Impact of sociodemographic factors on outcomes in patients with peritoneal malignancies following cytoreduction and chemoperfusion.

BACKGROUND AND OBJECTIVES: Sociodemographic factors have been shown to impact surgical outcomes. However, the effects of these factors on patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are not well known. This study aims to evaluate the impact of sociodemographic factors on patients undergoing CRS/HIPEC. METHODS: Adult patients at a tertiary center who underwent CRS/HIPEC were evaluated. Perioperative variables were collected and analyzed. A national database was also used to evaluate patients undergoing CRS/HIPEC. RESULTS: There were 90 patients who underwent CRS/HIPEC (32% non-White). There was no statistically significant difference in postoperative complications, length of stay, or discharge disposition based upon race (white vs. non-White patients), socioeconomic status (SES), or insurance type. Nationally, we found that Black and Hispanic patients were less likely to undergo CRS/HIPEC than Non-Hispanic white patients (Black: odds ratio [OR]: 0.60, [confidence interval {CI}: 0.39-0.94]; Hispanic: OR: 0.52, [CI: 0.28-0.98]). However, there were no significant differences in postoperative complications based upon race/ethnicity. CONCLUSION: Sociodemographic factors including race, SES, and insurance status did not impact postoperative outcomes in patients undergoing CRS/HIPEC at our single institution. On a national level, Black and Hispanic patients underwent CRS/HIPEC at lower rates compared to white patients.

Medical Students from Socioeconomically Disadvantaged Backgrounds are Less Likely to Match into Surgery.

BACKGROUND: This study aims to understand the demographic and academic characteristics that play a role in enrollment in surgical residency programs as well as any racial or socioeconomic disparities that may exist for medical students entering surgical specialties at the Loyola University Chicago Stritch School of Medicine (LUC-SSOM). METHODS: Demographic data for 993 medical students graduating between 2013 and 2019 from LUC-SSOM were compared using a series of t tests, Chi-square tests, and logistic regression models. RESULTS: Students entering surgical residency programs had two times greater odds of coming from a family with a median family income greater than $75,000 than those entering non-surgical residencies (OR 2.19, 95% CI [1.35, 3.53]). Students from disadvantaged backgrounds had 50% decreased odds of going into surgery when compared to those not entering surgery (OR 0.50, 95% CI [0.28, 0.90]). CONCLUSIONS: Students from low socioeconomic status backgrounds face more barriers in pursuing surgical subspecialties.

Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair.

BACKGROUND: Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality. RESULTS: Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409). CONCLUSIONS: When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.

Trends, Cost, and Mortality From Sepsis After Trauma in the United States: An Evaluation of the National Inpatient Sample of Hospitalizations, 2012-2016.

OBJECTIVES: Identification and outcomes in patients with sepsis have improved over the years, but little data are available in patients with trauma who develop sepsis. We aimed to examine the cost and epidemiology of sepsis in patients hospitalized after trauma. DESIGN: Retrospective cohort study. PATIENTS: National Inpatient Sample. INTERVENTIONS: Sepsis was identified between 2012 and 2016 using implicit and explicit International Classification of Diseases, Ninth and Tenth Revision codes. Analyses were stratified by injury severity score greater than or equal to 15. Annual trends were modeled using generalized linear models. Survey-adjusted logistic regression was used to compare the odds for in-hospital mortality, and the average marginal effects were calculated to compare the cost of hospitalization with and without sepsis. MEASUREMENTS AND MAIN RESULTS: There were 320,450 (SE = 3,642) traumatic injury discharges from U.S. hospitals with sepsis between 2012 and 2016, representing 6.0% (95% CI, 5.9-6.0%) of the total trauma population (n = 5,329,714; SE = 47,447). In-hospital mortality associated with sepsis after trauma did not change over the study period (p > 0.40). In adjusted analysis, severe (injury severity score ≥ 15) and nonsevere injured septic patients had an odds ratio of 1.39 (95% CI, 1.31-1.47) and 4.32 (95% CI, 4.06-4.59) for in-hospital mortality, respectively. The adjusted marginal cost for sepsis compared with nonsepsis was $16,646 (95% CI, $16,294-$16,997), and it was greater than the marginal cost for severe injury compared with nonsevere injury $8,851 (95% CI, $8,366-$8,796). CONCLUSIONS: While national trends for sepsis mortality have improved over the years, our analysis of National Inpatient Sample did not support this trend in the trauma population. The odds risk for death after sepsis and the cost of care remained high regardless of severity of injury. More rigor is needed in tracking sepsis after trauma and evaluating the effectiveness of hospital mandates and policies to improve sepsis care in patients after trauma.

