Using the win ratio to compare laparoscopic versus open liver resection for colorectal cancer liver metastases.

Background: We sought to assess the overall benefit of laparoscopic versus open hepatectomy for treatment of colorectal liver metastases (CRLMs) using the win ratio, a novel methodological approach. Methods: CRLM patients undergoing curative-intent resection in 2001-2018 were identified from an international multi-institutional database. Patients were paired and matched based on age, number and size of lesions, lymph node status and receipt of preoperative chemotherapy. The win ratio was calculated based on margin status, severity of postoperative complications, 90-day mortality, time to recurrence, and time to death. Results: Among 962 patients, the majority underwent open hepatectomy (n=832, 86.5%), while a minority underwent laparoscopic hepatectomy (n=130, 13.5%). Among matched patient-to-patient pairs, the odds of the patient undergoing laparoscopic resection "winning" were 1.77 [WR: 1.77, 95% confidence interval (CI): 1.42-2.34]. The win ratio favored laparoscopic hepatectomy independent of low (WR: 2.94, 95% CI: 1.20-6.39), medium (WR: 1.56, 95% CI: 1.16-2.10) or high (WR: 7.25, 95% CI: 1.13-32.0) tumor burden, as well as unilobar (WR: 1.71, 95% CI: 1.25-2.31) or bilobar (WR: 4.57, 95% CI: 2.36-8.64) disease. The odds of "winning" were particularly pronounced relative to short-term outcomes (i.e., 90-day mortality and severity of postoperative complications) (WR: 4.06, 95% CI: 2.33-7.78). Conclusions: Patients undergoing laparoscopic hepatectomy had 77% increased odds of "winning". Laparoscopic liver resection should be strongly considered as a preferred approach to resection in CRLM patients.

Association of County-level Upward Economic Mobility with Stage at Diagnosis and Receipt of Treatment Among Patients Diagnosed with Pancreatic Adenocarcinoma.

OBJECTIVE: Determining the impact of county-level upward economic mobility on stage at diagnosis and receipt of treatment among Medicare beneficiaries with pancreatic adenocarcinoma. SUMMARY BACKGROUND DATA: The extent to which economic mobility contributes to socioeconomic disparities in health outcomes remains largely unknown. METHODS: Pancreatic adenocarcinoma patients diagnosed in 2004-2015 were identified from the SEER-Medicare linked database. Information on countylevel upward economic mobility was obtained from the Opportunity Atlas. Its impact on early-stage diagnosis (stage I or II), as well as receipt of chemotherapy or surgery was analyzed, stratified by patient race/ethnicity. RESULTS: Among 25,233 patients with pancreatic adenocarcinoma, 37.1% (n = 9349) were diagnosed at an early stage; only 16.7% (n = 4218) underwent resection, whereas 31.7% (n = 7996) received chemotherapy. In turn, 10,073 (39.9%) patients received any treatment. Individuals from counties with high upward economic mobility were more likely to be diagnosed at an earlier stage (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.25), as well as to receive surgery (OR 1.58, 95% CI 1.41-1.77) or chemotherapy (OR 1.51, 95% CI 1.39-1.63). White patients and patients who identified as neither White or Black had increased odds of being diagnosed at an early stage (OR 1.12, 95% CI 1.02-1.22 and OR 1.35, 95% CI 1.02-1.80, respectively) and of receiving treatment (OR 1.73, 95% CI 1.59-1.88 and OR 1.49, 95% CI 1.13-1.98, respectively) when they resided in a county of high vs low upward economic mobility. The impact of economic mobility on stage at diagnosis and receipt of treatment was much less pronounced among Black patients (high vs low, OR 1.28, 95% CI 0.96-1.71 and OR 1.30, 95% CI 0.99-1.72, respectively). CONCLUSIONS: Pancreatic adenocarcinoma patients from higher upward mobility areas were more likely to be diagnosed at an earlier stage, as well as to receive surgery or chemotherapy. The impact of county-level upward mobility was less pronounced among Black patients.

