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). SUMMARY BACKGROUND DATA: 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 (EB) 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 and 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 those with a high social vulnerability index (33.3% vs. 32.1%) (all P<0.001). On multivariable analysis after EB, patients treated by an IMG surgeon were less likely to experience adverse postoperative outcomes including 90-day readmission (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.

Practice Patterns and Outcomes Among Surgical Oncology Fellowship Graduates Performing Complex Cancer Surgery in the United States Across Different Career Stages.

BACKGROUND: Practice patterns and potential quality differences among surgical oncology fellowship graduates relative to years of independent practice have not been defined. METHODS: Medicare claims were used to identify patients who underwent esophagectomy, pancreatectomy, hepatectomy, or rectal resection for cancer between 2016 and 2021. Surgical oncology fellowship graduates were identified, and the association between years of independent practice, serious complications, and 90-day mortality was examined. RESULTS: Overall, 11,746 cancer operations (pancreatectomy [61.2%], hepatectomy [19.5%], rectal resection [13.7%], esophagectomy [5.6%]) were performed by 676 surgical oncology fellowship graduates (females: 17.7%). The operations were performed for 4147 patients (35.3%) by early-career surgeons (1-7 years), for 4104 patients (34.9%) by mid-career surgeons (8-14 years), and for 3495 patients (29.8%) by late-career surgeons (>15 years). The patients who had surgery by early-career surgeons were treated more frequently at a Midwestern (24.9% vs. 14.2%) than at a Northeastern institution (20.6% vs. 26.9%) compared with individuals treated by late-career surgeons (p < 0.05). Surgical oncologists had comparable risk-adjusted serious complications and 90-day mortality rates irrespective of career stage (early career [13.0% and 7.2%], mid-career [12.6% and 6.3%], late career [12.8% and 6.5%], respectively; all p > 0.05). Surgeon case-specific volume independently predicted serious complications across all career stages (high vs. low volume: early career [odds ratio {OR}, 0.80; 95% confidence interval {CI}, 0.65-0.98]; mid-career [OR, 0.81; 95% CI, 0.66-0.99]; late career [OR, 0.78; 95% CI, 0.62-0.97]). CONCLUSION: Among surgical oncology fellowship graduates performing complex cancer surgery, rates of serious complications and 90-day mortality were comparable between the early-career and mid/late-career stages. Individual surgeon case-specific volume was strongly associated with postoperative outcomes irrespective of years of independent practice or career stage.

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.

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.

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery.

BACKGROUND: We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission. RESULTS: Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001). CONCLUSION: PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

BACKGROUND: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Impact of an artificial intelligence based model to predict non-transplantable recurrence among patients with hepatocellular carcinoma.

OBJECTIVE: We sought to develop Artificial Intelligence (AI) based models to predict non-transplantable recurrence (NTR) of hepatocellular carcinoma (HCC) following hepatic resection (HR). METHODS: HCC patients who underwent HR between 2000-2020 were identified from a multi-institutional database. NTR was defined as recurrence beyond Milan Criteria. Different machine learning (ML) and deep learning (DL) techniques were used to develop and validate two prediction models for NTR, one using only preoperative factors and a second using both preoperative and postoperative factors. RESULTS: Overall, 1763 HCC patients were included. Among 877 patients with recurrence, 364 (41.5%) patients developed NTR. An ensemble AI model demonstrated the highest area under ROC curves (AUC) of 0.751 (95% CI: 0.719-0.782) and 0.717 (95% CI:0.653-0.782) in the training and testing cohorts, respectively which improved to 0.858 (95% CI: 0.835-0.884) and 0.764 (95% CI: 0.704-0.826), respectively after incorporation of postoperative pathologic factors. Radiologic tumor burden score and pathological microvascular invasion were the most important preoperative and postoperative factors, respectively to predict NTR. Patients predicted to develop NTR had overall 1- and 5-year survival of 75.6% and 28.2%, versus 93.4% and 55.9%, respectively, among patients predicted to not develop NTR (p < 0.0001). CONCLUSION: The AI preoperative model may help inform decision of HR versus LT for HCC, while the combined AI model can frame individualized postoperative care (https://altaf-pawlik-hcc-ntr-calculator.streamlit.app/).

Disparities in clinical trial enrollment among patients with gastrointestinal cancer relative to minority-serving and safety-netting hospitals.

BACKGROUND: For results to be generalizable to all patients with cancer, clinical trials need to include a diverse patient demographic that is representative of the general population. We sought to characterize the effect of receiving care at a minority-serving hospital (MSH) and/or safety-net hospital on clinical trial enrollment among patients with gastrointestinal (GI) malignancies. METHODS: Adult patients with GI cancer who underwent oncologic surgery and were enrolled in institutional-/National Cancer Institute-funded clinical trials between 2012 and 2019 were identified in the National Cancer Database. Multivariable regression was used to assess the relationship between MSH and safety-net status relative to clinical trial enrollment. RESULTS: Among 1,112,594 patients, 994,598 (89.4%) were treated at a non-MSH, whereas 117,996 (10.6%) were treated at an MSH. Only 1857 patients (0.2%) were enrolled in a clinical trial; most patients received care at a non-MSH (1794 [96.6%]). On multivariable analysis, the odds of enrollment in a clinical trial were markedly lower among patients treated at an MSH vs non-MSH (odds ratio [OR], 0.32; 95% CI, 0.22-0.46). In addition, even after controlling for receipt of care at MSH, Black patients remained at lower odds of enrollment in a clinical trial than White patients (OR, 0.57; 95% CI, 0.45-0.73; both P < .05). CONCLUSION: Overall, clinical trial participation among patients with GI cancer was extremely low. Patients treated at an MSH and high safety-net burden hospitals and Black individuals were much less likely to be enrolled in a clinical trial. Efforts should be made to improve trial enrollment and address disparities in trial representation.

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.

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.

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.

Effect of Telemedicine Use on Medical Spending and Health Care Utilization among Patients with Gastrointestinal Cancer.

INTRODUCTION: 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 a newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database. Healthcare utilization, total medical outpatient insurance payments within one-year post-diagnosis, and out-of-pocket (OOP) expenses between telemedicine users and non-users were assessed after propensity score matching (PSM). RESULTS: Among 32,677 patients with a GI cancer (esophageal, n=1,862, 5.7%; gastric, n=2,009, 6.1%; liver, n=2,929, 9.0%; bile duct, n=597, 1.8%; pancreas, n=3,083, 9.4%; colorectal, n=22,197, 67.9%), a total of 3,063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n=3,064; non-users, n=3,064), 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<0.001) 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<0.001). Total medical spending per month and utilization of emergency room visits for telemedicine users was higher versus non-users (median: $10,658, IQR $5,112-$18,528 vs. non-users: $10,103, IQR $4,628-$16,750; 46.8% vs. 42.6%, both p<0.01), while monthly OOP costs were comparable (median: $273, IQR $137-$449 for telemedicine users vs. non-users: $268, IQR $142-$434, p=0.625). 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 higher ER visits rate and total medical spending per month, although monthly OOP costs were comparable with non-users.