehensive Complication Index at 30 days after ileostomy closure. The secondary outcomes included complications, severe complications, reoperations, and readmissions within 30 days of ileostomy closure. RESULTS The trial was stopped after interim analysis because of a high rate of complications after early ileostomy closure. Among 36 patients analyzed, 1 patient (3%) had unplanned proctectomy with end-ileostomy. Of the remaining 35 patients, 28 patients (80%) were clinically eligible for early closure and underwent radiologic assessment. There were 3 radiologic failures. Of the 25 remaining patients, 22 patients (88%) were randomly assigned to early closure (n = 10) or late closure (n = 12), and 3 patients were excluded. Median Comprehensive Complication Index was 14.8 (0-54) and 0 (0-23) after early and late closure (p = 0.02). One or more complications occurred in 7 patients (70%) after early closure and in 2 patients (17%) after late closure (p = 0.01)' and complications were severe in 3 patients (30%) after early closure and 0 patients after late closure (p = 0.04). Reoperation was required in 1 patient (10%) and 0 patients (p = 0.26) after early closure and readmission was required in 7 patients (70%) and 1 patient (8%) after late closure (p = 0.003). LIMITATIONS This study was limited by early study closure and selection bias. CONCLUSIONS Early closure of a diverting ileostomy in patients with ulcerative colitis who underwent IPAA is associated with an unacceptably high rate of complications. See Video Abstract at http://links.lww.com/DCR/C68. ALTA TASA DE COMPLICACIONES DESPUS DEL CIERRE PRECOZ DE LA ILEOSTOMA TERMINACIN TEMPRANA DEL ENSAYO ALEATORIZADO DE INTERVALO CORTO VERSUS LARGO PARA LA REVERSIN DE LA ILEOSTOMA EN ASA DESPUS DE LA CIRUGA DE RESERVORIO ILEAL ANTECEDENTES:En los pacientes con colitis ulcerosa que se someten a una anastomosis del reservorio ileoanal, se utiliza una ileostomía de derivación para disminuir la gravedad de las complicaciones de la anastomosis. Por lo general, la ileostomía se cierra después de un intervalo de 2 a 4 meses. Se desconoce la seguridad del cierre más temprano de la ileostomía después de la cirugía de reservorio.OBJETIVO:Comparar los resultados posoperatorios en pacientes asignados al azar al cierre temprano (7-12 días) o tardío (≥ 8 semanas) de la ileostomía después de la construcción de un reservorio ileal.DISEÑO:Este fue un ensayo aleatorizado prospectivo multicéntrico.ESCENARIO:El estudio se realizó en unidades quirúrgicas colorrectales en hospitales seleccionados de los Estados Unidos.PACIENTES:Se incluyeron adultos con colitis ulcerosa que se sometieron a proctocolectomía en 2 o 3 tiempos con anastomosis ileoanal con reservorio.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron el Índice Integral de Complicaciones a los 30 días después del cierre de la ileostomía. Los resultados secundarios incluyeron complicaciones, complicaciones graves, reoperaciones y readmisiones dentro de los 30 días posteriores al cierre de la ileostomía.RESULTADOS:El ensayo se detuvo después del análisis interino debido a una alta tasa de complicaciones después del cierre temprano de la ileostomía. Entre los 36 pacientes analizados, 1 (3%) tuvo una proctectomía no planificada con ileostomía terminal. De los 35 pacientes restantes, 28 (80%) fueron clínicamente elegibles para el cierre temprano y se sometieron a una evaluación radiológica. Hubo 3 fracasos radiológicos. De los 25 pacientes restantes, 22 (88 %) se asignaron al azar a cierre temprano (n = 10) o tardío (n = 12) y 3 fueron excluidos. La mediana del Índice Integral de Complicaciones fue de 14,8 (0-54) y 0 (0-23) después del cierre temprano y tardío (p = 0,02). Una o más complicaciones ocurrieron en 7 pacientes (70%) después del cierre temprano y 2 (17%) pacientes después del cierre tardío (p = 0,01) y fueron graves en 3 (30%) y 0 pacientes, respectivamente (p = 0,04). Requirieron reintervención en 1 (10%) y 0 (p = 0,26) y reingreso en 7 (70%) y 1 (8%) pacientes (p = 0,003).LIMITACIONES:Este estudio estuvo limitado por el cierre temprano del estudio; sesgo de selección.CONCLUSIONES:El cierre temprano de una ileostomía de derivación en pacientes con colitis ulcerosa con anastomosis de reservorio ileoanal se asocia con una tasa inaceptablemente alta de complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/C68. (Traducción-Dr. Felipe Bellolio).
Collapse
Affiliation(s)
- Jon D Vogel
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Phillip R Fleshner
- Cedars-Sinai Medical Center, Colorectal Surgery Program, Los Angeles, California
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Vitaliy Y Poylin
- Department of Surgery, Northwestern University, Chicago, Illinois
| | | | | | - Evangelos Messaris
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthew G Mutch
- Washington University, Department of Surgery, St. Louis, Michigan
| | - Neil H Hyman
- University of Chicago, Department of Surgery, Chicago, Illinois
| |
Collapse
|
13
|
Warren E, Gamboa AC, Medin C, Hendren S, Regenbogen SE, Holder-Murray J, Kalady M, Ejaz A, Hawkins A, Wise P, Silviera M, Maithel SK, Balch GC. Association of transanal minimally invasive surgical approach with oncologic outcomes over conventional transanal excision for early-stage rectal cancer: An analysis of the US Rectal Cancer Consortium. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
145 Background: For early-stage rectal cancer, minimally invasive surgical (MIS) approaches such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have not been widely adopted over conventional transanal excision (TAE). Direct comparisons are lacking. Our aim was to compare oncologic and perioperative outcomes between the two approaches. Methods: We identified patients with Tis or T1 tumors who underwent TAE or MIS (TEM or TAMIS) between 2007-2017 from the US Rectal Cancer Consortium database. Patients who received neoadjuvant therapy were excluded. Primary outcomes were rate of recurrence and recurrence-free survival (RFS). Results: Of 1881 patients, 89 met inclusion criteria: 44 TAE and 45 MIS (20 TEM, 25 TAMIS). Median age was similar between groups (63.5 years TAE vs 61 years MIS; p=0.582). Patients in each group had similar functional status and tumor size (1.86 cm TAE vs 1.79 cm MIS, p=0.837). The majority of patients had tumors ≤ 6 cm from the anal verge (75.7% TAE vs 65.5% MIS, p=0.544). The TAE group had a 10.3% margin positive rate versus 0% in the MIS group (p=0.049). There was a lower incidence of recurrence in the MIS group (4.5%) compared to TAE (26%, p=0.01); all recurred locally except for one in the TAE group. Median follow-up time was 23.7 months. On Kaplan-Meier analysis, MIS approach was associated with improved 5-year RFS (86.4%, p=0.005) and local RFS (86.4%, p=0.01), versus TAE (46.9% and 50.5%, respectively). On univariate cox regression analysis, lymphovascular invasion was associated with worse RFS (HR 4.23, p=0.033) and local RFS (HR 5.26, p=0.02), while MIS approach was associated with improved RFS (HR 0.15, p=0.015) and local RFS (HR 0.17, p=0.023). On multivariable cox regression, only MIS approach remained associated with improved RFS (HR 0.09, p=0.028) and local RFS (HR 0.11, p=0.045). Perioperative complication and readmission rates were equal between the two groups. Conclusions: In patients with Tis and T1 rectal cancers who undergo local excision, an MIS approach (TEM or TAMIS) is associated with a decreased rate of recurrence and improved RFS and local RFS compared to TAE, with no significant difference in perioperative complication rate. The MIS approach should be more frequently incorporated into standard practice. [Table: see text]
Collapse
Affiliation(s)
| | | | | | | | | | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew Kalady
- Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Paul Wise
- Washington University in St. Louis, St. Louis, MO
| | - Matthew Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Glen C. Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University, Atlanta, GA
| |
Collapse
|
14
|
De Roo AC, Ha J, Regenbogen SE, Hoffman GJ. Impact of Medicare eligibility on informal caregiving for surgery and stroke. Health Serv Res 2023; 58:128-139. [PMID: 35791447 PMCID: PMC9836945 DOI: 10.1111/1475-6773.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65. DATA SOURCES Health and Retirement Study survey data (1998-2018). STUDY DESIGN We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility. DATA COLLECTION Not applicable. PRINCIPAL FINDINGS A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt. CONCLUSIONS Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.