Telehealth Utilization Among Surgical Oncology Patients at a Large Academic Cancer Center.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth within medicine. Data on sociodemographic and clinical characteristics associated with telehealth utilization among cancer surgical patients have not been well-defined. METHODS: Cancer patients who had a surgical oncology visit at the James Cancer Hospital in March 2020-May 2021 were included. Patient demographic and clinical characteristics were recorded; access to modern information technology was measured using the Digital Divide Index (DDI). A logistic regression model was used to assess odds of receiving a telehealth. RESULTS: Among 2942 patients, median DDI was 18.2 (interquartile range 17.4-22.1). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.98 per 10-year increase), sex (male vs. female: OR 1.83, 95% CI 1.45-2.32), cancer type (pancreatic vs. breast: OR 9.19, 95% CI 6.38-13.23; colorectal vs. breast: OR 5.31, 95% CI 3.71-7.58), insurance type (Medicare vs. Medicaid: OR 1.58, 95% CI 1.04-2.41) and county of residence (distant vs. neighboring: OR 1.33, 95% CI 1.06-1.66) were associated with increased odds of receiving a telehealth visit. Patients from high DDI counties were not less likely to receive telehealth visits versus patients from low DDI counties (OR 1.15, 95% CI 0.85-1.57). CONCLUSIONS: Several patient sociodemographic and clinical characteristics had an impact on the likelihood of receiving a telehealth visit versus an in-person visit, suggesting that telehealth may not be equally accessible to all surgical oncology patients.

Burnout Assessment Among Surgeons and Surgical Trainees During the COVID-19 Pandemic: A Systematic Review.

BACKGROUND: The objective of the current study was to summarize current research on burnout among surgical trainees and surgeons during the COVID-19 pandemic. METHODS: PubMed, SCOPUS, Embase, and Psych INFO were systematically searched for studies that evaluated burnout during the COVID-19 pandemic among surgical trainees and surgeons. RESULTS: A total of 29 articles met inclusion criteria, most of which originated from the United States (n = 18, 62.1%). Rates of burnout ranged from 6.0% to 86.0%. Personal factors responsible for burnout were fear of contracting/transmitting COVID-19 (8 studies, 27.6%), female gender (8, 27.6%), and younger age (5, 17.2%). Professional factors contributing to burnout included increased COVID-19 patient clinical load (6, 20.7%), limited work experience (6, 20.7%), reduction in operative cases (5, 17.2%) and redeployment to COVID-19 wards (4, 13.8%). The COVID-19 pandemic negatively impacted surgical education due to reduced number of operative cases (11, 37.9%), decreased hands-on experience (4, 13.8%), and not being able to complete case requirements (3, 10.34%). The shift of didactics to virtual formats (3, 10.3%), increased use of telemedicine (2, 6.9%), and improved camaraderie among residents (1, 3.4%) were viewed as positive consequences. CONCLUSION: COVID-19 related burnout was reported in as many as 1 in 2 surgical trainees and attending surgeons. Intrinsic- (i.e., gender, age), family- (i.e., family/being married/having children or being single/not having children), as well as work-related extrinsic- (i.e., work-force deployment, risk of infection/spread, changes in educational format) factors were strongly associated with risk of burnout. These factors should be considered when designing interventions to ameliorate burnout among surgical trainees and surgeons.

Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis.

INTRODUCTION: Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach. METHODS: Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission. RESULTS: Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14). CONCLUSIONS: MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.

Association of County-Level Upward Economic Mobility with Stage at Diagnosis and Receipt of Curative-Intent Treatment among Patients with Hepatocellular Carcinoma.

BACKGROUND: Upward economic mobility represents the ability of children to surpass their parents financially and improve their economic status. The extent to which it contributes to socioeconomic disparities in health outcomes remains largely unknown. METHODS: Patients diagnosed with hepatocellular carcinoma (HCC) in 2004-2015 were identified from the SEER-Medicare linked database. Information on county-level upward economic mobility was obtained from the Opportunity Atlas, and its impact on early-stage diagnosis (tumor size ≤ 5 cm, no nodal involvement or distant metastases, no major vascular invasion or extrahepatic extension) and receipt of curative-intent treatment (resection, transplantation, or ablation) was examined. RESULTS: Among 9190 Medicare beneficiaries diagnosed with HCC, the majority were White (64.9%, n = 5965). Overall, 44.7% (n = 4105) of patients were diagnosed with early-stage HCC and 29.7% (n = 2731) underwent curative-intent treatment. While higher upward economic mobility was not associated with HCC diagnosis at an early stage (OR 0.94, 95% CI 0.83-1.06), patients with early-stage HCC from areas of high upward economic mobility had increased odds of undergoing curative-intent treatment (OR 1.25, 95% CI 1.03-1.51). Upward economic mobility had no impact on the likelihood to undergo curative-intent treatment for early-stage HCC among White (OR 1.15, 95% CI 0.91-1.45), Black (OR 1.94, 95% CI 0.85-4.45) or Asian patients (OR 0.77, 95% CI 0.44-1.36). In contrast, non-White patients other than Blacks or Asians diagnosed with early-stage HCC had markedly higher odds of receiving curative-intent treatment if the individual resided in an area characterized by higher versus lower upward economic mobility (OR 2.58, 95% CI 1.50-4.46). CONCLUSIONS: While community-level economic mobility was not associated with stage of diagnosis, it affected the likelihood of undergoing curative-intent treatment for early-stage HCC, especially among minority patients other than Black or Asian patients.

