Casey A. Boyd

Overuse of Preoperative Cardiac Stress Testing in Medicare Patients Undergoing Elective Noncardiac Surgery

Objective:To determine the frequency and predictors of cardiac stress testing before elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation. Background:The American College of Cardiology/American Heart Association guidelines indicate that patients without class I (American Heart Association high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery. Methods:We used 5% Medicare inpatient claims data (1996–2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urological, or orthopedic procedures (N = 211,202). We examined the use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N = 74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing. Results:Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N = 2803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (P < 0.0001). A multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female sex [odds ratio (OR) 1.11; 95% CI: 1.02–1.21], presence of other comorbidities [OR 1.22; 95% confidence interval (CI): 1.09–1.35], high-risk procedure (OR 2.42; 95% CI: 2.04–2.89), and larger hospital size (OR 1.17; 95% CI: 1.03–1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR 1.24; 95% CI: 1.05–1.45) were also more likely to receive stress tests. Conclusions:In a 5% sample of Medicare claims data, 2803 patients underwent preoperative stress testing without any indications. When these results were applied to the entire Medicare population, we estimated that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications has increased significantly over time.

The effect of depression on stage at diagnosis, treatment, and survival in pancreatic adenocarcinoma

BACKGROUND Depression has been associated with delayed presentation, inadequate treatment, and poor survival in patients with cancer. METHODS Using Surveillance, Epidemiology and End Results and Medicare linked data (1992-2005), we identified patients with pancreatic adenocarcinoma (N = 23,745). International classification of diseases, 9th edition, clinical modification codes were used to evaluate depression during the 3 to 27 months before the diagnosis of cancer. The effect of depression on receipt of therapy and survival was evaluated in univariate and multivariate models. RESULTS Of patients with pancreatic cancer in our study, 7.9% had a diagnosis of depression (N = 1,868). Depression was associated with increased age, female sex, white race, single or widowed status, and advanced stage disease (P < .0001). In an adjusted model, patients with locoregional disease and depression had 37% lower odds of undergoing surgical resection (odds ratio, 0.63; 95% confidence interval, 0.52-0.76). In patients with locoregional disease, depression was associated with lower 2-year survival (hazard ratio, 1.20; 95% confidence interval, 1.09-1.32). After adjusting for surgical resection, this association was attenuated (hazard ratio, 1.14; 95% confidence interval, 1.04-1.26). In patients who underwent surgical resection, depression was a significant predictor of survival (hazard ratio, 1.34; 95% confidence interval, 1.04-1.73). Patients with distant disease and depression had 21% lower odds of receiving chemotherapy (odds ratio, 0.79; 95% confidence interval, 0.70-0.90). After adjusting for chemotherapy for distant disease, depression was no longer a significant predictor of survival (hazard ratio, 1.03; 95% confidence interval, 0.97-1.09). CONCLUSION The decreased survival associated with depression appears to be mediated by a lower likelihood of appropriate treatment in depressed patients. Accurate recognition and treatment of pancreatic cancer patients with depression may improve treatment rates and survival.

Overuse of CT in Patients with Complicated Gallstone Disease

BACKGROUND When compared with ultrasound, CT scans are more expensive, have substantial radiation exposure and lower sensitivity, specificity, positive, and negative predictive values for patients with gallstone disease. STUDY DESIGN We reviewed data on patients emergently admitted with complicated gallstone disease between January 2005 and May 2010. Use of CT and ultrasound imaging on admission was described. Multivariate logistic regression was used to evaluate factors predicting receipt of CT. RESULTS Five hundred and sixty-two consecutive patients presented emergently with complicated gallstone disease. Mean age was 45 years. Seventy-two percent of patients were female, 46% were white, and 41% were Hispanic. Seventy-two percent of patients had an ultrasound during the initial evaluation and 41% had a CT. Both studies were performed in 25% of patients (n = 141), 16% (n = 93) had CT only, and 47% (n = 259) had ultrasound only. CT was performed first in 67% of those who underwent both studies. Evening imaging (7 PM-7 AM, odds ratio [OR] = 4.44; 95% CI, 2.88-6.85), increased age (OR = 1.14 per 5-year increase; 95% CI, 1.07-1.21), leukocytosis (OR = 1.67; 95% CI, 1.10-2.53), and hyperamylasemia (OR = 2.02; 95% CI, 1.16-3.51) predicted use of CT. CONCLUSIONS Our study demonstrates the overuse of CT in evaluation of complicated gallstone disease. Evening imaging was the biggest predictor of CT use, suggesting that CT is performed not to clarify the diagnosis, but rather a surrogate for the indicated study. Surgeons and emergency physicians should be trained to perform right upper quadrant ultrasound to avoid unnecessary studies in the appropriate clinical setting.