Collapse
Affiliation(s)
- Ana C. De Roo
- Department of SurgeryUniversity of MichiganAnn ArborMichiganUSA,Center for Healthcare Outcomes and PolicyUniversity of MichiganAnn ArborMichiganUSA,Institute for Healthcare Policy and Innovation, University of MichiganAnn ArborMichiganUSA
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Scott E. Regenbogen
- Department of SurgeryUniversity of MichiganAnn ArborMichiganUSA,Center for Healthcare Outcomes and PolicyUniversity of MichiganAnn ArborMichiganUSA,Institute for Healthcare Policy and Innovation, University of MichiganAnn ArborMichiganUSA
| | - Geoffrey J. Hoffman
- Institute for Healthcare Policy and Innovation, University of MichiganAnn ArborMichiganUSA,Department of Systems, Populations and LeadershipUniversity of Michigan School of NursingAnn ArborMichiganUSA
| |
Collapse
|
15
|
Aiken TJ, King R, Russell MM, Regenbogen SE, Lawson E, Zafar SN. Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons. J Thromb Thrombolysis 2023; 55:376-381. [PMID: 36454476 DOI: 10.1007/s11239-022-02733-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. METHODS An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. RESULTS The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. CONCLUSION Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.
Collapse
Affiliation(s)
- Taylor J Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Ray King
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.,Division of Colorectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Elise Lawson
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA.,Division of Colorectal Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Syed Nabeel Zafar
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA. .,Division of Surgical Oncology, University of Wisconsin-Madison, Madison, WI, USA.
| |
Collapse
|
16
|
Medin C, Gamboa AC, Warren E, Regenbogen SE, Hendren S, Holder-Murray J, Kalady M, Ejaz A, Hawkins A, Silviera M, Maithel SK, Balch GC. Neoadjuvant chemoradiation does not improve outcomes for patients undergoing resection for upper rectal cancer: A US Rectal Cancer Consortium analysis. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
143 Background: The use of neoadjuvant chemoradiation (NCRT) for upper rectal cancer remains controversial. Our aim was to determine whether NCRT was associated with improved outcomes. Methods: The US Rectal Cancer Consortium was queried for patients who underwent resection of non-metastatic upper rectal cancer (≥12cm from anal verge) from 2007-2017. Primary outcomes were recurrence-free (RFS) and overall survival (OS). Secondary outcomes were postoperative complications. Results: 193 pts met inclusion criteria; 100 (52%) did not receive NCRT and 93 (48%) did. Median age was similar between groups (non-NCRT: 62 yrs; NCRT: 57 yrs; p=0.71). Patients in each group had similar gender and pathological stage (non-NCRT: 22% stage I, 32% stage II, 36% stage III; NCRT: 21% stage I, 23% stage II, 33% stage III; p=0.143). Median follow-up was 31 months (non-NCRT) and 34 months (NCRT). On Kaplan-Meier analysis, NCRT was not associated with improved RFS compared to non-NCRT (3-year RFS 85% vs. 80%; p=0.34) or OS (3-year OS 88% vs. 90%; p=0.49). This finding persisted on multivariable cox regression. R0 resection rate was similar between groups at 99% (non-NCRT) and 97% (NCRT; p=0.27). Anastomotic leak occurred in 11% of both cohorts. Creation of a diverting loop ileostomy (DLI) was nearly 3 times higher in NCRT (82%) versus non-NCRT patients (29%; p<0.001). Conclusions: Among patients with non-metastatic upper rectal cancer, NCRT did not improve survival or recurrence rates, but was associated with a nearly threefold higher DLI rate. Although NCRT is a mainstay of treatment for lower rectal cancer, our results do not support its use in upper rectal cancer. [Table: see text]
Collapse
Affiliation(s)
| | | | | | | | | | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew Kalady
- Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Matthew Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Glen C. Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University, Atlanta, GA
| |
Collapse
|
17
|
Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
Collapse
|
18
|
Hawkins AT, Rothman R, Geiger TM, Bonnet KR, Mutch MG, Regenbogen SE, Schlundt DG, Penson DF. Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis. Ann Surg Open 2022; 3:e157. [PMID: 35528025 PMCID: PMC9074822 DOI: 10.1097/as9.0000000000000157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/04/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making. Summary Background Data The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions. Methods We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework. Results 25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/]. Conclusions Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.
Collapse
Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| |
Collapse
|
19
|
De Roo AC, Shubeck SP, Cain-Nielsen AH, Norton EC, Regenbogen SE. Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy. Dis Colon Rectum 2022; 65:758-766. [PMID: 35394941 PMCID: PMC8994054 DOI: 10.1097/dcr.0000000000002020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Prospective payment models have incentivized reductions in length of stay after surgery. The benefits of abbreviated postoperative hospitalization could be undermined by increased readmissions or postacute care use, particularly for older adults or those with comorbid conditions. OBJECTIVE The purpose of this study was to determine whether hospitals with accelerated postsurgical discharge accrue total episode savings or incur greater postdischarge payments among patients stratified by age and comorbidity. DESIGN This was a retrospective cross-sectional study. SETTING National data from the 100% Medicare Provider Analysis and Review files for July 2012 to June 2015 were used. PATIENTS We included Medicare beneficiaries undergoing elective colectomy and stratified the cohort by age (65-69, 70-79, ≥80 y) and Elixhauser comorbidity score (low: ≤0; medium: 1-5; and high: >5). Patients were categorized by the hospital's mode length of stay, reflecting "usual" care. MAIN OUTCOMES MEASURES In a multilevel model, we compared mean total episode payments and components thereof among age and comorbidity categories, stratified by hospital mode length of stay. RESULTS Among 88,860 patients, mean total episode payments were lower in shortest versus longest length of stay hospitals across all age and comorbidity strata and were similar between age groups (65-69 y: $28,951 vs $30,566, p = 0.014; 70-79 y: $31,157 vs $32,044, p = 0.073; ≥80 y: $33,779 vs $35,771, p = 0.005) but greater among higher comorbidity (low: $23,107 vs $24,894, p = 0.001; medium: $30,809 vs $32,282, p = 0.038; high: $44,097 vs $46641, p < 0.001). Postdischarge payments were similar among length-of-stay hospitals by age (65-69 y: ∆$529; 70-79 y: ∆$291; ≥80 y: ∆$872, p = 0.25) but greater among high comorbidity (low: ∆$477; medium: ∆$480; high: ∆$1059; p = 0.02). LIMITATIONS Administrative data do not capture patient-level factors that influence postacute care use (preference, caregiver availability). CONCLUSIONS Hospitals achieving shortest length of stay after surgery accrue lower total episode payments without a compensatory increase in postacute care spending, even among patients at oldest age and with greatest comorbidity. See Video Abstract at http://links.lww.com/DCR/B624. CONSECUENCIAS DE LA EDAD Y LAS COMORBILIDADES ASOCIADAS, EN EL COSTO DE LA ATENCIN EN PACIENTES SOMETIDOS A COLECTOMA EN PROGRAMAS DE ALTA POSOPERATORIA ACELERADA ANTECEDENTES:Los modelos de pago prospectivo, han sido un incentivo para reducir la estancia hospitalaria después de la cirugía. Los beneficios de una hospitalización posoperatoria "abreviada" podrían verse afectados por un aumento en los reingresos o en la necesidad de cuidados postoperatorios tempranos luego del periodo agudo, particularmente en los adultos mayores o en aquellos con comorbilidades.OBJETIVO:Determinar si los hospitales que han establecido protocolos de alta posoperatoria "acelerada" generan un ahorro en cada episodio de atención o incurren en mayores gastos después del alta, entre los pacientes estratificados por edad y por comorbilidades.DISEÑO:Estudio transversal retrospectivo.AJUSTE:Revisión a partir de la base de datos nacional del 100% de los archivos del Medicare Provider Analysis and Review desde julio de 2012 hasta junio de 2015.PACIENTES:Se incluye a los beneficiarios de Medicare a quienes se les practicó una colectomía electiva. La cohorte se estratificó por edad (65-69 años, 70-79, ≥80) y por la puntuación de comorbilidad de Elixhauser (baja: ≤0; media: 1-5; y alta: > 5). Los pacientes se categorizaron de acuerdo