Survival Outcomes and Patterns of Care for Stage II or III Resected Gastric Cancer by Race and Ethnicity.

Importance: Many multimodality treatment regimens exist for gastric adenocarcinoma, including neoadjuvant vs adjuvant chemotherapy, radiation, or both. Neoadjuvant therapy is recommended in the United States for patients with locally advanced gastric cancer; however, it is unknown whether the outcomes of neoadjuvant therapy are associated with race and ethnicity. Objective: To evaluate the differences in outcomes by race and ethnicity of patients with noncardia gastric cancer undergoing surgical procedures with and without neoadjuvant therapy. Design, Setting, and Participants: This retrospective cohort study examined the National Cancer Database from the American College of Surgeons for patients with clinical stage II or III gastric adenocarcinoma, excluding gastric cardia tumors, undergoing surgical resection procedures from January 2006 to December 2019. Statistical analysis was performed from December 2021 to May 2023. Exposure: Patients were stratified by race and ethnicity, and their outcomes were analyzed for those who received and did not receive neoadjuvant therapy. Main Outcomes and Measures: The Cox proportional hazard model was used to compare overall survival (OS) between racial and ethnic groups (Asian, Black, Hispanic, and White) overall and according to receipt of neoadjuvant therapy. Among those who received neoadjuvant therapy, proportional differences in pathological responses were calculated in each group. Results: Among a total of 6938 patients in the cohort, 4266 (61.4%) were male; mean (SD) age was 65.9 (12.8) years; 1046 (15.8%) were Asian, 1606 (24.3%) were Black, 1175 (17.8%) were Hispanic, and 3540 (53.6%) were White. Compared with other races and ethnicities, the group of White patients had significantly more who were 65 years or older with more comorbidities. White patients underwent surgical resection procedures alone without neoadjuvant or adjuvant therapy more frequently than other races and ethnicities. Asian and Black patients had the highest proportion of being downstaged or achieving pathological complete response after neoadjuvant therapy. In multivariate models, perioperative chemotherapy was associated with improved OS (HR, 0.79 [95% CI, 0.69-0.90]), whereas number of positive lymph nodes and surgical margins were associated with the largest decreases in OS. Asian and Hispanic race and ethnicity were associated with significantly improved OS compared with Black and White races (eg, Asian patients: HR, 0.64 [95% CI, 0.58-0.72]; and Hispanic patients: HR, 0.77 [95% CI, 0.69-0.85]). Black race was associated with improved OS compared with White race when receiving neoadjuvant therapy (HR, 0.78 [95% CI, 0.67-0.90]). Conclusions and Relevance: In this large nationwide cohort study of survival outcomes among patients with resected clinical stage II or III gastric cancer, there were significant differences in response to treatment and OS between different racial and ethnic groups.

Hepatitis B virus screening in Asian immigrants: Community-based campaign to increase screening and linkage to care: A cross-sectional study.

Background and Aims: Despite established screening guidelines, many Asian immigrants remain unscreened. Furthermore, those with chronic hepatitis B (CHB) are not linked to care citing multiple barriers. The objective of this study was to determine the role of our community-based hepatitis B virus (HBV) campaign on HBV screening and the success of linkage to care (LTC) efforts. Methods: Asian immigrants from the New Jersey and New York metropolitan areas were screened for HBV from 2009 to 2019. We started to collect LTC data starting in 2015, and those found to be positive were followed up. In 2017, because of low LTC rates, nurse navigators were hired to aid in the LTC process. Those excluded from the LTC process included those who were already linked to care, declined, and/or had moved or passed away. Results: Total of 13,566 participants were screened from 2009 to 2019, of which, the results for 13,466 were available. Of these, 372 (2.7%) were found to have positive HBV status. Approximately 49.3% were female and 50.1% were male, and the rest were of unknown gender. A total of 1191 (10.0%) participants were found to be HBV negative but required vaccination. When we started to track LTC, we found 195 participants that were eligible for LTC between 2015 and 2017 after the exclusion criteria were applied. It was found that only 33.8% were successfully linked to care in that time period. After hiring nurse navigators, we saw LTC rates increase to 85.7% in 2018 and to 89.7% in 2019. Conclusion: HBV community screening initiatives are imperative to increase screening rates in the Asian immigrant population. We were also able to demonstrate that nurse navigators can successfully help increase LTC rates. Our HBV community screening model can address issues with barriers to care including lack of access in comparable populations.

