Jillian K. Smith

Underutilization of therapy for hepatocellular carcinoma in the medicare population

The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and the care of these patients remains highly specialized and complex. Multiple treatment options are available for HCC but their use and effectiveness remain unknown.

Impact of center volume on outcomes of increased-risk liver transplants.

The use of high‐risk donor livers, which is reflective of the gross national shortage of organs available for transplantation, has gained momentum. Despite the demand, many marginal livers are discarded annually. We evaluated the impact of center volume on survival outcomes associated with liver transplantation using high–donor risk index (DRI) allografts. We queried the Scientific Registry of Transplant Recipients database for deceased donor liver transplants (n = 31,576) performed between 2002 and 2008 for patients who were 18 years old or older, and we excluded partial and multiple liver transplants. A high‐DRI cohort (n = 15,668), which was composed of patients receiving grafts with DRIs > 1.90, was analyzed separately. Transplant centers (n = 102) were categorized into tertiles by their annual procedure volumes: high‐volume centers (HVCs; 78‐215 cases per year), medium‐volume centers (MVCs; 49‐77 cases per year), and low‐volume centers (LVCs; 5‐48 cases per year). The endpoints were allograft survival and recipient survival. In comparison with their lower volume counterparts, HVCs used donors with higher mean DRIs (2.07 for HVCs, 2.01 for MVCs, and 1.91 for LVCs), more donors who were 60 years old or older (18.02% for HVCs, 16.85% for MVCs, and 12.39% for LVCs), more donors who died after a stroke (46.52% for HVCs, 43.71% for MVCs, and 43.36% for LVCs), and more donation after cardiac death organs (5.04% for HVCs, 4.45% for MVCs, and 3.51% for LVCs, all P values < 0.001). Multivariate risk‐adjusted frailty models showed that increased procedure volume at a transplant center led to decreased risks of allograft failure [hazard ratio (HR) = 0.93, 95% confidence interval (CI) = 0.89‐0.98, P = 0.002] and recipient death (HR = 0.90, 95% CI = 0.83‐0.97, P = 0.004) for high‐DRI liver transplants. In conclusion, HVCs more frequently used higher DRI livers and achieved better risk‐adjusted allograft and recipient survival. A greater understanding of the outcomes of transplantation with high‐DRI livers may improve their utilization, the postoperative outcomes, and future allocation practices. Liver Transpl 17:1191–1199, 2011.

Outcomes following resection of pancreatic cancer

Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long‐term survival after resection. J. Surg. Oncol. 2013;107:97–103.

Complications After Pancreatectomy for Neuroendocrine Tumors: A National Study

BACKGROUND Although resection of pancreatic neuroendocrine tumors (PNETs) has a demonstrated survival advantage, further evaluation of the overall morbidity of these procedures is needed. Our objective was to examine a composite outcome of major postoperative complications, including in-hospital mortality. MATERIALS AND METHODS The Nationwide Inpatient Sample (NIS), 1998-2006, was used to identify all patients with a diagnosis of PNET who had undergone pancreatectomy. Candidate predictors consisted of patient and hospital characteristics. Univariate analyses included chi(2) tests. Multivariate analyses were performed with logistic regression to determine which predictors were independently associated with the composite outcome. RESULTS A total of 463 (2274 nationally weighted) patients were identified. Overall composite postoperative complication rate was 29.6%. The majority of complications involved infections (11.1%), digestive complications (8.8%), or pulmonary compromise (7.3%). In-hospital mortality rate was 1.7%. High Charlson comorbidity score, procedure type of Whipple or total pancreatectomy, and urban hospital location were all associated with significantly increased complication rate. Logistic regression analysis demonstrated: Charlson score of > or =3 versus score of 0 (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 2.1-8.3), surgery type of Whipple or total pancreatectomy versus partial pancreatectomy (adjusted OR 2.7, 95% CI 1.8-4.1), and hospital location of urban versus rural (adjusted OR 4.5, 95% CI 3.0-6.9). CONCLUSIONS While in-hospital mortality rates are low for surgical resection of PNETs, there is a considerable overall postoperative complication rate associated with these procedures. Careful patient and surgery selection may be the key to a surgical treatment approach for PNETs that may optimize outcomes.

