Jessica N. Cohan

Impact of Patient Age on Procedure Type for Ulcerative Colitis: A National Study.

BACKGROUND: Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results. OBJECTIVE: The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database. DESIGN: This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age. SETTINGS: This study was conducted in a university teaching hospital. PATIENTS: Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study. MAIN OUTCOME MEASURES: The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression. RESULTS: Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ⩽50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ⩽50 years of age (adjusted OR, 0.88 per year; p = 0.021). LIMITATIONS: We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity. CONCLUSIONS: Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

A Novel Decision Aid for Surgical Patients with Ulcerative Colitis: Results of a Pilot Study

BACKGROUND: Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons. OBJECTIVE: The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons. DESIGN: This was a prospective cohort study. SETTINGS: Patients and surgeons were enrolled from 3 colorectal surgery clinics. PATIENTS: Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected. INTERVENTIONS: Patients used a multilingual decision aid before meeting with the surgeon. MAIN OUTCOME MEASURES: We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid. RESULTS: Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients’ knowledge scores improved by 39% (p < 0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid. LIMITATIONS: The study included a small sample with no comparison group. CONCLUSIONS: A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.

Faecal incontinence in men referred for specialty care: a cross-sectional study

Little is known about men with faecal incontinence. We compared clinical findings and quality of life in a large cohort of men and women with faecal incontinence to guide its evaluation and treatment in men.

Differences in Symptom Severity and Quality of Life in Patients With Obstructive Defecation and Colonic Inertia.

BACKGROUND: Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life. OBJECTIVE: We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms. DESIGN: This study was a cross-sectional analysis of a prospective database. SETTING: Patients were enrolled at a single tertiary referral center. PATIENTS: We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument. MAIN OUTCOME MEASURES: The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey. RESULTS: Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p < 0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ⩽ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06). LIMITATIONS: The use of patient self-report instruments resulted in a proportion of patients with incomplete data. CONCLUSION: Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

Center the Patient in the Decision Process: A Tool to Inform the Consent and Share the Decision-Making in Patients With Rectal Cancer.

163 Diseases of the Colon & ReCtum Volume 59: 3 (2016) treatment for rectal cancer is complex and nuanced, requiring interdisciplinary treatment and consideration of individual patient factors. one decision that must be made in patients with midrectal to low rectal cancers is whether to proceed with a low anterior resection (laR) with or without a temporary ileostomy or abdominoperineal resection (aPR) and permanent colostomy. it is generally assumed that patients would prefer to avoid a permanent stoma if possible, and, in fact, avoiding a stoma has been proposed as a quality measure in rectal cancer treatment. however, because laR has disadvantages, such as the potential for bowel dysfunction and the need for an additional operation for ileostomy reversal, it is important that patients are actively engaged in the decision-making process. in fact, informed consent depends on it. shared decision-making has been proposed as a way to achieve true informed consent in diseases with more than 1 good treatment option, because it involves eliciting patient preferences and values and results in patientcentered treatment planning. Physicians generally agree that shared decision-making should be a core component of treatment planning; however, multiple studies show that shared decision-making is rarely achieved in clinical practice. this was shown specifically in surgeons treating patients with rectosigmoid cancer, where 93% reported that shared decision-making was important, but shared decision-making was not observed in any clinical encounters. in fact, aPR as a surgical option was discussed with less than a quarter of patients. Barriers included the perception that patients were not capable of participating, time constraints, and lack of access to decisional support services. to address these barriers to shared decision-making in this patient population, the authors of the accompanying article developed and tested a decision aid in 32 patients with midrectal to low rectal cancers who were candidates for laR and aPR. the decision aid was provided in printed article and online formats after meeting with the surgeon. Before using the decision aid, none of the participants preferred aPR to laR, although 13 patients (41%) were undecided. after using the decision aid, 2 patients (6%) preferred aPR, 19 patients (59%) preferred laR, and 11 (34%) remained undecided. the decision aid had a measurable impact on patient knowledge (scores increased by 38%) and decisional conflict (scores decreased by 24%). Patients also reported high levels of satisfaction with the decision aid, and most stated that they would recommend it to others. We applaud the authors for undertaking the development of such a complex and comprehensive patient education tool. it was designed in accordance with internationally accepted standards for decision aids. it provides patient-appropriate, evidence-based information and values clarification exercises. in this way, patients can understand the relevant information in the context of what makes sense for them as individuals. the other strength of this tool is that it is self-administered and therefore may be easy to integrate into a diverse array of clinical settings. the fact that there were few changes in procedure preference after using the decision aid is not, in fact, a limitation. Patients had improvements in decisional conflict and knowledge, which indicate that patients are better informed and confident in decision-making, regardless of procedure preference. although the decision aid is likely easily disseminated and has some evidence of efficacy, the study does have some limitations. first, it enrolled a small number of patients from a single clinic, so the generalizability of the results is limited. in addition, without a randomized design, the absolute impact of the decision aid on improved knowledge and decreased decisional conflict is not clear. finally, additional information about the knowledge questionnaire Center the Patient in the Decision Process: A Tool to Inform the Consent and Share the Decision-Making in Patients With Rectal Cancer

Impact of Surgery on Relationship Quality in Patients With Ulcerative Colitis and Their Partners.

