Trends and predictors of inflation-adjusted costs in transcatheter and surgical aortic valve replacement in a nationally representative sample.

BACKGROUND: Transcatheter aortic valve replacement has become an accepted alternative to surgical aortic valve replacement. We examined the trends and predictors in inflation-adjusted costs of transcatheter aortic valve replacement and surgical aortic valve replacement. METHODS: National Inpatient Sample identified patients who underwent aortic valve replacement for severe aortic stenosis by International Classification of Diseases, Ninth and Tenth Revisions, codes. Hospitalization costs were inflation-adjusted using the Federal Reserve's consumer price index to reflect current valuation. Outcomes of interest were unadjusted trend in annual cost for each procedure and predictors of in-patient cost. Generalized linear models with a log link function identified predictors of adjusted costs. Interaction terms determined where cost predictors were different by operation type. RESULTS: Between 2011 and 2019, the mean annual inflation-adjusted cost of surgical aortic valve replacement increased from $62,853 to $63,743, in contrast to decreasing cost of transcatheter aortic valve replacement from $64,913 to $56,042 ($1,854 per year; P = .004). Significant independent predictors of patient-level cost included operation type (transcatheter aortic valve replacement associated with $9,625 increase; P < .001), incidence of in-hospital mortality ($28,836 increase; P < .001), elective status ($2,410 decrease; P < .001), Elixhauser Index ($995 increase; P < .001), and postoperative length of stay ($2,014 per day increase; P < .001). Compared to discharges with Medicare, discharges with private insurance and Medicaid paid $736 less (P = .004) and $1,863 less (P = .01), respectively. Increasing hospital volume was a significant predictor of decreasing patient level cost (P < .001). CONCLUSION: Annual cost of transcatheter aortic valve replacement has decreased significantly and has been a more cost-effective modality compared to surgical aortic valve replacement since 2017. Predictors of patient-level costs allow for mindful preparation of healthcare systems for aortic valve replacement.

Esophageal perforation after anterior cervical spine surgery.

Objective: To report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches. Methods: This is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity. Results: A total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively. Conclusions: Esophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

Thymic Neuroendocrine Tumors and Thymic Carcinoma: Demographics, Treatment, and Survival.

OBJECTIVE: Although rare, thymic neuroendocrine tumors (TNET) and thymic carcinoma (TC) are the most common thymic nonthymomatous malignancies; their survival outcomes have not been thoroughly compared. We analyzed the clinical, treatment, and survival characteristics of TNET and TC. METHODS: We retrospectively identified patients with a histologic diagnosis of TNET or TC in the National Cancer Database (2004 to 2015). Exclusion criteria were age <18 years and unstaged tumors. Descriptive statistics, survival analysis, and multivariable Cox regression analyses were used in elucidating associations. RESULTS: One thousand four hundred eighty-nine patients were included (TNET: 19.8%). Patients with TNET were significantly younger (57 vs 62.5 years), more likely to be male (70.5% vs 60.0%), and have localized tumors (45.4% vs 32.3%). Patients with TC more frequently underwent chemotherapy (56.1% vs 34.9%), radiation (56.9% vs 39.3%), and trimodality therapy (21.3% vs 11.5%), while resection rates were similar (55.3% vs 58.3%). The 5-year survival was 62% for TNET and 52% for TC, but comparable following multivariable adjustment. Age, stage, and Charlson-Deyo score were negative predictors of survival, while surgery and trimodality therapy were positive predictors. On subanalysis, adjuvant radiation therapy (ART) improved the survival of margin-positive tumors and was an independent predictor of survival for both tumor types (hazard ratio = 0.5). CONCLUSIONS: Our analysis of the largest series of TNET and TC showed a survival rate surpassing 50% at 5 years. These outcomes seem to be influenced by surgical resection and ART. Standardized staging and surgical protocols including lymph node sampling are still warranted to better elucidate the treatment algorithm of these tumors.

The Revised 2017 MSPE: Better, But Not "Outstanding".

AIM: The medical student performance evaluation (MSPE) is relied on as an objective summary evaluation by surgical program directors. In 2017, an MSPE task force released recommendations for best practice for their format and content. The purpose of this study was to analyze US medical schools' adherence to these guidelines. METHODS: MSPEs from 113 of 147 Liaison committee on Medical Education (LCME)-accredited medical schools were analyzed for measurable attributes such as word counts, transparent clerkship grading, comparative performance data, and statements of professionalism. 2017 MSPEs were compared to a baseline group of 45 MSPEs from 2016 to measure change over time. Measurable attributes were compared using the Fisher exact and Mann Whitney-U tests. A p value < 0.05 was deemed statistically significant. RESULTS: We analyzed 113 MSPEs from 2017. The median page count decreased by one from the prior year, with a narrower range of variation. 96% of schools reported a discreet grade in surgery. We observed substantial compliance with the recommendation for a statement of professionalism, noteworthy characteristics, and comparative clerkship data. More schools were observed to report school-wide rankings. There were significant variations in the graphical depiction of student achievement. CONCLUSIONS: In response to the 2017 task force guidelines, MSPEs have become more standardized and transparent with regard to medical student evaluation. There is increased (but not ubiquitous) adherence with the recommendation for three noteworthy characteristics and statements of professionalism. Of particular importance to surgical program directors, 95.6% of 2017 MSPEs report a grade in the surgical clerkship and 85.8% include school-wide comparative clerkship performance data. Still, only 69.9% currently report school-wide summative performance data.

Establishment of a Regional Virtual Tumor Board Program to Improve the Process of Care for Patients With Hepatocellular Carcinoma.

PURPOSE: Multidisciplinary evaluation (MDE) of hepatocellular cancer (HCC) is the current standard, often provided through a tumor board (TB) forum; this standard is limited by oncology workforce shortages and lack of a TB at every institution. Virtual TBs (VTBs) may help overcome these limitations. Our study aim was to assess the impact of a regional VTB on the MDE process for patients with HCC. METHODS: A retrospective cohort study was conducted, including patients with HCC referred to a tertiary cancer center from regional facilities (2009 to 2013). Baseline characteristics and outcomes were compared based on the referral mechanism: VTB versus subspecialty consultation (non-VTB). The primary outcome was comprehensive MDE (all required specialists present and key topics discussed). Secondary outcomes included timeliness of MDE and travel burden to complete MDE. Univariable and multivariable logistic regressions were performed to examine the association of a VTB with comprehensive MDE. RESULTS: A total of 116 patients were included in the study; 48 (41.4%) were evaluated through the VTB. A higher proportion of VTB patients received comprehensive MDE (91.7% v 64.7%; P = .001); the VTB was independently associated with higher odds of accomplishing comprehensive MDE (odds ratio, 6.0; 95% CI, 1.2 to 29.9; P = .02). VTB patients completed MDE significantly faster (median, 23 v 39 days; P < .001), with lower travel burden (median, 0 v 683 miles traveled; P < .001). CONCLUSION: This VTB program positively affected the process of care for patients with HCC by improving the quality and timeliness of the MDE process, while avoiding the burden arising from travel needs. Future studies should focus on implementation of VTB programs on a wider scale.