Impact of neighborhood characteristics on textbook outcome following major surgery.

BACKGROUND: The aim of the current study was to determine the impact of neighborhood characteristics on textbook outcome (TO) following surgery. METHODS: Medicare beneficiaries undergoing AAA repair, CABG, colectomy, or lung resection. Neighborhood characteristics associated with TO were identified. RESULTS: Among 852,128 Medicare beneficiaries, a 10% increase in the mean percentage of college or advanced degree residents (OR:1.04, 95% CI = 1.04-1.05) was associated with 4% greater odds of a TO, whereas 2% lower odds of TO were noted with a 10% increase in the mean percentage of single-parent households (OR: 0.98, 95% CI = 0.97-0.99). Of note, the highest odds of an extended LOS (OR:1.06, 95% CI: 1.05-1.06) and 90-d mortality (OR: 1.05, 95% CI: 1.04-1.06) were observed with single-parent households. CONCLUSIONS: Among patients undergoing a range of common surgical procedures, increases in college or advanced degrees residents and a decrease in single-parent households led to significantly higher odds of achieving a TO.

Financial Impact of Out-of-Pocket Costs Among Patients Undergoing Resection for Colorectal Carcinoma.

INTRODUCTION: Little is known about the societal burden of cancer surgical care in terms of out-of-pocket (OOP) costs. The current study sought to define OOP costs incurred by patients undergoing colorectal cancer resection. METHODS: Privately insured patients undergoing colorectal cancer resection between 2013 and 2017 were identified from the IBM MarketScan database. Total and OOP costs were calculated within 1 year prior to and 1 year post surgery. A multivariable linear regression model was used to estimate total OOP costs relative to patient demographic and clinical characteristics. RESULTS: Among 10,935 patients, 7289 (66.7%) had primary colon cancer while 3643 (33.3%) had rectal cancer. Median total costs were US$93,967 (IQR US$51027-168,251). Median OOP costs were US$4417 (IQR US$2519-6943), or 4.5% (IQR 2.2-8.1%) of total costs. OOP costs varied over the course of patient care; specifically, median OOP costs in the preoperative period were US$432 (IQR US$130-1452) versus US$2146 (IQR US$851-3525) in the perioperative period and US$969 (IQR US$327-2239) in the postoperative period. On multivariable analysis, receipt of chemotherapy (+US$1368, 95%CI +US$1211 to +US$1525) or radiotherapy (+US$842, 95% CI +US$626 to +US$1059) was associated with higher total OOP costs. Patients with a health maintenance organization (HMO) (-US$2119, 95% CI -US$2550 to -US$1689) or a point-of-service plan (-US$938, 95% CI -US$1385 to -US$491) had lower total OOP costs than patients with comprehensive insurance. In contrast, patients with a consumer-driven or a high-deductible health plan had considerably higher total OOP costs than patients with comprehensive insurance (+US$1400, 95% CI +US$972 to +US$1827 and +US$3243, 95% CI +US$2767 to +US$3717, respectively). CONCLUSIONS: Privately insured colorectal cancer patients undergoing surgical resection pay a median of US$4417 in OOP costs, or 4.5% of total costs. OOP costs varied with receipt of chemotherapy or radiotherapy, region of residence, and insurance plan type.

Machine Learning Approach to Stratifying Prognosis Relative to Tumor Burden after Resection of Colorectal Liver Metastases: An International Cohort Analysis.

BACKGROUND: Assessing overall tumor burden on the basis of tumor number and size may assist in prognostic stratification of patients after resection of colorectal liver metastases (CRLM). We sought to define the prognostic accuracy of tumor burden by using machine learning (ML) algorithms compared with other commonly used prognostic scoring systems. STUDY DESIGN: Patients who underwent hepatectomy for CRLM between 2001 and 2018 were identified from a multi-institutional database and split into training and validation cohorts. ML was used to define tumor burden (ML-TB) based on CRLM tumor number and size thresholds associated with 5-year overall survival. Prognostic ability of ML-TB was compared with the Fong and Genetic and Morphological Evaluation scores using Cohen's d. RESULTS: Among 1,344 patients who underwent resection of CRLM, median tumor number (2, interquartile range 1 to 3) and size (3 cm, interquartile range 2.0 to 5.0) were comparable in the training (n = 672) vs validation (n = 672) cohorts; patient age (training 60.8 vs validation 61.0) and preoperative CEA (training 10.2 ng/mL vs validation 8.3 ng/mL) was also similar (p > 0.05). ML empirically derived optimal cutoff thresholds for number of lesions (3) and size of the largest lesion (1.3 cm) in the training cohort, which were then used to categorize patients in the validation cohort into 3 prognostic groups. Patients with low, average, or high ML-TB had markedly different 5-year overall survival (51.6%, 40.9%, and 23.1%, respectively; p < 0.001). ML-TB was more effective at stratifying patients relative to 5-year overall survival (low vs high ML-TB, d = 2.73) vs the Fong clinical (d = 1.61) or Genetic and Morphological Evaluation (d = 0.84) scores. CONCLUSIONS: Using a large international cohort, ML was able to stratify patients into 3 distinct prognostic categories based on overall tumor burden. ML-TB was noted to be superior to other CRLM prognostic scoring systems.

