The Characterization of Violent Deaths Among Asian and Pacific Islander Americans.

INTRODUCTION: Health disparities in the Asian and Pacific Islander Americans (APIAs) community have not been well described, unlike non-Hispanic Black and Hispanic communities. However, there has been a rise in violence against the APIA community. This study explores and characterizes violent death by incident (e.g., homicide, suicide), weapon (e.g., firearm, strangulation), and location types among APIAs as they compare with other racial or ethnic groups. METHODS: We used the National Violent Death Reporting System from 2003 to 2018 to characterize violent deaths among APIA and compared them to all other races. We compared these racial categories in two ways. First, we compared all races as a categorical variable that included six non-Hispanic racial categories including "Other or unspecified" and "two or more races. We then created a binary variable of APIA versus All Other Races for analysis. We explored the incident type of death, substance abuse disorders, mental health history, and gang involvement among other variables. We used Chi-square tests for categorical variables and Mann-Whitney U-tests for continuous variables. RESULTS: Overall, APIAs had a unique pattern of violent death. APIAs were more likely to commit suicide (71.74%-62.21%, P<0.001) and less likely to die of homicide than other races (17.56%-24.31%, P<0.001). In the cases of homicide, APIAs were more likely to have their deaths precipitated by another crime (40.87% versus 27.87%, P < 0.001). APIAs were more than twice as likely to die of strangulation than other races (39.93%-18.06%, P<0.001). Conversely, APIAs were less likely to die by firearm than other races (29.69-51.51, P<0.001). CONCLUSIONS: APIAs have a unique pattern of violence based on analysis of data from the National Violent Death Reporting System. Our data reveal a significant difference in the incident, weapon and location type as compared to Americans of other races, which begs further inquiry into the patterns of change in time and factors that contribute to inter-racial differences in death patterns.

The Effect of Social Vulnerability on Initial Stage and Treatment for Non-Small Cell Lung Cancer.

OBJECTIVE: The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies. MATERIALS AND METHODS: NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes. RESULTS: Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80). CONCLUSIONS: Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care.

Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population.

OBJECTIVE: The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. SUMMARY BACKGROUND DATA: Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. METHODS: This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. RESULTS: Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p â€‹< â€‹0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p â€‹< â€‹0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. CONCLUSIONS: High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.

Left out in the cold: Homicide amongst persons experiencing homelessness.

BACKGROUND: There is no American population-level study comparing the characteristics of homicides involving victims who were vs were not experiencing homelessness at time of death. We aim to identify variables surrounding homeless homicide that are unique, and intervenable. METHODS: In this retrospective cohort study, we reviewed the National Violent Death Reporting System (NVDRS) from 2003 to 2018 and compared the characteristics surrounding homicides of victims who were not-homeless (cohort 1) vs experiencing homelessness (cohort 2) at death. We utilized the available perpetrator data to characterize the average perpetrator for each cohort. We considered housing status to be our primary predictor and recorded NVDRS variables, such as age of victims and likelihood to know perpetrators, to be our primary outcomes. RESULTS: 81,212 Homicide Victims and 60,982 Homicide Perpetrators were included in analysis. Homeless cohort victims were more likely younger, White, male, and to have a known mental health or substance abuse disorder. PEH were also more likely to have co-morbid mental health and substance abuse disorders but were roughly half as likely to be getting treatment for said disorders. Circumstances surrounding incidents, including geographic location, mechanism of injury, and premeditation, varied; homeless cohort victims were more likely to die in random acts of violence, but were less likely to die via firearm. CONCLUSIONS: There is room for targeted interventions against homeless homicides. LEVEL OF EVIDENCE: Epidemiological, Level IV.

Social vulnerability is associated with post-operative morbidity following robotic-assisted lung resection.