Gallstone pancreatitis in older patients: Are we operating enough?

BACKGROUND The recommended therapy for mild gallstone pancreatitis is cholecystectomy on initial hospitalization. METHODS Using a 5% national Medicare sample (1996-2005), we evaluated adherence to current recommendations for gallstone pancreatitis (cholecystectomy rates on initial hospitalization and the use of endoscopic retrograde cholangiopancreatography [ERCP]/sphincterotomy). We evaluated predictors of cholecystectomy, gallstone-related readmissions, and 2-year mortality. RESULTS Adherence to current guidelines was low. Only 57% of 8,452 Medicare beneficiaries presenting to an acute care hospital with a first episode of mild gallstone pancreatitis underwent cholecystectomy on initial hospitalization. Of the patients who did not undergo cholecystectomy, 55% were never evaluated by a surgeon. Likewise, only 28% of patients who did not undergo cholecystectomy had a sphincterotomy. The 2-year readmission rates were higher among patients who did not undergo cholecystectomy (44% vs 4%; P < .0001), and 33% of these patients required cholecystectomy after discharge. In the no cholecystectomy group, ERCP prevented readmissions (hazard ratio, 0.53; 95% confidence interval, 0.47-0.61) and when readmissions occurred they were less likely to be for gallstone pancreatitis in patients who had an ERCP (27.8% vs 53.2%; P < .0001). On multivariate analysis, patients who were older, black, admitted to a nonsurgical service, lived in certain US regions, and had specific comorbidities were less likely to undergo cholecystectomy. CONCLUSION Adherence to current recommendations for the management of mild gallstone pancreatitis is low in older patients. Our data suggest that >40% of patients who did not undergo cholecystectomy would have benefited from early definitive therapy. Implementation of policies to increase adherence to guidelines would prevent gallstone-related morbidity and mortality in older patients.

Cost-effectiveness analysis of cholecystectomy during Roux-en-Y gastric bypass for morbid obesity

BACKGROUND Controversy exists regarding the use of concurrent cholecystectomy during Roux-en-Y gastric bypass performed for morbid obesity. METHODS A decision model was developed to evaluate the cost-effectiveness of current strategies: routine concurrent cholecystectomy, Roux-en-Y gastric bypass alone with or without postoperative ursodiol therapy, and selective cholecystectomy based on preoperative findings on ultrasonography. Probabilities were obtained from a comprehensive literature review. Costs and hospital days were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. One-way sensitivity analyses were performed. RESULTS The least expensive strategy was to perform RYGB alone without preoperative ultrasonography, with an average cost (over RYGB costs) of

Pancreatic Neoplasms in Pregnancy: Diagnosis, Complications, and Management

537 per patient. RYGB with concurrent cholecystectomy had a cost of

Unexpected Gynecologic Findings During Abdominal Surgery

631. Selective cholecystectomy based on preoperative ultrasonography was dominated by the other 2 strategies. Our model was most sensitive to the probability of developing gallbladder-related symptoms after RYGB alone. When the incidence of gallbladder-related symptoms was <4.6%, the dominant strategy was to perform a RYGB alone without preoperative ultrasonography. For values >6.9%, performing concurrent cholecystectomy at the time of the RYGB was superior to other strategies. When ursodiol was used, the least expensive strategy was to perform a concurrent cholecystectomy during RYGB. CONCLUSION The main factor determining the most cost-effective strategy is the incidence of gallbladder-related symptoms after RYGB. The use of ursodiol was associated with an increase in cost that does not justify its use after RYGB. Finally, selective cholecystectomy based on preoperative ultrasonography was dominated by the other strategies in the scenarios evaluated.