Use of Surgery for Post-Prostatectomy Incontinence.

PURPOSE: Stress urinary incontinence following radical prostatectomy is common and potentially debilitating. Surgical therapy with a urethral sling or an artificial urinary sphincter is an effective option with high patient satisfaction in men in whom conservative measures fail to treat post-prostatectomy incontinence. We sought to characterize the contemporary utilization of surgical therapy of post-prostatectomy incontinence using an all payer database. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project databases for Florida from 2006 to 2015 and identified men who underwent radical prostatectomy between 2006 and 2012 using ICD procedure codes. Patients were tracked longitudinally for placement of an ambulatory or inpatient urethral sling, or an artificial urinary sphincter between 2006 and 2015. Patient and clinical data were extracted and analyzed with descriptive statistics. A multivariable logistic regression model was constructed to determine risk adjusted predictors of subsequent incontinence surgery. RESULTS: During the study period 29,287 men underwent radical prostatectomy, of whom 1,068 (3.6%) were treated with subsequent incontinence surgery a median of 23.5 months after prostatectomy. On multivariate analysis risk factors for incontinence surgery included age groups 61 to 70 years (OR 1.25, p=0.008) and 71 to 80 years (OR 1.34, p=0.022), Medicare insurance (OR 1.33, p <0.005) and an increased Charlson Comorbidity Index (OR 1.13 per unit increase, p <0.005). CONCLUSIONS: Of patients who underwent radical prostatectomy 3.6% subsequently underwent stress urinary incontinence surgery. Post-prostatectomy incontinence surgery is likely under performed and delayed in performance based on the previously reported prevalence of severe post-prostatectomy incontinence and the natural history of symptoms. Efforts to increase prompt repair of refractory or severe incontinence can greatly improve patient quality of life after radical prostatectomy.

Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: Composite outcomes may more accurately reflect patient and provider expectations around optimal care. We sought to determine the impact of achieving a so-called "textbook oncologic outcome" (TOO) among patients undergoing resection of pancreatic adenocarcinoma (PDAC). METHODS: Patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2006 and 2016 were identified in the National Cancer Database (NCDB). TOO was defined by: margin negative resection, compliant lymph node evaluation, no prolonged length-of-stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Factors associated with TOO and overall survival (OS) were evaluated using multivariable logistic and Cox regression models, respectively. RESULTS: Among 18 608 patients who underwent PD at 782 hospitals, many patients successfully achieved certain TOO factors such as R0 margin (77.9%) and no 30-day mortality (96.9%), while other TOO criteria such as receipt of adjuvant therapy (48.2%) were achieved less frequently. Overall, only 3124 (16.8%) patients achieved a TOO. Factors associated with lower odds of TOO included: older age, Black race, Medicaid insurance, Community facility, and low PD facility (<20 PD/y) (all P < .05). Achievement of a TOO was associated with lower risk of mortality (HR 0.74; 95% CI, 0.70-0.77). CONCLUSIONS: While TOO was associated with improved long-term survival, TOO was only achieved in 16.8% of patients undergoing PD.

The Impact of the Affordable Care Act Medicaid Expansion on Vascular Surgery.