con la modalidad de la duración de la estancia hospitalaria del hospital, lo que representa lo que se considera es una atención usual para dicho centro.PRINCIPALES MEDIDAS DE RESULTADO:En un modelo multinivel, comparamos la media de los pagos por episodio y los componentes de los mismos, entre las categorías de edad y comorbilidad, estratificados por la modalidad de la duración de la estancia hospitalaria.RESULTADOS:En los 88,860 pacientes, los pagos promedio por episodio fueron menores en los hospitales con una modalidad de estancia más corta frente a los de mayor duración, en todos los estratos de edad y comorbilidad, y fueron similares entre los grupos de edad (65-69: $28,951 vs $30,566, p = 0,014; 70-79: $31,157 vs $32,044, p = 0,073; ≥ 80 $33,779 vs $35,771, p = 0,005), pero mayor entre los pacientes con comorbilidades más altas (baja: $23,107 vs $24,894, p = 0,001; media $30,809 vs $32,282, p = 0,038; alta: $44,097 vs $46,641, p <0,001). Los pagos generados luego del alta hospitalaria fueron similares con relación a la estancia hospitalaria de los diferentes hospitales con respecto a la edad (65-69 años: ∆ $529; 70-79 años: ∆ $291; ≥80 años: ∆ $872, p = 0,25), pero mayores en aquellos con más alta comorbilidad (baja ∆ $477, medio ∆ $480, alto ∆ $1059, p = 0,02).LIMITACIONES:Las bases de datos administrativas no capturan los factores del paciente que influyen en el cuidado luego del estado posoperatorio agudo (preferencia, disponibilidad del proveedor del cuidado).CONCLUSIONES:Los hospitales que logran una estancia hospitalaria más corta después de la cirugía, acumulan pagos más bajos por episodio, sin un incremento compensatorio del gasto en la atención pos-aguda, incluso entre pacientes de mayor edad y con mayor comorbilidad. Consulte Video Resumen en http://links.lww.com/DCR/B624. (Traducción-Dr Eduardo Londoño-Schimmer).
Collapse
Affiliation(s)
- Ana C. De Roo
- University of Michigan Center for Health Outcomes and Policy
- University of Michigan Department of Surgery
| | - Sarah P. Shubeck
- University of Michigan Center for Health Outcomes and Policy
- University of Michigan Department of Surgery
| | - Anne H. Cain-Nielsen
- University of Michigan Center for Health Outcomes and Policy
- University of Michigan Department of Surgery
| | - Edward C. Norton
- Department of Health Management and Policy, School of Public Health, University of Michigan
- National Bureau of Economic Research, Cambridge, MA USA
| | - Scott E. Regenbogen
- University of Michigan Center for Health Outcomes and Policy
- University of Michigan Department of Surgery
| |
Collapse
|
20
|
Kanters AE, Evilsizer SK, Regenbogen SE, Hendren S, Campbell DA, Dimick JB, Byrn JC. Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale. Dis Colon Rectum 2022; 65:444-451. [PMID: 34840292 DOI: 10.1097/dcr.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).
Collapse
Affiliation(s)
- Arielle E Kanters
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | | | - Scott E Regenbogen
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Samantha Hendren
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | | | - Justin B Dimick
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John C Byrn
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
21
|
Hrebinko K, Reitz KM, Gamboa A, Regenbogen SE, Hawkins AT, Abdel-Misih SRZ, Wise PE, Balch GC, Holder-Murray JM. Neighborhood-Level Socioeconomic Status and Survival in Rectal Cancer: An Analysis of the US Rectal Cancer Consortium (USRCC). J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Turgeon MK, Gamboa AC, Regenbogen SE, Holder-Murray J, Abdel-Misih SR, Hawkins AT, Silviera ML, Maithel SK, Balch GC. A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go? Dis Colon Rectum 2021; 64:1198-1211. [PMID: 34192711 PMCID: PMC8573719 DOI: 10.1097/dcr.0000000000002052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal level of pedicle ligation during proctectomy for rectal cancer, either at the origin of the inferior mesenteric artery or the superior rectal artery, is still debated. OBJECTIVE The objective was to determine whether superior rectal artery ligation portends equivalent technical or oncologic outcomes. DESIGN This was a retrospective analysis of a rectal cancer database (2007-2017). SETTINGS The study was conducted at 6 tertiary referral centers in the United States (Emory University, University of Michigan, University of Pittsburgh Medical Center, The Ohio State University Wexner Medical Center, Vanderbilt University Medical Center, and Washington University School of Medicine in St. Louis). PATIENTS Patients with primary, nonmetastatic rectal cancer who underwent low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES Anastomotic leak, lymph node harvest, locoregional recurrence-free survival, recurrence-free survival, and overall survival were measured. RESULTS Of 877 patients, 86% (n = 755) received an inferior mesenteric artery ligation, whereas 14% (n = 122) received a superior rectal artery ligation. A total of 12%, 33%, 24%, and 31% were pathologic stage 0, I, II, and III. Median follow-up was 31 months. Superior rectal artery ligation was associated with a similar anastomotic leak rate compared with inferior mesenteric artery ligation (9% vs 8%; p = 1.0). The median number of lymph nodes removed was identical (15 vs 15; p = 0.38). On multivariable analysis accounting for relevant clinicopathologic factors, superior rectal artery ligation was not associated with increased anastomotic leak rate, worse lymph node harvest, or worse locoregional recurrence-free survival, recurrence-free survival, or overall survival (all p values >0.1). LIMITATIONS This was a retrospective design. CONCLUSIONS Compared with inferior mesenteric artery ligation, superior rectal artery ligation is not associated with either worse technical or oncologic outcomes. Given the potential risks of inadequate blood flow to the proximal limb of the anastomosis and autonomic nerve injury, we advocate for increased use of superior rectal artery ligation. See Video Abstract at http://links.lww.com/DCR/B646. ESTUDIO DEL CONSORCIO DE CNCER DE RECTO DE ESTADOS UNIDOS DE LIGADURA BAJA DE LA ARTERIA MESENTRICA INFERIOR CONTRA LIGADURA ALTA DE LA ARTERIA MESENTRICA INFERIOR QU TAN ALTO DEBEMOS EXTENDERNOS ANTECEDENTES:el nivel óptimo de la ligadura del pedículo en la proctectomía para el cáncer de recto, ya sea en el origen de la arteria mesentérica inferior o en la arteria rectal superior aún no esta definido.OBJETIVO:El objetivo era determinar si la ligadura de la arteria rectal superior pronostica resultados técnicos u oncológicos similares.DISEÑO:Análisis retrospectivo de una base de datos de cáncer de recto (2007-2017).ESCENARIO:el estudio se realizó en seis centros de referencia de tercer nivel en los Estados Unidos (Universidad de Emory, Universidad de Michigan, Centro médico de la Universidad de Pittsburgh, Centro médico Wexner de la Universidad Estatal de Ohio, Centro médico de la Universidad de Vanderbilt y Escuela de Medicina de la Universidad de Washington en St. Louis).PACIENTES:Se incluyeron pacientes con cáncer de recto primario no metastásico que se sometieron a resección anterior baja o resección abdominoperineal.PRINCIPALES VARIABLES ANALIZADAS:Se midió la fuga anastomótica, los ganglios linfáticos recuperados, la sobrevida sin recidiva locorregional, la sobrevida sin recidiva y la sobrevida global.RESULTADOS:De 877 pacientes, en el 86% (n = 755) se realizó una ligadura de la arteria mesentérica inferior, y en el 14% (n = 122) se realizó una ligadura de la arteria rectal superior. El 12%, 33%, 24% y 31% estaban en estadio patológico 0, I, II y III respectivamente. La mediana de seguimiento fue de 31 meses. La ligadura de la arteria rectal superior se asoció con una tasa de fuga anastomótica similar a la ligadura de la arteria mesentérica inferior (9 vs 8%, p = 1,0). La mediana del número de ganglios linfáticos extirpados fue idéntica (15 contra 15, p = 0,38). En el análisis multivariado que tiene en cuenta los factores clínico-patológicos relevantes, la ligadura de la arteria rectal superior no se asoció con una mayor tasa de fuga anastomótica, una peor cosecha de ganglios linfáticos o una peor sobrevida libre de recurrencia locorregional, sobrevida libre de recurrencia o sobrevida global (todos p> 0,1).LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:En comparación con la ligadura de la arteria mesentérica inferior, la ligadura de la arteria rectal superior no se asocia a peores resultados técnicos ni oncológicos. Debido a los riesgos potenciales de un flujo sanguíneo inadecuado del muñon proximal de la anastomosis y la lesión de los nervios autonómicos, proponemos una mayor realización de la ligadura de la arteria rectal superior. Consulte Video Resumen en http://links.lww.com/DCR/B646.
