Impact of GLP-1RA on the Risk of Adverse Liver Outcomes Among Patients With Alcohol-Associated Liver Disease and Type 2 Diabetes.

BACKGROUND AND AIMS: We sought to characterise the impact of GLP-1RA on adverse liver outcomes (ALO) among patients with alcohol-associated liver disease (ALD) and Type 2 diabetes mellitus (T2DM). METHODS: Patients with T2DM newly diagnosed with ALD between 2013 and 2020 were identified using IBM MarketScan database and were categorised by GLP-1RA exposure. Overlap propensity score weighting (OPSW) followed by Poisson regression models was used to analyse adjusted risk of ALO, a composite endpoint defined by first occurrence of hepatic decompensation (HD), portal hypertension (PH), hepatocellular carcinoma (HCC) or liver transplantation (LT) relative to GLP-1RA. RESULTS: Among 14 730 patients, most individuals were male (n = 9752, 66.2%) with median age of 57 (IQR 52-61) years; 2.2% (n = 317) of patients had GLP-1RA exposure. Overall, 32.0% (n = 4717) of patients experienced HD, 15.9% (n = 2345) had PH, 3.8% (n = 563) developed HCC, while 2.5% (n = 374) underwent transplantation. Non-GLP-1RA patients had higher incidence of HD (32.2% vs. 22.4%) and HCC (3.9% vs. 0.3%) versus patients taking GLP-1RA (both p < 0.001); in contrast, there was no difference in incidence of PH (14.5% vs. 16.0%) and LT (1.3% vs. 2.6%) (both p > 0.05). After OPSW, overall incidence of ALO was lower in GLP-1RA cohort (GLP-1RA: 12.0%, 95%CI 9.0-16.0 vs. non-GLP-1RA: 21.0%, 95%CI 20.0-22.0) with an absolute incidence risk reduction of 9.0% (95%CI 3.0%-15.0%) associated with GLP-1RA. GLP-1RA was most strongly associated with lower likelihood of HD with reduced adjusted incidence rate of 0.56 (95%CI 0.36-0.86) relative to non-GLP-1RA individuals. CONCLUSIONS: GLP-1RA may have a hepatoprotective impact among patients with ALD and T2DM.

Variation in physician spending and its association with postoperative outcomes among patients undergoing surgery for gastrointestinal cancer.

BACKGROUND: There is significant variation in inpatient expenditures among physicians and hospitals. This study aimed to characterize the association between variation in physician spending and short-term outcomes among patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC). METHODS: Patients who underwent surgery for PDAC and CRC from 2010 to 2020 were identified using the Surveillance, Epidemiology, and End Result-Medicare-linked database. The cohort was divided into quartiles based on adjusted physician spending, and multivariate models were used to assess the association between physician spending and patient outcomes. RESULTS: Among 27,596 Medicare beneficiaries, 25,615 (92.8%) underwent surgery for CRC and 1981 (7.2%) underwent surgery for PDAC. Of the variations in spending, 79.9% were due to patient-level factors, 13.3% were due to hospital characteristics, and 6.8% were due to surgeon-level variables. On multivariate analysis, there was no association between physician spending and 30-day readmission (with complications: first quartile [Q1], reference; Q4: odds ratio [OR], 1.10; 95% CI, 0.86-1.41; P = .123; without complications: Q1, reference; Q3, stage IV: OR, 0.97; 95% CI, 0.68-1.40; P = .882) or between physician spending and 30-day mortality (without complications: Q1, reference; Q2, stage I: OR, 1.17; 95% CI, 0.45-3.01; P = .804). However, an increase in physician spending was associated with higher 30-day mortality among patients with complications (Q1, reference; Q4: OR, 2.28; 95% CI, 1.72-3.03; P < .001). CONCLUSION: There was more variation in healthcare spending across hospitals than across individual physicians. No consistent association between variation in physician spending and patient outcomes was noted. Wasteful spending can be reduced through targeted interventions aimed at reducing variations at the physician and hospital levels.

Preoperative identification of early extrahepatic recurrence after hepatectomy for colorectal liver metastases: A machine learning approach.