Preventive Cancer Screening in Asian Americans: Need for Community Outreach Programs.

BACKGROUND: Asian Americans (AA) are the only racial group in the United States to experience cancer as the number one cause of mortality. Yet, Asian Americans have one of the lowest rates of cancer screenings of all minority groups in the United States. METHODS: A cross-sectional and population-based study design was used. Cross-sectional data was collected from 1,650 AA participants via a survey given during two annual community health festivals in 2017 and 2018. Survey variables included sociodemographic measures, self-reported English-language proficiency level, access to primary care, attitudes on preventative cancer screening, current screening status and barriers to undergoing cancer screening. RESULTS: Nearly 66% (n=1,081) reported not having a primary care physician (PCP). While the majority of the participants (n=1,510, 92%) stated that preventative cancer screenings were important, only a small portion (n=1,091, 16%) were up-to-date on cancer screening procedures. The biggest barriers to preventative cancer screening were: 1) Lack of insurance (n=840, 40%); 2) Cost of seeing a physician (n=517, 24%); and 3) Do not feel the need (n=299, 14%). CONCLUSIONS: To overcome the barriers we identified and effectively increase cancer screenings in Asian Americans, community outreach should be considered to provide linkage to primary care physicians and navigation to low-cost screening programs.

Integrating hepatitis C virus screening of baby boomers at a community hospital emergency department.

Approximately 2.4 million Americans are infected with hepatitis C virus (HCV), and persons born from 1945 through 1965 (i.e. baby boomers) account for nearly three-fourths of all HCV infections. The purpose of this study was to implement HCV screening for baby boomers presenting to a community hospital emergency department (ED) and to facilitate linkage to care. We developed a process within our electronic medical record system to screen patients for HCV testing eligibility, link eligible patients to laboratory orders, notify patients of HCV test results (via patient navigator) and track follow-up care. We tracked performance from February 2016 to December 2018. Sociodemographic compositions and linkage to care rates of all participants were evaluated. A total of 14,927 patients from the birth cohort of 1945-1965 were screened for HCV. Of those tested, 555 (3.7%) had a positive HCV antibody test and 147 were HCV RNA-positive patients (1.0%) demonstrating that only 27% of HCV antibody-positive individuals were chronically infected. Males, black race and USA-born baby boomers had a higher prevalence of HCV antibody and viral load positivity (p < 0.05). Initially, only 17.6% of patients were ultimately linked to care, which improved to over 94% after the implementation of patient navigation support. There is a need for HCV screening protocol in the community. The cost of implementing an HCV screening programme must include information technology and a team of care coordinators to improve screening rates and facilitate linkage to continual care using the four pillars framework.

Rectal bleeding and endoscopy need in Sierra Leone: results of a nationwide, community-based survey.