Collapse
Affiliation(s)
- Michael K. Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Scott E. Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sherif R.Z. Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander T. Hawkins
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew L. Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Shishir K. Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Glen C. Balch
- Division of Colon and Rectal Surgery, Department of Surgery, Emory University, Atlanta, Georgia
| |
Collapse
|
23
|
Hanna DN, Gamboa AC, Balch GC, Regenbogen SE, Holder-Murray J, Abdel-Misih SRZ, Silviera ML, Feng MP, Stewart TG, Wang L, Hawkins AT. Perioperative Blood Transfusions Are Associated With Worse Overall Survival But Not Disease-Free Survival After Curative Rectal Cancer Resection: A Propensity Score-Matched Analysis. Dis Colon Rectum 2021; 64:946-954. [PMID: 34214054 PMCID: PMC8259769 DOI: 10.1097/dcr.0000000000002006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effects of blood transfusions on oncologic outcomes after surgery remain inconclusive. Thus, we examined the association between receiving a perioperative blood transfusion and oncologic outcomes in patients undergoing curative rectal cancer resection. OBJECTIVE The purpose of this study was to assess the association between receiving a perioperative blood transfusion with disease-free and overall survival in patients undergoing curative resection of clinical stage I to III rectal cancer. We hypothesized that blood transfusion is associated with worse disease-free and overall survival in this patient cohort. DESIGN This was a retrospective cohort study using a propensity score-matched analysis. SETTINGS The study involved 6 tertiary academic medical centers in the United States contributing to the United States Rectal Cancer Consortium. PATIENTS Patients who underwent curative resection for rectal cancer from 2010 to 2018 were included. MAIN OUTCOME MEASURES The primary outcome was disease-free survival. The secondary outcomes were overall survival, intensive care unit length of stay, hospital length of stay, surgical site infection, and readmission. RESULTS Of the 924 patients eligible for matching, 312 patients were matched, including 100 patients who received a transfusion and 212 who did not. In a propensity score-matched analysis, receiving a perioperative blood transfusion was not associated with worse 5-year disease-free survival (transfused, 78%; not transfused, 83%; p = 0.32) but was associated with worse 5-year overall survival (transfused 65% vs not transfused 86%; p < 0.001) and increased hospital length of stay (transfused, 9.9 d; not transfused, 7.6 d; p = 0.001). LIMITATIONS Despite propensity matching, confounding may remain. Propensity matching may limit the power to detect a difference in disease-free survival. CONCLUSIONS Receiving a perioperative blood transfusion is not associated with worse disease-free survival but is associated with worse overall survival. Such findings are important for clinicians and patients to understand when considering perioperative blood transfusions. See Video Abstract at http://links.lww.com/DCR/B531. LAS TRANSFUSIONES DE SANGRE PERIOPERATORIAS SE ASOCIAN CON UNA PEOR SOBREVIDA GLOBAL, PERO NO CON LA SOBREVIDA LIBRE DE ENFERMEDAD POSTERIOR A LA RESECCIN CURATIVA DEL CNCER DE RECTO UN PUNTAJE DE PROPENSIN POR ANLISIS DE CONCORDANCIA ANTECEDENTES:El impacto de las transfusiones de sangre en los resultados oncológicos posteriores a la cirugía no son concluyentes. Por lo anterior, estudiamos la asociación entre recibir una transfusión de sangre perioperatoria y los resultados oncológicos en pacientes llevados a resección curativa de cáncer de recto.OBJETIVO:El propósito de este estudio fue evaluar la asociación entre recibir una transfusión de sangre perioperatoria con la sobrevida libre de enfermedad y la sobrevida general en pacientes llevados a resección curativa de cáncer de recto en estadio clínico I-III. Nuestra hipótesis es que la transfusión de sangre se asocia con una peor sobrevida global y libre de enfermedad en esta cohorte de pacientes.DISEÑO:Es un estudio de cohorte retrospectivo que utilizó un puntaje de propensión por análisis de concordancia.AMBITO:El estudio se realizó en seis centros médicos académicos de tercer nivel en los Estados Unidos que contribuían al Consorcio de Cáncer de Recto de los Estados Unidos.PACIENTES:Se incluyeron pacientes que fueron llevados a resección curativa por cáncer de recto entre 2010 y 2018.PRINCIPALES VARIABLES EVALUADAS:El objeitvo principal fue la sobrevida libre de enfermedad. Los objetivos secundarios fueron la sobrevida global, el tiempo de estancia en la unidad de cuidados intensivos, el tiempo de la estancia hospitalaria, la infección del sitio quirúrgico y el reingreso.RESULTADOS:De los 924 pacientes elegibles para el emparejamiento, se emparejaron 312 pacientes, incluidos 100 pacientes que recibieron una transfusión y 212 que no. En el puntaje de propensión por análisis de concordancia, recibir una transfusión de sangre perioperatoria no se asoció con una peor sobrevida libre de enfermedad a 5 años (TRANSFUSIÓN 78%; NO TRANSFUSIÓN 83%; p = 0,32), pero se asoció con una peor sobrevida global a 5 años (TRANSFUSION 65% vs NO TRANSFUSION 86%; p <0,001) y aumento de la estancia hospitalaria (TRANSFUSIÓN 9,9 días; NO TRANSFUSION 7,6 días; p = 0,001).LIMITACIONES:A pesar de la concordancia de propensión, pueden existir desviaciones. El emparejamiento de propensión puede limitar el poder para detectar una diferencia en la sobrevida libre de enfermedad.CONCLUSIONES:Recibir una transfusión de sangre perioperatoria no se asocia con una peor sobrevida libre de enfermedad, pero sí con una peor sobrevida global. Es importante que los médicos y los pacientes comprendan estos hallazgos al considerar las transfusiones de sangre perioperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B531. (Traducción-Dr Lisbeth Alarcon-Bernes).
