Peter A. Learn

Laparoscopic surgery for Crohn's disease: Reasons for conversion

Objective To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohns disease. Background Data Laparoscopic management of patients with complications of Crohns produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. Methods Data regarding patients who underwent attempted laparoscopic procedures for Crohns (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. Results One hundred ten patients (age 37 ± 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileo-cecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 ± 0.2 days and 4.4 ± 0.2 days, respectively. Mean time to discharge was 6 ± 0.2 days. Conclusions Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS Five years (2006–2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13–1.35]; 90 days, 1.18 [1.09–1.28]; and 180 days, 1.15 [1.07–1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69–1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III

Association Between Race and Postoperative Outcomes in a Universally Insured Population Versus Patients in the State of California

Objective: To compare disparities in postoperative outcomes for African Americans after surgical intervention in the universally insured military system, versus the civilian setting in California. Background: Health reform proponents cite the reduction of disparities for African Americans and minorities as an expected benefit. The impact of universal health insurance on reducing surgical disparities for African Americans has not previously been examined. Methods: We used Department of Defense health insurance (Tricare) data (2006–2010) to measure outcomes for African Americans as compared with Whites after 12 major surgical procedures across multiple specialties. The experience of African Americans in the Tricare system was compared with a similar cohort undergoing surgery in the state of California using the State Inpatient Database (2007–2011). Results: No significant difference in postoperative complications [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.81, 1.03] or mortality (OR 0.98; 95% CI 0.43, 2.25) were encountered between African Americans and Whites receiving surgery at hospitals administered by the Department of Defense. African Americans in California who were uninsured or on Medicaid had significantly increased odds of mortality (OR 4.76; 95% CI 2.82, 8.05), complications (OR 1.67; 95% CI 1.34, 2.08), failure to rescue (OR 2.72; 95% CI 1.25, 5.94), and readmission (OR 1.78; 95% CI 1.45, 2.19). Conclusions: In the equal access military healthcare system, African Americans have outcomes similar to Whites. Disparities were evident in California, especially among those without private insurance. These facts point toward the potential benefits of a federally administered system in which all patients are treated uniformly.

Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures

Importance The overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery. Objectives To describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills. Design, Setting, and Participants The Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing. Exposures Length of initial prescription for opioid pain medication. Main Outcomes and Measures Need for an additional subsequent prescription for opioid pain medication, or a refill. Results Of the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women’s health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%). Conclusions and Relevance Ideally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians

Importance Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment. Objective To explore evidence for provider-induced demand in the management of carotid artery stenosis. Design, Setting, and Participants The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016. Main Outcomes and Measures The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand. Results Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001). Conclusions and Relevance Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BACKGROUND Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge. METHODS We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients. RESULTS Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge. CONCLUSIONS Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

The Use of Prostate Specific Antigen Screening in Purchased versus Direct Care Settings: Data from the TRICARE® Military Database

Purpose: Fee for service reimbursement incentives may affect care. We compared the odds of prostate specific antigen screening among former and active duty United States military service members based on receipt of primary care from integrated military health facilities vs community providers reimbursed via fee for service. Materials and Methods: We retrospectively studied the records of all active duty and retired male service members 40 to 64 years old who were covered by the TRICARE® military health benefit in 2010. Beneficiaries may receive primary care at military run facilities via the direct care system or with private physicians via the purchased care system. We compared rates of prostate specific antigen screening between propensity score weighted cohorts of 219,290 men who received primary care in the direct care system and 177,748 who received it in the purchased care system. Results: The screening rate was 35% in the direct care system vs 26% in the purchased care system. After propensity score weighting the former men were significantly more likely to undergo prostate specific antigen screening than men who received primary care in the purchased care system (adjusted OR 1.76, 95% CI 1.729–1.781). Age older than 52 years, rank and black race were associated with increased odds of prostate specific antigen screening in each cohort. Conclusions: These results suggest that salaried primary care providers employed at integrated military facilities are more likely to order prostate specific antigen screening compared to those reimbursed in a fee for service fashion by military insurance. Growing understanding of how fee for service incentives impact prostate specific antigen screening by primary care providers may enable advocates and policy makers to leverage reimbursement systems as a tool to change prostate cancer screening.