BACKGROUND: Machine learning (ML) may provide novel insights into data patterns and improve model prediction accuracy. The current study sought to develop and validate an ML model to predict early extra-hepatic recurrence (EEHR) among patients undergoing resection of colorectal liver metastasis (CRLM). METHODS: Patients with CRLM who underwent curative-intent resection between 2000 and 2020 were identified from an international multi-institutional database. An eXtreme gradient boosting (XGBoost) model was developed to estimate the risk of EEHR, defined as extrahepatic recurrence within 12 months after hepatectomy, using clinicopathological factors. The relative importance of factors was determined using Shapley additive explanations (SHAP) values. RESULTS: Among 1410 patients undergoing curative-intent resection, 131 (9.3%) patients experienced EEHR. Median OS among patients with and without EEHR was 35.4 months (interquartile range [IQR] 29.9-46.7) versus 120.5 months (IQR 97.2-134.0), respectively (p < 0.001). The ML predictive model had c-index values of 0.77 (95% CI, 0.72-0.81) and 0.77 (95% CI, 0.73-0.80) in the entire dataset and the validation data set with bootstrapping resamples, respectively. The SHAP algorithm demonstrated that T and N primary tumor categories, as well as tumor burden score were the three most important predictors of EEHR. An easy-to-use risk calculator for EEHR was developed and made available online at: https://junkawashima.shinyapps.io/EEHR/. CONCLUSIONS: An easy-to-use online calculator was developed using ML to help clinicians predict the chance of EEHR after curative-intent resection for CRLM. This tool may help clinicians in decision-making related to treatment strategies for patients with CRLM.

Impact of Spousal Mental Illness on Healthcare Utilization Among Patients With Gastrointestinal Cancer.

BACKGROUND: Informal caregiving involves increased responsibilities, with financial and emotional challenges, thereby affecting the well-being of the caregiver. We aimed to investigate the effect of spousal mental illness on hospital visits and medical spending among patients with gastrointestinal (GI) cancer. METHODS: Patients who underwent GI cancer surgery between 2013 and 2020 were identified from the IBM Marketscan database. Multivariable regression analysis was used to examine the association between spousal mental illness and healthcare utilization. RESULTS: A total of 6,035 patients underwent GI surgery for a malignant indication. Median age was 54 years (IQR: 49-59), most patients were male (n = 3592, 59.5%), and had a CCI score of ≤ 2 (n = 5512, 91.3%). Of note, in the 1 year follow-up period, 19.4% (anxiety: n = 509, 8.4%; depression: n = 301, 5.0%; both anxiety and depression: n = 273, 4.5%; severe mental illness: n = 86, 1.4%) of spouses developed a mental illness. On multivariable analysis, after controlling for competing factors, spousal mental illness remained independently associated with increased odds of emergency department visits (OR 1.20, 95% CI 1.05-1.38) and becoming a super healthcare utilizer (OR 1.37, 95% CI 1.04-1.79), as well as 12.1% (95% CI 10.6-15.3) higher medical spending. CONCLUSION: Among patients with GI cancer spousal mental illness is associated with higher rates of outpatient visits, emergency department visits, and expenditures during the 1-year postoperative period. These findings underscore the importance of caregiving resources and counseling in alleviating caregiver burden, thereby reducing the overall burden on the healthcare system.

Impact of hospital volume and facility characteristics on postoperative outcomes after hepatectomy: A mediation analysis.

BACKGROUND: The impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy. METHODS: Data on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue. RESULTS: The analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue. CONCLUSIONS: Hospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection.

Clinical Outcomes, Costs, and Value of Surgery Among Older Patients with Colon Cancer at US News and World Report Ranked Versus Unranked Hospitals.

