Association of Frailty With Post-Operative Outcomes of Older Adults Undergoing Elective Ostomy Reversal.

BACKGROUND: Ostomy reversal is a common surgical procedure; however, it is not without associated risks. Patient selection for this elective procedure is therefore critically important. Elderly patients represent a growing population and a substantial proportion of patients that present for evaluation after ostomy creation due to the most common etiologies. This study aims to assess the impact of frailty on the outcomes of ostomy reversal among older adults. METHODS: Patients ≥65 years who underwent ostomy reversal from 2015 to 2019 were identified in the NSQIP database. Frailty was calculated using the 5-item Modified Frailty Index (MFI). Multivariate regression was performed to evaluate the association of frailty with post-operative 30-day mortality, 30-day serious complications, discharge to a facility, and 30-day readmission. RESULTS: A total of 13,053 patients were included, of which 18.7% were frail (MFI ≥ 2). Patients who underwent colostomy reversal had higher rates of serious complications (P < .0001) and discharge to facility (P < .0001) compared to other reversals. In multivariate analysis, frailty was associated with increased odds of serious complications (OR 1.52, 95% CI 1.31-1.77), discharge to facility (OR 2.14, 95% CI 1.79-2.57), and readmission (OR 1.23, 95% CI 1.04-1.46), but not mortality. Frail patients had predicted probabilities 1.4 times higher for serious complications and 1.7-2.2 times greater for discharge to facility than non-frail patients. CONCLUSIONS: Among older adults undergoing elective ostomy reversal, frailty is independently associated with increased odds of 30-day serious complications, discharge to facility, and 30-day readmission. As a potentially modifiable risk factor, identification of frailty offers the opportunity for shared decision-making and prehabilitation.

Racial Disparities in Surgical Outcomes of Acute Diverticulitis: Have We Moved the Needle?

INTRODUCTION: There has been increasing national attention on reducing healthcare disparities. Prior studies cite worse surgical outcomes and less use of laparoscopy for Black patients with diverticulitis. Re-evaluation of these disparities is lacking despite national initiatives to improve health equity. This study aimed to evaluate the association of race with short-term outcomes and surgical approaches in patients with acute diverticulitis. METHODS: The National Surgical Quality Improvement Program database was queried for patients who underwent nonelective surgery for acute diverticulitis from 2015 to 2019. Severity of presentation, morbidity, mortality, surgical approach, and ostomy creation were compared by race. RESULTS: Of the 13,996 patients included in the study, 82.4% were White, 7.6% were Black, 1.1% Asian, 0.61% American Indian/Alaska Native, and 0.20% Native Hawaiian/Pacific Islander (NH/PI). Overall 30-day morbidity was 44.3% and 30-day mortality was 3.9%. In a multivariate logistic regression analysis, compared to Whites, Black race was independently associated with higher 30-day morbidity (Odds Ratio: 1.24, 95% confidence interval: 1.07-1.43, P = 0.003) and NH/PI race was independently associated with higher mortality (Odds Ratio: 5.35, 95% confidence interval: 1.32-21.6, P = 0.019). There was no difference in complicated disease (abscess or perforation), use of laparoscopy, or ostomy creation among races. CONCLUSIONS: Despite national efforts to achieve equity in healthcare, disparities persist in surgical outcomes for those with diverticulitis. Black and NH/PI race are independently associated with increased morbidity and mortality, respectively. Use of laparoscopy, however, is no longer different by race suggesting some gaps may be closing.

Impact of Automated Reminder Calls in a Safety-Net Setting on Surgical Clinic No-Show Rates.

In surgical clinics, missed appointments may lead to delayed diagnosis and postponed surgical intervention. Automated reminder calls (robocalls) have replaced live staff phone calls in many systems as a cost-saving measure. This study aims to evaluate whether robocalls reduced the outpatient appointment no-show rate for surgical patients in a county hospital. Demographic and clinic data from two surgical clinics at a safety net hospital were collected over two time periods: 3-months immediately before robocalls went live and 3-months immediately after robocalls went live. No-show rates were compared between time periods. Multivariate analysis confirmed that robocalls were independently associated with reduced no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .032). In addition, new appointments were independently predictive of higher no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .048). Robocalls appear to be an effective tool for improving appointment attendance overall. Furthermore, robocalls may free limited staff to perform higher value work in the healthcare system.

Predictors of poor outcomes after cholecystectomy in gallstone pancreatitis: NSQIP analysis of 30-day morbidity and mortality.

