Jay S. Lee

Analytic morphomics, core muscle size, and surgical outcomes.

Objective:Assess the relationship between lean core muscle size, measured on preoperative cross-sectional images, and surgical outcomes. Background:Novel measures of preoperative risk are needed. Analytic morphomic analysis of cross-sectional diagnostic images may elucidate vast amounts of patient-specific data, which are never assessed by clinicians. Methods:The study population included all patients within the Michigan Surgical Quality Collaborative database with a computerized tomography(CT) scan before major, elective general or vascular surgery (N = 1453). The lean core muscle size was calculated using analytic morphomic techniques. The primary outcome measure was survival, whereas secondary outcomes included surgical complications and costs. Covariate adjusted outcomes were assessed using Kaplan-Meier analysis, multivariate cox regression, multivariate logistic regression, and generalized estimating equation methods. Results:The mean follow-up was 2.3 years and 214 patients died during the observation period. The covariate-adjusted hazard ratio for lean core muscle area was 1.45 (P = 0.028), indicating that mortality increased by 45% per 1000 mm2 decrease in lean core muscle area. When stratified into tertiles of core muscle size, the 1-year survival was 87% versus 95% for the smallest versus largest tertile, whereas the 3-year survival was 75% versus 91%, respectively (P < 0.003 for both comparisons). The estimated average risk of complications significantly differed and was 20.9%, 15.0%, and 12.3% in the lower, middle, and upper tertiles of lean core muscle area, respectively. Covariate-adjusted cost increased significantly by an estimated

Surgical Site Infection and Analytic Morphometric Assessment of Body Composition in Patients Undergoing Midline Laparotomy

10,110 per 1000 mm2 decrease in core muscle size (P = 0.003). Conclusions:Core muscle size is an independent and potentially important preoperative risk factor. The techniques used to assess preoperative CT scans, namely analytic morphomics, may represent a novel approach to better understanding patient risk.

Abdominal aortic calcification and surgical outcomes in patients with no known cardiovascular risk factors.

BACKGROUND Obesity is a known risk factor for surgical site infection (SSI). Our hypothesis is that morphometric measures of midline subcutaneous fat will be associated with increased risk of SSI and will predict SSI better than conventional measures of obesity. STUDY DESIGN We identified 655 patients who underwent midline laparotomy (2006 to 2009) using the Michigan Surgical Quality Collaborative database. Using novel, semiautomated analytic morphometric techniques, the thickness of subcutaneous fat along the linea alba was measured between T12 and L4. To adjust for variations in patient size, subcutaneous fat was normalized to the distance between the vertebrae and anterior skin. Logistic regression analyses were used to identify factors independently associated with the incidence of SSI. RESULTS Overall, SSIs were observed in 12.5% (n = 82) of the population. Logistic regression revealed that patients with increased subcutaneous fat had significantly greater odds of developing a superficial incisional SSI (odds ratio [OR] = 1.76 per 10% increase, 95% CI 1.10 to 2.83, p = 0.019). Smoking, steroid use, American Society of Anesthesiologists (ASA) classification, and incision-to-close operative time were also significant independent risk factors for superficial incisional SSI. When comparing subcutaneous fat and body mass index (BMI) as the only model variables, subcutaneous fat significantly improved model predictions of superficial incisional SSI (area under the receiver operating characteristic curve [AUC] 0.60, p = 0.023); BMI did not (AUC 0.52, p = 0.73). CONCLUSIONS Abdominal subcutaneous fat is an independent predictor of superficial incisional SSI after midline laparotomy. Novel morphometric measures may improve risk stratification and help elucidate the pathophysiology of surgical complications.

Postoperative Opioid Prescribing and the Pain Scores on Hospital Consumer Assessment of Healthcare Providers and Systems Survey