BACKGROUND: The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility such that all adults with an income level up to 138% of the federal poverty threshold in 2014 qualified for Medicaid benefits. Prior studies have shown that the ACA Medicaid expansion was associated with increased access to care. The impact of the ACA Medicaid expansion on patients undergoing complex care for major vascular pathology has not been evaluated. METHODS: The Healthcare Cost and Utilization Project State Inpatient Database was used to identify patients undergoing care for major vascular pathology in 6 states from 2010 to 2014. The analysis cohort included adult patients between the ages of 18 and 64 years who underwent a nonemergent surgical procedure for an abdominal aortic aneurysm, thoracic aortic aneurysm, carotid artery stenosis, peripheral vascular disease, or chronic kidney disease. Poisson regression was used to determine the incidence rate ratios (IRRs). RESULTS: There were a total of 83,960 patients in the study cohort. Compared with nonexpansion states, inpatient admissions for Medicaid patients with an abdominal or thoracic aneurysm and carotid stenosis diagnosis increased significantly (IRR, 1.20, 1.27, 1.06, respectively; P < 0.05) in states that expanded Medicaid. Vascular-related surgeries increased for carotid endarterectomy, lower extremity revascularization, lower extremity amputation, and arteriovenous fistula in expansion states (IRR, 1.24, 1.10, 1.11, 1.16, respectively; P < 0.05) compared with nonexpansion states. CONCLUSIONS: In states that expanded Medicaid coverage under the ACA, the rate of vascular-related surgeries and admissions for Medicaid patients increased. We conclude that expanding insurance coverage results in enhanced access to vascular surgery.

Impact of Post-Hospital Syndrome on Penile Prosthesis Outcomes: A Period of Global Health Risk.

PURPOSE: Post-hospital syndrome is an acquired transient period of health vulnerability following inpatient admission. We assessed the impact of a preoperative hospitalization on outcomes following penile prosthesis surgery and sought to optimize surgical timing after inpatient admission. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery Database for California from 2007 to 2011 and for Florida from 2009 to 2014. Patients were identified as having undergone prosthesis placement by ICD-9 and CPT codes. The primary exposure was post-hospital syndrome, defined as any inpatient admission 90 days or less before prosthesis placement. Patients were further categorized by how recently the inpatient hospitalization occurred. The primary study outcome was 30-day hospital readmission. Secondary outcomes were length of stay, and device and postoperative complications. RESULTS: We identified 16,923 patients who received a penile prosthesis, of whom 477 (3%) had post-hospital syndrome exposure 90 days or less before prosthesis placement. After risk adjustment patients with post-hospital syndrome had higher odds of 30-day readmission (OR 3.0, 95% CI 2.2-4.1), length of stay 2 days or longer (OR 1.7, 95% CI 1.3-2.3) and device complications (OR 1.7, 95% CI 1.2-2.5). When categorizing patients by 30-day intervals, we found a linear decrease in the risk of 30-day readmission as the interval increased between post-hospital syndrome exposure and prosthesis surgery. CONCLUSIONS: Post-hospital syndrome exposure is a risk adjusted predictor of 30-day readmissions, prolonged length of stay and device complications. Medical optimization and delayed surgery can help combat the adverse effects associated with post-hospital syndrome exposure and may improve surgical outcomes.

Predictors of Death in Necrotizing Skin and Soft Tissue Infection.

BACKGROUND: Necrotizing skin and soft tissue infection (NSTI) is a surgical emergency that is associated with high morbidity and mortality. This study aims to identify predictors of in-hospital death following a NSTI. MATERIAL AND METHODS: We queried the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for California between 2006 and 2011. We used conventional and advanced statistical methods to identify predictors of in-hospital mortality, which included: logistic regression, stepwise logistic regression, decision trees, and K-nearest neighbor (KNN) algorithms. RESULTS: A total of 10,158 patients had a NSTI. The full and stepwise logistic regression models had a ROC AUC in the validation dataset of 0.83 (95% CI [0.80, 0.86]) and 0.81 (95% CI [0.78, 0.83]), respectively. The KNN and decision tree model had a ROC AUC of 0.84 (95% CI [0.81, 0.85]) and 0.69 (95% CI [0.65, 0.72]), respectively. The top predictors of in-hospital mortality in the KNN and stepwise logistic model included: (1) the presence of in-hospital coagulopathy, (2) having an infectious or parasitic diagnoses, (3) electrolyte disturbances, (4) advanced age, and (5) the total number of beds in a hospital. CONCLUSION: Patients with a NSTI have high rates of in-hospital mortality. This study highlights the important factors in managing patients with a NSTI which include: correcting coagulopathy and electrolyte imbalances, treating underlying infectious processes, providing adequate resources to the elderly population, and managing patients in high-volume centers.

