Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (-0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

Predictive factors of weight regain following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Strategies to address weight recidivism following Roux-en-Y gastric bypass (RYGB) could be developed if patients at risk were identified in advance. This study aimed to determine factors that predict weight regain. METHODS: Retrospective review was performed of patients who underwent laparoscopic RYGB at a single institution over 10 years. Group-based modeling was used to estimate trajectories of weight regain after nadir and stratify patients based on percent weight change (%WC). RESULTS: Three trajectories were identified from 586 patients: 121 had ongoing weight loss, 343 were weight stable, and 122 regained weight. Male sex (p = 0.020) and white race (p < 0.001) were associated with stable weight or weight regain. Being from a neighborhood of socioeconomic advantage (p = 0.035) was associated with weight regain. Patients with weight regain experienced improved percent weight loss (%WL) at nadir (p < 0.001) and ΔBMI (p = 0.002), yet they had higher weight and BMI and lower %WL and ΔBMI than the other two groups during long-term follow-up. On multivariate analyses, those who regained weight were more likely from socioeconomically advantaged neighborhoods (OR 1.82, CI 1.18-2.79). CONCLUSIONS: Several patient-related characteristics predicted an increased likelihood of weight regain. Further studies are needed to elucidate how these factors contribute to weight recidivism following bariatric surgery.

Emotional intelligence in surgery is associated with resident job satisfaction.

BACKGROUND: Emotional intelligence (EI) has been associated with improved work performance and job satisfaction in several industries. We evaluated whether EI was associated with higher measures of work performance and job satisfaction in surgical residents. METHODS: We distributed the validated Trait EI Questionnaire and job satisfaction survey to all general surgery residents at a single institution in 2015. EI and job satisfaction scores were compared with resident performance using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for postgraduate year level. RESULTS: The survey response rate was 68.9% with 31 resident participants. Global EI was associated with scores on USMLE Step 2 (r = 0.46, P = 0.01) and Step 3 (r = 0.54, P = 0.01) but not ABSITE percentile scores (r = 0.06, P = 0.77). None of the 16 surgical milestone scores were significantly associated with global EI or EI factors before or after adjustment for postgraduate level. Global EI was associated with overall job satisfaction (r = 0.37, P = 0.04). Of the facets of job satisfaction, global EI was significantly associated with views of supervision (r = 0.42, P = 0.02) and nature of work (r = 0.41, P = 0.02). CONCLUSIONS: EI was associated with job satisfaction and USMLE performance but not ACGME competency-based milestones or ABSITE scores. EI may be an important factor for fulfillment in surgical training that is not currently captured with traditional in-training performance measures.

Readmission rates after lower extremity bypass vary significantly by surgical indication.

OBJECTIVE: Readmission rates after vascular surgery are among the highest within surgical specialties, and lower extremity bypass has the highest readmission rate of vascular surgery procedures. We analyzed how 30-day readmissions and risk factors for readmissions vary by indication for lower extremity bypass. METHODS: We queried the 2012-2014 American College of Surgeons National Surgical Quality Improvement Program procedure-targeted vascular cohort to identify all patients who underwent lower extremity bypass. Emergent procedures and planned readmissions were excluded. Patients were stratified by surgical indication: claudication, critical limb ischemia rest pain (CLI RP), critical limb ischemia tissue loss (CLI TL), and other. The χ2 and Wilcoxon rank sum tests were used to test the differences between categorical and continuous variables, respectively. Logistic regression was used to estimate odds ratios for predictors of readmission adjusted for preoperative factors that were selected a priori. RESULTS: The overall 30-day readmission rate among the 6112 patients who underwent lower extremity bypass was 14.8%. Readmission rates varied significantly on the basis of the indication for surgery. In unadjusted comparisons, 18.8% of patients with CLI TL were readmitted compared with 16.5% with CLI RP, 9.4% with claudication, and 8.2% with other indications (P < .001). After adjustment for preoperative factors, 30-day readmissions were higher for patients with CLI TL (odds ratio, 1.67; 95% confidence interval, 1.35-2.06) and CLI RP (odds ratio, 1.70; 95% confidence interval, 1.38-2.09) compared with patients with claudication. CONCLUSIONS: The 30-day readmission rates after lower extremity bypass vary significantly by surgical indication. Because lower extremity bypasses are performed for multiple indications, if readmission rates are publically reported and hospitals can be penalized for higher than expected readmission rates, the expected readmission rates should be adjusted for surgical indication.

