Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty.

OBJECTIVE: To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty. SUMMARY BACKGROUND DATA: The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown. METHODS: We performed qualitative thematic analysis of transcripts from semi-structured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at two academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients. RESULTS: We identified 5 themes: perceptions of perioperative CPR in patients with frailty vary by provider specialty; judgments regarding appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology; resuscitation in patients with frailty is sometimes associated with moral distress; biases such as ableism and ageism may skew clinicians' perceptions of appropriateness of perioperative CPR in patients with frailty; and evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate. CONCLUSIONS: Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases such as ageism and ableism.

Prevalence, Management, and Outcomes Related to Preoperative Medical Orders for Life Sustaining Treatment (MOLST) in an Adult Surgical Population: Preoperative MOLST and Code Status Discussions.

OBJECTIVE: To determine prevalence of documented preoperative code status discussions and postoperative outcomes (specifically mortality, readmission, and discharge disposition) of patients with completed MOLST forms before surgery. SUMMARY OF BACKGROUND DATA: A MOLST form documents patient care preference regarding treatment limitations. When considering surgery in these patients, preoperative discussion is necessary to ensure concordance of care. Little is known about prevalence of these discussions and postoperative outcomes. METHODS: A retrospective cohort study was conducted consisting of all patients having surgery during a 1-year period at a tertiary care academic center in Boston, Massachusetts. RESULTS: Among 21,787 surgical patients meeting inclusion criteria, 402 (1.8%) patients had preoperative MOLST. Within the MOLST, 224 (55.7%) patients had chosen to limit cardiopulmonary resuscitation and 214 (53.2%) had chosen to limit intubation and mechanical ventilation. Code status discussion was documented presurgery in 169 (42.0%) patients with MOLST. Surgery was elective or nonurgent for 362 (90%), and median length of stay (Q1, Q3) was 5.1 days (1.9, 9.9). The minority of patients with preoperative MOLST were discharged home [169 (42%), and 103 (25.6%) patients were readmitted within 30 days. Patients with preoperative MOLST had a 30-day mortality of 9.2% (37 patients) and cumulative 90-day mortality of 14.9% (60 patients). CONCLUSIONS: Fewer than half of surgical patients with preoperative MOLST have documented code status discussions before surgery. Given their high risk of postoperative mortality and the diversity of preferences found in MOLST, thoughtful discussion before surgery is critical to ensure concordant perioperative care.

Validation of the Pictorial Fit-Frail Scale in a Thoracic Surgery Clinic.

OBJECTIVE: Examine feasibility and construct validity of Pictorial Fit-Frail scale (PFFS) for the first time in older surgical patients. BACKGROUND: The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics. METHODS: Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and Frailty Questionnaire (FRAIL) scale were obtained. To assess the validity of the PFFS in this population, the Spearman rank correlations (r spearman ) between PFFS trans and VES-13, FI-CGA, FRAIL were calculated. RESULTS: All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFS trans was 0.27 (interquartile range [IQR] 0.12-0.34), PFFS was 11 (IQR 5-14), and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFS trans and FI-CGA (r spearman = 0.81, P < 0.001) and a moderate correlation between PFFS trans and VES-13 and FRAIL score (r spearman = 0.68 and 0.64 respectively, P < 0.001). CONCLUSIONS: PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.

Which Geriatric Variables Most Strongly Inform Discharge Disposition After Emergency Surgery?

INTRODUCTION: Older adults account for an increasing proportion of emergency surgical procedures and have longer hospital lengths of stay than their elective counterparts. Identifying those at greatest risk of discharge to a postacute care facility would improve postoperative planning. We aimed to examine the role of preoperative cognitive and functional status on discharge disposition after emergency surgery in older adults. METHODS: We used American College of Surgeons National Surgical Quality Improvement Program Geriatric Pilot Project data from 2014 to 2018 to identify patients ≥65 y who underwent inpatient emergency surgery. The primary outcome was nonhome discharge, defined as discharge to an acute rehabilitation facility, a skilled nursing facility, or a nonhome unskilled facility. Logistic regression controlling for patient characteristics was used to determine the association of preoperative geriatric-specific variables with nonhome discharge. RESULTS: Of 3494 patients, 53.9% were not discharged home. In multivariable analysis, a fall within the past year (odds ratio [OR] = 5.3, 95% confidence interval [CI] = 4.4-6.5) was most strongly associated with nonhome discharge. The outcome was also independently associated with preoperative use of a mobility aid (OR = 2.0, 95% CI = 1.7-2.4), partially dependent functional status (OR = 1.8, 95% CI = 1.4-2.5), and surrogate consent (OR = 1.4, 95% CI = 1.1-1.8), but not cognitive impairment (OR = 1.0, 95% CI = 0.7-1.3). CONCLUSIONS: Assessing for a history of falls and impaired mobility at the initial surgical evaluation can rapidly identify patients most likely to need postacute care. Further work is needed to assess the association between pre-existing cognitive impairment and discharge disposition after emergency surgery.

Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team.

BACKGROUND: As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS: Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS: From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS: Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.

Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

Variation in Patient-Reported Advance Care Preferences in the Preoperative Setting.

