Socioecological Determinants of Health and the Quality of Colonoscopy in Rural Alabama.

BACKGROUND: Rural patients suffer higher incidence of and mortality from colorectal cancer. Ensuring high-quality screening is essential to address these disparities. OBJECTIVE: To investigate whether socioecological determinants of health are associated with colonoscopy quality in rural Alabama. DESIGN: Retrospective review. SETTING: Data across three rural hospitals in Alabama from August 2021 to July 2023. PATIENTS: We included adults (≥18 years) who underwent screening or diagnostic colonoscopy and completed a validated survey that measures socioecological determinants of health. MAIN OUTCOME MEASURES: Primary outcomes included bowel preparation quality, cecal intubation, and adenoma detection rate. We linked th e survey responses to these quality metrics to identify factors associated with outcomes. Analyses included the χ 2, Fisher's Exact and Kruskal-Wallis Rank sum tests, with p < 0.05 considered statistically significant. RESULTS: The 84 patients surveyed were 66.7% male, 50.0% Black, and had a median age of 64 years. Optimal bowel preparation was present in 88.0%, 89.3% had successful cecal intubations, and overall adenoma detection rate was 45.8%. Patients with suboptimal bowel preparation described lower rates of internet access (60.0% vs. 87.4%, p < 0.05), more difficulty understanding written information (30.0% vs. 1.4%, p < 0.05) and lacked a sense of responsibility for their health (30.0% vs. 51.4%, p < 0.05) compared to those having optimal bowel preparation. Those with unsuccessful cecal intubations had lower physician-trust (55.6% vs. 73.3%, p < 0.05), while patients with successful cecal intubations were more confident in preventing health-related problems (53.3% vs. 33.3%, p < 0.05) and had a more supportive social environment (72.0% vs. 66.7%, p < 0.05). LIMITATIONS: Retrospective design and small sample size limiting multivariable analyses. CONCLUSION: In rural Alabama, health literacy, internet access, and physician-trust were associated with low-quality colonoscopy, while a higher patient sense of responsibility and a supportive social environment was associated with higher-quality metrics. These findings identify potential targets for improving colonoscopy quality in rural settings. See Video Abstract.

Novel Characterization of Socioecological Determinants of Health in Rural Alabama.

INTRODUCTION: Socioecological determinants of health (SEDOHs) influence disparities in surgical outcomes. However, SEDOHs are challenging to measure, limiting our ability to address disparities. Using a validated survey (SEDOH-88), we assessed SEDOHs in three rural communities in Alabama. We hypothesized that SEDOHs would vary significantly across sites but measuring them would be acceptable and feasible. MATERIALS AND METHODS: This was a retrospective review of a prospectively maintained database involving surgical patients who completed the SEDOH-88 and a secondary survey assessing it's acceptability or feasibility from August 2021 to July 2023. Included patients underwent endoscopic, minimally invasive, or open surgery at three rural hospitals: Demopolis (DM), Alexander City (AC), and Greenville (GV). RESULTS: The 107 participants comprised 48 (44.9%) from DM, 27 (25.2%) from AC, and 32 (29.9%) from GV, respectively. The median age was 64 y, and 65.6% were female. When comparing DM to AC and GV by individual factors, DM had the largest Black population (78.7 versus 22.2 versus 48.3%, P < 0.001) and more often required help reading hospital materials (20.5 versus 3.7 versus 10.3%, P = 0.007). When comparing DM to AC and GV by structural and environmental factors, DM had more Medicaid enrollees (27.3 versus 3.7 versus 6.9%, P = 0.033) and lacked fresh produce (18.2 versus 25.9 versus 39.3%, P = 0.033) and internet access (63.6 versus 100.0 versus 86.2%, P < 0.001). The SEDOH-88 had an overall 90.9% positive acceptability and feasibility score. CONCLUSIONS: SEDOHs varied significantly across rural communities regarding individual (race or health literacy), structural (insurance), and environmental-level factors (nutritious food or internet access). The high acceptability and feasibility of the SEDOH-88 shows it's potential utility in identifying targets for future disparity-reducing interventions.

