Dane Klett

Racial/ethnic disparities in perioperative outcomes of major procedures: Results from the national surgical quality improvement program

Objective: To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Background: Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. Methods: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Results: Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Conclusions: Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Impact of smoking on perioperative outcomes after major surgery

BACKGROUND To investigate the impact of smoking on perioperative outcomes in patients undergoing one of the 16 major cardiovascular, orthopedic, or oncologic surgical procedures. METHODS We relied on the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2011). Procedure-specific multivariable logistic regression models assessed the association between smoking status (non, former, or current smokers) and risk of 30-day morbidity and mortality. RESULTS Overall, 141,802 patients were identified. A total of 12.5%, 14.6%, and 14.9% of non, former, and current smokers, respectively, experienced at least one complication (P < .001). In multivariable models, current smokers had higher odds of overall, pulmonary, wound, and septic/shock complications following most cardiovascular and oncologic surgeries compared with nonsmokers. The odds of experiencing such adverse outcomes were significantly lower in former smokers compared with current smokers, but still higher compared with nonsmokers. CONCLUSIONS The effect of smoking on perioperative outcomes is procedure dependent. Current and, even though mitigated, former smoking negatively influence outcomes following cardiovascular or oncologic procedures. Patients undergoing major procedures should be encouraged to discontinue tobacco smoking to achieve optimal procedural outcomes.

Sepsis after major cancer surgery.

BACKGROUND Cancer patients undergoing procedures are at increased risk of sepsis. We sought to evaluate the incidence of postoperative sepsis following major cancer surgeries (MCS), and to describe patient and/or hospital characteristics associated with heightened risk. METHODS Patients undergoing 1 of 8 MCS (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, and prostatectomy) within the Nationwide Inpatient Sample from 1999-2009 were identified (N = 2,502,710). Logistic regression models fitted with generalized estimating equations were used to estimate primary predictors (procedure, age, gender, race, insurance, Charlson Comorbidity Index, hospital volume, and hospital bed size) effect on sepsis and sepsis-associated mortality. Trends were evaluated with linear regression. RESULTS The incidence of MCS-related sepsis increased 2.0% per year (P < 0.001), whereas mortality remained stable. Odds of sepsis were highest among esophagectomy patients (odds ratio [OR]: 3.13, 2.76-3.55) and those with non-private insurance (OR: 1.33, 1.19-1.48 to OR: 1.89, 1.71-2.09). Odds of sepsis-related mortality were highest among lung resection patients (OR: 2.30, 2.00-2.64) and those experiencing perioperative liver failure (OR: 5.68, 4.30-7.52). Increasing hospital volume was associated with lower odds of sepsis and sepsis-related mortality (OR: 0.89, 0.84-0.95 to OR: 0.58, 0.53-0.62 and OR: 0.88, 0.77-0.99 to OR: 0.78, 0.67-0.93). CONCLUSIONS Between 1999 and 2009, the incidence of MCS-related sepsis increased; however, sepsis-related mortality remained stable. Significant disparities exist in patient and hospital characteristics associated with MCS-related sepsis. Hospital volume is an important modifiable risk factor associated with improved sepsis-related outcomes following MCS.

Role of insulin resistance in uric acid nephrolithiasis.

Metabolic syndrome has been implicated in the pathogenesis of uric acid stones. Although not completely understood, its role is supported by many studies demonstrating increased prevalence of uric acid stones in patients with metabolic syndrome and in particular insulin resistance, a major component of metabolic syndrome. This review presents epidemiologic studies demonstrating the association between metabolic syndrome and nephrolithiasis in general as well as the relationship between insulin resistance and uric acid stone formation, in particular. We also review studies that explore the pathophysiologic relationship between insulin resistance and uric acid nephrolithiasis.

Predicting pathological outcomes in patients undergoing robot‐assisted radical prostatectomy for high‐risk prostate cancer: a preoperative nomogram

To identify which high‐risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP).