BACKGROUND: US News and World Report (USNWR) hospital rankings influence patient choice of hospital, but their association with surgical outcomes remains ill-defined. We sought to characterize clinical outcomes and costs of surgery for colon cancer among USNWR top ranked and unranked hospitals. METHODS: Using Medicare Standard Analytic Files, patients aged ≥65 years undergoing surgery for colon cancer were identified. Hospitals were categorized as 'ranked' or 'unranked' based on USNWR cancer hospital rankings. One-to-one matching was performed between patients treated at ranked and unranked hospitals, and clinical outcomes and costs of surgery were compared. RESULTS: Among 50 ranked and 2522 unranked hospitals, 13,650 patient pairs were compared. Overall, 30-day mortality was 2.13% in ranked hospitals versus 3.68% in unranked hospitals (p < 0.0001), and the overall paired cost difference was $8159 (p < 0.0001). As patient risk increased, 30-day mortality differences became larger, with the ranked hospitals having 30-day mortality of 7.59% versus 11.84% for unranked hospitals among the highest-risk patients (p < 0.0001). Overall paired cost differences also increased with increasing patient risk, with cost of care being $72,229 for ranked hospitals versus $56,512 for unranked hospitals among the highest-risk patients (difference = $14,394; p = 0.02). The difference in cost per 1% reduction in 30-day mortality was $9009 (95% confidence interval [CI] $6422-$11,597) for lowest-risk patients, which dropped to $3387 (95% CI $2656-$4119) for highest-risk patients (p < 0.0001). CONCLUSION: Treatment at USNWR-ranked hospitals, particularly for higher-risk patients, was associated with better outcomes but higher-cost care. The benefit of being treated at highly ranked USNWR hospitals was most pronounced among high-risk patients.

Upper gastrointestinal cancers: Trends and determinants of location of death.

BACKGROUND: Patients diagnosed with upper gastrointestinal cancers often require extensive end-of-life care. We sought to investigate social determinants of health associated with disparities in the location of death among patients who died of upper gastrointestinal cancers. METHODS: Patients who died between 2003 and 2020 from esophageal cancer, gastric cancer, hepatobiliary cancer, and pancreatic cancer were identified using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Social determinants of health were assessed using the Social Vulnerability Index. Patients were categorized on the basis of location of death: inpatient hospital, home, nursing home, hospice, and outpatient medical facility/emergency department. Multivariable regression and mediation analyses defined the association of patient race as well as social determinants of health with location of death. RESULTS: Among 815,780 decedents (esophageal cancer: 15.3%; gastric cancer: 3.6%; hepatobiliary cancer: 36.6%; pancreatic cancer: 54.5%), most were male (60.8%), aged 55-74 years (52.3%), and White (89.1%). Most decedents died at home (55.7%), followed by inpatient hospital (24.8%), hospice (9.0%), nursing home (8.1%), and outpatient medical facility/emergency department (2.5%). During the study period, location of death shifted notably from inpatient hospital (36.8% to 21.3%) to home (45.8% to 56.3%). Residents of high Social Vulnerability Index areas were more likely to die at inpatient hospital compared with home (31.8% vs 24.3%) (P < .001). Black race (reference: White; odds ratio; 0.41, 95% confidence interval, 0.40-0.42) and social vulnerability (reference: low Social Vulnerability Index; odds ratio, 0.64, 95% confidence interval, 0.63-0.65) remained independently associated with lower odds of dying at home compared with an inpatient hospital. Notably, 65% of the overall race-based association with death at inpatient hospital was driven indirectly through social determinants of health. CONCLUSION: Social determinants are important drivers of end-of-life care and impact the potential ability of patients with cancer to die at home.

The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery.

INTRODUCTION: Environmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social-environmental inequalities were associated with surgical outcomes following a complex operation. METHODS: In this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social-environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social-environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. RESULTS: Among 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social-environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). CONCLUSIONS: Cumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.

Development of an artificial intelligence-based model to predict early recurrence of neuroendocrine liver metastasis after resection.