Impact of testosterone replacement therapy on thromboembolism, heart disease and obstructive sleep apnoea in men

To assess the association of testosterone replacement therapy (TRT) with thromboembolism, cardiovascular disease (stroke, coronary artery disease and heart failure) and obstructive sleep apnoea (OSA).

MP91-04 ADVERSE EFFECTS OF TESTOSTERONE REPLACEMENT THERAPY FOR MEN, A MATCHED COHORT STUDY

INTRODUCTION AND OBJECTIVES: To evaluate role of lowintensity shock wave therapy (LI-SWT) in penile rehabilitation (PR) post nerve sparing radical cysto-prostatectomy (NS-RCP). METHODS: Eighty seven sexually active men with muscle invasive bladder cancer were enrolled in this prospective study. After bilateral NS-RCP with orthotopic diversion (W-Pouch) by a single expert surgeon between January 2015 & October 2016, patients were randomized into 3 groups (29 patients/group). SWL Group received 12 sessions of penile LI-SWT (2/week for 3 weeks, then 3 weeks free of treatment, then 2/week for another 3 weeks). Phosphodiesterase type-5 inhibitors (PDE5i) Group received oral PDE5i of 50 mg /day for 6 months. Control Group was followed up only without any therapy. Patients were assessed before surgery and at 1 (FU1), 3 (FU2), 6 (FU3) and 9-month (FU4) post operatively. Effectiveness was assessed by IIEF-15 questionnaire and erection hardness score (EHS). RESULTS: Mean age was 54.1 5.9 years with mean followup period 15.9 4.2 months. There were no statistically significant differences regarding preoperative patients demographic data & tumor criteria. At FU1; All patients have insufficient erection for vaginal penetration. EHS < 2; with decrease of preoperative IIEF-EF mean score from 28 to 6.6. In SWL group; At FU2; 17/29 patients regained potency which is maintained in 15 only at FU3&4. However; 6 of remaining 12 patients regained & maintained potency at FU3&4. Statistical evaluation showed significant increase in IIEF-EF score from 6.6 at FU1 to 23 at FU2, 24 at FU3 and 24.5 at FU4 ( P <0.001). In PDE5i group; At FU2; 16/29 patients regained & maintained potency at FU3&4. However; 7 of remaining 13 patients regained & maintained potency at FU3&4. Statistical evaluation showed significant increase in IIEF-EF score from 6.6 at FU1 to 22.8 at FU2, 24 at FU3 and 24.7 at FU4 (P <0.001). In Control group; At FU2; 12/29 patients regained & maintained potency at FU3&4. However; 6 of remaining 17 patients regained & maintained potency at FU3&4. Statistical evaluation showed no significant difference in potency recovery rates at FU2 & FU3,4 among the groups ( P 1⁄4 0.14 & P 1⁄4 0.24 respectively). Potency recovery rates at FU2 were 58.6% vs 55.2% vs 41.4% in SWL, PDE5i and Control group, respectively. While potency recovery rates at FU3,4 were 72.4% vs 79.3% vs 62.1% in SWL, PDE5i and Control group, respectively. CONCLUSIONS: LI-SWT is safe and as effective as oral PDE5i in PR post NS-RCP. A large-scale study is required to determine the value of this treatment modality in ED post NS-RCP.

Race-based differences in duration of stay among universally insured coronary artery bypass graft patients in military versus civilian hospitals

Background. Duration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white differences in duration of stay among TRICARE‐covered patients undergoing coronary artery bypass graft. Methods. Patients aged 18–64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD‐9CM 36.10–36.20) between 2006–2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient‐ and hospital‐level factors. Results. Of 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07–1.22) with no race‐based differences at military facilities. Conclusion. Among coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race‐related variability in duration of stay.