BACKGROUND: Contemporary nationwide outcomes of gallstone pancreatitis (GSP) managed by cholecystectomy at the index hospitalization are limited. This study aims to define the rate of 30-day morbidity and mortality and identify associated perioperative risk factors in patients undergoing cholecystectomy for GSP. METHODS: Patients from the ACS-NSQIP database with GSP without pancreatic necrosis, who underwent cholecystectomy during the index hospitalization from 2017 to 2019 were selected. Factors associated with 30-day morbidity and mortality were analyzed. RESULTS: Of the 4021 patients identified, 1375 (34.5%) were male, 2891 (71.9%) were White, 3923 (97.6%) underwent laparoscopic surgery, and 52.4 years (SD ± 18.9) was the mean age. There were 155 (3.8%) patients who developed morbidity and 15 (0.37%) who died within 30 days of surgery. In bivariate regression analysis, both 30-day morbidity and mortality were associated with older age, elevated pre-operative BUN, hypertension, chronic obstructive pulmonary disease, congestive heart failure, acute kidney injury, and dyspnea. ASA of I or II and laparoscopic surgery were protective against 30-day morbidity and mortality. In multivariable regression analysis, factors independently associated with increased 30-day morbidity included preoperative SIRS/sepsis [OR: 1.68 (95% CI: 1.01-2.79), p = 0.048], and age [OR: 1.03 (95% CI: 1.01-1.04), p = 0.001]. Factors associated with increased 30-day mortality included tobacco use [OR: 8.62 (95% CI: 2.11-35.19), p = 0.003] and age [OR: 1.10 (95% CI: 1.04-1.17), p = 0.002]. CONCLUSIONS: Patients with GSP without pancreatic necrosis can undergo cholecystectomy during the index admission with very low risk of 30-day morbidity or mortality.

The impact of waste reduction in general surgery operating rooms.

INTRODUCTION: Operating rooms are responsible for a significant burden of waste and negative environmental impact. This study aimed to reduce OR waste and improve both environmental impact and hospital cost savings. METHODS: The unused items in two standard single-use surgical packs were tracked for general surgery cases. A new pack was created excluding the most frequently unused items. The feasibility of the new pack was then tested, and a projected cost savings analysis was performed. RESULTS: A total of 35 general surgery operations were tracked using two standard packs ($89.51 or $93.68 per case, each 23.2 lbs). The new pack ($46.88 per case, 20.8 lbs) was then successfully used in nine cases. The projected cost-savings of substituting the new pack was $45,719 annually with a 2437 pounds annual waste reduction. CONCLUSIONS: Simple and feasible adjustments to standard single-use surgical packs can have a significant impact on waste reduction and cost-savings.

Is laparoscopic surgery safe for elderly patients with diverticulitis? A national database study.

PURPOSE: Laparoscopy is the preferred approach to elective surgery for diverticulitis and is increasingly common in the emergent setting. Although diverticulitis is most prevalent among older adults, little is known about the safety of laparoscopy for elderly patients with diverticulitis. This study aims to compare 30-day outcomes of a laparoscopic versus open approach for diverticulitis among elderly patients undergoing elective and urgent/emergent surgery. METHODS: Patients ≥ 65 years who underwent surgery for diverticulitis from 2015 to 2019 were identified from the ACS-NSQIP database. Elective and non-elective groups were analyzed separately. Coarsened exact matching matched laparoscopic and open patients 1:1 based on preoperative factors to minimize selection bias by creating comparable cohorts. Short-term outcomes of laparoscopic versus open surgery were compared. RESULTS: A total of 15,316 patients were included, 69.2% female and 88% White, with a mean age of 72.7 ± 6.1 years. Approximately half (50.9%) of cases were laparoscopic and 60.6% were elective. After matching, laparoscopy was associated with lower 30-day morbidity in both the elective (OR, 0.47; 95%CI, 0.38-0.58) and non-elective (OR, 0.76; 95%CI, 0.58-0.98) cohorts. Laparoscopic surgery in both cohorts was associated with fewer surgical site infections (SSIs) (elective, OR 0.43; 95%CI, 0.33-0.57; non-elective, OR, 0.66; 95%CI, 0.44-0.98) and shorter length of stay (LOS) (elective, mean difference, 1.7 days; 95%CI, 1.5-1.9; non-elective, mean difference, 1.2 days; 95%CI, 0.43-2.1). CONCLUSION: Elderly patients undergoing both elective and non-elective laparoscopic surgery for diverticulitis have less 30-day morbidity, SSIs, and shorter LOS compared to an open approach. Therefore, laparoscopy for elderly patients is safe in elective surgery and in select emergent cases as well.