Collapse
Affiliation(s)
- David N Hanna
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, Tennessee
| | - Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Emory University Medical Center, Atlanta, Georgia
| | - Glen C Balch
- Division of Surgical Oncology, Department of Surgery, Emory University Medical Center, Atlanta, Georgia
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sherif R Z Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, Stony Brook University Hospital, Stony Brook, New York
| | - Matthew L Silviera
- Section of Colon and Rectal Surgery, Division of General Surgery, Washington University Hospital, St. Louis, Missouri
| | - Michael P Feng
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, Tennessee
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, Tennessee
| |
Collapse
|
24
|
Abstract
OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.
Collapse
Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John D Syrjamaki
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
25
|
Vu JV, George BC, Clark M, Rivard SJ, Regenbogen SE, Kwakye G. Readiness of Graduating General Surgery Residents to Perform Colorectal Procedures. J Surg Educ 2021; 78:1127-1135. [PMID: 33431299 PMCID: PMC8217079 DOI: 10.1016/j.jsurg.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/19/2020] [Accepted: 12/16/2020] [Indexed: 05/11/2023]
Abstract
OBJECTIVE In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency. DESIGN This was a retrospective observational cohort study. Attending ratings of residents' intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects. SETTING Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC). PATIENTS We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations. RESULTS A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure. CONCLUSIONS General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice.
Collapse
Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn.
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn
| | - Michael Clark
- Consulting for Statistics, Computing, and Analytics Research (CSCAR), University of Michigan, Ann Arbor, Michigan
| | | | | | - Gifty Kwakye
- Department of Surgery, University of Michigan, Ann Arbor, Michiagn
| |
Collapse
|
26
|
Sheetz KH, Norton EC, Dimick JB, Regenbogen SE. Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016. JAMA Surg 2021; 155:41-49. [PMID: 31617874 DOI: 10.1001/jamasurg.2019.4083] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. Objective To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. Design, Setting, and Participants This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. Exposures Receipt of robotic colectomy. Main Outcomes and Measures Incidence of postoperative medical and surgical complications and length of stay. Results A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). Conclusions and Relevance While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor.,Department of Health Management and Policy, University of Michigan, Ann Arbor.,Department of Economics, University of Michigan, Ann Arbor.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor.,Surgical Innovation Editor, JAMA Surgery
| | - Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor
| |
Collapse
|
27
|
Rivard SJ, Vitous CA, Cocroft S, Varlamos C, Duby A, Suwanabol PA, Regenbogen SE, Maguire LH, Kwakye G. Colorectal surgery patient perspectives on healthcare during the CoVID-19 pandemic. Am J Surg 2021; 222:759-765. [PMID: 33812662 PMCID: PMC7970406 DOI: 10.1016/j.amjsurg.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/25/2022]
Abstract
Background To focus on critical care needs of coronavirus patients, elective operations were postponed and selectively rescheduled. The effect of these measures on patients was unknown. We sought to understand patients’ perspectives regarding surgical care during the CoVID-19 pandemic to improve future responses. Methods We performed qualitative interviews with patients whose operations were postponed. Interviews explored patient responses to: 1) surgery postponement; 2) experience of surgery; 3) impacts of rescheduling/postponement on emotional/physical health; 4) identifying areas of improvement. Interviews were recorded, transcribed, coded, and analyzed through an integrated approach. Results Patient perspectives fell within the following domains: 1) reactions to surgery postponement/rescheduling; 2) experience of surgery during CoVID-19 pandemic; 3) reflections on communication; 4) patient trust in surgeons and healthcare. Conclusions We found no patient-reported barriers to rescheduling surgery. Several areas of care which could be improved (communication). There was an unexpected sense of trust in surgeons and the hospital.
Collapse
Affiliation(s)
| | | | | | | | - Ashley Duby
- Michigan Medicine, Department of Colorectal Surgery, USA
| | | | | | | | - Gifty Kwakye
- Michigan Medicine, Department of Colorectal Surgery, USA
| |
Collapse
|
28
|
Brescia AA, Vu JV, He C, Li J, Harrington SD, Thompson MP, Norton EC, Regenbogen SE, Syrjamaki JD, Prager RL, Likosky DS. Determinants of Value in Coronary Artery Bypass Grafting. Circ Cardiovasc Qual Outcomes 2020; 13:e006374. [PMID: 33176461 DOI: 10.1161/circoutcomes.119.006374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.
Collapse
Affiliation(s)
- Alexander A Brescia
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor
| | - Joceline V Vu
- Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
| | - Jun Li
- Department of Epidemiology (J.L.), School of Public Health, University of Michigan, Ann Arbor
| | | | - Michael P Thompson
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.).,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Department of Economics (E.C.N.), School of Public Health, University of Michigan, Ann Arbor.,Department of Health Management and Policy (E.C.N.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - John D Syrjamaki
- Department of Surgery (J.V.V., S.E.R., J.D.S.), School of Public Health, University of Michigan, Ann Arbor.,Henry Ford Macomb Hospital, Clinton Township, MI (S.D.H.). Michigan Value Collaborative, Ann Arbor (M.P.T., E.C.N., S.E.R., J.D.S.)
| | - Richard L Prager
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine (A.A.B., M.P.T., R.L.P., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy (A.A.B., M.P.T., E.C.N., S.E.R., D.S.L.), School of Public Health, University of Michigan, Ann Arbor.,Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor (C.H., M.P.T., R.L.P., D.S.L.)
| | | |
Collapse
|
29
|
Schuman AD, Spector ME, Jaffe CA, Shuman AG, Chinn SB, Regenbogen SE, Rosko AJ. Changes in Diagnosis of Thyroid Cancer Among Medicaid Beneficiaries Following Medicaid Expansion. JAMA Surg 2020; 155:1080-1081. [PMID: 32936239 DOI: 10.1001/jamasurg.2020.3290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Ari D Schuman
- University of Michigan Medical School, Ann Arbor.,Now with Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Craig A Jaffe
- Endocrine Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
30
|
Gamboa AC, Lee RM, Turgeon MK, Varlamos C, Regenbogen SE, Hrebinko KA, Holder-Murray J, Wiseman JT, Ejaz A, Feng MP, Hawkins AT, Bauer P, Silviera M, Maithel SK, Balch GC. Impact of Postoperative Complications on Oncologic Outcomes After Rectal Cancer Surgery: An Analysis of the US Rectal Cancer Consortium. Ann Surg Oncol 2020; 28:1712-1721. [PMID: 32968958 DOI: 10.1245/s10434-020-08976-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not well studied. METHODS The United States Rectal Cancer Consortium (2007-2017) was reviewed for primary rectal adenocarcinoma patients who underwent R0/R1 resection. Ninety-day POCs were categorized as major or minor and were grouped into infectious, cardiopulmonary, thromboembolic, renal, or intestinal dysmotility. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS Among 1136 patients, the POC rate was 46% (n = 527), with 63% classified as minor and 32% classified as major. Of all POCs, infectious complications comprised 20%, cardiopulmonary 3%, thromboembolic 5%, renal 9%, and intestinal dysmotility 19%. Compared with minor or no POCs, major POCs were associated with both worse RFS and worse OS (both p < 0.01). Compared with no POCs, a single POC was associated with worse RFS (p < 0.01), while multiple POCs were associated with worse OS (p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (p < 0.01), while cardiopulmonary and thromboembolic POCs were associated with worse OS (both p < 0.01). Renal POCs were associated with both worse RFS (p < 0.001) and worse OS (p = 0.01). After accounting for pathologic stage, neoadjuvant therapy, and final margin status, Multivariable analysis (MVA) demonstrated worse outcomes with cardiopulmonary, thromboembolic, and renal POCs for OS (cardiopulmonary: hazard ratio [HR] 3.6, p = 0.01; thromboembolic: HR 19.4, p < 0.01; renal: HR 2.4, p = 0.01), and renal and infectious POCs for RFS (infectious: HR 2.1, p < 0.01; renal: HR 3.2, p < 0.01). CONCLUSIONS Major complications after proctectomy for cancer are associated with decreased RFS and OS. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.