Outcomes associated with preoperative weight loss after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for achieving and maintaining weight loss and for improving obesity-related comorbidities. As part of the approval process for bariatric surgery, many insurance companies require patients to have documented recent participation in a supervised weight loss program. The goal of this study was to evaluate the relationship of preoperative weight changes with outcomes following LRYGB. METHODS: A retrospective review was conducted of adult patients undergoing LRYGB between 2008 and 2012 at a single institution. Patients were stratified into quartiles based on % excess weight gain (0-4.99 % and ≥5 % EWG) and % excess weight loss (0-4.99 % and ≥5 % EWL). Generalized linear models were used to examine differences in postoperative weight outcomes at 6, 12, and 24 months. Covariates included in the final adjusted models were determined using backwards stepwise selection. RESULTS: Of the 300 patients included in the study, there were no significant demographic differences among the quartiles. However, there was an increased time to operation for patients who gained or lost ≥5 % excess body weight (p < 0.001). Although there was no statistical significance in postoperative complications, there was a higher rate of complications in patients with ≥5 % EWG compared to those with ≥5 % EWL (12.5 vs. 4.8 %, respectively; p = 0.29). Unadjusted and adjusted generalized linear models showed no statistically significant association between preoperative % excess weight change and weight loss outcomes at 24 months. CONCLUSION: Patients with the greatest % preoperative excess weight change had the longest intervals from initial visit to operation. No significant differences were seen in perioperative and postoperative outcomes. This study suggests preoperative weight loss requirements may delay the time to operation without improving postoperative outcomes or weight loss.

Venous thromboembolic events: How low can you go?

BACKGROUND: We evaluated postoperative venous thromboembolism (VTE) chemical prophylaxis adherence to assess the preventability of VTEs. METHODS: A case-control study was performed using the 2011-2015 ACS-NSQIP single institution database. Cases were identified as patients who experienced postoperative VTE within 30 days following surgery. Controls were matched 2:1 on procedure, age, and BMI. Association between inpatient chemical prophylaxis adherence and postoperative VTE was evaluated with conditional logistic regression. RESULTS: Seventy-three cases were matched to 145 controls. Complete inpatient VTE chemical prophylaxis adherence did not differ between cases and controls (45.2% vs. 46.2%, p = 1.00). Odds of postoperative VTE increased if a patient's prophylaxis was interrupted (OR 6.34, 95% CI 1.82-22.13). However, 53.7% of instances of interrupted prophylaxis were medically justified by concern for bleeding, spine operation, or for additional upcoming procedure. CONCLUSIONS: Nearly half of patients who experienced postoperative VTEs received appropriate guideline-driven care. Most interruptions in chemical prophylaxis were justified medically. This further questions the preventability of postoperative VTEs and the utility of this outcome as a valid measure of hospital quality.

Racial Disparities in Readmissions for Patients with Inflammatory Bowel Disease (IBD) After Colorectal Surgery.

BACKGROUND: The incidence of inflammatory bowel disease (IBD) in minorities is increasing, and health outcome disparities are becoming more apparent. Our aim was to investigate the contribution of race to readmissions in IBD patients undergoing colorectal surgery. DESIGN: The National Surgical Quality Improvement Program database from 2012 to 2013 was queried for all patients with IBD undergoing elective colorectal surgery. After stratifying by race, unadjusted univariate and bivariate comparisons were made. Primary outcome was all-cause 30-day readmission. Predictors of readmission were identified using multivariable logistic regression. RESULTS: Of the 2523 patients with IBD who underwent elective colon surgery, 15.0 % were readmitted within 30 days of index operation. Black patients constituted 7.7 % of the entire cohort. Black patients were significantly different in smoking status (27 vs. 22 %) and Crohn's diagnosis (84 vs. 73 %) (p < 0.05). Black patients had significantly higher readmission rates (20 vs. 15 %) and longer length-of-stays (8 vs. 6 days) after surgery (p < 0.05). On multivariable analysis, black race remained a significant predictor for 30-day readmissions in patients with IBD (odds ratio 1.6, 95 % confidence interval 1.1-2.5). CONCLUSIONS: Black patients with IBD have an increased risk for readmission after colorectal surgery. Efforts to reduce readmissions need to target not only well-studied risk factors such as postoperative complications, but also investigate non-NSQIP-measured elements such as social and behavioral determinants of health.

Association of race and socioeconomic status with outcomes following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Obesity poses serious health consequences, and bariatric surgery remains the most effective and durable treatment. The goal of this study was to identify the association of race and socioeconomic characteristics with clinical outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A retrospective review of all patients who underwent LRYGB between 2004 and 2010 was conducted. Outcomes analyzed included percent excess weight loss (%EWL), percent weight loss (%WL), change in body mass index (ΔBMI), and improvement or remission of obesity-associated medical conditions. RESULTS: In total, 663 patients met inclusion criteria with 170 (25.6%) African Americans and 493 (74.4%) European Americans. When compared to European Americans, the African American group included significantly more women and had a significantly higher preoperative BMI and lower socioeconomic status. In adjusted analyses, African Americans had significantly lower %EWL, %WL, and ΔBMI than the European Americans at 1-, 2-, and 5-year intervals of follow-up. Adjusted spline models including all follow-up visits for all patients also demonstrated a significant difference between the races in %EWL, %WL, and ΔBMI. Both races had similar improvement or remission of type 2 diabetes mellitus, obstructive sleep apnea, hyperlipidemia, and hypertension. CONCLUSION: Although African Americans had a statistically significant lower %EWL, %WL, and ΔBMI, both groups had durable weight loss and comparable rates of improvement or remission of obesity-associated comorbidities. Thus, both groups have significant improvement in their overall health after LRYGB.