Impact of the Affordable Care Act (ACA) Medicaid Expansion on Cancer Admissions and Surgeries.

OBJECTIVE: This study aims to evaluate the trends in cancer (CA) admissions and surgeries after the Affordable Care Act (ACA) Medicaid expansion. METHODS: This is a retrospective study using HCUP-SID analyzing inpatient CA (pancreas, esophagus, lung, bladder, breast, colorectal, prostate, and gastric) admissions and surgeries pre- (2010-2013) and post- (2014) Medicaid expansion. Surgery was defined as observed resection rate per 100 cancer admissions. Nonexpansion (FL) and expansion states (IA, MD, and NY) were compared. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID). RESULTS: There were 317, 858 patients in our sample which included those with private insurance, Medicaid, or no insurance. Pancreas, breast, colorectal, prostate, and gastric CA admissions significantly increased in expansion states but decreased in nonexpansion states. (IRR 1.12, 1.14, 1.11, 1.34, 1.23; P < .05) Lung and colorectal CA surgeries (IRR 1.30, 1.25; P < .05) increased, while breast CA surgeries (IRR 1.25; P < .05) decreased less in expansion states. Government subsidized, or self-pay patients had greater odds of undergoing lung, bladder, and colorectal CA surgery (OR 0.45 vs 0.33; 0.60 vs 0.48; 0.47 vs 0.39; P < .05) in expansion states after reform. CONCLUSIONS: In states that expanded Medicaid coverage under the ACA, the rate of surgeries for colorectal and lung CA increased significantly, while breast CA surgeries decreased less. Parenthetically, these cancers are subject to population screening programs. We conclude that expanding insurance coverage results in enhanced access to cancer surgery.

Put Me in the Game Coach! Resident Participation in High-risk Surgery in the Era of Big Data.

BACKGROUND: With the emphasis on quality metrics guiding reimbursement, concerns have emerged regarding resident participation in patient care. This study aimed to evaluate whether resident participation in high-risk elective general surgery procedures is safe. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2005-2012) was used to identify patients undergoing one of five high-risk general surgery procedures. Resident and nonresident groups were created using a 2:1 propensity score match. Postoperative outcomes were calculated using univariate statistics and multivariable logistic regression for the two groups. Predictors of mortality and morbidity were identified using machine learning in the form of decision trees. RESULTS: Twenty-five thousand three hundred sixty three patients met our inclusion criteria. Following matching, each group contained 500 patients and was comparable for matched characteristics. Thirty-day mortality was similar between the groups (2.4% versus 2.6%; P = 0.839). Deep surgical site infection (0% versus 1.6%; P = 0.005), urinary tract infection (5% versus 2.5%; P = 0.029), and operative time (275.6 min versus 250 min; P = 0.0064) were significantly higher with resident participation. Resident participation was not predictive of mortality or complications, while age, American society of anesthesiologists class, and functional status were leading predictors of both. CONCLUSIONS: Despite growing time constraints and pressure to perform, surgical resident participation remains safe. Residents should be given active roles in the operating room, even in the most challenging cases.

Racial and Ethnic Postoperative Outcomes After Surgery: The Hispanic Paradox.

