Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics.

OBJECTIVE: The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND: Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS: New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS: Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS: Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.

Readmissions With Dehydration After Ileostomy Creation: Rethinking Risk Factors.

BACKGROUND: Twenty-nine percent of postileostomy discharges are readmitted, most commonly because of dehydration. However, there is a lack of detailed data specifically evaluating factors associated with readmission with dehydration. In addition, patients with a history of an ileostomy have often been excluded from previous studies and therefore represent a group of understudied ileostomates. OBJECTIVE: This study aimed to evaluate factors available at discharge associated with 30-day readmission for dehydration, rather than all-cause readmissions. DESIGN: This was a retrospective cohort study. SETTING: Study patients received ileostomies at a tertiary academic medical center from 2014 to 2016. PATIENTS: Patients with a preexisting ileostomy that was not recreated per the operative note were excluded, whereas those who received a new ileostomy were included. MAIN OUTCOME MEASURE: The primary outcome measured was 30-day readmission for dehydration as defined by objective clinical criteria. RESULTS: A total of 262 patients underwent ileostomy creation and were discharged alive. Twenty-five percent were ≥65 years of age, 53% were men, 14% had a history of ileostomy, 18% had a creatinine >1.0 on discharge, and 26% had high ileostomy output at any time during the index admission. Among all ileostomates, the all-cause readmission rate was 30%. Mean days to readmission for any cause was 8.5, whereas for dehydration it was 11.6 days. Of the readmissions, 37% were readmitted with a diagnosis of dehydration, and dehydration was the sole reason in 26%. Among those with dehydration, the most common length of stay was 2 days. In multivariable logistic regression, 30-day readmission with dehydration was associated with older age, male sex, history of an ileostomy, high ileostomy output during index admission, and a discharge creatinine >1.0. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Ileostomy dehydration efforts have focused on new ileostomy patients; however, our data suggest that patients with a history of an ileostomy are actually at risk for readmission with dehydration. Further studies aimed at the reduction of readmission with dehydration after ileostomy are warranted and should include patients with a history of an ileostomy. See Video Abstract at http://links.lww.com/DCR/A643.

Nationwide Heterogeneity in Hospital-Specific Probabilities of Rectal Cancer Understaging and Its Effects on Outcomes.

BACKGROUND: Rectal cancer patients who are understaged may not be offered the highest quality treatment modalities, which are based on an accurate assessment of preoperative staging. The objective of this study was to evaluate heterogeneity in the probability of being understaged at Commission on Cancer hospitals in the United States and to assess how this variation affects outcomes. METHODS: The 2006-2013 National Cancer Data Base was queried for clinical stage I-III rectal cancer patients who underwent resection. The initial clinical stage was compared with the "gold standard," pathological stage. A Bayesian multilevel logistic regression model was used to characterize variation in hospital-specific probabilities of being understaged (clinical stage < pathologic stage). Separate analyses assessed the impact of being understaged on positive circumferential resection margins (CRM), receipt of adjuvant chemotherapy, and 5-year overall survival. RESULTS: Among 12,684 patients who did not receive neoadjuvant chemoradiation and treated at 1176 hospitals, 3044 (24%) were understaged. After patient level risk-adjustment, a 24-fold difference in the probability of being understaged was observed between hospitals (range 3-72%, median = 15%). Understaging was independently associated with positive CRM [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.39, 1.92] and receipt of adjuvant chemotherapy (OR 14.22, 95% CI 13.55, 18.88). Despite an increase in the delivery of systemic therapy after surgical resection, understaging was associated with worse survival (hazard ratio = 1.61, 95% CI 1.48, 1.95). CONCLUSIONS: Deficiencies in high-quality rectal cancer management begin with incorrect clinical staging. The risk-adjusted probability of understaging varied widely between hospitals. This institutional failure to provide optimal oncological management at the start of care was associated with worse long-term survival.

Patterns and Yearly Time Trends in the Use of Radiation Therapy During the Last 30 Days of Life Among Patients With Metastatic Rectal Cancer in the United States From 2004 to 2012.

PURPOSE: Although radiation therapy (RT) can provide palliative benefits for patients with metastatic rectal cancer, its role at the end of life remains unclear. The objective of this study was to assess sociodemographic and clinical factors associated with the use of RT during the last 30 days of life and to evaluate yearly time trends in RT utilization among stage IV patients with rectal cancer. METHODS: The 2004 to 2012 National Cancer DataBase was queried for patients with metastatic rectal cancer who had a documented death during follow-up. A Bayesian multilevel logistic regression model was used to characterize predictive factors and yearly time trends associated with RT use in the last 30 days of life. RESULTS: Among 10 431 patients who met inclusion criteria, 345 (3%) received RT during the last 30 days of life. Factors independently associated with RT use included older age, female sex, African American race, nonprivate insurance, higher comorbidity burden, and worse grade. The odds of RT use at the end of life decreased by 28% between 2007 and 2009 (odds ratio [OR] = 0.72, 95% Credible Interval (CI) = 0.58-0.93), but then increased by 16% from 2010 to 2012 (OR = 1.16, 95% CI = 1.13-1.33), relative to 2004 to 2006. CONCLUSION: Radiation therapy use for patients with metastatic rectal cancer is beneficial, and efforts to optimize its appropriate use are important. Several factors associated with RT use during the last 30 days of life included disparities in sociodemographic and clinical subgroups. Research is needed to understand the underlying causes of these inequalities and the role of predictive models in clinical decision-making.

Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes.

BACKGROUND: It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection. OBJECTIVE: The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers. DESIGN: This was a population-based study. SETTINGS: The National Cancer Database was queried for patients with rectal cancer. PATIENTS: Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included. MAIN OUTCOME MEASURES: The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival. RESULTS: A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group. LIMITATIONS: We lacked data regarding patient and physician decision making and surgeon-specific factors. CONCLUSIONS: Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at http://links.lww.com/DCR/A446.

Emergent Colectomy Is Independently Associated with Decreased Long-Term Overall Survival in Colon Cancer Patients.

BACKGROUND: The purpose of this study was to examine the long-term overall survival (OS) of colon cancer patients who underwent emergent resection versus patients who were resected electively. METHODS: The 2006-2012 National Cancer Data Base was queried for colon cancer patients who underwent surgical resection. Emergent resection was defined as resection within 24 h of diagnosis. A mixed-effects logistic regression was used to estimate the effect of emergent resection on 30- and 90-day mortality. A propensity score-matched mixed-effects Cox proportional-hazards model was used to estimate the effect of emergent resection on 5-year OS. RESULTS: Two hundred fourteen thousand one hundred seventy-four patients met inclusion criteria, 30% of the cohort had an emergent resection. After controlling for patient and hospital factors, pathological stage, lymph node yield, margin status, and adjuvant chemotherapy, emergent resection was associated with increased odds of 30-day mortality (OR = 1.69, 95% CI = 1.60, 1.78) and hazard of death at 5 years (HR = 1.13, 95% CI = 1.09, 1.15) compared to elective resections. CONCLUSION: Emergent resection for colon cancer is independently associated with poor short-term outcomes and decreased 5-year OS compared to elective resection. With 30% of cases in this study emergent, these findings underlie the importance of adherence to colon cancer screening guidelines to limit the need for emergent resections.

Variation in Delayed Time to Adjuvant Chemotherapy and Disease-Specific Survival in Stage III Colon Cancer Patients.

BACKGROUND: There is a paucity of literature quantifying the extent to which time to adjuvant chemotherapy for stage III colon cancer patients varies between individual surgeons, medical oncologists, and hospitals. METHODS: A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System and Medicare claims to identify stage III colon cancer patients from 2004 to 2009 who underwent resection and received adjuvant chemotherapy. Multilevel logistic regression models characterized variation in delayed time to adjuvant chemotherapy (>8 weeks vs. ≤8 weeks). Multilevel competing-risks Cox proportional hazards models assessed the effect of delayed time to adjuvant chemotherapy on disease-specific survival. RESULTS: The proportion of delayed time to adjuvant chemotherapy was 36 % in 1133 patients treated by 516 surgeons and 351 medical oncologists at 163 hospitals. After controlling for case-mix, the majority of the clustering variation (72 %) in delayed time to adjuvant chemotherapy is attributed to differences between medical oncologists. Risk-adjusted surgeon-specific, medical oncologist-specific, and hospital-specific probabilities of delayed time to adjuvant chemotherapy ranged from 30 to 38, 17 to 59, and 27 to 43 %, respectively. Delayed time to adjuvant chemotherapy was associated with disease-specific survival (hazard ratio [HR] 1.24, 95 % confidence interval [CI] 1.07-1.45). CONCLUSIONS: These findings suggest there is substantial variation in time to adjuvant chemotherapy among stage III colon cancer patients. Reasons for delays may be due to system factors that influence individual providers to make varying decisions on the time of initiation. Future research should identify what these factors may be and how to address them to promote better delivery of care.

Variation in Hospital-Specific Rates of Suboptimal Lymphadenectomy and Survival in Colon Cancer: Evidence from the National Cancer Data Base.

BACKGROUND: Little is known about between-hospital differences in the rate of suboptimal lymphadenectomy. This study characterizes variation in hospital-specific rates of suboptimal lymphadenectomy and its effect on overall survival in a national hospital-based registry. METHODS: Stage I-III colon cancer patients were identified from the 2003-2012 National Cancer Data Base. Bayesian multilevel logistic regression models were used to assess the impact of patient- and hospital-level factors on hospital-specific rates of suboptimal lymphadenectomy (<12 lymph nodes), and multilevel Cox models were used to estimate the effect of suboptimal lymphadenectomy at the patient (yes vs. no) and hospital level (quartiles of hospital-specific rates) on overall survival. RESULTS: A total of 360,846 patients across 1345 hospitals in the US met the inclusion criteria, of which 25 % had a suboptimal lymphadenectomy. Wide variation was observed in hospital-specific rates of suboptimal lymphadenectomy (range 0-82 %, median 44 %). Older age, male sex, comorbidity score, no insurance, positive margins, lower tumor grade, lower T and N stage, and sigmoid and left colectomy were associated with higher odds of suboptimal lymphadenectomy. Patients treated at lower-volume and non-academic hospitals had higher odds of suboptimal lymphadenectomy. Patient- and hospital-level factors explained 5 % of the between-hospital variability in suboptimal lymphadenectomy, leaving 95 % unexplained. Higher suboptimal lymphadenectomy rates were associated with worse survival (quartile 4 vs. quartile 1: hazard ratio 1.19, 95 % confidence interval 1.16-1.22). CONCLUSION: Large differences in hospital-specific rates of suboptimal lymphadenectomy were observed, and this variation was associated with survival. Quality improvement initiatives targeting hospital-level adherence to the national standard may improve overall survival among resected colon cancer patients.