BACKGROUND: High-quality shared decision-making for patients undergoing elective surgical procedures includes eliciting patient goals and treatment preferences. This is particularly important, should complications occur and life-sustaining therapies be considered. Our objective was to determine the preoperative care preferences of older higher-risk patients undergoing elective procedures and to determine any factors associated with a preference for limitations to life-sustaining treatments. METHODS: Cross-sectional survey conducted between May and December 2018. Patients ≥55 years of age presenting for a preprocedural evaluation in a high-risk anesthesia clinic were queried on their desire for life-sustaining treatments (cardiopulmonary resuscitation, mechanical ventilation, dialysis, and artificial nutrition) as well as tolerance for declines in health states (physical disability, cognitive disability, and daily severe pain). RESULTS: One hundred patients completed the survey. The median patient age was 68. Most patients were Caucasian (87%) and had an American Society of Anesthesiologists (ASA) score of III (88%). The majority of patients (89%) desired cardiopulmonary resuscitation. However, most patients would not accept mechanical ventilation, dialysis, or artificial nutrition for an indefinite period of time. Similarly, most patients (67%-81%) indicated they would not desire treatments to sustain life in the event of permanent physical disability, cognitive disability, or daily severe pain. CONCLUSIONS: Among older, higher-risk patients presenting for elective procedures, most patients chose limitations to life-sustaining treatments. This work highlights the need for an in-depth goals of care discussion and establishment of advance care preferences before a procedure or operative intervention.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial.

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Critical event debriefing: a checklist for the aftermath.

PURPOSE OF REVIEW: Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. RECENT FINDINGS: Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. SUMMARY: There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.

Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery.

BACKGROUND: Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome). METHODS: In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay. RESULTS: The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium. CONCLUSIONS: Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

Advances in anesthesia education: increasing access and collaboration in medical education, from E-learning to telesimulation.

PURPOSE OF REVIEW: The landscape of medical education continues to evolve. Educators and learners must stay informed on current medical literature, in addition to focusing efforts on current educational trends and evidence-based methods. The present review summarizes recent advancements in anesthesiology education, specifically highlighting trends in e-learning and telesimulation, and identifies possible future directions for the field. RECENT FINDINGS: Websites and online platforms continue to be a primary source of educational content; top websites are more likely to utilize standardized editorial processes. Podcasts and videocasts are important tools desired by learners for asynchronous education. Social media has been utilized to enhance the reach and visibility of journal articles, and less often as a primary educational venue; its efficacy in comparison with other e-learning platforms has not been adequately evaluated. Telesimulation can effectively disseminate practical techniques and clinical knowledge sharing, extending the capabilities of simulation beyond previous restrictions in geography, space, and available expertise. SUMMARY: E-learning has changed the way anesthesiology learners acquire knowledge, expanding content and curricula available and promoting international collaboration. More work should be done to expand the principles of accessible and collaborative education to psychomotor and cognitive learning via telesimulation.

Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery.

BACKGROUND: A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk. METHODS: A modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines. RESULTS: Significant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events. CONCLUSIONS: Future research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.

Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care.

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Review from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Effect of Preoperative Diabetes Management on Glycemic Control and Clinical Outcomes After Elective Surgery.

OBJECTIVE: The aim of this study was to evaluate whether preoperative diabetes management can improve glycemic control and clinical outcomes after elective surgery. BACKGROUND: There is lack of data on the importance of diabetes treatment before elective surgery. Diabetes is often ignored before surgery and aggressively treated afterwards. METHODS: Patients with diabetes were identified and treated proactively before their scheduled surgeries. Data for all elective surgeries over 2 years before and 2 years after implementation of the program were collected. RESULTS: Out of 31,392 patients undergoing first surgery, 3909 had diabetes; 2072 before and 1835 after the program. Mean blood glucose on the day of surgery was 146.4 ±â€Š51.9 mg/dL before and 139.9 ±â€Š45.6 mg/dL after the program (P = 0.0028). Proportion of patients seen by the inpatient diabetes team increased. Mean blood glucose during hospital stay was 166.7 ±â€Š42.9 mg/dL before and 158.3 ±â€Š46.6 mg/dL after program (P < 0.0001). The proportion of patients with hypoglycemic episodes (<50 mg/dL) was 4.93% before and 2.48% after the program (P < 0.0001). Length of hospital stay (LOS) decreased among patients with diabetes (4.8 ±â€Š5.3 to 4.6 ±â€Š4.3 days; P = 0.01) and remained unchanged among patients without diabetes (4.0 ±â€Š4.5 and 4.1 ±â€Š4.8, respectively; P = 0.42). Changes in intravenous antibiotic use, patients discharged to home, renal insufficiency, myocardial infarction, stroke, and in-hospital mortality were similar among diabetic and nondiabetic groups. CONCLUSIONS: Preoperative and inpatient diabetes management improves glycemic control on the day of surgery and postoperatively and decreases the incidence of hypoglycemia. These changes may eventually improve clinical outcomes. Although statistically significant, the decrease in LOS was of equivocal clinical significance in this study.

Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management.

OBJECTIVE: To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). BACKGROUND: MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. METHODS: Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. RESULTS: Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)]. CONCLUSIONS: VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.