BACKGROUND: The Hispanic population in the United States have previously been shown to have, in some cases, better health outcomes than non-Hispanic whites (NHWs) despite having lower socioeconomic status and higher frequency of comorbidities. This epidemiologic finding is coined as the Hispanic Paradox (HP). Few studies have evaluated if the HP exists in surgical patients. Our study aimed to examine postoperative complications between Hispanic and NHW patients undergoing low- to high-risk procedures. MATERIALS AND METHODS: We conducted a retrospective cohort study analyzing adult patients who underwent high-, intermediate-, and low-risk procedures. The Healthcare Cost and Utilization Project California State Inpatient Database between 2006 and 2011 was used to identify the patient cohort. Candidate variables for the adjusted model were determined a priori and included patient demographics with the ethnic group as the exposure of interest. RESULTS: The median age for Hispanics was 52 (SD 19.3) y, and 38.8% were male (n = 87,837). A higher proportion of Hispanics had Medicaid insurance (23.9% versus 3.8%) or were self-pay (14.2% versus 4.5%) compared with NHWs. In adjusted analysis, Hispanics had a higher odds risk for postoperative complications across all risk categories combined (OR 1.06, 95% CI 1.04-1.09). They also had an increased in-hospital (OR 1.38, 95% CI 1.14-1.30) and 30-d mortality in high-risk procedures (OR 1.34, 95% CI 1.19-1.51). CONCLUSIONS: Hispanics undergoing low- to high-risk surgery have worse outcomes compared with NHWs. These results do not support the hypothesis of an HP in surgical outcomes.

Exploring the paradigm of robotic surgery and its contribution to the growth of surgical volume.

Background: Robotic surgery is an appealing option for both surgeons and patients. The question around the introduction of new surgical technology, such as robotics, with the potential link to increased procedure-specific volume has not been addressed. We hypothesize that hospital adoption of robotic technology increases the total volume of specific procedures as compared to nonrobotic hospitals. Methods: The 2010-2020 Florida Agency for Health Care Administration Inpatient database was queried for open, laparoscopic, and robotic colectomy, lobectomy, gastric bypass, and antireflux procedures. International Classification of Diseases, 9th and 10th Revisions, codes were used. Difference in difference method was used to evaluate the impact of robotics on total procedure-specific volume of robotic hospitals versus nonrobotic hospitals before and after adopting robotic technology. Incident rate ratios from the difference in difference analysis determined the significance of adding robotics. Patient demographics were evaluated using χ2 test. Results: A total of 291,826 procedures were performed at 217 hospitals, 151 with robotic capabilities. Robotic hospitals experienced a 37% increase in surgical volume due to robotic technology (incident rate ratio 1.37, P < .05), which was consistent for each surgery except antireflux procedures (incident rate ratio 0.95). Robotic procedures had significantly higher charges for medical/surgical supplies; however, the mean length of stay for robotic procedures was significantly shorter than that of laparoscopic and open cases. Conclusion: Hospital adoption of robotic technology significantly increases surgical volume for select procedures. Hospitals should consider the benefits of introducing robotic technology which leads to higher volume and decreased length of stay, benefitting both hospital systems and patients.

Adopting robotic thoracic surgery impacts hospital overall lung resection case volume.

PURPOSE: We sought to evaluate the role of robotic-assisted lung surgery on hospital volume using difference in difference (DID). We propose hospital adoption of robotic thoracic technology increases total volume of specific procedures as compared to non-robotic hospitals. METHODS: The 2010-2015 Florida Agency for Health Care Administration dataset was queried for open, video-assisted thoracoscopic, and robotic-assisted thoracic surgeries. Incident Rate Ratios (IRR) from DID analysis determined the significance of robotic technology. For each technique, length of stay and elements of charges were compared to determine statistical significance. RESULTS: A total of 28,484 lung resection procedures performed at 162 hospitals, 65 of which had robotic capabilities were included. Robotic hospitals experienced an 85% increase in total lung surgical volume (IRR 1.85, p-value <0.001). This increase in volume was consistent for each lung resection procedure separately. CONCLUSION: Hospital adoption of robotic technology significantly increases the overall lung surgical volume for select lung resection procedures.

Does adoption of new technology increase surgical volume? The robotic inguinal hernia repair model.