BACKGROUND: Low-income and middle-income countries (LMICs) face a large burden of gastrointestinal diseases that benefit from prompt endoscopic diagnosis and treatment. This study aimed to estimate the prevalence of gross rectal bleeding among adults in Sierra Leone. METHODS: A cluster randomised, cross-sectional household survey using the SOSAS tool was undertaken in Sierra Leone. 75 clusters of 25 households with two randomly selected respondents in each were sampled to estimate the prevalence of and disability from rectal bleeding. Barriers to care were also assessed. FINDINGS: 3645 individuals responded to the survery, 15 with rectal bleeding. Nine responders (64%) had been bleeding for more than a year. The prevalence of rectal bleeding was 412 per 100 000 people. In view of these findings, an estimated 24 604 individuals with rectal bleeding are in need of evaluation in Sierra Leone. Eight (53%) of the 15 people with rectal bleeding sought care from a traditional healer. If medical care was not sought, the most common reason was absence of financial resources (ten people; 77%), followed by no capable facility availability (two; 15%), and inability to leave work or family for the time needed (one; 8%). Seven (54%) of those with rectal bleeding reported some form of disability, including five (39%) that had bleeding that prevented usual work. INTERPRETATION: The high prevalence of rectal bleeding identified in Sierra Leone represents a major unmet health-care need. This study did not examine the cause of bleeding. However, the high prevalence, chronicity, and disability among respondents with bleeding suggest a substantial burden of disease. Additionally, because microscopic haematochezia was not assessed, these data represent a bare-minimum estimate of rectal bleeding in need of evaluation and treatment. In view of the substantial burden of conditions that can be diagnosed, treated, or palliated with timely endoscopic therapy, it is appropriate to consider endoscopy among efforts to develop health system capacity in LMICs. FUNDING: Surgeons OverSeas, the Thompson Family Foundation, and the Fogarty International Center.

Surgical management of hepatocellular carcinoma after Fontan procedure.

The Fontan operation has successfully prolonged the lives of patients born with single-ventricle physiology. A long-term consequence of post-Fontan elevation in systemic venous pressure and low cardiac output is chronic liver inflammation and cirrhosis, which lead to an increased risk of hepatocellular carcinoma (HCC). Surgical management of patients with post-Fontan physiology and HCC is challenging, as the requirement for adequate preload in order to sustain cardiac output conflicts with the low central venous pressure (CVP) that minimizes blood loss during hepatectomy. Consequently, liver resection is rarely performed, and most reports describe nonsurgical treatments for locoregional control of the tumors in these patients. Here, we present a multidisciplinary approach to a successful surgical resection of a HCC in a patient with Fontan physiology.

Pediatric specialist care is associated with a lower risk of bowel resection in children with intussusception: a population-based analysis.

BACKGROUND: Although previous studies have shown that radiologic intussusception reduction is more likely at children's hospitals, no study to date has compared outcomes among children advancing to surgical intervention. We hypothesized that rates of bowel resection would differ between hospitals with and without pediatric surgeons. STUDY DESIGN: We conducted a population-based retrospective cohort study using Washington State discharge records. All children younger than 18 years undergoing operative intussusception reduction between 1999 and 2009 were included (n = 327). Data were collected on demographics, disease severity, comorbidities, and concomitant gastrointestinal pathology. Multivariate logistic regression was used to estimate odds of intestinal resection during operative intussusception reduction. RESULTS: Pediatric hospitals treated a smaller proportion of children older than 4 years of age (12.1% vs 44.4%), as well as a greater proportion of Medicaid patients (50.9% vs 42.6%). Patients at pediatric hospitals had a lower prevalence of underlying intestinal anomalies or identifiable mass lesions (14.3% vs 16.7%). "Severe disease" (perforation, ischemia, acidosis) was more common at pediatric hospitals (17.6% vs 9.3%). Overall, bowel resection was more commonly performed at nonpediatric hospitals (59.3% vs 33.0%). On multivariate analysis, the odds of bowel resection were significantly lower at pediatric compared with nonpediatric hospitals (odds ratio [OR] 0.20, p < 0.001), and this association was strongest in younger patients. Adjusted odds of postoperative complications were greater for bowel resection patients (OR 2.83, p < 0.001). CONCLUSIONS: Bowel resection during operative intussusception reduction is more likely at hospitals without pediatric surgeons, and is associated with increased complications. Improved outcomes may be achieved by efforts aimed at standardizing care and decreasing variability in the treatment of pediatric intussusception.

Nationally representative household survey of surgery and mortality in Sierra Leone.