Introduction:In the setting of cardiovascular (CV) risk evaluation before major elective surgery, current risk assessment tools are relatively poor for discriminating among patients. For example, patients with clinical CV risk factors can be clearly identified; but among those without appreciated clinical CV risk, there may be a subset with stigmata of CV disease noted during the preoperative radiographic evaluation. Our study evaluated the relationship between abdominal aortic (AA) calcification measured on preoperative computed tomography (CT) imaging and surgical complications in patients undergoing general elective and vascular surgery. We hypothesized that patients with no known CV risk factors but significant aortic calcification on preoperative imaging will have inferior surgical outcomes. Methods:The study group included 1180 patients from the Michigan Surgical Quality Collaborative (MSQC) database who underwent major general or vascular elective surgery between 2006 and 2009 and who had a CT scan of the abdomen specifically for preoperative planning. AA calcification was measured using novel analytic morphomic techniques and reported as a percentage of the total wall area containing calcification. Patients were divided into cohorts by clinical CV risk and extent of AA calcification. Univariate analysis was used to compare postoperative morbidity between patient cohorts. Multivariate logistic regression analysis was used to compare continuous AA calcification with overall morbidity in patients with no clinical CV risk factors. Results:AA calcification was strongly skewed to the right (53.5% had no AA calcification) and was significantly correlated with age (&rgr; = 0.43, P < 0.001). Unadjusted univariate analysis of morbidity showed no significant differences in complication rates between patients in the clinical CV risk and significant AA calcification (no known CV risk factor) categories. The clinical CV risk (P < 0.001) and significant AA calcification without CV risk factors (P = 0.009) populations both had significantly more infectious and overall complications than patients with no AA calcification and no clinical CV risk. Multivariate logistic regression confirmed that AA calcification was a significant predictor of morbidity in patients with no clinical CV risk factors (odds ratio = 1.35, P = 0.017). Discussion:This study suggests that AA calcification may be related to progression of CV disease and surgical outcomes. A better understanding of the complex interaction of patient physiology with overall ability to recover from major surgery, using novel approaches such as analytic morphomics, has great potential to improve risk stratification and patient selection.

Persistent Opioid Use Among Pediatric Patients After Surgery

In 2012, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to capture key elements of patient satisfaction, including pain management. HCAHPS surveys are administered to patients 48 hours to 6 weeks after discharge, and scores are used to determine hospital payments.1 However, patients complete surveys during a time when many are filling postdischarge opioid prescriptions. This timing has raised concerns that HCAHPS measures could inadvertently incentivize clinicians to overprescribe opioids after discharge to ensure satisfactory ratings and reimbursement.2,3 Citing these concerns, CMS announced it will remove pain management from its determination of hospital payments beginning in 2018, even though little is known regarding the potential correlation between HCAHPS scores and postdischarge opioid prescribing.3 We sought to evaluate the association between HCAHPS pain measures and postoperative opioid prescribing in surgical patients, which accounts for nearly 40% of surgical prescriptions.

The Michigan Surgical Home and Optimization Program is a scalable model to improve care and reduce costs

Through a national sample of adolescents and young adults, we investigated the incidence of persistent opioid use after common pediatric surgeries. BACKGROUND: Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients. METHODS: We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure. RESULTS: Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%–15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00–1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01–5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill. CONCLUSIONS: Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.

Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework

Background: The Michigan Surgical Home and Optimization Program is a structured, home‐based, preoperative training program targeting physical, nutritional, and psychological guidance. The purpose of this study was to determine if participation in this program was associated with reduced hospital duration of stay and health care costs. Methods: We conducted a retrospective, single center, cohort study evaluating patients who participated in the Michigan Surgical Home and Optimization Program and subsequently underwent major elective general and thoracic operative care between June 2014 and December 2015. Propensity score matching was used to match program participants to a control group who underwent operative care prior to program implementation. Primary outcome measures were hospital duration of stay and payer costs. Multivariate regression was used to determine the covariate‐adjusted effect of program participation. Results: A total of 641 patients participated in the program; 82% were actively engaged in the program, recording physical activity at least 3 times per week for the majority of the program; 182 patients were propensity matched to patients who underwent operative care prior to program implementation. Multivariate analysis demonstrated that participation in the Michigan Surgical Home and Optimization Program was associated with a 31% reduction in hospital duration of stay (P < .001) and 28% lower total costs (P < .001) after adjusting for covariates. Conclusion: A home‐based, preoperative training program decreased hospital duration of stay, lowered costs of care, and was well accepted by patients. Further efforts will focus on broader implementation and linking participation to postoperative complications and rigorous patient‐reported outcomes.

Specialist Physicians’ Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors

BackgroundExcessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior.MethodsPrior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing.ResultsTwenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines).ConclusionsKey determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.

Morphometric Age and Surgical Risk

Objective:Our objective was to determine specialist physicians’ attitudes and practices regarding disclosure of pre-referral errors. Summary Background Data:Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. Methods:We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. Results:Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the professions reputation, and to patient–physician relationships. Conclusions:Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.