Sophia Y. Chen

Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis

BACKGROUND Little is reported about postdischarge complications after bariatric surgery. We sought to identify the rates of postdischarge complications, associated risk factors, and their influence on early hospital readmission. METHODS Using the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) (2005-2013), we identified patients ≥18 years of age who underwent a bariatric operation with a primary diagnosis of morbid/severe obesity and a body mass index ≥35. The incidence of postdischarge complication was the primary outcome, and hospital readmission was the secondary outcome. The association between postdischarge complications and various patient factors was explored by the use of multivariable logistic regression. RESULTS A total of 113,898 patients were identified with an overall postdischarge complication rate of 3.2% within 30 days of operation. The rates decreased from 2005 to 2006 (4.6%) to 2013 (3.0%) (P < .001). On average, postdischarge complications occurred 10 days postoperatively, with wound infection (49.4%), reoperation (30.7%), urinary tract infection (16.9%), shock/sepsis (12.4%), and organ space surgical-site infection (11.0%) being the most common. Patients undergoing open gastric bypass had the greatest postdischarge complication rate of 8.5%. Of those patients experiencing postdischarge complications, 51.6% were readmitted. The overall readmission rate was 4.9%. The factors associated most strongly with increased odds of postdischarge complications were body mass index ≥ 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time. CONCLUSION Postdischarge complications after bariatric surgery represent a substantial source of patient morbidity and hospital readmissions. The majority of postdischarge complications are infection-related, including surgical-site infections and catheter-associated urinary tract infections. Adopting and implementing standardized pre- and postoperative strategies to decrease perioperative infection may help to decrease the rate of postdischarge complications and associated readmissions and enhance overall quality of care.

Post-discharge complications after esophagectomy account for high readmission rates.

AIM To identify rates of post-discharge complications (PDC), associated risk factors, and their influence on early hospital outcomes after esophagectomy. METHODS We used the 2005-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients ≥ 18 years of age who underwent an esophagectomy. These procedures were categorized into four operative approaches: transhiatal, Ivor-Lewis, 3-holes, and non-gastric conduit. We selected patient data based on clinical relevance to patients undergoing esophagectomy and compared demographic and clinical characteristics. The primary outcome was PDC, and secondary outcomes were hospital readmission and reoperation. The patients were then divided in 3 groups: no complication (Group 1), only pre-discharge complication (Group 2), and PDC patients (Group 3). A modified Poisson regression analysis was used to identify risk factors associated with developing post-discharge complication, and risk ratios were estimated. RESULTS 4483 total patients were identified, with 8.9% developing PDC within 30-d after esophagectomy. Patients who experienced complications post-discharge had a median initial hospital length of stay (LOS) of 9 d; however, PDC occurred on average 14 d following surgery. Patients with PDC had greater rates of wound infection (41.0% vs 19.3%, P < 0.001), venous thromboembolism (16.3% vs 8.9%, P < 0.001), and organ space surgical site infection (17.1% vs 11.0%, P = 0.001) than patients with pre-discharge complication. The readmission rate in our entire population was 12.8%. PDC patients were overwhelmingly more likely to have a reoperation (39.5% vs 22.4%, P < 0.001) and readmission (66.9% vs 6.6%, P < 0.001). BMI 25-29.9 and BMI ≥ 30 were associated with increased risk of PDC compared to normal BMI (18.5-25). CONCLUSION PDC after esophagectomy account for significant number of reoperations and readmissions. Efforts should be directed towards optimizing patients health pre-discharge, with possible prevention programs at discharge.

Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery

Importance Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. Objective To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. Design, Setting, and Participants This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. Interventions Hepatic or pancreatic resection. Main Outcomes and Measures Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. Results Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (−5.4%; 95% CI, −10.0% to −0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, −14.0% to −2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, −13.0% to −3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, −19.3% to −7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, −16.2% to −4.4%; P = .001) compared with unconcentrated markets. Conclusions and Relevance Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.