PURPOSE: We sought to develop an artificial intelligence (AI)-based model to predict early recurrence (ER) after curative-intent resection of neuroendocrine liver metastases (NELMs). METHODS: Patients with NELM who underwent resection were identified from a multi-institutional database. ER was defined as recurrence within 12 months of surgery. Different AI-based models were developed to predict ER using 10 clinicopathologic factors. RESULTS: Overall, 473 patients with NELM were included. Among 284 patients with recurrence (60.0%), 118 patients (41.5%) developed an ER. An ensemble AI model demonstrated the highest area under receiver operating characteristic curves of 0.763 and 0.716 in the training and testing cohorts, respectively. Maximum diameter of the primary neuroendocrine tumor, NELM radiologic tumor burden score, and bilateral liver involvement were the factors most strongly associated with risk of NELM ER. Patients predicted to develop ER had worse 5-year recurrence-free survival and overall survival (21.4% vs 37.1% [P = .002] and 61.6% vs 90.3% [P = .03], respectively) than patients not predicted to recur. An easy-to-use tool was made available online: (https://altaf-pawlik-nelm-earlyrecurrence-calculator.streamlit.app/). CONCLUSION: An AI-based model demonstrated excellent discrimination to predict ER of NELM after resection. The model may help identify patients who can benefit the most from curative-intent resection, risk stratify patients according to prognosis, as well as guide tailored surveillance and treatment decisions including consideration of nonsurgical treatment options.

Association of county-level provider density with hepatobiliary cancer incidence and mortality.

BACKGROUND: Access to healthcare providers is a key factor in reducing cancer incidence and mortality, underscoring the significance of provider density as a crucial metric of health quality. We sought to characterize the association of provider density on hepatobiliary cancer population-level incidence and mortality. STUDY DESIGN: County-level hepatobiliary cancer incidence and mortality data from 2016 to 2020 and provider data from 2016 to 2018 were obtained from the CDC and Area Health Resource File. Multivariable logistic regression was utilized to evaluate the relationship between provider density and hepatobiliary cancer incidence and mortality. RESULTS: Among 1359 counties, 851 (62.6%) and 508 (37.4%) counties were categorized as urban and rural, respectively. The median number of providers in any given county was 104 (IQR: 44-306), while provider density was 120.1 (IQR: 86.7-172.2) per 100,000 population; median household income was $51,928 (IQR: $45,050-$61,655). Low provider-density counties were more likely to have a greater proportion of residents over 65 years of age (52.7% vs. 49.6%) who were uninsured (17.4% vs. 13.2%) versus higher provider-density counties (p < 0.05). Moreover, all-stage incidence, late-stage incidence, and mortality rates were higher in counties with low provider density. On multivariable analysis, moderate, and high provider density were associated with lower odds of all-stage incidence, late-stage incidence, and mortality. CONCLUSION: Higher county-level provider density was associated with lower hepatobiliary cancer-related incidence and mortality. Efforts to increase access to healthcare providers may improve healthcare equity as well as long-term cancer outcomes.

Preoperative and postoperative predictive models of early recurrence for colorectal liver metastases following chemotherapy and curative-intent one-stage hepatectomy.

INTRODUCTION: Accurate prediction of patients at risk for early recurrence (ER) among patients with colorectal liver metastases (CRLM) following preoperative chemotherapy and hepatectomy remains limited. METHODS: Patients with CRLM who received chemotherapy prior to undergoing curative-intent resection between 2000 and 2020 were identified from an international multi-institutional database. Multivariable Cox regression analysis was used to assess clinicopathological factors associated with ER, and an online calculator was developed and validated. RESULTS: Among 768 patients undergoing preoperative chemotherapy and curative-intent resection, 128 (16.7 %) patients had ER. Multivariable Cox analysis demonstrated that Eastern Cooperative Oncology Group Performance status ≥1 (HR 2.09, 95%CI 1.46-2.98), rectal cancer (HR 1.95, 95%CI 1.35-2.83), lymph node metastases (HR 2.39, 95%CI 1.60-3.56), mutated Kirsten rat sarcoma oncogene status (HR 1.95, 95%CI 1.25-3.02), increase in tumor burden score during chemotherapy (HR 1.51, 95%CI 1.03-2.24), and bilateral metastases (HR 1.94, 95%CI 1.35-2.79) were independent predictors of ER in the preoperative setting. In the postoperative model, in addition to the aforementioned factors, tumor regression grade was associated with higher hazards of ER (HR 1.91, 95%CI 1.32-2.75), while receipt of adjuvant chemotherapy was associated with lower likelihood of ER (HR 0.44, 95%CI 0.30-0.63). The discriminative accuracy of the preoperative (training: c-index: 0.77, 95%CI 0.72-0.81; internal validation: c-index: 0.79, 95%CI 0.75-0.82) and postoperative (training: c-index: 0.79, 95%CI 0.75-0.83; internal validation: c-index: 0.81, 95%CI 0.77-0.84) models was favorable (https://junkawashima.shinyapps.io/CRLMfollwingchemotherapy/). CONCLUSIONS: Patient-, tumor- and treatment-related characteristics in the preoperative and postoperative setting were utilized to develop an online, easy-to-use risk calculator for ER following resection of CRLM.