BACKGROUND: There is limited evidence to characterize the burden of unmet need of surgical diseases in low- and middle-income countries. The purpose of this study was to determine rate of deaths attributable to a surgical condition and reasons for not seeking surgical care in Sierra Leone. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a survey tool developed collaboratively to be used for cross-sectional data collection of the prevalence of surgical conditions in any country. A population-weighted cluster-sample household survey was conducted throughout Sierra Leone in 2012 using the SOSAS survey tool. RESULTS: Total of 1,840 households (11,870 individuals) were sampled, yielding a 98.3 % response rate. Overall, there were 709 total deaths reported (6.0 %). The mean age at death was 36.4 ± 30.1 years: 330 (46.6 %) were female. Most deaths occurred at home (58.1 % vs. 34.1 % in hospitals). Of the 709 deaths, 237 (33.4 %) were associated with conditions included in our predefined surgical disease category. Abdominal distension/pain was the most commonly associated surgical condition (13.9 %) followed by perinatal bleeding/illness (6.0 %). Among the 237 with surgical conditions, 51 (21.9 %) did not seek medical care, most commonly because of a lack of money (35.3 %) or inability to provide timely care (37.3 %). CONCLUSIONS: A large proportion of deaths in Sierra Leone was associated with surgical conditions, the majority of which did not undergo surgical intervention. Our results indicate that to remove barriers to effective surgical care in Sierra Leone policymakers should first focus on relieving financial burdens and increasing access to timely surgical care.

Akt and mTORC1 have different roles during liver tumorigenesis in mice.

BACKGROUND & AIMS: Phosphatidylinositide 3-kinase (PI3K) is deregulated in many human tumor types, including primary liver malignancies. The kinase v-akt murine thymoma viral oncogene homolog 1 (Akt) and mammalian target of rapamycin complex (mTORC1) are effectors of PI3K that promote cell growth and survival, but their individual roles in tumorigenesis are not well defined. METHODS: In livers of albumin (Alb)-Cre mice, we selectively deleted tuberous sclerosis (Tsc)1, a negative regulator of Ras homolog enriched in brain and mTORC1, along with Phosphatase and tensin homolog (Pten), a negative regulator of PI3K. Tumor tissues were characterized by histologic and biochemical analyses. RESULTS: The Tsc1fl/fl;AlbCre, Ptenfl/fl;AlbCre, and Tsc1fl/fl;Ptenfl/fl;AlbCre mice developed liver tumors that differed in size, number, and histologic features. Livers of Tsc1fl/fl;AlbCre mice did not develop steatosis; tumors arose later than in the other strains of mice and were predominantly hepatocellular carcinomas. Livers of the Ptenfl/fl;AlbCre mice developed steatosis and most of the tumors that formed were intrahepatic cholangiocarcinomas. Livers of Tsc1fl/fl;Ptenfl/fl;AlbCre formed large numbers of tumors, of mixed histologies, with the earliest onset of any strain, indicating that loss of Tsc1 and Pten have synergistic effects on tumorigenesis. In these mice, the combination of rapamycin and MK2206 was more effective in reducing liver cell proliferation and inducing cell death than either reagent alone. Tumor differentiation correlated with Akt and mTORC1 activities; the ratio of Akt:mTORC1 activity was high throughout the course of intrahepatic cholangiocarcinomas development and low during hepatocellular carcinoma development. Compared with surrounding nontumor liver tissue, tumors from all 3 strains had increased activities of Akt, mTORC1, and mitogen-activated protein kinase and overexpressed fibroblast growth factor receptor 1. Inhibition of fibroblast growth factor receptor 1 in Tsc1-null mice suppressed Akt and mitogen-activated protein kinase activities in tumor cells. CONCLUSIONS: Based on analyses of knockout mice, mTORC1 and Akt have different yet synergistic effects during the development of liver tumors in mice.

The impact of accreditation on safety and cost of bariatric surgery.

BACKGROUND: The objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services' national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003-2009). METHODS: We performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments. RESULTS: A total of 30,755 patients (43.9 ± 11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [-3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543 ± $40,145 to $24,510 ± $37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (-.8%; P = .02) and complication rates (-2.7%; P = .01) were lower at the COEs after the NCD. CONCLUSIONS: The accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. BACKGROUND: There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. METHODS: The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. RESULTS: Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. CONCLUSIONS: Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Evaluating the association of preoperative functional status and postoperative functional decline in older patients undergoing major surgery.