Colectomy performance improvement within NSQIP 2005-2008

BACKGROUND All open and laparoscopic colectomies submitted to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were evaluated for trends and improvements in operative outcomes. METHODS 48,247 adults (≥18 y old) underwent colectomy in ACS NSQIP, as grouped by surgical approach (laparoscopic versus open), urgency (emergent versus elective), and operative year (2005 to 2008). Primary outcomes measured morbidity, mortality, perioperative, and postoperative complications. RESULTS The proportion of laparoscopic colectomies performed increased annually (26.3% to 34.0%), while open colectomies decreased (73.7% to 66.0%; P < 0.0001). Most emergent colectomies were open procedures (93.5%) representing 24.3% of all open cases. The overall risk-adjusted morbidity and mortality for all colectomy procedures did not show a statistically significant change over time, however, morbidity and mortality increased among open colectomies (r = 0.03) and decreased among laparoscopic colectomies (r = -0.04; P < 0.0001). Postoperative complications reduced significantly including superficial surgical site infections (9.17% to 8.20%, P < 0.004), pneumonia (4.60% to 3.97%, P < 0.0001), and sepsis (4.72%, 2005; 6.81%, 2006; 5.62%, 2007; 5.09%, 2008; P < 0.0002). Perioperative improvements included operative time (169.2 to 160.0 min), PRBC transfusions (0.27 to 0.25 units) and length of stay (10.5 to 6.61 d; P < 0.0001). CONCLUSION It appears that laparoscopic colectomies are growing in popularity over open colectomies, but the need for emergent open procedures remains unchanged. Across all colectomies, however, key postoperative and perioperative complications have improved over time. Participation in ACS NSQIP demonstrates quality improvement and may encourage greater enrollment.

Perioperative mortality after pancreatectomy: A risk score to aid decision-making

BACKGROUND Undergoing a pancreatectomy obligates the patient to risks and benefits. For complex operations such as pancreatectomy, the objective assessment of baseline risks may be useful in decision-making. We developed an integer-based risk score estimating in-hospital mortality after pancreatectomy, incorporating institution-specific mortality rates to enhance its use. METHODS Pancreatic resections were identified from the Nationwide Inpatient Sample (1998-2006), and categorized as proximal, distal, or nonspecified by the International Classification of Diseases, 9th edition. Logistic regression and bootstrap methods were used to estimate in-hospital mortality using demographics, diagnosis, comorbidities (Charlson index), procedure, and hospital volume; 80% of this cohort was selected randomly to create the score and 20% was used for validation. Score assignments were subsequently individually fitted to risk distributions around specific mortality rates. RESULTS Sixteen thousand one hundred sixteen patient discharges were identified. Nationwide in-hospital mortality was 5.3%. Integers were assigned to predictors (age group, Charlson index, sex, diagnosis, pancreatectomy type, and hospital volume) and applied to an additive score. Three score groups were defined to stratify in-hospital mortality (national mortality, 1.3%, 4.9%, and 14.3%; P < .0001), with sufficient discrimination of derivation and validation sets (C statistics, 0.72 and 0.74). Score groups were shifted algorithmically to calculate risk based on institutional data (eg, with institutional mortality of 2.0%, low-, medium-, and high-risk patient groups had 0.5%, 1.9%, and 5.4% mortality, respectively). A web-based tool was developed and is available online (http://www.umassmed.edu/surgery/panc_mortality_custom.aspx). CONCLUSION To maximize patient benefit, objective assessment of risk for major procedures is necessary. We developed a Surgical Outcomes Analysis and Research risk score predicting pancreatectomy mortality that combines national and institution-specific data to enhance decision-making. This type of risk stratification tool may identify opportunities to improve care for patients undergoing specific operative procedures.

Rankings versus reality in pancreatic cancer surgery: a real-world comparison

BACKGROUND Patients are increasingly confronted with systems for rating hospitals. However, the correlations between publicized ratings and actual outcomes after pancreatectomy are unknown. METHODS The Massachusetts Division of Health Care Finance and Policy Hospital Inpatient Discharge Database was queried to identify pancreatic cancer resections carried out during 2005-2009. Hospitals performing fewer than 10 pancreatic resections in the 5-year period were excluded. Primary outcomes included mortality, complications, median length of stay (LoS) and a composite outcomes score (COS) combining primary outcomes. Ranks were determined and compared for: (i) volume, and (ii) ratings identified from consumer-directed hospital ratings including the US News & World Report (USN), Consumer Reports, Healthgrades and Hospital Compare. An inter-rater reliability analysis was performed and correlation coefficients (r) between outcomes and ratings, and between rating systems were calculated. RESULTS Eleven hospitals in which a total of 804 pancreatectomies were conducted were identified. Surgical volume correlated with overall outcome, but was not the strongest indicator. The highest correlation referred to that between USN rank and overall outcome. Mortality was most strongly correlated with Healthgrades ratings (r = 0.50); however, Healthgrades ratings demonstrated poorer correlations with all other outcomes. Consumer Reports ratings showed inverse correlations. CONCLUSIONS The plethora of publicly available hospital ratings systems demonstrates heterogeneity. Volume remains a good but imperfect indicator of surgical outcomes. Further systematic investigation into which measures predict quality outcomes in pancreatic cancer surgery will benefit both patients and providers.