Robotic Inguinal Hernia repair has been associated with higher costs but shorter length of stay. Robotic surgery is an appealing option for patients undergoing elective hernia surgery however given the high startup, maintenance and operating costs, the adoption of robotic technology may not guarantee increased profitability. Our hypothesis is that the introduction of robotic technology increases the overall surgical volume of inguinal hernia repairs within a hospital as compared to non-robotic hospitals. The 2010-2018 Florida Agency for Health Care Administration Ambulatory Patient data were queried for Open, Laparoscopic and Robotic inguinal hernia repairs using ICD9, ICD10 and CPT codes. Using a difference in difference (DID) technique, we determined the difference of the total hernia volume of robotic hospitals pre- and post-adoption of robotic technology. In addition, selected hospitals which were early adopters of robotic technology were compared to with their surrounding non-robotic competitor hospitals. Incident Rate Ratios-IRR, from the difference in difference analysis determined the significance of robotic technology. Hospital and patient demographic data were evaluated, and chi square test were used to determine statistical significance. p < 0.05 was considered significant. There were a total of 258,785 inguinal hernia repairs (5774 Robotic, 88,265 Laparoscopic and 164,746 Open) performed at 398 hospitals, 94 of which had robotic capabilities. Of all the procedure types, around 90% were primary inguinal hernia repairs. The majority of patients in this cohort were white non-Hispanic or Latino males (85%, 84%, 92%), age group 51-70 (46%), holding commercial health insurance (43%) and belonged to the lowest Charlson comorbidity index level (82%). Facility types designation for almost all robotic hospitals was hospital (99%), whereas 65% of non-robotic hospitals were ambulatory surgery centers and all other hospitals. Robotic hospitals experienced a 9.5% increase in total volume of inguinal hernia repairs after introduction of robotic technology (Incident Rate Ratios-IRR 1.095, p value < 0.0001). A significant increase in total hernia volume was observed for the early adopter hospitals with the IRR(s) ranging 1.20-2.51 (all p values < 0.0001), implying that adoption of robotic technology can in fact lead to very significant increase in total hernia volume for a hospital. The introduction of robotic technology leads to an increase in the overall volume of inguinal hernia repairs performed at a given hospital. To further evaluate the impact of robotic technology and significance of this methodology, additional work is underway using additional procedures and data from other states.

Introduction of transcatheter aortic valve replacement technology increases overall aortic valve surgical volume: Evaluating the Florida experience.

OBJECTIVE: Transcatheter aortic valve replacement technology is increasingly used for aortic valve stenosis. We sought to evaluate the adoption of transcatheter aortic valve replacement technology with respect to overall surgical aortic valve replacement volume in Florida. METHODS: The 2010-2019 Florida Agency for Health Care Administration data set was queried. Difference-in-difference analysis was used to evaluate the impact of transcatheter aortic valve replacement on the total aortic valve surgical volume of transcatheter aortic valve replacement versus nonperforming hospitals. Length of stay and elements of charges were compared for the raw and 1:1 propensity matched data. RESULTS: A total of 46,032 surgical aortic valve procedures were performed at 88 hospitals. Transcatheter aortic valve replacement performing hospitals experienced a 21% increase in total aortic valve surgical volume. Length of stay was significantly less for patients undergoing transcatheter aortic valve replacement. Propensity matched transcatheter aortic valve replacement patients had less gross total charges. CONCLUSION: Introduction of transcatheter aortic valve replacement technology significantly increased overall surgical aortic valve volume and may be associated with less gross total hospital charges.

ACCESS TO HEALTHCARE INSURANCE INCREASES THE RATES OF SURGERY FOR DIVERTICULITIS.

OBJECTIVE: The goal of this study was to examine the effect of the Affordable Care Act Medicaid expansion on rates of hospitalization and surgery for diverticulitis. STUDY SETTINGS: Data were obtained from the Healthcare Cost and Utilization Project State Inpatient Databases from 2010 to 2014. STUDY DESIGN: Retrospective cohort study analyzing adult patients undergoing surgery for diverticulitis in the expansion and nonexpansion states, pre (2010-2013) and post (2014) Medicaid expansion. FINDINGS: There were a total of 159,419 patients in our cohort analysis. 75,575 (49%) in expansion states and 81,844 (51%) in non-expansion states. In multivariable Poisson regression, the rate of surgical procedures for diverticular disease increased among Medicaid patients (IRR 1.80; p<.01) whereas surgery rates in self-pay patients decreased (IRR 0.67; p<.01) in expansion states compared to non-expansion states. CONCLUSIONS: In states that expanded Medicaid coverage under the Affordable Care Act, the rate of surgery for diverticular disease in Medicaid patients increased. Therefore, legislation that increases healthcare access may increase the utilization of surgical care for diverticular disease.