Postoperative Outcomes Among Patients Undergoing Cancer Surgery: United States versus International Medical Graduates.

OBJECTIVE: We sought to characterize postoperative outcomes among patients who underwent an oncologic operation relative to whether the treating surgeon was an international medical graduate (IMG) versus a United States medical graduate (USMG). BACKGROUND: IMGs comprise approximately one quarter of the physician workforce in the United States. METHODS: The 100% Medicare Standard Analytic Files were utilized to extract data on patients with breast, lung, hepato-pancreato-biliary (HPB), and colorectal cancer who underwent surgical resection between 2014 and 2020. Entropy balancing and multivariable regression analysis were performed to evaluate the association between postoperative outcomes among USMG and IMG surgeons. RESULTS: Among 285,930 beneficiaries, 242,914 (85.0%) and 43,016 (15.0%) underwent surgery by a USMG or IMG surgeon, respectively. Overall, 129,576 (45.3%) individuals were male, and 168,848 (59.1%) patients had a Charlson Comorbidity Index score >2. Notably, IMG surgeons were more likely to care for racial/ethnic minority patients (14.7% vs 12.5%) and individuals with a high social vulnerability index (33.3% vs 32.1%) (all P <0.001). On multivariable analysis after entropy balancing, patients treated by an IMG surgeon were less likely to experience adverse postoperative outcomes, including 90-day readmission [odds ratio (OR) 0.89, 95% CI: 0.80-0.99] and index complications (OR: 0.84, 95% CI: 0.74-0.95) versus USMG surgeons (all P <0.05). Patients treated by IMG versus USMG surgeons had no difference in likelihood to achieve a textbook outcome (OR: 1.10, 95% CI: 0.99-1.21; P =0.077). CONCLUSIONS: Postoperative outcomes among patients treated by IMG surgeons were roughly equivalent to those of USMG surgeons. In addition, IMG surgeons were more likely to care for patients with multiple comorbidities and individuals from vulnerable communities.

Association of surgeon's sex, and surgeon-patient dyad with financial outcomes among patients undergoing cancer surgery.

BACKGROUND AND OBJECTIVES: Surgeon sex has been associated with perioperative clinical outcomes among patients undergoing oncologic surgery. There may be variations in financial outcomes relative to the surgeon-patient dyad. We sought to define the association of surgeon's sex with perioperative financial outcomes following cancer surgery. METHODS: Patients who underwent resection of lung, breast, hepato-pancreato-biliary (HPB), or colorectal cancer between 2014 and 2021 were identified from the Medicare Standard Analytic Files. A generalized linear model with gamma regression was utilized to characterize the association between sex concordance and expenditures. RESULTS: Among 207,935 Medicare beneficiaries (breast: n = 14,753, 7.1%, lung: n = 59,644, 28.7%, HPB: n = 23,400, 11.3%, colorectal: n = 110,118, 53.0%), 87.8% (n = 182,643) and 12.2% (n = 25,292) of patients were treated by male and female surgeons, respectively. On multivariable analysis, female surgeon sex was associated with slightly reduced index expenditures (mean difference -$353, 95%CI -$580, -$126; p = 0.003). However, there were no differences in 90-day post-discharge inpatient (mean difference -$-225, 95%CI -$570, -$121; p = 0.205) and total expenditures (mean difference $133, 95%CI -$279, $545; p = 0.525). CONCLUSIONS: There was minor risk-adjusted variation in perioperative expenditures relative to surgeon sex. To improve perioperative financial outcomes, a diverse surgical workforce with respect to patient and surgeon sex is warranted.

Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma.

BACKGROUND: Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection. METHODS: Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival. RESULTS: A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001). CONCLUSION: Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.

Impact of patient, hospital, and operative characteristics relative to social determinants of health: Compliance with National Comprehensive Cancer Network guidelines for colon cancer.

BACKGROUND: Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN) guidelines remains suboptimal. We sought to assess the effect of patient characteristics (PCs), operative characteristics (OCs), hospital characteristics (HCs), and social determinants of health (SDoH) on noncompliance with NCCN guidelines for colon cancer. METHODS: Patients treated for stage I to III colon cancer from 2004 to 2017 were identified from the National Cancer Database. Multilevel multivariate regression analysis was performed to identify factors associated with receipt of NCCN-compliant care and quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH. RESULTS: Among 468,097 patients with colon cancer treated across 1319 hospitals, 1 in 4 patients did not receive NCCN-compliant care (122,170 [26.1%]). On regression analysis, older age (odds ratio [OR], 0.96; 95% CI, 0.96-0.96), female sex (OR, 0.97; 95% CI, 0.96-0.99), Black race (OR, 0.96; 95% CI, 0.94-0.98), higher Charlson-Deyo score (OR, 0.84; 95% CI, 0.82-0.86), tumor stage ≥II (OR, 0.42; 95% CI, 0.40-0.44), and tumor grade ≥ 3 (OR, 0.33; 95% CI, 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all P values <.05). Higher hospital volume (OR, 1.02; 95% CI, 1.02-1.03), minimally invasive or robotic surgical approach (OR, 1.26; 95% CI, 1.23-1.29), adequate (≥12) lymph node assessment (OR, 3.46; 95% CI, 3.38-3.53), private insurance status (OR, 1.33; 95% CI, 1.26-1.40), Medicare insurance status (OR, 1.42; 95% CI, 1.35-1.49), and higher educational status (OR, 1.06; 95% CI, 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all P values <.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, and OCs contributed 12.9% to the variation in guideline-compliant care, while SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care. CONCLUSION: The variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, whereas SDoH were associated with a smaller proportion of the variation.

Effect of telemedicine use on medical spending and health care utilization among patients with gastrointestinal cancer.

BACKGROUND: We sought to assess the impact of telemedicine on healthcare utilization and medical expenditures among patients with a diagnosis of gastrointestinal (GI) cancer. METHODS: Patients with newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database (IBM Watson Health) . Healthcare utilization, total medical outpatient insurance payments within 1 year post-diagnosis, and out-of-pocket (OOP) expenses among telemedicine users and non-users were assessed after propensity score matching (PSM). RESULTS: Among the 32,677 patients with GI cancer (esophageal, n = 1862, 5.7%; gastric, n = 2009, 6.1%; liver, n = 2929, 9.0%; bile duct, n = 597, 1.8%; pancreas, n = 3083, 9.4%; colorectal, n = 22,197, 67.9%), a total of 3063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n = 3064; non-users, n = 3064), telemedicine users demonstrated a higher frequency of clinic visits (median: 5.0 days, IQR 4.0-7.0 vs non-users: 2.0 days, IQR 2.0-3.0, P < .001) and fewer potential days missed from daily activities (median: 7.5 days, IQR 4.5-12.5 vs non-users: 8.5 days, IQR 5.5-13.5, P < .001). Total medical spending per month and utilization of emergency room (ER) visits for telemedicine users were higher vs non-users (median: $10,658, IQR $5112-$18,528 vs non-users: $10,103, IQR $4628-$16,750; 46.8% vs 42.6%, both P < .01), whereas monthly OOP costs were comparable (median: $273, IQR $137-$449 for telemedicine users vs non-users: $268, IQR $142-$434, P = .625). CONCLUSION: Telemedicine utilization was associated with increased outpatient clinic visits yet reduced potential days missed from daily activities among patients with GI cancer. Telemedicine users tended to have more ER visits and total medical spending per month, although monthly OOP costs were comparable with non-users.

