Catherine E. Sharoky

Association of Surgical Practice Patterns and Clinical Outcomes With Surgeon Training in University- or Nonuniversity-Based Residency Program

Importance Important metrics of residency program success include the clinical outcomes achieved by trainees after transitioning to practice. Previous studies have shown significant differences in reported training experiences of general surgery residents at nonuniversity-based residency (NUBR) and university-based residency (UBR) programs. Objective To examine the differences in practice patterns and clinical outcomes between surgeons trained in NUBR and those trained in UBR programs. Design, Setting, and Participants This observational cohort study linked the claims data of patients who underwent general surgery procedures in New York, Florida, and Pennsylvania between January 1, 2012, and December 31, 2013, to demographic and training information of surgeons in the American Medical Association Physician Masterfile. Patients who underwent a qualifying procedure were grouped by surgeon. Practice pattern analysis was performed on 3638 surgeons and 1 237 621 patients, representing 214 residency programs. Clinical outcomes analysis was performed on 2301 surgeons and 312 584 patients. Data analysis was conducted from February 1, 2017, to July 31, 2017. Exposures NUBR or UBR training status. Main Outcomes and Measures Inpatient mortality, complications, and prolonged length of stay. Results No significant differences were observed between the NUBR-trained surgeons and UBR-trained surgeons in age (mean, 53.3 years vs 53.7 years), sex (female, 18.2% vs 16.9%), or years of clinical experience (mean, 16.5 years vs 16.5 years). Overall, NUBR-trained surgeons compared with UBR-trained surgeons performed more procedures (median interquartile range [IQR], 328 [93-661] vs 164 [49-444]; Pu2009<u2009.001) and performed a greater proportion of procedures in the outpatient setting (risk difference, 6.5; 95% CI, 6.4 to 6.7; Pu2009<u2009.001). Before matching, the mean proportion of patients with documented inpatient mortality was lower for NUBR-trained surgeons than for UBR-trained surgeons (risk difference, −1.01; 95% CI, −1.41 to −0.61; Pu2009<u2009.001). The mean proportion of patients with complications (risk difference, −3.17%; 95% CI, −4.21 to −2.13; Pu2009<u2009.001) and prolonged length of stay (risk difference, −1.89%; 95% CI, −2.79 to −0.98; Pu2009<u2009.001) was also lower for NUBR-trained surgeons. After matching, no significant differences in patient mortality, complications, and prolonged length of stay were found between NUBR- and UBR-trained surgeons. Conclusions and Relevance Surgeons trained in NUBR and UBR programs have distinct practice patterns. After controlling for patient, procedure, and hospital factors, no differences were observed in the inpatient outcomes between the 2 groups.

Prophylactic Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Does Not Increase Postoperative Morbidity

BackgroundProphylactic cholecystectomy at time of surgery for small bowel neuroendocrine tumor (SBNET) has been advocated, as these patients often go on to require somatostatin analogue therapy, which is known to increase risk of cholestasis and associated complications. Little is known regarding patterns of adoption of this practice or its associated morbidity.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database (2008–2014) was queried to identify patients who underwent SBNET resection. The risk differences of morbidity and mortality associated with performance of concurrent cholecystectomy were determined with multivariable adjustment for confounders.ResultsAmong 1300 patients who underwent SBNET resection, 144 (11.1%) underwent concurrent cholecystectomy. Median age of patients undergoing cholecystectomy was 62xa0years [interquartile range (IQR) 52–69xa0years], and 75 were male. They more commonly had disseminated cancer (36.1 vs. 11.6%, pxa0<xa00.001) or SBNET located in duodenum (10.4 vs. 4.9%, pxa0=xa00.045) without difference in other baseline characteristics. Operative time was significantly longer in the cholecystectomy group (median 172 vs. 123xa0min, pxa0<xa00.001). Rate of postoperative morbidity was not significantly different between cholecystectomy and no-cholecystectomy groups (11.8 vs. 11.1%, pxa0=xa00.79). After adjustment for confounding, the risk difference of morbidity attributable to cholecystectomy was +xa00.4% [95% confidence interval (CI) −xa04.9 to +xa05.6%]. Mortality within 30xa0days was not significantly different between cholecystectomy and no-cholecystectomy groups (1.4 vs. 0.6%, pxa0=xa00.29).ConclusionsConcurrent cholecystectomy at time of resection of SBNET is not associated with higher morbidity or mortality yet is performed in a minority of patients. Prospective study can identify which patients may derive benefit from this approach.

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study

Abstract Background: Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade. Methods: We used Pennsylvania Trauma Outcomes Study registry data from 2006–15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS. Results: Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40–2.55), African American race (OR 1.71 95%CI 1.34–2.18), and Asian race (OR 2.25, 95%CI 1.22–4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures. Conclusions: PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.

