Carla F. Justiniano

Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective.

Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the “intensity” of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.

Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes

BACKGROUND: It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection. OBJECTIVE: The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers. DESIGN: This was a population-based study. SETTINGS: The National Cancer Database was queried for patients with rectal cancer. PATIENTS: Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included. MAIN OUTCOME MEASURES: The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival. RESULTS: A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group. LIMITATIONS: We lacked data regarding patient and physician decision making and surgeon-specific factors. CONCLUSIONS: Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at http://links.lww.com/DCR/A446.

Long-term Deleterious Impact of Surgeon Care Fragmentation After Colorectal Surgery on Survival: Continuity of Care Continues to Count

BACKGROUND: Surgical care fragmentation at readmission impacts short-term outcomes. However, the long-term impact of surgical care fragmentation is unknown. OBJECTIVE: The purpose was to evaluate the impact of surgical care fragmentation, encompassing both surgeon and hospital care, at readmission after colorectal surgery on 1-year survival. DESIGN: This was a retrospective cohort study. SETTING: The study included patients undergoing colorectal resection in New York State from 2004 to 2014. PATIENTS: Included were 20,016 patients undergoing colorectal resection who were readmitted within 30 days of discharge and categorized by source-of-care fragmentation. Each readmission was classified by the source of fragmentation: readmission to the index hospital and managed by another provider, readmission to another hospital by the index surgeon, and readmission to another hospital by another provider. Patients readmitted to the index hospital and managed by the index surgeon served as controls. MAIN OUTCOME MEASURES: One-year overall survival and 1-year colorectal cancer-specific survival were the outcomes measured. RESULTS: After propensity adjustment, surgeon care fragmentation was independently associated with decreased survival. In comparison with patients without surgical care fragmentation (patients readmitted to the index hospital and managed by the index surgeon), patients readmitted to the index hospital and managed by another provider had over a 2-fold risk (HR, 2.33; 95% CI, 2.10–2.60) and patients readmitted to another hospital by another provider had almost a 2-fold risk (HR, 1.91; 95% CI, 1.63–2.25) of 1-year mortality. Among 9545 patients with a colorectal cancer diagnosis, surgical care fragmentation was once again associated with decreased survival with patients readmitted to the index hospital and managed by another provider having a HR of 2.12 (95% CI, 1.76–2.56) and patients readmitted to another hospital by another provider having a HR of 1.57 (95% CI, 1.17–2.11) compared with patients readmitted to the index hospital and managed by the index surgeon. LIMITATIONS: Limitations include possible miscoding of data, retrospective design, and selection bias. CONCLUSIONS: After accounting for patient, index hospital, index surgeon, and readmission factors, there is a significant 2-fold decrease in survival associated with surgeon care fragmentation regardless of hospital continuity. See Video Abstract at http://links.lww.com/DCR/A431.

Population-based study of outcomes following an initial acute diverticular abscess: Outcomes after an initial acute diverticular abscess

Studies examining long‐term outcomes following resolution of an acute diverticular abscess have been limited to single‐institution chart reviews. This observational cohort study compared outcomes between elective colectomy and non‐operative management following admission for an initial acute diverticular abscess.

Nationwide Heterogeneity in Hospital-Specific Probabilities of Rectal Cancer Understaging and Its Effects on Outcomes

BackgroundRectal cancer patients who are understaged may not be offered the highest quality treatment modalities, which are based on an accurate assessment of preoperative staging. The objective of this study was to evaluate heterogeneity in the probability of being understaged at Commission on Cancer hospitals in the United States and to assess how this variation affects outcomes.MethodsThe 2006–2013 National Cancer Data Base was queried for clinical stage I–III rectal cancer patients who underwent resection. The initial clinical stage was compared with the “gold standard,” pathological stage. A Bayesian multilevel logistic regression model was used to characterize variation in hospital-specific probabilities of being understaged (clinical stage < pathologic stage). Separate analyses assessed the impact of being understaged on positive circumferential resection margins (CRM), receipt of adjuvant chemotherapy, and 5-year overall survival.ResultsAmong 12,684 patients who did not receive neoadjuvant chemoradiation and treated at 1176 hospitals, 3044 (24%) were understaged. After patient level risk-adjustment, a 24-fold difference in the probability of being understaged was observed between hospitals (range 3–72%, median = 15%). Understaging was independently associated with positive CRM [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.39, 1.92] and receipt of adjuvant chemotherapy (OR 14.22, 95% CI 13.55, 18.88). Despite an increase in the delivery of systemic therapy after surgical resection, understaging was associated with worse survival (hazard ratio = 1.61, 95% CI 1.48, 1.95).ConclusionsDeficiencies in high-quality rectal cancer management begin with incorrect clinical staging. The risk-adjusted probability of understaging varied widely between hospitals. This institutional failure to provide optimal oncological management at the start of care was associated with worse long-term survival.

Patterns and Yearly Time Trends in the Use of Radiation Therapy During the Last 30 Days of Life Among Patients With Metastatic Rectal Cancer in the United States From 2004 to 2012

Purpose: Although radiation therapy (RT) can provide palliative benefits for patients with metastatic rectal cancer, its role at the end of life remains unclear. The objective of this study was to assess sociodemographic and clinical factors associated with the use of RT during the last 30 days of life and to evaluate yearly time trends in RT utilization among stage IV patients with rectal cancer. Methods: The 2004 to 2012 National Cancer DataBase was queried for patients with metastatic rectal cancer who had a documented death during follow-up. A Bayesian multilevel logistic regression model was used to characterize predictive factors and yearly time trends associated with RT use in the last 30 days of life. Results: Among 10 431 patients who met inclusion criteria, 345 (3%) received RT during the last 30 days of life. Factors independently associated with RT use included older age, female sex, African American race, nonprivate insurance, higher comorbidity burden, and worse grade. The odds of RT use at the end of life decreased by 28% between 2007 and 2009 (odds ratio [OR] = 0.72, 95% Credible Interval (CI) = 0.58-0.93), but then increased by 16% from 2010 to 2012 (OR = 1.16, 95% CI = 1.13-1.33), relative to 2004 to 2006. Conclusion: Radiation therapy use for patients with metastatic rectal cancer is beneficial, and efforts to optimize its appropriate use are important. Several factors associated with RT use during the last 30 days of life included disparities in sociodemographic and clinical subgroups. Research is needed to understand the underlying causes of these inequalities and the role of predictive models in clinical decision-making.