Collapse
Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Christopher Varlamos
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Katherine A Hrebinko
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jason T Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Michael P Feng
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip Bauer
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Silviera
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Glen C Balch
- Division of Colon and Rectal Surgery, Department of Surgery, Emory University, Atlanta, GA, USA.
| |
Collapse
|
31
|
Schuman AD, Syrjamaki JD, Norton EC, Hallstrom BR, Regenbogen SE. Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission. Surgery 2020; 169:341-346. [PMID: 32900495 DOI: 10.1016/j.surg.2020.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.
Collapse
Affiliation(s)
- Ari D Schuman
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX
| | - John D Syrjamaki
- Michigan Value Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Brian R Hallstrom
- Department of Orthopedic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| |
Collapse
|
32
|
Vu JV, Morris AM, Maguire LH, De Roo AC, Mukkamala A, Krauss JC, Regenbogen SE, Hendren S, Hardiman KM. Development and characteristics of a multidisciplinary colorectal cancer clinic. Am J Surg 2020; 221:826-831. [PMID: 32943178 DOI: 10.1016/j.amjsurg.2020.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/09/2020] [Accepted: 08/23/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Multidisciplinary cancer clinics deliver streamlined care and facilitate collaboration between specialties. We described patient volume and specialty service utilization, including surgery, of a multidisciplinary colorectal cancer clinic established at a tertiary care academic institution. METHODS We conducted a retrospective observational cohort study of adult patients with colorectal adenocarcinoma from 2012 to 2017. We performed a descriptive analysis of patient volume, percentage of rectal cancer patients, and the number of patients who saw and received surgery, chemotherapy, and radiation each year. RESULTS Over 5 years, 1711 patients were served at the multidisciplinary clinic. Patient volume increased 37%, from n = 228 (annualized) to n = 312. The percentage of rectal cancer patients increased from 29% in 2013 to 42% in 2017. The highest rate of utilization was for surgery; 792 (46%) patients had surgery at the multidisciplinary clinic institution, and 510 (30%) received chemotherapy there. Out of 635 rectal cancer patients, 114 (18%) received radiation there. CONCLUSIONS Over the five-year experience of a colorectal cancer-focused multidisciplinary clinic, overall patient volume increased by 37%. Over the study period, 63% of patients seen at the multidisciplinary clinic ultimately received at least one treatment modality at the clinic institution. Overall, the clinic's establishment resulted in the increased referral of complex patients.
Collapse
Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, United States.
| | - Arden M Morris
- S-SPIRE Center, Department of Surgery, Stanford University, United States
| | | | - Ana C De Roo
- Department of Surgery, University of Michigan, United States
| | | | - John C Krauss
- Division of Hematology/Oncology, Department of Internal Medicine, and Department of Learning Health Sciences, University of Michigan, United States
| | | | | | | |
Collapse
|
33
|
Schuman AD, Rosko AJ, Regenbogen SE, Chinn SB. Abstract A139: Volume and quality in head and neck cancer. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp19-a139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
INTRODUCTION: There has been significant interest in the relationship between hospital volume and outcomes across fields. However, the relationship between hospital volume, established quality metrics, and survival has not been established for head and neck cancer. We investigated the relationship between hospital volume and outcomes for head and neck cancer. METHODS: Using the National Cancer Database (2004-2016) data for upper aerodigestive tract squamous cell carcinoma, hospital volume deciles were determined. Univariate log-rank analysis was used to determine volume thresholds with significantly different overall survival (OS). The primary outcome measure was overall survival; other outcomes included complete neck dissection (≥18 lymph nodes removed), negative margins, and time to adjuvant radiation <6 weeks. Statistical analysis was performed using multivariable logistic regression and Cox proportional hazards models. RESULTS: Data from 270,047 patients and 1325 facilities were analyzed. Volume thresholds were: fewer than 22 cases per year (lowest volume), 22-38 cases per year (low-moderate volume), 38-122 cases per year (moderate volume), 122-160 cases per year (high-moderate volume), and 160 or more cases per year (highest volume). There was a positive trend in the adjusted odds ratio of complete neck dissection compared to moderate volume (OR range 0.53-1.52 from lowest to highest volume, p-for-trend<0.0001). There was also a positive trend in the odds of negative margins with increasing volume (OR range 0.85-1.45 lowest-highest, p-for-trend<0.0001). All centers had similar odds for time to post-operative radiation less than six weeks. Unadjusted five year OS was 52.3% in the lowest volume, 52.9% in the low-moderate volume, 54.4% in the moderate volume, 56.0% in the high-moderate volume, and 57.6% in the highest volume group. Cox proportional hazards models showed decreased survival in the lowest (HR 1.10, 99% CI 1.05-1.15, p<0.001) and low-moderate volume groups (HR 1.07, 99% CI 1.02-1.13, p<0.001) compared to moderate volume, and a protective effect in the higher volume groups (high-moderate volume HR 0.95, 99% CI 0.86-1.05, p=0.23; highest volume HR 0.94, 99% CI 0.87-1.01, p=0.04). The same trend was present when data were stratified by anatomical site. Among those who initially received non-surgical treatment, the lowest and low-moderate volume groups had significantly lower survival compared to moderate volume. However, the non-surgical high-moderate and highest volume groups were not significantly different from moderate volume. No groups significantly differed among patients who had surgery first. CONCLUSION: This study of a nationally representative database confirms the volume-outcome relationship for all head and neck cancer treatment and shows that surgical quality metrics are associated with hospital volume. When stratified by treatment type, volume was associated with overall survival for patients who had non-surgical treatment as their initial course.
Citation Format: Ari D Schuman, Andrew J Rosko, Scott E Regenbogen, Steven B Chinn. Volume and quality in head and neck cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A139.
Collapse
Affiliation(s)
- Ari D Schuman
- 1University of Michigan Medical School, Ann Arbor, MI, USA,
| | - Andrew J Rosko
- 2Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA,
| | | | - Steven B Chinn
- 2Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA,
| |
Collapse
|
34
|
Abstract
Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.
Collapse
Affiliation(s)
- Ana C. De Roo
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
35
|
Antunez AG, Kanters AE, Regenbogen SE. Evaluation of Access to Hospitals Most Ready to Achieve National Accreditation for Rectal Cancer Treatment. JAMA Surg 2020; 154:516-523. [PMID: 30785616 DOI: 10.1001/jamasurg.2018.5521] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities. Objectives To characterize hospitals' readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation. Design, Setting, and Participants A total of 1315 American College of Surgeons Commission on Cancer-accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018. Exposures Hospitals' readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards. Main Outcomes and Measures Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital. Results Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence. Conclusions and Relevance Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.
Collapse
Affiliation(s)
- Alexis G Antunez
- University of Michigan Medical School, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Arielle E Kanters
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
36
|
Gamboa AC, Lee RM, Turgeon MK, Varlamos C, Regenbogen SE, Hrebinko K, Holder-Murray J, Wiseman JT, Ejaz A, Feng MP, Hawkins A, Bauer P, Silviera M, Maithel SK, Balch GC. Impact of postoperative complications on oncologic outcomes after rectal cancer surgery: An analysis of the United States Rectal Cancer Consortium. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
41 Background: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not known. Methods: The US Rectal Cancer Consortium (2007-17) was reviewed for patients with primary rectal adenocarcinoma who underwent R0/R1 low anterior resection (LAR) or abdominoperineal resection (APR). 90-day POCs were categorized as major vs minor and grouped into infectious, cardiopulmonary (CP), thromboembolic (TE), renal, or intestinal dysmotility. Primary outcomes were 5-yr overall survival (OS) and recurrence-free survival (RFS). Results: Of 1136 pts, median age was 59 yrs (IQR 51-67), 61% were male (n = 693), median f/u was 31 mos (IQR 13-54). 70% underwent LAR (n = 799) and 30% APR (n = 337). Complication rate was 46% (n = 527), with 63% minor (n = 330) and 32% major (n = 170). Of all POCs, infectious complications comprised 20% (n = 105), cardiopulmonary 3% (n = 14), thromboembolic 5% (n = 25), renal 9% (n = 46) and intestinal dysmotility 19% (n = 100). When compared to minor or no POCs, major POCs were associated with both worse RFS (48 vs 63 vs 76% p < 0.01) and OS (64 vs 76 vs 80% p < 0.01). While a single POC was associated with worse RFS (61 vs 76% p < 0.01), multiple POCs were associated with worse OS (62% vs 79% p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (56 vs 76% p < 0.01) while CP and TE POCs were associated with worse OS (CP 40 vs 78% p < 0.01; TE 63 vs 78% p < 0.01). Postoperative renal dysfunction was associated with both worse RFS (26 vs 76%, p < 0.001) and OS (62 vs 78% p = 0.01). This persisted on MV analysis for OS when accounting for pathologic stage, receipt of neoadjuvant therapy, and final margin status (CP: HR 3.6 p = 0.01; TE: HR 19.4 p < 0.01; renal: HR 2.4 p = 0.01) and for RFS (infectious: HR 2.1 p < 0.01; renal: HR 3.2 p < 0.01). Conclusions: Major complications after proctectomy for cancer are associated with decreased recurrence-free and overall survival. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.