The Impact of Primary Care Physicians on the Surgical Presentation and Outcomes of Colorectal Cancer in Vulnerable Populations.

BACKGROUND: Multiple socioeconomic and clinical factors have been implicated in the health disparities that exist amongst vulnerable populations with colorectal cancer. Efforts have been directed toward addressing these factors to improve outcomes. We evaluate the impact of primary care physicians (PCP) on the surgical presentation and outcomes of colorectal cancer at a safety-net hospital. METHODS: A retrospective chart review of 331 patients diagnosed with colorectal adenocarcinoma between 2014 and 2020 at a single-institution urban county medical center. RESULTS: The cohort was predominantly male (59%) and Hispanic (52.1%). Thirty-two percent of patients had a PCP at time of diagnosis. Patients with PCPs compared to those without PCPs had significantly lower rates of acute presentation (perforation or obstruction) (17.0 vs 38.1%, P < .001), higher rates of surgical resection (83.0 vs 70.7%, P = .016), and were less likely to have metastatic disease at presentation (20.4 vs 33.5%, P = .02). Overall, having a PCP also improved probability of survival (HR 1.36, P < .04). CONCLUSION: Having a PCP at the time of colorectal cancer diagnosis is associated with improved outcomes in a safety-net population, with significant differences in surgical presentation and resection.

Early Cholecystectomy in Gallstone Pancreatitis Patients With and Without End Organ Dysfunction: A NQSIP Analysis.

INTRODUCTION: While literature widely supports early cholecystectomy for mild gallstone pancreatitis (GSP), this has not been reflected in clinical practice. Early cholecystectomy for GSP with end organ dysfunction remains controversial. OBJECTIVE: This study aims to evaluate the rate and outcomes of early cholecystectomy (<3 days from admission) in mild GSP patients with end organ dysfunction (+EOD) and without (-EOD). METHODS: Patients with GSP without necrosis were identified from 2017 to 2019 NSQIP database and categorized into GSP±EOD. Coarsened Exact Matching was used to match patients based on preoperative risk factors in each group, and outcomes were compared. RESULTS: There was a total of 3104 patients -EOD and 917 +EOD in the aggregate cohort. Early cholecystectomy was performed in 1520 (49.0%) of GSP-EOD and in 407 (44.4%) of GSP+EOD. In the matched cohorts, there were no significant differences in 30-day mortality, morbidity, or reoperation for early cholecystectomy in either group. In GSP-EOD, early cholecystectomy was associated with shorter LOS (2.9 ± 1.5 vs. 5.6 ± 3.0 days, P < .001), shorter operative time (69.7 ± 34.4 vs. 73.3 ± 36.6 min, P = .045), and more concurrent biliary procedures (52.1% vs. 35.4%, P < .001). Similarly, early cholecystectomy in GSP+EOD was associated with shorter LOS (3.3 ± 1.8 vs. 6.9 ± 6.6 days, P < .001), shorter operative time (65.9 ± 32.1 vs. 76.0 ± 40.7, P < .001), and more concurrent biliary procedure (46.0% vs. 34.9%, P = .002). CONCLUSIONS: This study supports early cholecystectomy in patients with mild GSP. Even with end organ dysfunction, early cholecystectomy appears to be safe given there is no difference in morbidity and mortality, and the potential benefit of reduced LOS.

Outcomes of Highest Grade (IV and V) Liver Injuries in Blunt and Penetrating Trauma.

BACKGROUND: High-grade hepatic trauma can be devastating, with complications being common if patients survive. Studies comparing outcome differences between blunt and penetrating mechanism are lacking. This study aimed to describe and evaluate the association of traumatic mechanism with complications in patients sustaining grades IV and V liver injuries. METHODS: A retrospective review of all adults who suffered grades IV and V liver injury from 2015-2020 was performed at a level I trauma center in an urban area. Outcomes in patients with blunt and penetrating mechanisms were compared. RESULTS: A total of 103 patients were included, of which 44 (43%) were penetrating and the remainder blunt. Patients with penetrating injuries were younger, more often male, and more likely to undergo initial operative management (82% vs 40%, P < .001). Regardless of mechanism, high grade liver injuries had similar rates of complications, including bile leak (17% vs 23%, P = .559) and intrabdominal abscess (7% vs 16%, P = .239), and similar need for endoscopic retrograde cholangiopancreatography (12% vs 19%, P = .379). Penetrating injuries required more re-interventions (42% vs 19%, P = .033), specifically more percutaneous drainage procedures (36% vs 12%, P = .016). Overall mortality was 29% and did not differ by mechanism. DISCUSSION: Morbidity and mortality are high for grades IV and V liver injuries. Penetrating high-grade hepatic injuries are more likely to be managed operatively, but mortality and overall complications are similar to blunt mechanisms. This may allow for uniform algorithms to define management strategies regardless of mechanism.