Overuse of Computed Tomography in Patients With Complicated Gallstone Disease

BackgroundNeoplasms of the pancreas during pregnancy are rare, with less than 25 cases of benign and malignant tumors reported in the literature.MethodsWe present three unique cases of pancreatic tumors occurring during pregnancy—one mucinous cystic neoplasm and two adenocarcinomas. We review the literature regarding pancreatic neoplasms during pregnancy and discuss the diagnosis, complications, and management of these tumors.ResultsMagnetic resonance imaging and ultrasound are the imaging modalities of choice in pregnancy. In patients with benign or premalignant tumors, surgical resection may be postponed until the second trimester. In symptomatic patients, or if there is a concern for intrauterine growth restriction, urgent surgical intervention should be performed. With malignant tumors, the benefit of delaying surgery must be balanced with the risk of maternal disease progression. Termination of the pregnancy should be discussed when a malignant tumor is diagnosed during the first trimester. Pancreatic tumors diagnosed during the third trimester may be resected after delivery. If malignant, early delivery of the fetus and subsequent maternal operation can be considered at appropriate fetal maturity.ConclusionWhen these tumors occur during pregnancy, they present a diagnostic and treatment dilemma, with variation in treatment based on gestational age and patient preference.

415 Patients with Adenosquamous Carcinoma of the Pancreas: A Population-Based Analysis of Prognosis and Survival

As general surgeons, we are often asked to evaluate acute abdominal pain. The differential diagnosis of abdominal pain is broad, and includes disorders of the gastrointestinal, urogenital, gynecologic, vascular, and pulmonary systems. Abdominal pain may be caused by infectious, inflammatory, anatomic, or neoplastic processes. The management of abdominal pain varies by etiology, and accurate diagnosis is key to avoiding inappropriate treatment. Specifically, abdominal pain in women presents an additional diagnostic dilemma. Disease processes found exclusively in women should be kept in mind when presented with a female patient with abdominal pain. In women of childbearing age, pregnancy and conditions causing acute abdominal pain only during pregnancy must be considered, and all women of childbearing age should have either a serum or urine β-human chorionic gonadotropin (HCG) level as part of the initial diagnostic workup. In a pregnant patient, the differential diagnosis is modified, and should include disorders specific to pregnancy. Gynecological disorders that specifically occur during pregnancy include ectopic pregnancy, threatened abortion, retroverted gravid uterus, spontaneous uterine rupture, and chorioamnionitis. In addition, there are disease processes that are not specific to, but frequently occur during pregnancy. These may include torsion of a normal ovary or ovarian cyst or mass, pyelonephritis, pelvic inflammatory disease, acute salpingitis, tubo-ovarian abscess, pyosalpinx, torsion or degeneration of a uterine fibroid, and hemorrhage or rupture of an ovarian cyst. Accurate recognition and treatment of the disease is integral in order to achieve the best outcome for both the mother and developing fetus. Finally, both pregnant and non-pregnant women experience typical general surgical problems, including acute cholecystitis, appendicitis, diverticulitis, bowel obstruction, and perforated ulcers. However, the treatment of these diseases may be modified during pregnancy. For example, acute cholecystitis is often managed non-operatively during the first and third trimesters of pregnancy, while surgical intervention is recommended in the second trimester. For other conditions, surgical intervention is recommended regardless of gestational age. For instance, given the risk of rupture with acute appendicitis during pregnancy, appendectomy is indicated regardless of gestational age. Acute appendicitis is the most common surgical emergency,1 and is also the most common cause of non-gynecological pelvic pain.2 Many gynecologic conditions can mimic acute appendicitis, making the diagnosis unclear. Pelvic pathology may also be confused with other intraabdominal disease processes. For example, diverticulitis may be mimicked by an ovarian cyst or tubo-ovarian abscess; pelvic inflammatory disease may be misdiagnosed as generalized peritonitis secondary to a