Nina P. Tamirisa

Relative contributions of complications and failure to rescue on mortality in older patients undergoing pancreatectomy

Background:For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. Methods:We identified 2694 patients who underwent pancreatic resection from the American College of Surgeons’ National Surgical Quality Improvement Pancreatectomy Demonstration Project at 37 high-volume centers. Overall morbidity and in-hospital mortality were determined in patients younger than 80 years (N = 2496) and 80 years or older (N = 198). Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. Results:No significant differences were observed between patients younger than 80 years and those 80 years or older in the rates of overall complications (41.4% vs 39.4%, P = 0.58). In-hospital mortality increased in patients 80 years or older compared to patients younger than 80 years (3.0% vs 1.1%, P = 0.02). Failures to rescue rates were higher in patients 80 years or older (7.7% vs 2.7%, P = 0.01). Across 37 high-volume centers, unadjusted complication rates ranged from 25.0% to 72.2% and failure to rescue rates ranged from 0.0% to 25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, chronic obstructive pulmonary disease, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. Conclusions:In experienced hands, the rates of complications after pancreatectomy in patients 80 years or older compared to patients younger than 80 years were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.

Comparison of Comorbidity Scores in Predicting Surgical Outcomes.

Introduction:The optimal methodology for assessing comorbidity to predict various surgical outcomes such as mortality, readmissions, complications, and failure to rescue (FTR) using claims data has not been established. Objective:Compare diagnosis-based and prescription-based comorbidity scores for predicting surgical outcomes. Methods:We used 100% Texas Medicare data (2006–2011) and included patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement (N=39,616). The ability of diagnosis-based [Charlson comorbidity score, Elixhauser comorbidity score, Combined Comorbidity Score, Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC)] versus prescription-based Chronic disease score in predicting 30-day mortality, 1-year mortality, 30-day readmission, complications, and FTR were compared using c-statistics (c) and integrated discrimination improvement (IDI). Results:The overall 30-day mortality was 5.8%, 1-year mortality was 17.7%, 30-day readmission was 14.1%, complication rate was 39.7%, and FTR was 14.5%. CMS-HCC performed the best in predicting surgical outcomes (30-d mortality, c=0.797, IDI=4.59%; 1-y mortality, c=0.798, IDI=9.60%; 30-d readmission, c=0.630, IDI=1.27%; complications, c=0.766, IDI=9.37%; FTR, c=0.811, IDI=5.24%) followed by Elixhauser comorbidity index/disease categories (30-d mortality, c=0.750, IDI=2.37%; 1-y mortality, c=0.755, IDI=5.82%; 30-d readmission, c=0.629, IDI=1.43%; complications, c=0.730, IDI=3.99%; FTR, c=0.749, IDI=2.17%). Addition of prescription-based scores to diagnosis-based scores did not improve performance. Conclusions:The CMS-HCC had superior performance in predicting surgical outcomes. Prescription-based scores, alone or in addition to diagnosis-based scores, were not better than any diagnosis-based scoring system.

Trajectory of care and use of multimodality therapy in older patients with pancreatic adenocarcinoma

INTRODUCTION Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients. OBJECTIVE To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer. METHODS We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment. RESULTS We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P < .0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P < .0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy. CONCLUSION Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.

Preop-gallstones: A prognostic nomogram for the management of symptomatic cholelithiasis in older patients

OBJECTIVE AND BACKGROUND The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients. METHODS We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients. RESULTS We identified 92,436 patients who presented to the emergency department (8.3%) or physicians office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75). CONCLUSIONS Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients

BACKGROUND Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. MATERIALS AND METHODS The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. RESULTS There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. CONCLUSIONS Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

BACKGROUND We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. STUDY DESIGN We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patients risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed. RESULTS In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode. CONCLUSIONS The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

Patient and physician views of shared decision making in cancer

Engaging patients in shared decision making involves patient knowledge of treatment options and physician elicitation of patient preferences.