Assessing the Financial Burden Associated with Treatment Options for Resectable Pancreatic Cancer

Objective: The aim of this study is to assess the financial burden associated with treatment options for resectable pancreatic cancer. Background: As the volume of cancer care increases in the United States, there is growing interest among both clinicians and policy-makers to reduce its financial impact on the healthcare system. However, costs relative to the survival benefit for differing treatment modalities used in practice have not been described. Methods: Patients undergoing resection for pancreatic cancer were identified in the Truven Health MarketScan database. Associations between chemoradiation therapies and survival were performed using parameterized multivariable accelerated failure time models. Median payments over time were calculated for surgery, chemoradiation, and subsequent hospitalizations. Results: A total of 2408 patients were included. Median survival among all patients was 21.1 months [95% confidence interval (CI): 19.8–22.5 months], whereas median follow-up time was 25.1 months (95% CI: 23.5–26.5 months). After controlling for comorbidity, receipt of neoadjuvant therapy, and nodal involvement, a longer survival was associated with undergoing combination gemcitabine and nab-paclitaxel [time ratio (TR) = 1.26, 95% CI: 1.02–1.57, P = 0.035) or capecitabine and radiation (TR = 1.25, 95% CI: 1.04–1.51, P = 0.018). However, median cumulative payments for gemcitabine with nab-paclitaxel were highest overall [median

Functional dependence versus frailty in gastrointestinal surgery: Are they comparable in predicting short-term outcomes?

74,051, interquartile range (IQR):

The relationship of hospital market concentration, costs, and quality for major surgical procedures

38,929–

Physiologic correlates of intraoperative blood transfusion among patients undergoing major gastrointestinal operations

133,603). Conclusions: Total payments for an episode of care relative to improvement in survival vary significantly by treatment modality. These data can be used to inform management decisions about pursuing further care for pancreatic cancer. Future investigations should seek to refine estimates of the cost-effectiveness of different treatments.

Su1748 Does Quality of Care Matter? A Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients With Locally Advanced Esophageal Cancer

Background: Frailty and functional dependence are important factors in assessing preoperative risk. No studies to date have compared frailty with functional dependence as a predictor of surgical outcomes. We sought to compare the impact of frailty and functional dependence on early outcomes after gastrointestinal surgery. Methods: Patients who underwent gastrointestinal surgery were identified using the American College of Surgeons National Surgical Quality Improvement Program database (2012–2015). Propensity score matching analysis was used to separately match dependent and independent patients, and patients with modified frailty index <3 and modified frailty index ≥3 on baseline characteristics. Multivariable logistic regression analysis was used. Postoperative outcomes were compared. Results: Of 765,082 patients, 1.71% were dependent and 1.49% had a modified frailty index score ≥3. Similar outcomes were observed in matched cohorts for those who were dependent and patients with a modified frailty index score ≥3: readmission (15.61% dependent and 15.75% modified frailty index ≥3), overall morbidity (37.91% and 34.81%), serious morbidity (19.06% and 17.06%), mortality (6.73% and 5.43%), and reoperation (7.01% and 6.48%). Dependent and modified frailty index ≥3 patients had similar odds of outcomes on adjusted multivariable logistic analysis and shared 3 of the top 5 indicators for readmission: complication of surgical procedure (11.46% dependent and 11.23% mFI ≥3), intestinal obstruction (10.70% and 7.65%), and organ space surgical site infection (7.93% and 8.65%). Comparable outcomes and reasons for readmission were also obtained for dependent patients and colectomy patients with a modified frailty index score ≥3. Conclusion: Frailty and functional dependence are comparable in predicting postoperative outcomes after gastrointestinal surgery. Functional dependence should be considered an acceptable and practical alternative for preoperative risk stratification in a clinical setting.

Metformin Use Is Associated with Improved Survival in Patients Undergoing Resection for Pancreatic Cancer

BACKGROUND Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care. METHODS Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. RESULTS A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -

Does Quality of Care Matter? A Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients with Locally Advanced Esophageal Cancer.

3064 (95% CI: -