Association of county-level provider density and social vulnerability with colorectal cancer-related mortality.

BACKGROUND: Health care providers play a crucial role in increasing overall awareness, screening, and treatment of cancer, leading to reduced cancer mortality. We sought to characterize the impact of provider density on colorectal cancer population-level mortality. METHODS: County-level provider data, obtained from the Area Health Resource File between 2016 and 2018, were used to calculate provider density per county. These data were merged with county-level colorectal cancer mortality 2016-2020 data from the Centers for Disease Control and Prevention. Multivariable regression was performed to define the association between provider density and colorectal cancer mortality. RESULTS: Among 2,863 counties included in the analytic cohort, 1,132 (39.5%) and 1,731 (60.5%) counties were categorized as urban and rural, respectively. The colorectal cancer-related crude mortality rate was higher in counties with low provider density versus counties with moderate or high provider density (low = 22.9, moderate = 21.6, high = 19.3 per 100,000 individuals; P < .001). On multivariable analysis, the odds of colorectal cancer mortality were lower in counties with moderate and high provider density versus counties with low provider density (moderate odds ratio 0.97, 95% confidence interval 0.94-0.99; high odds ratio 0.88, 95% confidence interval 0.86-0.91). High provider density remained associated with a lower likelihood of colorectal cancer mortality independent of social vulnerability index (low social vulnerability index and high provider density: odds ratio 0.85, 95% confidence interval 0.81-0.89; high social vulnerability index and high provider density: odds ratio 0.93, 95% confidence interval 0.89-0.98). CONCLUSION: Regardless of social vulnerability index, high county-level provider density was associated with lower colorectal cancer-related mortality. Efforts to increase access to health care providers may improve health care equity, as well as long-term cancer outcomes.

Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery.

BACKGROUND: New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS: Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION: Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.

Healthcare utilization and expenditures among patients with venous thromboembolism following gastrointestinal cancer surgery.

BACKGROUND: We sought to assess healthcare utilization and expenditures among patients who developed venous thromboembolism (VTE) after gastrointestinal cancer surgery. METHODS: Patients who underwent surgery for esophageal, gastric, hepatic, biliary duct, pancreatic, and colorectal cancer between 2013 and 2020 were identified using the MarketScan database. Entropy balancing was performed to obtain a cohort that was well balanced relative to different clinical covariates. Generalized linear models were used to compare 1-year postdischarge costs among patients who did and did not develop a postoperative VTE. RESULTS: Among 20,253 individuals in the analytical cohort (esophagus [n = 518 {2.6%}], stomach [n = 970 {4.8%}], liver [n = 608 {3.0%}], bile duct [n = 294 {1.5%}], pancreas [n = 1511 {7.5%}], colon [n = 12,222 {60.3%}], and rectum [n = 4130 {20.4%}]), 894 (4.4%) developed VTE. Overall, most patients were male (n = 10,656 [52.6%]), aged between 55 and 64 years (n = 10,372 [51.2%]), and were employed full time (n = 11,408 [56.3%]). On multivariable analysis, VTE was associated with higher inpatient (mean difference [MD], $17,547; 95% CI, $15,141-$19,952), outpatient (MD, $8769; 95% CI, $7045-$10,491), and pharmacy (MD, $2811; 95% CI, $2509-$3113) expenditures (all P < .001). Furthermore, patients who developed VTE had higher out-of-pocket costs for inpatient (MD, $159; 95% CI, $66-$253) and pharmacy (MD, $122; 95% CI, $109-$136) services (all P < .001). CONCLUSION: Among privately insured patients aged <65 years, VTE was associated with increased healthcare utilization and expenditures during the first year after discharge.

Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy.

BACKGROUND: This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS: Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS: Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION: Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.