The diminishing returns of robotic diffusion: complications after robot‐assisted radical prostatectomy

Jesse D. Sammon*, Firas Abdollah*, Dane E. Klett*, Daniel Pucheril*, Akshay Sood*, Quoc-Dien Trinh* and Mani Menon* *VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, and Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

PD38-01 HETEROGENEITY OF RECOMMENDED PSA SCREENING PRACTICES IN MEN AGED 55-69 IN THE UNITED STATES

PD38-01 HETEROGENEITY OF RECOMMENDED PSA SCREENING PRACTICES IN MEN AGED 55-69 IN THE UNITED STATES Jesse Sammon*, Firas Abdollah, Akshay Sood, Dane Klett, Daniel Pucheril, James Peabody, Mani Menon, Detroit, MI; Quoc-Dien Trinh, Boston, MA INTRODUCTION AND OBJECTIVES: Routine screening for prostate cancer using prostate specific antigen (PSA) is a widely contested practice and recommendations have recently changed dramatically in the United States. Nonetheless, nationwide patterns of PSA screening are largely unknown. We sought to elucidate contemporary PSA screening prevalence with a focus on heterogeneity between states among men recommended to consider PSA screening. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) is the world’s largest continuously conducted health survey. Male respondents 55-69 without a prior history of prostate cancer, or prostate problem, who reported PSA testing within the 12 months preceding the 2012 BRFSS survey were considered to have undergone screening. Complex samples logistic regression was used to estimate an individual’s predicted probability of undergoing PSA screening. RESULTS: In 2012, 57,015 unique responses from men 55-69 were captured by the BRFSS, a weighted estimate of 23.7 million men, of which, 9.5 million (40%) reported undergoing screening. Access to regular health care was most strongly associated with higher rates of screening (OR 3.02, CI 2.6-3.51). Additional predictors included income >75,000 (OR 2.15, CI 1.8-2.57), college education (OR 1.97, CI 1.67-2.32) health insurance (OR 1.87, CI 1.6-2.18) and age 65-69 (OR 1.8, CI 1.65-1.97). Rates of screening ranged from 27% in Hawaii to 48% in Missouri. CONCLUSIONS: The degree of heterogeneity in state-by-state PSA screening prevalence is a concerning and surprising study finding. This likely reflects both the considerable disagreement amongst experts and conflicting recommendations. These results also suggest that national guidelines have had limited effect on clinical practice among health providers. Table 1 Complex Samples Logistic Regression multivariable analysis of predictors of PSA screening in U.S. men age 55-69, BRFSS 2012 Characteristic OR (95% CI) Age Group 55-59 60-64 1.46 (1.35-1.59 65-69 1.8 (1.65-1.97) Race/Ethnicity White, Non-Hispanic Black, Non-Hispanic 1.19 (1.03-1.37) Asian, Non-Hispanic 0.4 (0.27-0.58) American Indian/Alaskan Native, Non-Hispanic 0.9 (0.65-1.25)

MP54-07 INCIDENCE, ADMISSION RATES AND ECONOMIC BURDEN OF PEDIATRIC EMERGENCY DEPARTMENT VISITS FOR URINARY TRACT INFECTION

INTRODUCTION AND OBJECTIVES: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as UTIs. We sought to assess the contemporary national-trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure. Further, we describe the predictors of hospitalization in these children. METHODS: Relying on the Nationwide Emergency Department Sample (2006-2011; age 17years) national trends in pediatric UTI ED visits, subsequent hospitalization, and total charges were examined using the estimated annual percent change (EAPC) methodology. Multivariable regression analyses were used to evaluate predictors of hospitalization following pediatric UTI ED visit. RESULTS: Of the 1,904,379 children presenting to the ED for management of UTI, 86,042 (4.7%) underwent admission. Female ED visits accounted for 90% of total visits and increased significantly (EAPC 3.28%; p1⁄40.003; fig. 1) over the study period. Male UTI incidence remained unchanged (p1⁄40.292). Overall hospital admission rates declined significantly (EAPC -5.59%; p1⁄40.021). Total charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p<0.001). This increase in expenditure was mainly driven by increased utilization of diagnostic CT scanning (EAPC 22.86%; p<0.001). Utilization of USG (p1⁄40.805), X-ray (p1⁄40.196) and non-imaging diagnostic modalities (urine analysis/ culture; p1⁄40.121) did not change over the study period. In multivariable analysis, the predictors of admission included younger age (p<0.001), male gender (OR1⁄42.05, p<0.001), higher comorbidity status (OR1⁄414.81, p<0.001), concurrent hydronephrosis (OR1⁄449.42, p<0.001) or stone disease (OR1⁄46.44, p<0.001). CONCLUSIONS: In children presenting to the ED with UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% were admitted for further management. Managing these high-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and hospitalizations, and reduce associated healthcare costs.