Effect of centre volume and high donor risk index on liver allograft survival

BACKGROUND A growth in the utilization of high-risk allografts is reflective of a critical national shortage and the increasing waiting list mortality. Using risk-adjusted models, the aim of the present study was to determine whether a volume-outcome relationship existed among liver transplants at high risk for allograft failure. METHODS From 2002 to 2008, the Scientific Registry of Transplant Recipients (SRTR) database for all adult deceased donor liver transplants (n = 31 587) was queried. Transplant centres (n = 102) were categorized by volume into tertiles: low (LVC; 31 cases/year), medium (MVC: 64 cases/year) and high (HVC: 102 cases/year). Donor risk comparison groups were stratified by quartiles of the Donor Risk Index (DRI) spectrum: low risk (DRI ≤ 1.63), moderate risk (1.64 > DRI > 1.90), high risk (1.91 > DRI > 2.26) and very high risk (DRI ≥ 2.27). RESULTS HVC more frequently used higher-risk livers (median DRI: LVC: 1.82, MVC: 1.90, HVC: 1.97; P < 0.0001) and achieved better risk adjusted allograft survival outcomes compared with LVC (HR: 0.90, 95%CI: 0.85-0.95). For high and very high risk groups, transplantation at a HVC did contribute to improved graft survival [high risk: hazard ratio (HR): 0.85, 95% confidence interval (CI): 0.76-0.96; Very High Risk: HR: 0.88, 95%CI: 0.78-0.99]. CONCLUSION While DRI remains an important aspect of allograft survival prediction models, liver transplantation at a HVC appears to result in improved allograft survival with high and very high risk DRI organs compared with LVC.

Tumor Registry Versus Physician Medical Record Review: A Direct Comparison of Patients With Pancreatic Neuroendocrine Tumors

PURPOSE Tumor registry (TR) data are becoming more prominently cited in research through increased use of the National Cancer Database. We aimed to establish the accuracy of TR data by comparing them with physician medical record review (MD review) using pancreatic neuroendocrine tumors (NETs) as an example. METHODS For MD review, the health information system of an academic medical center was queried for patients with pancreatic International Classification of Diseases, ninth revision (ICD-9), codes from January 2000 to August 2008. A single physician investigator analyzed those medical records and identified patients with pancreatic NETs. For TR data, patients with pancreatic NETs were identified by two separate strategies. For the period of January 2000 to December 2006, patients were identified through manual review of pathology reports, admission and discharge sheets, and clinic visit logs. For January 2007 to August 2008, patients were identified using an automated case-finding program. RESULTS In MD review, 1,192 patients with pancreatic ICD-9 codes were identified, 34 of whom were found to have pancreatic NETs. The TR indicated 15 patients with pancreatic NETs, four of whom were not identified during MD review. Of the total 38 patients identified by either strategy, pancreatic NET identification rate of the TR was 39.5% compared with 89.5% in MD review. CONCLUSION Academic TR analysis indicates a substantial proportion of patients with pancreatic NETs are not identified when compared with MD review. Most instances of patients going unidentified are the result of registry time lag and case-finding methodologies; specifically, physicians may define tumors with malignant potential differently. This may be applicable to other individual tumor registries as well as aggregate registry-based national studies.

Electronic medical record: research tool for pancreatic cancer

BACKGROUND A novel data warehouse based on automated retrieval from an institutional health care information system (HIS) was made available to be compared with a traditional prospectively maintained surgical database. METHODS A newly established institutional data warehouse at a single-institution academic medical center autopopulated by HIS was queried for International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes for pancreatic neoplasm. Patients with ICD-9-CM diagnosis codes for pancreatic neoplasm were captured. A parallel query was performed using a prospective database populated by manual entry. Duplicated patients and those unique to either data set were identified. All patients were manually reviewed to determine the accuracy of diagnosis. RESULTS A total of 1107 patients were identified from the HIS-linked data set with pancreatic neoplasm from 1999-2009. Of these, 254 (22.9%) patients were also captured by the surgical database, whereas 853 (77.1%) patients were only in the HIS-linked data set. Manual review of the HIS-only group demonstrated that 45.0% of patients were without identifiable pancreatic pathology, suggesting erroneous capture, whereas 36.3% of patients were consistent with pancreatic neoplasm and 18.7% with other pancreatic pathology. Of the 394 patients identified by the surgical database, 254 (64.5%) patients were captured by HIS, whereas 140 (35.5%) patients were not. Manual review of patients only captured by the surgical database demonstrated 85.9% with pancreatic neoplasm and 14.1% with other pancreatic pathology. Finally, review of the 254 patient overlap demonstrated that 80.3% of patients had pancreatic neoplasm and 19.7% had other pancreatic pathology. CONCLUSIONS These results suggest that cautious interpretation of administrative data rely only on ICD-9-CM diagnosis codes and clinical correlation through previously validated mechanisms.