Collapse
Affiliation(s)
- Adriana C. Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Rachel M. Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Michael K. Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA
| | - Christopher Varlamos
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Scott E. Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Katherine Hrebinko
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jason T. Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Michael P. Feng
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Philip Bauer
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Matthew Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Glen C. Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University, Atlanta, GA
| |
Collapse
|
37
|
Regenbogen SE, Hawkins AT. Choosing Your First Job as a Surgeon and Health Services Researcher. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
38
|
De Roo AC, Vu JV, Regenbogen SE. Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy. J Surg Res 2019; 247:264-270. [PMID: 31706540 DOI: 10.1016/j.jss.2019.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/23/2019] [Accepted: 10/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Both enhanced recovery and anesthesia literature recommend multimodal perioperative analgesia to hasten recovery, prevent adverse events, and reduce opioid use after surgery. However, adherence to, and outcomes of, these recommendations are unknown. We sought to characterize use of multimodal analgesia and its association with length of stay after colectomy. MATERIALS AND METHODS Within a statewide, 72-hospital collaborative quality initiative, we evaluated postoperative analgesia regimens among adult patients undergoing elective colectomy between 2012 and 2015. We used logistic regression to identify factors associated with the use of multimodal analgesia and performed multivariable linear regression to evaluate its association with postoperative length of stay (LOS). RESULTS Among 7265 patients who underwent elective colectomy in the study period, 4660 (64.1%) received multimodal analgesia, 2405 (33.1%) received opioids alone, and 200 (2.8%) received one nonopioid pain medication alone. Multimodal analgesia was independently associated with shorter adjusted postoperative LOS, compared with opioids alone (5.60 d [95% CI 5.38-5.81] versus 5.96 d [5.68-6.24], P = 0.016). CONCLUSIONS Multimodal analgesia is associated with shorter LOS, yet one-third of patients statewide received opioids alone after colectomy. As surgeons increasingly focus on our role in the opioid crisis, particularly in postdischarge opioid prescribing, we must also focus on inpatient postoperative pain management to limit opioid exposure. At the hospital level, this may have the added benefit of decreasing LOS and hastening recovery.
Collapse
Affiliation(s)
- Ana C De Roo
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
| | - Joceline V Vu
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| |
Collapse
|
39
|
Provenzale D, Gupta S, Ahnen DJ, Markowitz AJ, Chung DC, Mayer RJ, Regenbogen SE, Blanco AM, Bray T, Cooper G, Early DS, Ford JM, Giardiello FM, Grady W, Hall MJ, Halverson AL, Hamilton SR, Hampel H, Klapman JB, Larson DW, Lazenby AJ, Llor X, Lynch PM, Mikkelson J, Ness RM, Slavin TP, Sugandha S, Weiss JM, Dwyer MA, Ogba N. NCCN Guidelines Insights: Colorectal Cancer Screening, Version 1.2018. J Natl Compr Canc Netw 2019; 16:939-949. [PMID: 30099370 DOI: 10.6004/jnccn.2018.0067] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The NCCN Guidelines for Colorectal Cancer (CRC) Screening outline various screening modalities as well as recommended screening strategies for individuals at average or increased-risk of developing sporadic CRC. The NCCN panel meets at least annually to review comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize 2018 updates to the NCCN Guidelines, with a primary focus on modalities used to screen individuals at average-risk for CRC.
Collapse
|
40
|
Regenbogen SE, Cain-Nielsen AH, Syrjamaki JD, Chen LM, Norton EC. Spending On Postacute Care After Hospitalization In Commercial Insurance And Medicare Around Age Sixty-Five. Health Aff (Millwood) 2019; 38:1505-1513. [PMID: 31479364 DOI: 10.1377/hlthaff.2018.05445] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postacute care costs are the primary determinant of episode spending around hospitalization. Yet there is little evidence that greater spending on postacute care improves readmission rates or functional recovery. Recent Medicare payment reform evaluations have suggested that postacute care spending is responsive to episode-based incentives. However, it remains unknown whether Medicare payment policies are responsible for excess postacute care spending, compared with that of commercial payers. In a population-based, statewide collaborative of Michigan hospitals, we used regression discontinuity design among propensity-weighted, age-adjusted cohorts to compare postacute care spending between patients with commercial insurance and those with Medicare around age sixty-five. Spending was 68-230 percent greater among fee-for-service Medicare beneficiaries than among similar commercially insured people across varied medical and surgical conditions. Despite greater spending, there were no differences in readmission rates. These findings suggest that postacute care utilization is highly sensitive to payer influence, and there may be an opportunity for additional savings in Medicare without sacrificing quality.
Collapse
Affiliation(s)
- Scott E Regenbogen
- Scott E. Regenbogen ( ) is an associate professor in the Department of Surgery and Center for Healthcare Outcomes and Policy, University of Michigan, in Ann Arbor
| | - Anne H Cain-Nielsen
- Anne H. Cain-Nielsen is a lead statistician in the Department of Surgery and Center for Healthcare Outcomes and Policy, University of Michigan
| | - John D Syrjamaki
- John D. Syrjamaki is associate program manager and a senior analyst in the Michigan Value Collaborative, in Ann Arbor
| | - Lena M Chen
- Lena M. Chen was an associate professor in the Department of Internal Medicine, University of Michigan
| | - Edward C Norton
- Edward C. Norton is a professor of health management and policy in the School of Public Health and a professor in the Department of Economics, University of Michigan
| |
Collapse
|
41
|
Gupta S, Provenzale D, Llor X, Halverson AL, Grady W, Chung DC, Haraldsdottir S, Markowitz AJ, Slavin Jr TP, Hampel H, Ness RM, Weiss JM, Ahnen DJ, Chen LM, Cooper G, Early DS, Giardiello FM, Hall MJ, Hamilton SR, Kanth P, Klapman JB, Lazenby AJ, Lynch PM, Mayer RJ, Mikkelson J, Peter S, Regenbogen SE, Dwyer MA, Ogba N. NCCN Guidelines Insights: Genetic/Familial High-Risk Assessment: Colorectal, Version 2.2019. J Natl Compr Canc Netw 2019; 17:1032-1041. [DOI: 10.6004/jnccn.2019.0044] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Identifying individuals with hereditary syndromes allows for improved cancer surveillance, risk reduction, and optimized management. Establishing criteria for assessment allows for the identification of individuals who are carriers of pathogenic genetic variants. The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the assessment and management of patients with high-risk colorectal cancer syndromes. These NCCN Guidelines Insights focus on criteria for the evaluation of Lynch syndrome and considerations for use of multigene testing in the assessment of hereditary colorectal cancer syndromes.
