Disparities in Utilization and Outcomes of Minimally Invasive Techniques for Gastric Cancer Surgery in the United States.

BACKGROUND: This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States. METHODS: The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications. RESULTS: There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost. CONCLUSIONS: In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery.

OBJECTIVES: Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery. DESIGN: A retrospective analysis of administrative data. SETTING: The 2010-2017 National Readmissions Database. PARTICIPANTS: All pediatric patients undergoing congenital cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000). CONCLUSIONS: Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.

Impact of transplant center volume on donor heart offer utilization rates in the United States.

BACKGROUND: We tested the hypothesis that transplant centers (TCs) with higher volumes have higher donor heart (DH) offer utilization rates. METHODS: Using the Annual Data reports of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (SRTR) we reviewed all adult heart transplant offers between July 1, 2016 and June 29, 2019. Unadjusted donor offer utilization rates and observed to expected (O/E) DH utilization ratios adjusted using the SRTR model were calculated for each TC for all DH offers and for the following sub-categories: DH with left ventricular ejection fraction <60%, DH >40 years, DH >500 miles from TC, "hard-to-place hearts" (defined as those offered to >50 TCs) and DH designated as increased infectious risk. Univariable linear regression was used to identify a relationship between average yearly center volume and DH utilization. RESULTS: During the study 118,841 total offers were made to 107 TCs and 8300 transplants were performed. The unadjusted utilization rate was not associated with TC volume for all donor offers (p = .517). However, among all subcategories other than DH >40 years, the unadjusted DH utilization rate was associated with TC volume (p < .05). In addition, using the adjusted SRTR O/E ratio, there was a significant impact of TC volume on utilization rate for all donor offers (for an increase TC volume of 10 transplants/year coefficient = 0.095, 95% confidence interval: 0.037-0.151, p = .001). This relationship persisted with an identifiable change for each of the subcategories (p ≤ .001). CONCLUSIONS: TC volume is significantly correlated to DH offer utilization rate.

Immediate Auditory Feedback is Superior to Other Types of Feedback for Basic Surgical Skills Acquisition.

OBJECTIVE: We examined the effect of timing and type of feedback on medical students' knot-tying performance using visual versus auditory and immediate versus delayed feedback. We hypothesized that participants who received immediate auditory feedback would outperform those who received delayed and visual feedback. METHODS: Sixty-nine first- and second-year medical students were taught to tie 2-handed knots. All participants completed 3 pretest knot-tying trials without feedback. Participants were instructed to tie a knot sufficiently tight to stop the "blood" flow while minimizing the amount of force applied to the vessel. Task completion time was not a criterion. Participants were stratified and randomly assigned to 5 experimental groups based on type (auditory versus visual) and timing (immediate versus delayed) of feedback. The control group did not receive feedback. All groups trained to proficiency. Participants completed 3 posttest trials without feedback. RESULTS: There were fewer trials with leak (p < 0.01) and less force applied (p < 0.01) on the posttest compared to the pretest, regardless of study group. The immediate auditory feedback group required fewer trials to achieve proficiency than each of the other groups (p < 0.01) and had fewer leaks than the control, delayed auditory, and delayed visual groups (p < 0.02). CONCLUSIONS: In a surgical force feedback simulation model, immediate auditory feedback resulted in fewer training trials to reach proficiency and fewer leaks compared to visual and delayed forms of feedback.