perforated viscera; acute cholecystitis may be confused with ovarian, appendiceal, or uterine pathology in the right upper quadrant during pregnancy. Despite vast improvements in imaging over the last three decades, at times it may still be difficult to differentiate between gynecologic and nongynecologic causes of abdominal pain prior to laparotomy or laparoscopy. The first step in the evaluation of a woman with abdominal or pelvic pain should include a complete history and physical examination. History-taking should include the history of present illness and characterization of the abdominal pain, medical and surgical history (in particular, previous pelvic surgeries, including hysterectomy and oophorectomy), sexual and contraceptive histories, and last menstrual period. Physical exam should include abdominal, pelvic, and bimanual examinations. In particular, careful questioning about and inspection for vaginal discharge or bleeding on pelvic exam should be performed. Physicians are commonly taught that cervical motion tenderness is pathognomonic for pelvic inflammatory disease (PID). However, any disease process causing pelvic inflammation may result in cervical motion tenderness, and other diagnoses should not be excluded based on the presence of this sign.3 In women of childbearing age who have not had a hysterectomy, including those on contraceptives, those with an intrauterine device in place, and those with partners who have had a vasectomy, a pregnancy test via urine β-HCG should be performed. When the diagnosis is unclear and a gynecological cause is included in the differential diagnosis, a gynecology consult should be considered. In all pregnant patients with abdominal pain, a gynecology consult is strongly recommended to optimize fetal and maternal outcomes. If diagnostic uncertainty exists, laparoscopy with direct visualization of the pelvis and abdominal cavity is often the best modality for investigating pelvic pain in women. The goal of this chapter is to discuss common obstetric and gynecologic abnormalities which the general surgeon may encounter in the evaluation of the female patient with acute abdominal pain. We will differentiate those gynecologic conditions that are specific to pregnancy and those that are less common during pregnancy. As many of these conditions can be diagnosed preoperatively, the diagnostic workup for each will be discussed. In cases where the diagnosis is unclear or recognized intraoperatively, we will discuss the surgical management of each entity. At times, pelvic pathology is incidentally found during elective abdominal procedures for other diagnoses; in this case, the appropriate intraoperative management of incidentally recognized obstetrical/gynecological pathology will be discussed.

End-of-life care in Medicare beneficiaries dying with pancreatic cancer.

BACKGROUND—When compared to ultrasound, computed tomography scans (CT) are more expensive, have significant radiation exposure, and have lower sensitivity, specificity, positive, and negative predictive values for patients with gallstone disease. METHODS—We reviewed data on patients emergently admitted with complicated gallstone disease between 1/2005 and 5/2010. The use of CT and ultrasound imaging on admission was described. Multivariate logistic regression was used to evaluate factors predicting receipt of CT. RESULTS—562 consecutive patients presented emergently with complicated gallstone disease. The mean age was 45 years. 72% of patients were female, 46% were white, and 41% were Hispanic. 72% of patients had an ultrasound during the initial evaluation and 41% had a CT. Both studies were performed in 25% of patients (n=141), while 16% (n=93) had CT only and 47% (n=259) had ultrasound only. CT was performed first in 67% of those who underwent both studies. Evening imaging (7pm–7am; OR=4.44, 95% CI 2.88–6.85), increased age (OR=1.14 per 5-year increase, 95% CI 1.07–1.21), leukocytosis (OR=1.67, 95% CI 1.10–2.53), and hyperamylasemia (OR=2.02, 95% CI 1.16–3.51) predicted receipt of CT. CONCLUSIONS—Our study demonstrates the overuse of CT in the evaluation of complicated gallstone disease. Evening imaging was the biggest predictor of CT use, suggesting that CT is performed not to clarify the diagnosis, but rather a surrogate for the indicated study. Surgeons and emergency physicians should be trained to perform right upper quadrant ultrasounds to avoid receipt of unnecessary studies in the appropriate clinical setting.