Background: The social vulnerability index (SVI) is a neighborhood-based metric used to determine an individual's susceptibility to socioeconomic hardship, with high SVI indicating high susceptibility. SVI has previously been associated with surgical outcomes. We aimed to determine if SVI influences morbidity following robotic-assisted lung resection. Methods: This was a retrospective cohort study at one academic medical center (1/1/2021-11/30/2022). Patients undergoing robotic-assisted lung resection were grouped into low (<75th percentile) and high (≥75th percentile) SVI cohorts. The primary outcome was 30-day overall morbidity; secondary outcomes were individual 30-day post-operative outcomes. Univariate analysis was performed using Chi-squared or Mann-Whitney-U tests, and multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) of postoperative complications. Results: We included 320 patients, of which 40 patients (12.5%) in the high-SVI group and 280 (87.5%) in the low-SVI group. High SVI patients were more likely to be non-Caucasian and of Hispanic ethnicity, but there were no other differences in perioperative characteristics (all P>0.05). High SVI patients were more likely to experience a post-operative complication (42.5% vs. 24.6%, P=0.017), surgical site infection (SSI) (12.5% vs. 4.3%, P=0.047), hemothorax (5.0% vs. 0.0%, P=0.015), intensive care need (15.0% vs. 4.6%, P=0.021), sepsis (10.0% vs. 1.1%, P=0.006) and unplanned reoperation (5.0% vs. 0.4%, P=0.042). After risk-adjustment, the association of increased overall morbidity with high SVI persisted (OR =2.53; 95% confidence interval: 1.19-5.35). Conclusions: High SVI was associated with increased risk-adjusted odds of morbidity after robotic-assisted lung resection. Highly vulnerable patients should be allocated perioperative resources to help mitigate the increased risk of these complications.

Prioritizing rapid COVID-19 testing in emergency general surgery patients decreases burden of inpatient hospital admission.

Objectives: The COVID-19 pandemic has changed delivery of emergency general surgery (EGS) and contributed to widespread bed shortages. At our institution, rapid testing is not routinely approved for EGS patients. We examined common EGS conditions (appendicitis and acute cholecystitis), hypothesizing that necessity of testing for COVID-19 significantly delayed operative intervention. Methods: We performed a prepost study to examine a 2-month timeframe, or historical control, prior to COVID-19 testing (January 1, 2020-March 1, 2020) as well as a 2-month timeframe during the COVID-19 era (January 1, 2021-March 1, 2021). We chose conditions that are frequently treated surgically as outpatient or observation status. We examined time for COVID-19 test to result, and associated time to operative intervention (operating room (OR)) and need for admission. Results: Median time to COVID-19 test results was 7.4 hours (IQR 5.8-13.1). For appendectomy, time to surgical consultation or case request did not differ between cohorts. Time to OR after case request was significantly longer (12.5 vs 1.9 hours, p<0.001) and patients more frequently required admission prior to operative intervention if receiving treatment in the COVID-19 timeframe. Similarly, for cholecystectomy there were no differences in time to surgical consultation or case request, but time to OR after case request was longer in the COVID-19 era (21.1 vs 9.0 hours, p<0.001). Conclusion: While COVID-19 positivity rates have declined, the purpose of this study was to reflect on one element of our hospital system's response to the COVID-19 pandemic. Based on our institutional experience, waiting for COVID-19 test results directly impacts time to surgery, as well as the need for admission for a historically outpatient procedure. In the future, if the healthcare system is asked to respond to another pandemic or similar situation, expediting time to OR to eliminate unnecessary time in the hospital and non-critical admissions should be paramount. Level of evidence: Level III, prognostic/epidemiological.

Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients.

BACKGROUND: Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations. METHODS: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors. RESULTS: Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery. CONCLUSION: Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.

Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit.

BACKGROUND: Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival. METHODS: A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance. RESULTS: In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching. CONCLUSION: Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.

Safer Behind Bars? Comparing In-Custody Deaths Prior to and During Incarceration.

