Susie X. Sun

Length of Stay and Readmissions in Mastectomy Patients

Interest is growing in preventing readmissions as payers start to link reimbursement to readmission rates. The purpose of this study was to assess factors that contribute to 30‐day readmission rates for women undergoing mastectomy for breast cancer. Data from the Pennsylvania Health Care Cost Containment Council were queried for women undergoing mastectomy for breast cancer during 2011 (n = 2,919). The outcomes measured were length of stay (LOS) and 30‐day readmission. Univariate comparisons between characteristics of readmitted (n = 172) and nonreadmitted patients were performed using t‐tests and chi‐square tests. Readmission was modeled using logistic regression; LOS was modeled using linear regression and controlled for potential confounders. In multivariate analyses, patients with peripheral vascular disease were more likely to be readmitted (OR 4.36, p = 0.002). Increased LOS was also associated with increased odds of readmission (OR 1.26, p = <0.0001). Since LOS was an important predictor of readmission we also estimated determinants of LOS using linear regression. The occurrence of reconstructive surgery (p = <0.0001) and renal disease (p < 0.0001) were highly predictive of longer LOS. This study showed peripheral vascular disease and longer lengths of stay were associated with higher odds of readmission in women undergoing mastectomy. Clinicians should be cognizant that optimizing a patients vascular status before mastectomy may lead to lower rates of readmission. Additional research is needed to determine whether the relationship between readmissions and length of hospital stay is a causative versus associative phenomenon since LOS is a modifiable factor that may lead to lower readmissions.

Attributable cost of obesity in breast surgery: a matched cohort analysis

BACKGROUND The purpose of this study was to determine the economic impact of obesity on patients undergoing mastectomy and breast conservation (BC) for breast cancer. METHODS An analysis of female patients greater than or equal to 18 years undergoing mastectomy and BC for breast cancer between 2004 and 2010 using the Nationwide Inpatient Sample was conducted. RESULTS Of 55,903 patients in our study (49,985 mastectomy, 5,918 BC), 3,308 patients (5.92%) were obese. After propensity score matching, the cost for obese patients was higher at

Cost-effective Decisions in Detecting Silent Common Bile Duct Gallstones During Laparoscopic Cholecystectomy.

1,826 (P < .0001) for mastectomy and

Perceptions of mistreatment among trainees vary at different stages of clinical training

1,702 for BC (P < .0001). These costs were not significantly associated with overall complications and length of stay for mastectomy in the matched comparison group and not associated with overall complications and minimally associated with longer length of stay in the BC group. CONCLUSION By controlling for other patient factors, this study shows that obesity is attributable to a significantly higher cost for both BC (29%) and mastectomy (23%).

Large Databases for Health Services Research in Endocrine Surgery

Objective:To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy. Background:The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear. Methods:A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters. Results:In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost (

Deviation from the Standard of Care for Early Breast Cancer in the Elderly: What are the Consequences?

311 vs

Readmissions Following Gastric Bypass Surgery.

574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost (

Aligning perceptions of mistreatment among incoming medical trainees

1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM. Conclusions:In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.

Minimally invasive surgery for gastric cancer: the American experience

BackgroundMistreatment of trainees remains a frequently reported phenomenon in medical education. One barrier to creating an educational culture of respect and professionalism may be a lack of alignment in the perceptions of mistreatment among different learners. Through the use of clinical vignettes, our aim was to assess the perceptions of trainees toward themes of potential mistreatment at different stages of training.MethodsBased on observations from external experts embedded in the clinical learning environment, six thematic areas of potential mistreatment were identified: verbal abuse, specialty-choice discrimination, non-educational tasks, withholding/denying learning opportunities, neglect and gender/racial insensitivity. Corresponding clinical vignettes were created and distributed to 1) medical students, 2) incoming interns, 3) residents/fellows. Perceptions of the appropriateness of the interactions depicted in the vignettes were measured on a 5-point Likert scale. Scores were categorized into neutral or appropriate (≤3) or inappropriate (i.e. mistreatment) (>3) and compared using chi-squared tests.ResultsFour hundred twenty seven trainees participated (182 students, 120 interns, 125 residents/fellows). Proportions of students perceiving mistreatment differed significantly from those of interns and residents/fellows in domains of verbal abuse, specialty discrimination and gender/racial insensitivity (p < 0.05). In scenarios comparing interns to residents/fellows, no significant differences were noted in perceptions of mistreatment in the domains of non-educational tasks, withholding learning and neglect.ConclusionsPerceptions of mistreatment differ at different developmental stages of medical training. After exposure to the clinical learning environment, perceptions of incoming interns did not differ from those of residents/fellows, implicating clinical rotations as a key period in indoctrinating students into the prevailing culture. More longitudinal studies are needed to confirm or better examine this phenomenon.

Reply to Letter: “Cost-Effective Decisions in Managing Silent Common Bile Duct Stones Should Include all the Management Options to Help Decision Makers”

Studies using large, publicly available databases are providing new insights into treatment effects and comparative effectiveness in endocrine surgery. While observational studies using retrospective data have unique strengths, such as large sample sizes and a real-world context, they also have important limitations. This chapter reviews nine large databases that contain information on patients with endocrine diseases, many of whom may receive endocrine surgery. For each database, we provide a summary of the source of the data, a description of the outcomes that are available, a general description of covariates for which controls can be constructed, the primary strengths and limitations of the database, and a few examples of important research questions that has been addressed using the data. These descriptions may give investigators insights into the usefulness and appropriateness of such data for undertaking health services research.