Paul R. Sturrock

Surgeon Volume and Elective Resection for Colon Cancer: An Analysis of Outcomes and Use of Laparoscopy

BACKGROUND Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. STUDY DESIGN We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. RESULTS A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were

Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs.

927 (95% CI -

A simple risk score for predicting surgical site infections in inflammatory bowel disease.

1,567 to -

Racial Differences in Short-term Surgical Outcomes Following Surgery for Diverticulitis

287) lower in the HVS group compared with the LVS group. CONCLUSIONS Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Examination of Racial Disparities in the Receipt of Minimally Invasive Surgery Among a National Cohort of Adult Patients Undergoing Colorectal Surgery.

BACKGROUND:After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. OBJECTIVE:The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery. DESIGN:Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery. SETTINGS:This study was conducted at an academic hospital and its affiliates. PATIENTS:Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study. MAIN OUTCOME MEASURES:Readmission within 30 days of index discharge was the main outcome measured. RESULTS:A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32–1.57), stoma (OR 1.54; 95% CI 1.46–1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49–1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53–3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher (

Routine preoperative restaging CTs after neoadjuvant chemoradiation for locally advanced rectal cancer are low yield: A retrospective case study

26,917 vs

Characterizing Short-Term Outcomes Following Surgery for Rectal Cancer: the Role of Race and Insurance Status

13,817; p < 0.001) for readmitted than for nonreadmitted patients. LIMITATIONS:Follow-up was limited to 30 days after initial discharge. CONCLUSIONS:Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

Initiation of a Transanal Total Mesorectal Excision Program at an Academic Training Program: Evaluating Patient Safety and Quality Outcomes.

PURPOSE: Patients with inflammatory bowel disease are often at highest risk for surgical site infections. We sought to define the predictors of surgical site infections and to develop a risk score for predicting those at highest risk. METHODS: Patients undergoing a bowel resection for Crohns disease or ulcerative colitis were identified from National Surgical Quality Improvement Program 2008. Univariate and multivariate analyses were conducted to identify predictors of surgical site infections. Clinically relevant prediction categories were developed and the predictive behavior of the model was validated by use of National Surgical Quality Improvement Program 2007. An integer-based scoring system risk score was created proportional to the logistic regression coefficients, grouping patients into categories of similar risk. RESULTS: We identified 271,368 patients; 3981 of these patients underwent an operation for Crohns disease (n = 2895) or ulcerative colitis (n = 1086). Nine hundred (22.6%) patients developed surgical site infections. Predictors included weight loss, smoking, emergent surgery, wound class, operative time (minutes), and an ASA score >2. A risk score was developed by stratifying patients into low (0–5), 15.6%; medium (6–8), 25.2%; and high (>8), 36.1% risk. CONCLUSIONS: Patients with inflammatory bowel disease are at high risk for surgical site infections. Preoperative factors including weight loss, smoking, emergent surgery and an ASA score >2 are strong predictors of surgical site infections. Operative time and wound class are important intraoperative predictors. A risk score, based on pre- and intraoperative variables, can be used to identify patients at highest risk of developing surgical site infections. This may allow for appropriate process measures to be implemented to prevent and lessen the impact of surgical site infections in this high-risk population.

T1636 Predicting Post-Operative Mortality for Clostridium difficile-Associated Colitis

BackgroundDiverticular disease ranks as one of the more common gastrointestinal disorders among westernized nations. Few studies have examined racial differences in the care and surgical outcomes of diverticulitis. The aim of this study was to determine if race is a predictor of peri-operative morbidity and mortality following surgery for diverticulitis.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (2005–2008) was queried with the primary dependent variables being 30-day morbidity and mortality. Differences in morbidity and mortality between races were compared using χ2 and Student t tests. Logistic regression was used to calculate odds ratios for morbidity and mortality. To determine if the effect of race is modified by insurance status and case complexity, additional models were developed across age subgroups (<65 vs ≥65) and levels of case complexity.ResultsWe identified 4,709 white and 360 African American patients. Despite being younger (57.6 ± 0.74 vs 59 ± 0.2, p < 0.05), African Americans were more likely to present with hypertension, diabetes, renal failure, dependent functional status, American Society of Anesthesiology class ≥3 (all p < 0.0001) and were more likely to require urgent surgery (p < 0.05), intra-operative blood transfusions(p < 0.0001), and undergo open colectomy (p < 0.0001). On adjusted analysis, African American race emerged as an independent predictor of morbidity (p < 0.05) and mortality (p < 0.05), without differences across insurance categories and less complex procedures. African American race remained a strong predictor of morbidity in more complex procedures (p < 0.05).ConclusionAfrican Americans undergoing surgery for diverticulitis are more likely to have associated co-morbidities, require urgent surgery, undergo open surgery, and are at increased risk of morbidity and mortality. These findings highlight a need to address the root cause for disparities in care and outcomes after surgery.

Simple harmonic scalpel hemorrhoidectomy utilizing local anesthesia combined with intravenous sedation: a safe and rapid alternative to conventional hemorrhoidectomy.

BACKGROUND:Racial disparities in outcomes are well described among surgical patients. OBJECTIVE:The purpose of this work was to identify any racial disparities in the receipt of a minimally invasive approach for colorectal surgery. DESIGN:Adults undergoing colorectal surgery were studied using the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify predictors for the receipt of a minimally invasive approach. SETTINGS:The study was conducted at academic hospitals and their affiliates. PATIENTS:Adults ≥18 years of age who underwent surgery for colorectal cancer, diverticular disease, IBD, or benign colorectal tumor between 2008 and 2011 were included. MAIN OUTCOME MEASURES:The receipt of a minimally invasive surgical approach was the main measured outcome. RESULTS:A total of 82,474 adult patients met the study inclusion criteria. Of these, 69,664 (84%) were white, 10,874 (13%) were black, and 1936 (2%) were Asian. Blacks were younger, with higher rates of public insurance and higher comorbidity burden and baseline severity of illness compared with white and Asian patients. Black patients were less likely (adjusted OR = 0.83 (95% CI, 0.79–0.87)) and Asian patients more likely (adjusted OR = 1.34 (95% CI, 1.21–1.49)) than whites to receive minimally invasive surgery. This association did not change with stratification by insurance type (public or private). Black patients had higher rates of intensive care unit admission and nonhome discharge, as well as an increased length of stay compared with white and Asian patients. No differences in complications, readmission, or mortality rates were observed with minimally invasive surgery, but black patients were more likely to be readmitted or to die with open surgery. LIMITATIONS:The study was limited by the retrospective nature of its data. CONCLUSIONS:We identified racial differences in the receipt of a minimally invasive approach for colorectal surgery, regardless of insurance status, as well as improved outcomes for minority races who underwent a minimally invasive technique compared with open surgery. The improved outcomes associated with minimally invasive surgery should prompt efforts to increase rates of its use among black patients.