INTRODUCTION: This project aims to characterize trauma-associated deaths of the American incarcerated population through legal intervention (LI) or death by law enforcement officials while in custody before and during incarceration. We determined the preceding events leading to violent death, including initiation of medical care, use of restraints and force, and demographics of the victims. METHODS: We used National Violent Death Reporting System data from the years 2003-2019 to identify deaths that occurred while in custody or incarcerated, including discriminate and narrative data. Event information included weapon type, location of death, incident type, incarceration status, use of restraints, and prone positioning. RESULTS: There were 86 victims who died from LI included in the analysis. Most events occurred after incarceration. All victims in our cohort were male, and race was an associated factor for death by LI. Only 16% of victims had an education level above high school/general educational development. Death by firearm compared to other weapons was significantly more common in the in-custody but not yet incarcerated group (83% versus 42%, P ≤ 0.0001). Other associated factors included a history of mental health, physical confrontations, the belief that the victim had a weapon, and being restrained in prone positioning. CONCLUSIONS: Our study shows that racial minority victims are disproportionately affected by LI deaths. Firearms and restraint type were important factors in LI deaths. Our findings suggest that violence prevention in the justice system should focus on prevention and de-escalation across setting with specific attention to use of force and inmate access to the weapons of police, guards, and other law and justice system workers. More transparent quality data is sorely needed to adequately define and address this problem.

Immigrating to Unsafe Spaces: Unique Patterns of Homicide in Immigrant Victims Compared to Native-Born Citizens.

INTRODUCTION: Contrary to popular belief, immigrant enclaves produce less crime than other areas of the United States, yet that does not mean immigrants avoid violent crime altogether. The purpose of this project is to better characterize the victims of homicide in this population. Specifically, we sought to compare differences in victim demographics, injury patterns, and circumstances of violent death between the immigrant population and native-born victims of homicide. METHODS: We queried the National Violent Death Reporting System (NVDRS) from the years 2003-2019 for deaths in victims who were born outside of the United States. We extracted demographic information including age, race or ethnicity, means of homicide, and circumstances surrounding the event to compare immigrant to nonimmigrant deaths. RESULTS: Immigrant victims were less likely to be killed by a firearm and to have substance use or alcohol implicated. Immigrant victims were twice as likely to be killed during multiple homicide events that involved suicide of the perpetrator (2.1% to 1%, P ≤ 0.001) and to be killed by a stranger (12.9% to 6.2%, P ≤ 0.001). Immigrant victims were also more likely to be killed during the perpetration of another crime (19.1% to 15%, P ≤ 0.001), and more likely to be killed in a commercial setting such as a grocery store or retail outlet (7.6% to 2.4%, P ≤ 0.001). CONCLUSIONS: Injury prevention measures for the immigrant population require different techniques, focusing on distinct features of victimization centered on random acts in contrast to native-born citizens who tend to be victims of people they know.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Sex Differences in Violent Death During Incarceration and Legal Intervention.

INTRODUCTION: This study clarifies the differences in death during incarceration and legal intervention between males and females, delineating the differences in demographic features and the circumstances of the violent death including location, injury pattern, and perpetrator. METHODS: The data used are from the National Violent Death Reporting System database from 2003 to 2019. All victims were either in custody, in the process of custody, or in prison. Sex was coded as female or male and as assigned at birth. All analyses were conducted using SAS 9.4 software using chi-square tests, with an alpha of 0.05 to test significant differences in the circumstances of mortality and demographic characteristics for each group. RESULTS: Our findings show that suicide was the most common cause of death during incarceration for both females and males (89.8% versus 77.4%; P < 0.001). Homicide was less common in females (1.6% versus 14.8%; P < 0.001) and legal intervention only occurred in males (2.2%; P < 0.001). Male victims were more likely to be of non-White race/ethnicity compared to females, while females were more likely to be experiencing homelessness, have documented mental illness, and comorbid substance abuse. CONCLUSIONS: Victim sex is significantly associated with circumstances of violent death among the incarcerated and highlights the need for appropriate mental health and substance abuse treatment.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients.

INTRODUCTION: The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. METHODS: Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests. RESULTS: Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. CONCLUSIONS: The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

Suicide Among Persons Experiencing Homelessness.

INTRODUCTION: This study aims to characterize suicide and associated disparities among persons experiencing homelessness (PEH). MATERIALS AND METHODS: We reviewed suicide victims in the National Violent Death Reporting System (NVDRS) from 2003 to 2018 and compared factors surrounding suicides of PEH to factors of housed victims. We also utilized the Point-in-Time (PIT) survey (2010-2018), and census population estimates, to estimate suicide rates among PEH and the wider population. RESULTS: 1.1% of suicide victims were described as experiencing homelessness at the time of their deaths, a value that is disproportional given the overall homeless rates of 0.2% in the past decade. Compared to nonhomeless victims, PEH were more likely to be younger, Black, male, and nonveterans. PEH were significantly more likely to have an identified alcohol/substance use disorder. PEH were half as likely to die via firearm and were more likely to die in natural areas, motels, and the streets. PEH were significantly more likely to have a history of suicidal thoughts, a history of suicide attempts, and a history of disclosure of intent, particularly to health care workers. CONCLUSIONS: PEH are disproportionately overrepresented among all suicide victims, but the circumstances surrounding their deaths create opportunity for targeted interventions.

Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data.

INTRODUCTION: Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database. METHODS AND PROCEDURES: The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people). RESULTS: Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001). CONCLUSIONS: Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.

Does Adding a Measure of Social Vulnerability to a Surgical Risk Calculator Improve Its Performance?

BACKGROUND: Emerging literature suggests that measures of social vulnerability should be incorporated into surgical risk calculators. The Social Vulnerability Index (SVI) is a measure designed by the CDC that encompasses 15 socioeconomic and demographic variables at the census tract level. We examined whether adding the SVI into a parsimonious surgical risk calculator would improve model performance. STUDY DESIGN: The eight-variable Surgical Risk Preoperative Assessment System (SURPAS), developed using the entire American College of Surgeons (ACS) NSQIP database, was applied to local ACS-NSQIP data from 2012 to 2018 to predict 12 postoperative outcomes. Patient addresses were geocoded and used to estimate the SVI, which was then added to the model as a ninth predictor variable. Brier scores and c-indices were compared for the models with and without the SVI. RESULTS: The analysis included 31,222 patients from five hospitals. Brier scores were identical for eight outcomes and improved by only one to two points in the fourth decimal place for four outcomes with addition of the SVI. Similarly, c-indices were not significantly different (p values ranged from 0.15 to 0.96). Of note, the SVI was associated with most of the eight SURPAS predictor variables, suggesting that SURPAS may already indirectly capture this important risk factor. CONCLUSION: The eight-variable SURPAS prediction model was not significantly improved by adding the SVI, showing that this parsimonious tool functions well without including a measure of social vulnerability.

Social vulnerability is associated with increased morbidity following colorectal surgery.

INTRODUCTION: Neighborhood measures of social vulnerability encompassing multiple sociodemographic factors can be used to quantify disparities in outcomes. We hypothesize patients with high Social Vulnerability Index (SVI) are at increased risk of morbidity following colectomy. METHODS: We used local 2012-2017 National Surgical Quality Improvement Program (NSQIP) data to study colectomy patients, examining associations between SVI and postoperative outcomes. RESULTS: We included 976 patients from five hospitals. High SVI (>75th percentile) was associated with increased postoperative morbidity on unadjusted analysis (OR 1.84, 95% CI 1.35-2.52, p < 0.001); this association persisted after adjusting for demographics and comorbidities (OR 1.63, 95% CI 1.15-2.31, p = 0.005). The association with SVI was not significant after adjusting for perioperative risk modifiers such as emergent presentation (OR 1.37, 95% CI 0.95-1.98, p = 0.10). CONCLUSIONS: High social vulnerability is associated with increased postoperative complications. This effect appears mediated by perioperative risk factors, suggesting potential to improve outcomes by facilitating timely surgical intervention.

The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond.

2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

When more is less: Urban disparities in access to surgical care by transportation means.

BACKGROUND: Structural factors limiting access to surgical care require elucidation. We hypothesize transportation time to hospitals with surgical capacity disproportionately burdens minority populations. METHODS: We identified hospitals with surgical capacity within a 20-mile radius of our city center. Using geocoding, we estimated travel times from each census tract to the nearest facility by car or public bus. RESULTS: For 143 tracts within the county, drive time was 13 ± 4 min and bus time was 33 ± 15 min. Only 41.2% of the population had a facility within 30 min by bus; access was further diminished for those with minority race/ethnicity and/or no insurance. Bus time was associated with percent minority population in a census tract: for each 10% increase in minority population there was a 4.3-min increase in bus time (p < 0.001) when controlling for socioeconomic status and other characteristics. CONCLUSIONS: Geographic information systems analysis has potential to identify communities with disproportionate burden to access surgical services.