Fragmentation of practice: The adverse effect of surgeons moving around.

BACKGROUND: Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome. METHOD: Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis. RESULTS: Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05). CONCLUSION: Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery.

BACKGROUND: There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery. METHODS: Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome. RESULTS: Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4. CONCLUSION: Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.

Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients?

BACKGROUND AND OBJECTIVES: Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients. METHODS: Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy. RESULTS: Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p < 0.05). The odds of achieving a TOO improved over time (p-trend < 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45). CONCLUSIONS: Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery.

BACKGROUND: Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery. METHODS: Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined. RESULTS: Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]FPC vs 72 years [interquartile range: 68-77]non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]FPC vs 3 [interquartile range: 2-8]non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]FPC vs 51.3 [interquartile range: 27.9-69.4]non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84). CONCLUSION: Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

Association of Community Economic Distress and Breast and Colorectal Cancer Screening, Incidence, and Mortality Rates Among US Counties.

INTRODUCTION: Not all Americans may benefit equally from current improvements in breast and colorectal cancer screening and mortality rates. METHODS: We performed a cross-sectional retrospective review of county-level screening, incidence, and mortality rates for breast and colon cancer utilizing three publicly available data sources from the Centers for Disease Control and Prevention (CDC), and their association with the Distressed Communities Index (DCI), a measure of local economic prosperity across communities. RESULTS: After controlling for other factors, DCI was associated with county-level screening, incidence, and death rates per 100,000 for breast and colorectal cancer. There was an absolute increase of 0.77 (95% confidence interval [CI] 0.67-0.85, p < 0.001) in the proportion of women aged 40 years or older who had a screening mammogram for every 10-point decrease in DCI, which in turn correlated with an increase in the age-adjusted incidence by 1.68 per 100,000 (95% CI 1.37-2.00, p < 0.001). While the age-adjusted death rate for breast cancer was highest in the most distressed communities, the overall incidence of age-adjusted death decreased by 0.28 per 100,000 (95% CI -0.37 to -0.19, p < 0.001) with every 10-point decrease in DCI. For colorectal cancer, every 10-point decrease in DCI was similarly associated with an absolute 0.60 (95% CI 0.52-0.69, p < 0.001) increase in the proportion of individuals who had screening endoscopy. Increased colorectal screening in low-DCI counties was associated with a lower age-adjusted incidence rate (-0.80 per 100,000; 95% CI -0.94 to -0.65) and age-adjusted death rate (-0.55 per 100,000; 95% CI -0.62 to -0.49) of colorectal cancer per every 10-point decrease in DCI (p < 0.001). CONCLUSION: The association of county-level socioeconomic and healthcare factors with breast and colorectal cancer outcomes was notable, with level of community distress impacting cancer screening, incidence, and mortality rates.

Patterns of health care utilization among Medicare beneficiaries diagnosed with pancreatic adenocarcinoma.

BACKGROUND: Care patterns among patients diagnosed with pancreatic adenocarcinoma remain poorly defined. METHODS: Cluster analysis was performed on patients with pancreatic adenocarcinoma to assess time from diagnosis to death spent in different care settings (home self-care-dominant[HSC], acute in-hospital care-dominant[ACS], hospice care-dominant[HC] or mixed home and hospice care[MHH]). RESULTS: Among 32,816 patients, most belonged to the HSC group (n = 13,459, 41%), followed by MHH (n = 9,091, 28%), ACS (n = 5,737, 18%) and HC (n = 4,529, 14%). Only about 1 in 3 patients in the HSC (n = 4,028, 30%) or ACS (n = 2,206, 35%) received hospice services for at least one week before death. 16% of patients (n = 5,188) died in the hospital, which was most common among ACS patients (n = 1,640, 29%). Median daily expenditures varied according to health care utilization (HSC, $44.6, IQR 12.3-130.1 vs MHH, $162.3, IQR 60.5-351.9 vs ACS, $489.7, IQR 243.2-856.8 vs HC, $306.1, IQR 132.3-580.0; p < 0.001). CONCLUSIONS: Pancreatic adenocarcinoma patients differed with regards to health care utilization, hospice use and expenditures following diagnosis.