Collapse
Affiliation(s)
| | | | | | - Amy L. Halverson
- 4Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - William Grady
- 5Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | | | | | | | | | - Lee-may Chen
- 14UCSF Helen Diller Family Comprehensive Cancer Center
| | - Gregory Cooper
- 15Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Dayna S. Early
- 16Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
BACKGROUND With improving survival from colorectal cancer, there is a growing population of patients undergoing surveillance. National accreditation organizations have increasingly endorsed formal survivorship care planning. To effectively design patient-centered survivorship programs, an understanding of the prevalence of unmet psychosocial and symptomatic needs is required. OBJECTIVE The aim of this study is to understand the breadth of unmet needs among survivors of colorectal cancer. DESIGN This is a cross-sectional survey of patients undergoing surveillance after curative-intent therapy for colorectal cancer. SETTING This study was conducted June 2017 to January 2018 at an academic cancer center. PATIENTS There were 99 patients (58 with colon cancer, 41 with rectal cancer). MAIN OUTCOME MEASURES We measured patient-reported unmet needs by using a modification of the Cancer Survivor Unmet Needs instrument, within domains of emotional (stress, concerns about recurrence), relationship (fertility, interpersonal), logistical (need for accessible parking, case management), financial, treatment-related (neuropathy, bowel function), and surveillance-related needs. RESULTS The mean (±SD) age was 58 (±12), and the time from diagnosis was 34 (±18) months. Overall, 74% of patients reported at least one unmet need, 49% reported emotional needs, 24% relationship needs, 24% financial needs, 25% logistical needs, and 33% surveillance needs. Thirty-six (62%) patients with colon cancer and 37 (90%) patients with rectal cancer reported at least one ongoing problem (p = 0.002). Thirty-five (82%) patients with rectal cancer reported an unmet treatment-related need in comparison with 23 (40%) patients with colon cancer (p < 0.001). The median (interquartile range) number of ongoing needs were 1 (0-5) in patients with colon cancer and 4 (2-8) in patients with rectal cancer (p = 0.007). LIMITATIONS This study was limited by its small sample size and lack of generalizability, given the tertiary care setting. CONCLUSIONS The majority of colorectal cancer survivors reported unmet needs years after completion of curative-intent therapy. Patients with rectal cancer were significantly more likely to have unmet needs and may benefit from additional care during survivorship. Colorectal cancer survivorship programs should incorporate psychosocial and symptomatic care in addition to cancer surveillance. See Video Abstract at http://links.lww.com/DCR/A885.
Collapse
Affiliation(s)
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Samantha Hendren
- Division of Colorectal Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karin M Hardiman
- Division of Colorectal Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
43
|
Maguire LH, Geiger TM, Hardiman KM, Regenbogen SE, Hopkins MB, Muldoon RL, Ford MM, Hawkins AT. Surgical management of primary colonic lymphoma: Big data for a rare problem. J Surg Oncol 2019; 120:431-437. [PMID: 31187517 DOI: 10.1002/jso.25582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Primary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short-term outcomes, and five-year survival of patients undergoing nonpalliative surgery for PCL. METHODS We performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis. RESULTS We identified 2153 patients. Median patient age was 68. Diffuse large B-cell lymphoma accounted for 57% of tumors. 30- and 90-Day mortality were high (5.6% and 11.1%, respectively). Thirty-nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5-year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07-1.51; P = .01). CONCLUSIONS Patients undergoing surgery for PCL have high rates of margin positivity and high short-term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.
Collapse
Affiliation(s)
- Lillias H Maguire
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karin M Hardiman
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Benjamin Hopkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
44
|
Montgomery JR, Cain-Nielsen AH, Jenkins PC, Regenbogen SE, Hemmila MR. Prevalence and Payments for Traumatic Injury Compared With Common Acute Diseases by Episode of Care in Medicare Beneficiaries, 2008-2014. JAMA 2019; 321:2129-2131. [PMID: 31162560 PMCID: PMC6549280 DOI: 10.1001/jama.2019.1146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study uses Medicare Parts A and B claims data to compare hospitalizations for and spending on traumatic injury vs heart failure, pneumonia, stroke, and acute myocardial infarction in older adults between 2008 and 2014.
Collapse
|
45
|
Hardiman KM, Antunez AG, Kanters A, Schuman AD, Regenbogen SE. Clinical and pathological outcomes of induction chemotherapy before neoadjuvant radiotherapy in locally-advanced rectal cancer. J Surg Oncol 2019; 120:308-315. [PMID: 30993710 PMCID: PMC6635055 DOI: 10.1002/jso.25474] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/25/2019] [Indexed: 01/04/2023]
Abstract
Background and Objectives In North America, preoperative combination chemoradiation is the most commonly recommended and utilized approach to locally advanced rectal cancer. There is increasing interest in the use of induction chemotherapy (IC) before radiation and surgery in locally advanced rectal cancer. How widely IC is being used and whether it improves pathologic and oncologic outcomes is unknown. Methods We evaluated clinical stage 2 or 3 rectal cancer patients in the National Cancer Database between 2006 and 2015. We identified predictors of use of IC with multivariable logistic regression and compared survival between groups using Cox proportional hazards regression. Results Among 36 268 patients, IC use increased significantly over time from 5.5% in 2006 to 15.9% in 2015 (P < 0.001). Treatment at a hospital with a high IC rate was an independent predictor of receipt of IC. IC and traditional therapy yielded similar pathologic complete response rates (32.2% vs 30.5%,
P = 0.2) and similar 5‐year survival (82.4% vs 81.4%, 0.71). Conclusions Use of IC for locally advanced rectal cancer has increased significantly. The choice of IC seems to be driven more by institutional and regional practice patterns than clinical characteristics and is not associated with improved pathologic or oncologic outcomes.
Collapse
Affiliation(s)
- Karin M Hardiman
- Department of Surgery, Division of Colorectal Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | - Arielle Kanters
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Ari D Schuman
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Scott E Regenbogen
- Department of Surgery, Division of Colorectal Surgery, Michigan Medicine, Ann Arbor, Michigan.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| |
Collapse
|
46
|
Abstract
Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.
Collapse
|
47
|
Lin SC, Regenbogen SE, Hollingsworth JM, Funk R, Adler-Milstein J. Coordination of Care Around Surgery for Colon Cancer: Insights From National Patterns of Physician Encounters With Medicare Beneficiaries. J Oncol Pract 2018; 15:e110-e121. [PMID: 30550373 DOI: 10.1200/jop.18.00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.
Collapse
|
48
|
Kandagatla P, Nikolian VC, Matusko N, Mason S, Regenbogen SE, Hardiman KM. Patient-Reported Outcomes and Readmission after Ileostomy Creation in Older Adults. Am Surg 2018. [DOI: 10.1177/000313481808401141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs 81.4%, P < 0.01) and were more likely to have had surgery for cancer (22.9% vs 48.5%, P < 0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.
Collapse
Affiliation(s)
- Pridvi Kandagatla
- Department of Surgery, Henry Ford Health System/Wayne State University, Detroit, Michigan and
| | - Vahagn C. Nikolian
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shayna Mason
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Karin M. Hardiman
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
49
|
Kandagatla P, Nikolian VC, Matusko N, Mason S, Regenbogen SE, Hardiman KM. Patient-Reported Outcomes and Readmission after Ileostomy Creation in Older Adults. Am Surg 2018; 84:1814-1818. [PMID: 30747639 PMCID: PMC6613972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs 81.4%, P < 0.01) and were more likely to have had surgery for cancer (22.9% vs 48.5%, P < 0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.
Collapse
Affiliation(s)
- Pridvi Kandagatla
- Department of Surgery, Henry Ford Health System/Wayne State University, Detroit, MI 48201
| | - Vahagn C Nikolian
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Shayna Mason
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Scott E Regenbogen
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Karin M Hardiman
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| |
Collapse
|
50
|
Antunez AG, Kanters AE, Regenbogen SE. Predictors and Outcomes of Nodal Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|