This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Preoperative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.

Progress in the diagnosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program.

BACKGROUND AND OBJECTIVES: Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis, safely reducing negative appendectomies (NAs); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. METHODS: Data were collected prospectively for consecutive appendectomy patients (age > 15 years) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiological, operative, and pathological reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. RESULTS: Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, it was 15.4% (P < 0.001). This association was consistent for men (3% vs 10%, P < 0.001) and for women of reproductive age (6.9% vs 24.7%, P < 0.001). In a multivariate model adjusted for age, sex, and white blood cell count, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95% CI: 3.0-4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. CONCLUSIONS: Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change.

Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. DESIGN: Observational, prospectively designed cohort study. SETTING: Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). PATIENTS: Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. INTERVENTIONS: Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. MAIN OUTCOME MEASURE: Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. RESULTS: Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). CONCLUSION: Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

Adoption of laparoscopy for elective colorectal resection: a report from the Surgical Care and Outcomes Assessment Program.

BACKGROUND: The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. STUDY DESIGN: The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (ie, death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from the 4th quarter of 2005 through 4th quarter of 2010. RESULTS: Of the 9,705 patients undergoing elective colorectal operations (mean age 60.6 ± 15.6 years; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 4th quarter of 2005 to 41.6% in 4th quarter of 2010 (trend during study period, p < 0.001). After adjustment (for age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size, and urban vs rural location), the risk of transfusions (odds ratio [OR] = 0.52; 95% CI, 0.39-0.7), wound infections (OR = 0.45; 95% CI, 0.34-0.61), and composite of adverse events (OR = 0.58; 95% CI, 0.43-0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a substantial increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, an 80.4% increase) and, in particular, the number of resections for noncancer diagnoses and right-sided pathology. CONCLUSIONS: The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery.

ß-blocker continuation after noncardiac surgery: a report from the surgical care and outcomes assessment program.

BACKGROUND: Despite limited evidence of effect, ß-blocker continuation has become a national quality improvement metric. OBJECTIVE: To determine the effect of ß-blocker continuation on outcomes in patients undergoing elective noncardiac surgery. DESIGN, SETTING, AND PATIENTS: The Surgical Care and Outcomes Assessment Program is a Washington quality improvement benchmarking initiative based on clinical data from more than 55 hospitals. Linking Surgical Care and Outcomes Assessment Program data to Washington's hospital admission and vital status registries, we studied patients undergoing elective colorectal and bariatric surgical procedures at 38 hospitals between January 1, 2008, and December 31, 2009. MAIN OUTCOME MEASURES: Mortality, cardiac events, and the combined adverse event of cardiac events and/or mortality. RESULTS: Of 8431 patients, 23.5% were taking ß-blockers prior to surgery (mean [SD] age, 61.9 [13.7] years; 63.0% were women). Treatment with ß-blockers was continued on the day of surgery and during the postoperative period in 66.0% of patients. Continuation of ß-blockers both on the day of surgery and postoperatively improved from 57.2% in the first quarter of 2008 to 71.3% in the fourth quarter of 2009 (P value <.001). After adjusting for risk characteristics, failure to continue ß-blocker treatment was associated with a nearly 2-fold risk of 90-day combined adverse event (odds ratio, 1.97; 95% CI, 1.19-3.26). The odds were even greater among patients with higher cardiac risk (odds ratio, 5.91; 95% CI, 1.40- 25.00). The odds of combined adverse events continued to be elevated 1 year postoperatively (odds ratio, 1.66; 95% CI, 1.08-2.55). CONCLUSIONS: ß-Blocker continuation on the day of and after surgery was associated with fewer cardiac events and lower 90-day mortality. A focus on ß-blocker continuation is a worthwhile quality improvement target and should improve patient outcomes.