Surgeon and Facility Variation in the Use of Minimally Invasive Breast Biopsy in Texas

OBJECTIVE AND BACKGROUND Minimally invasive breast biopsy (MIBB) rates remain well below guideline recommendations of more than 90% and vary across geographic areas. Our aim was to determine the variation in use attributable to the surgeon and facility and determine the patient, surgeon, and facility characteristics associated with the use of MIBB. METHODS We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years with a breast biopsy (open or minimally invasive) and subsequent breast cancer diagnosis/operation within 1 year. The percentage of patients undergoing MIBB as the first diagnostic modality was estimated for each surgeon and facility. Three-level hierarchical generalized linear models (patients clustered within surgeons within facilities) were used to evaluate variation in MIBB use. RESULTS A total of 22,711 patients underwent a breast cancer operation by 1226 surgeons at 525 facilities. MIBB was the initial diagnostic modality in 62.4% of cases. Only 7.0% of facilities and 12.9% of surgeons used MIBB for more than 90% of patients. In 3-level models adjusted for patient characteristics, the percentage of patients who received MIBB ranged from 7.5% to 96.0% across facilities (mean = 50.1%, median = 49.2%) and from 8.0% to 87.0% across surgeons (mean = 50.3%, median = 50.9%). The variance in MIBB use was attributable to facility (8.8%) and surgeon (15.4%) characteristics. Lower surgeon and facility volume, longer surgeon years in practice, and smaller facility bed size were associated with lower rates of MIBB use. CONCLUSIONS Identification of surgeon and facility characteristics associated with low use of MIBB provides potential targets for interventions to improve MIBB rates and decrease variation in use. TYPE OF STUDY Retrospective cohort.

481 Management and Natural History of Older Patients Requiring Cholecystostomy Tube Drainage for Acute Gallbladder Disease

INTRODUCTION: Tube cholecystostomy (TC) is used in patients with acute cholecystitis (AC) deemed to be poor surgical candidates. Little is known about the optimal management of these patients after placement of the cholecystostomy tube. Our goal was to examine the trajectory of care and outcomes in these patients. METHODS: We used 5% Medicare Claims data (1996 to 2011) to identify patients ≥66 years who underwent TC for AC. All patients were followed for 2 years after TC. Descriptive statistics were used to describe the study cohort and trajectory of care. Kaplan-Meier curves and cumulative incidence curves were used to describe mortality and compare patients who did or did not undergo cholecystectomy. RESULTS: A total of 1668 patients underwent TC. Their trajectory of care is described in Figure 1. Overall mortality during the study period was 52.6%. The mean age was 80.2 ± 7.9 years and 905 (54.3%) were female. The mean Charlson comorbidity index was 3.7±2.9. 251 patients (15%) underwent cholecystectomy during index admission (48% lap, 52% open), with a 6.8% mortality rate. 1417 patients did not have cholecystectomy at the index admission, and 208 (14.7%) died. Of the 1209 patients who did not have cholecystectomy and who survived to discharge, 732 patients had at least one gallstone-related admission and 121 required at least one tube-related procedure. Subsequent cholecystectomy was performed in 404 patients, of whom 43 had prior tube manipulation. Cholecystectomy was performed at a mean time of 3.2±3.1 months from initial discharge in those who required tube manipulation and 2.7±3.9 months in those who did not. 72% of cholecystectomy were emergent and 60.6% were open. Of the 655 patients who underwent cholecystectomy at any time during the study period, the 2-year survival rate was 75.5%, compared to 37% in 805 patients who survived hospitalization and never underwent cholecystectomy (p=0.0001). Themean age (77.8±7.14 vs. 81.72±8.0, p<0.001) and Charlson comorbidity index (3.1±2.80 vs. 4.2±2.9, p=0.1579) were lower in patients undergoing cholecystectomy. DISCUSSION: Older patients with AC require a TC due to both severity of their gallbladder disease and significant comorbidities that preclude immediate surgical intervention. Fewer than half require cholecystectomy and many die of other causes without requiring cholecystectomy. The worse survival in patients without cholecystectomy, likely represents a selection bias, with the healthiest patients undergoing cholecystectomy.