Rachelle N. Damle

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 -

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

1,567 to -

The Increased Use of Computed Tomography Angiography and Magnetic Resonance Angiography as the Sole Imaging Modalities Prior to Infrainguinal Bypass Has Had No Effect on Outcomes

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.

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

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 (

Are "Goods for Guns" Good for the Community? An Update of a Community Gun Buyback Program

26,917 vs

Tunica vaginalis pedicle flap for repair of ruptured testis: A single-center experience with four patients

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.

Acute traumatic abdominal wall herniation with evisceration

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.

En bloc tibial thrombectomy

BACKGROUND Angiography remains the gold standard imaging modality before infrainguinal bypass. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have emerged as noninvasive alternatives for preoperative imaging. We sought to examine contemporary trends in the utilization of CTA and MRA as isolated imaging modalities before infrainguinal bypass and to compare outcomes following infrainguinal bypass in patients who underwent CTA or MRA versus those who underwent conventional arteriography. METHODS Patients undergoing infrainguinal bypass within the Vascular Study Group of New England were identified (2003-2012). Patients were stratified by preoperative imaging modality: CTA/MRA alone or conventional angiography. Trends in utilization of these modalities were examined and demographics of these groups were compared. Primary end points included primary patency, secondary patency, and major adverse limb events (MALE) at 1 year as determined by Kaplan-Meier analysis. Multivariable Cox proportional hazards models were constructed to evaluate the effect of imaging modality on primary patency, secondary patency, and MALE after adjusting for confounders. RESULTS In 3123 infrainguinal bypasses, CTA/MRA alone was used in 462 cases (15%) and angiography was used in 2661 cases (85%). Use of CTA/MRA alone increased over time, with 52 (11%) bypasses performed between 2003 and 2005, 189 (41%) bypasses performed between 2006 and 2009, and 221 (48%) bypasses performed between 2010 and 2012 (P < 0.001). Patients with CTA/MRA alone, compared with patients with angiography, more frequently underwent bypass for claudication (33% vs. 26%, P = 0.001) or acute limb ischemia (13% vs. 5%, P < 0.0001), more frequently had prosthetic conduits (39% vs. 30%, P = 0.001), and less frequently had tibial/pedal targets (32% vs. 40%, P = 0.002). After adjusting for these and other confounders, multivariable analysis demonstrated that the use of CTA/MRA alone was not associated with a significant difference in 1 year primary patency (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.78-1.16), secondary patency (HR 1.30, 95% CI 0.99-1.72), or MALE (HR 1.08, 95% CI 0.89-1.32). CONCLUSIONS CTA and MRA are being increasingly used as the sole preoperative imaging modality before infrainguinal bypass. This shift in practice patterns appears to have no measurable effect on outcomes at 1 year.

Clostridium difficile infection after colorectal surgery: a rare but costly complication

BackgroundThere is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery.DesignPatients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS).ResultsA total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26–1.81), ICU stays (OR 1.25, 95 % CI 1.03–1.51), and longer LOS (+1.67 days, 95 % CI 1.21–2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications.ConclusionsIn patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.