Pancreatic neuroendocrine tumors: Surgical outcomes and survival analysis.

BACKGROUND: Pancreatic neuroendocrine tumors are rare, with rising incidence and limited clinicopathological studies. METHODS: Adult patients with pNET at a single tertiary care center were retrospectively evaluated. RESULTS: In total, 87 patients with histologically confirmed pNET who underwent resection were evaluated. 11% of patients had functioning pNETs: 9 insulinoma and 1 VIPoma. The majority (88.5%) were nonfunctioning. The most common surgical procedure performed was distal pancreatectomy with splenectomy (36.8%). 35.6% of cases were performed with minimally invasive surgery (MIS). MIS patients had fewer postoperative complications, shorter length of stay, and fewer ICU admissions.Disease-free survival (DFS) was unaffected by tumor size (p = 0.5) or lymph node status (p = 0.62). Patients with high-grade (G3) tumors experienced significantly shorter DFS (p = 0.02). CONCLUSIONS: This series demonstrates that survival in patients with pNET is driven mostly by tumor grade, though overall most have long-term survival after surgical resection. Additionally, an MIS approach is efficacious in appropriately selected cases.

A Needs Assessment for Incoming Surgical Interns: Communication Effectiveness Is the Most Important Skill.

INTRODUCTION: Medical schools and surgical programs have implemented a "boot camp" to assist medical students' transition into surgical interns and help them contend with a deluge of new responsibilities. This study aims to determine what faculty, residents, and medical students identify as the most critical topics for a surgical boot camp curriculum. METHODS: Forty-five-question survey was developed through an iterative review with multiple surgical colleagues in conjunction with the American College of Surgeons/Association of Program Directors/the Association of Surgical Education resident prep curricular modules. The questions were grouped into 3 broad categories, which included technical skills, practical knowledge, and clinical knowledge. Data were analyzed by a chi-squared test for proportions and continuous variables were compared using t test or ANOVA tests, when appropriate. RESULTS: There was a total of 62 participants, 19 (31%) were attending surgeons, 28 (45%) were general surgery residents, and 15 (24%) were fourth-year medical students (MS4). The response rate for attendings was 45%, residents was 72%, and fourth-year medical students was 43%. Practical knowledge was the most important skill by all participants, followed by clinical knowledge and technical skills (mean score 4.4 vs 3.9 vs 3.2, p < 0.001). The top 5 most important practical knowledge skills to have according to all participants included: how to communicate with senior residents/attendings/nurses, how to use the electronic medical record, how to perform effective handoffs, and how to write orders. CONCLUSIONS: Our study demonstrates that communication skills are the most important according to attendings, residents, and medical students. This study has implications for prioritizing the curricular components of an often tightly scheduled surgical boot camp.

Do high-volume centers mitigate complication risk and reduce costs associated with performing pancreaticoduodenectomy in ethnic minorities?

INTRODUCTION: Few studies examine the impact of ethnicity on post-operative outcomes and costs associated with pancreaticoduodenectomy (PD). METHODS: Multivariable regression (MVR) was used to perform a risk-adjusted comparison of patients within the Healthcare Cost and Utilization Project Databases undergoing PD. RESULTS: 4742 patients underwent PD. 3871 (81%) were white, 456 (10%) black, and 415 (9%) Hispanic. Black and Hispanics were less likely than whites to undergo PD in high volume centers. Blacks and Hispanics had a higher risk of select post-operative complications, prolonged lengths of stay, and high-cost outliers. When PDs done in high volume centers were evaluated separately, blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR 0.44, 95% CI [0.33, 0.57], OR 0.56, 95% CI [0.43, 0.73]) than whites but costs for PD among the three ethnic groups were statistically identical. CONCLUSION: Racial and ethnic minorities undergoing PD are less likely to receive care at high-volume centers, are at an increased risk of post-operative morbidity, and have higher odds of being high-cost outliers than NHW.