BACKGROUND: Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known. OBJECTIVE: We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery. DESIGN: This was a prospective cohort in which we performed an exploratory analysis. SETTINGS: Patients were enrolled from an academic medical center. PATIENTS: Surgical patients with ulcerative colitis and their partners were invited to participate. INTERVENTIONS: Patients underwent proctocolectomy in 1, 2, or 3 stages. MAIN OUTCOME MEASURES: We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires. RESULTS: The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations. LIMITATIONS: This study included a small, highly selected sample. CONCLUSIONS: Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.

Simple interventions for complex complications: moving surgery forward.

Diseases of the Colon & ReCtum Volume 57: 1 (2014) Colorectal surgery continues to evolve as new technologies and medicines allow us to treat patients more effectively and improve their quality of life. at the same time, these advances are associated with new complications that can often be just as difficult to manage as the original condition itself, and we are practicing medicine in a period of increased demand for improved quality of care. one particular focus is reducing hospitalacquired infections, including ventilator-associated pneumonias and central-line, surgical-site, and Clostridium difficile infections, as well as catheter-associated urinary tract infections (Cautis). in the current issue of Diseases of the Colon & Rectum, nagle et al used a strikingly simple set of interventions to reduce Cautis in colorectal surgery. this is an important subject because Cautis are both costly and common, and therefore, have become one of the most heavily targeted morbidities in this new era of accountable care. Cautis were identified as a “never event” in the Deficit Reduction act of 2005 and are no longer reimbursed by medicare under the 2008 Pay for Performance program. multiple agencies have developed quality improvement programs linked to financial incentives and disincentives. each program comes with varying levels of cost and complexity of implementation. medical centers are tasked with determining which quality measures they will choose to track and how. there are a broad variety of data collection systems to choose from, each focusing on a different combination of clinical process and outcome measures. measures of patient satisfaction, quality of life, and variation in cost add another dimension of complexity. Yet, despite years of study, new technologies, and legislation, Cautis remain a substantial burden to the us healthcare system. they account for 40% of nosocomial infections with an associated cost of

Outcomes after ileoanal pouch surgery in frail and older adults

340 to

Uncomplicated Sigmoid Diverticulitis

370 million per year. Colorectal surgeons in particular have a responsibility to become involved in decreasing urinary tract infections (utis) in patients given that 70% of hospitalacquired utis occur in surgical patients, and colorectal patients are disproportionately affected. the electronic medical record (emR) is a powerful tool for tracking and improving performance related to these quality measures. it is a relatively recent technology that was meant to improve quality and efficiency while decreasing the cost of delivering health care. Because it is still in its early implementation phases and its use is largely fragmented, we have yet to see the full effect of its benefits. however, we know that the emR has a great capacity to improve healthcare delivery. a systematic review found that by using automatic reminder and warning systems, emRs increased the practice of guideline-based care, disease surveillance, and safety, although results from institutions differ because of variation in implementation. an important step will be to study how to best use these types of tools in the emR so that they can be standardized and their benefit fully realized. length of catheterization predicts the development of Cauti in surgical patients, and current Cauti rates may be related to physicians being unaware that their patients have a urinary catheter. therefore, there is a movement toward using the emR to improve outcomes. Reminder systems associated with the emR have been shown to be particularly effective at reducing the incidence of Cauti. a meta-analysis of 14 studies showed that length of catheterization was reduced by a mean of 2.6 days and the rate of Cauti was decreased by half when warnings generated by the emR were implemented. the hard stop, as compared with a reminder, was shown to be particularly effective in this study and resulted in a 61% decrease in Cauti events over the study period compared with controls, which is consistent with the current literature. sterility has also become a critical component of the campaign to reduce hospital-acquired infections. the success of the campaign to reduce blood stream infections associated with central lines was directly related to the implementation of strict sterile technique during insertion. in addition, a significant proportion of surgical site infections are caused by skin flora, suggesting that improvements in sterility in the operating room could decrease surgical site infection rates. however, this has been difficult to study given the pre-existing standard for sterile technique in operating rooms. Given that Cautis are often caused by organisms found on the skin or perineal region, sterility should be a consideration in their prevention as well. however, this has not been studied in surgical patients. this may be Simple Interventions for Complex Complications: Moving Surgery Forward