Characteristics of Vitamin B12 Deficiency in Patients With Plasma Cell Disorders.

BACKGROUND: Although increased rates of vitamin B12 deficiency have been reported in patients with plasma cell dyscrasias (PCDs), no mechanism has been identified. Excess free light chains (FLCs) could disrupt the renal proximal tubule receptors where B12 is reabsorbed. We sought to characterize the relationship between B12 deficiency and PCDs. We hypothesized that rates of B12 deficiency would be highest in patients with PCDs with high FLC burdens. METHODS: We reviewed the electronic medical records of 501 patients who met inclusion criteria (diagnosed PCD with documented serum B12 and FLC levels) to obtain clinical data recorded prior to patients' lowest B12 levels. RESULTS: Overall, 20.0% of patients had low vitamin B12. There was an expected negative correlation between estimated glomular filtration rate and FLC (rs = -0.317; P < .001). However, low B12 levels were more prevalent in patients with preserved renal function (P = .047). Low B12 was associated with lower mean corpuscular volume (P = .037). CONCLUSION: Higher FLC burden was associated with poor kidney function but not with low B12. Low B12 was seen more commonly in patients with preserved kidney function. Mean corpuscular volume was statistically but not clinically different between patients with low and normal B12 and, therefore, may not be a reliable indicator of B12 deficiency in PCDs. Prospective studies should compare B12 metabolites with FLC levels. Detection of B12 deficiency among patients with PCDs remains important to reduce neurologic dysfunction and cytopenias, sequelae common to B12 deficiency and PCDs.

Patient-, provider-, and system-level factors in low adherence to surveillance colonoscopy guidelines: implications for future interventions.

PURPOSE: Patients with a history of advanced adenomas are at increased risk of developing colorectal cancer (CRC), yet rates of adherence to current surveillance colonoscopy guidelines are poor. We determined rates of referral and adherence to 3-year interval surveillance colonoscopy in patients with advanced adenomas and identified modifiable factors as possible intervention targets to improve surveillance referral and adherence in these at-risk patients. METHODS: We reviewed electronic medical records (EMR) of patients (N = 103) who had pathology findings on screening colonoscopy that warranted a 3-year surveillance colonoscopy. We abstracted demographics, surveillance colonoscopy completion rate, documentation of initial pathology in the "Problem List" of the EMR, and timing and nature of visits to a primary care physician (PCP). RESULTS: Only 22 (21.4 %) patients had a record of surveillance colonoscopy completion. Among non-completers, 50.6 % of patients had no PCP visit within a year of their surveillance due date, 19.8 % saw a PCP and were not referred, and 29.6 % saw a PCP and were referred to either a gastroenterology consultation or a surveillance colonoscopy. Pathology found on initial screening was noted in the Problem List of 77.3 % of completers but only 33.3 % of non-completers (p ≤ 0.001). CONCLUSIONS: Possible targets for interventions include using EMRs to improve physician communication and encouraging patients to have timely PCP visits and follow-through after colonoscopy referral. Clinical studies in this area have the potential to improve outcomes for patients by reducing CRC mortality through early detection.

Increasing colonoscopy screening for Latino Americans through a patient navigation model: a randomized clinical trial.

Latinos have a higher rate of mortality and lower rate of colorectal cancer (CRC) screening than most racial groups in the United States. This study examines the predictors of screening colonoscopy (SC) for CRC among Latinos in a patient navigation (PN) intervention. Participants were randomized to either a culturally-targeted PN group (n = 225) or a standard PN group (n = 167). Each completed an interview assessing sociodemographic and intrapersonal information. There was no difference in SC completion between PN groups (80.9 and 79.0 %). Logistic regression revealed that low language acculturation (OR = 2.22) and annual income above $10,000 (OR = 1.97) were independent predictors of completion. Both standard and culturally-targeted PN successfully increased SC completion by nearly 30 % above the recent estimation for physician-referred patients. Our findings suggest a need to further reduce barriers to SC in low income and highly acculturated Latino groups.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial.

BACKGROUND: Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats. METHODS: In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information. RESULTS: Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion. CONCLUSIONS: In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content. IMPACT: Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.