Hospitalization in the Year Preceding Major Oncologic Surgery Increases Risk for Adverse Postoperative Events

BackgroundHospitalization is associated with negative clinical effects that last beyond discharge. This study aimed to determine whether hospitalization in the year before major oncologic surgery is associated with adverse outcomes.MethodsPatients 18xa0years of age or older with stomach, pancreas, colon, or rectal cancer who underwent resection in California and New York (2008–2010) were included in the study. Patients with hospitalization in the year prior to oncologic resection (HYPOR) were identified. Multivariable logistic regression was used to examine the association of prior hospitalization with the following adverse outcomes: inpatient mortality, complications, complex discharge needs, and 90-day readmission. Subset analysis by cancer type was performed. Outcomes based on temporal proximity of hospitalization to month of surgical admission were evaluated.ResultsOf 32,292 patients, 16.3% (nxa0=xa05276) were HYPOR. Patients with prior hospitalization were older (median age, 72 vs 67xa0years; pxa0<xa00.001) and had more comorbidities (Elixhauser Index ≥3, 86.5 vs 75.3%; pxa0<xa00.001). In the multivariable analysis, HYPOR was associated with complications (odds ratio [OR], 1.28; 95% confidence interval [CI] 1.18–1.40), complex discharge (OR, 1.44; 95% CI 1.34–1.55), and 90-day readmission (OR, 1.45; 95% CI 1.35–1.56). The interval from HYPOR to resection was not associated with adverse outcomes.ConclusionsPatients hospitalized in the year before oncologic resection are at increased risk for postoperative adverse events. Recent hospitalization is a risk factor that is easily ascertainable and should be used by clinicians to identify patients who may need additional support around the time of oncologic resection.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery

BACKGROUNDnHypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures.nnnMATERIALS AND METHODSnThe 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5xa0g/dL [normal], 3.49-3.0xa0g/dL [mild], 2.99-2.5xa0g/dL [moderate], and <2.5xa0g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined.nnnRESULTSnA total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM.nnnCONCLUSIONSnMore than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.

An Instrumental Variables Design for the Effect of Emergency General Surgery

Abstract Confounding by indication is a critical challenge in evaluating the effectiveness of surgical interventions using observational data. The threat from confounding is compounded when using medical claims data due to the inability to measure risk severity. If there are unobserved differences in risk severity across patients, treatment effect estimates based on methods such a multivariate regression may be biased in an unknown direction. A research design based on instrumental variables offers one possibility for reducing bias from unobserved confounding compared to risk adjustment with observed confounders. This study investigates whether a physician’s preference for operative care is a valid instrumental variable for studying the effect of emergency surgery. We review the plausibility of the necessary causal assumptions in an investigation of the effect of emergency general surgery (EGS) on inpatient mortality among adults using medical claims data from Florida, Pennsylvania, and New York in 2012–2013. In a departure from the extant literature, we use the framework of stochastic monotonicity which is more plausible in the context of a preference-based instrument. We compare estimates from an instrumental variables design to estimates from a design based on matching that assumes all confounders are observed. Estimates from matching show lower mortality rates for patients that undergo EGS compared to estimates based in the instrumental variables framework. Results vary substantially by condition type. We also present sensitivity analyses as well as bounds for the population level average treatment effect. We conclude with a discussion of the interpretation of estimates from both approaches.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission

Background: Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30‐day mortality, postoperative duration of stay >30 days, and complications. Methods: Patients >18 years in The American College of Surgeons National Surgical Quality Improvement Program (2011–2014) who had 1 of 7 emergency operations between hospital day 3–18 were included. Patients with operations >95th percentile after admission (>18 days; n = 581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes. Results: Of 10,093 patients with emergency operations, most were elderly (median 66 years old [interquartile ratio: 53–77 years]), white, and female. Postoperative 30‐day mortality was 12.6% (n = 1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30 days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11–18 compared with day 3–6 was associated with death (odds ratio 1.6 [1.3–2.0]), postoperative duration of stay >30 days (odds ratio 2.0 [1.6–2.6]), and complications (odds ratio 1.5 [1.3–1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8–10.4]). Conclusion: Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.

Disparities in operative outcomes in patients with comorbid mental illness

Background. Patients with mental health disorders have worse medical outcomes and experience excess mortality compared with those without a mental health comorbidity. This study aimed to evaluate the relationship between mental health comorbidities and surgical outcomes. Methods. This retrospective cohort study used the National Inpatient Sample (2009–2011) to select patients who underwent one of the 4 most common general surgery procedures (cholecystectomy and common duct exploration, colorectal resection, excision and lysis of peritoneal adhesions, and appendectomy). Patients with a concurrent mental health diagnosis were identified. Multivariable logistic regression examined outcomes, including prolonged length of stay, in‐hospital mortality, and postoperative complications. Results. Of the 579,851 patients included, 38,702 patients (6.7%) had a mental health diagnosis. Mood disorders were most prevalent (58.7%), followed by substance abuse (23.8%). After adjustment for confounders, including sex, race, number of comorbidities, admission status, open operations, insurance, and income quartile, we found that having a mental health diagnosis conferred a 40% greater odds of including prolonged length of stay (OR 1.41, P < .001) and increased odds of any complication (OR 1.18, P < .001). Odds of death were slightly less in the mental health diagnosis cohort. Conclusions. General surgery patients with comorbid mental disease experience a greater incidence of postoperative complications and longer hospitalizations. Recognizing these disparate outcomes is the first step in understanding how to optimize care for this frequently marginalized population.