Can screen-time help? An analysis of usage of patient engagement technology following colorectal surgery.

BACKGROUND: Patient engagement technologies (PETs) guide patients through the perioperative period. We aimed to investigate the levels of patient engagement with PETs through the peri-operative period and its impact on clinical outcomes. METHODS: Retrospective cohort study of patients undergoing elective colorectal surgery from 2018 to 2022. Outcomes were length of stay, readmissions, and complications within 30 days of index hospitalization. RESULTS: 359 (89.1%) patients activated the PET. Patients completed a median of 7 surveys, 2 in-hospital health-checks, and 1 post-discharge health-check. Median LOS was 3 days, 57 (14.1%) patients were readmitted, and 56 (13.9%) had a complication. Patients who completed no surveys had longer LOS than those who completed 2 or more. Patients who were readmitted and had post-operative complications completed significantly fewer surveys and post-discharge health-checks. Completion of surveys in more phases was associated with shorter LOS and lower readmission rates. Completion of more post-discharge health-checks was associated with lower complication rate. CONCLUSIONS: The use of PETs improves patient outcomes and experiences in the perioperative period. Patients who engage more frequently with PETs have shorter LOS with lower readmission and post-operative complication rates.

Understanding the Impact of Enhanced Recovery Programs on Social Vulnerability, Race, and Colorectal Surgery Outcomes.

BACKGROUND: Increasing social vulnerability, measured by the Social Vulnerability Index, has been associated with worse surgical outcomes. However, less is known about the impact of social vulnerability on patients who underwent colorectal surgery under enhanced recovery programs. OBJECTIVE: We hypothesized that increasing social vulnerability is associated with worse outcomes before enhanced recovery implementation, but that after implementation, disparities in outcomes would be reduced. DESIGN: Retrospective cohort study using multivariable logistic regression to identify associations of social vulnerability and enhanced recovery with outcomes. SETTINGS: Institutional American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Patients undergoing elective colorectal surgery (2010-2020). Enhanced recovery programs were implemented in 2015. Those adhering to 70% or more of enhanced recovery program components were defined as enhanced recovery and all others as nonenhanced recovery. OUTCOMES: Length of stay, complications, and readmissions. RESULTS: Of 1523 patients, 589 (38.7%) were in the enhanced recovery group, with 625 patients (41%) in the lowest third of the Social Vulnerability Index, 411 (27%) in the highest third. There were no differences in Social Vulnerability Index distribution by the enhanced recovery group. On multivariable modeling, social vulnerability was not associated with increased length of stay, complications, or readmissions in the enhanced recovery group. Black race was associated with increased length of stay in both the nonenhanced recovery (OR 1.2; 95% CI, 1.1-1.3) and enhanced recovery groups (OR 1.2; 95% CI, 1.1-1.4). Enhanced recovery adherence was associated with reductions in racial disparities in complications as the Black race was associated with increased odds of complications in the nonenhanced recovery group (OR 1.9; 95% CI, 1.2-3.0) but not in the enhanced recovery group (OR 0.8; 95% CI, 0.4-1.6). LIMITATIONS: Details of potential factors affecting enhanced recovery program adherence were not assessed and are the subject of current work by this team. CONCLUSION: High social vulnerability was not associated with worse outcomes among both enhanced recovery and nonenhanced recovery colorectal patients. Enhanced recovery program adherence was associated with reductions in racial disparities in complication rates. However, disparities in length of stay remain, and work is needed to understand the underlying mechanisms driving these disparities. See Video Abstract . COMPRENDIENDO EL IMPACTO DE LOS PROGRAMAS DE RECUPERACIN MEJORADA EN LA VULNERABILIDAD SOCIAL, LA RAZA Y LOS RESULTADOS DE LA CIRUGA COLORRECTAL: ANTECEDENTES:El aumento de la vulnerabilidad social medida por el índice de vulnerabilidad social se ha asociado con peores resultados quirúrgicos. Sin embargo, se sabe menos sobre el impacto de la vulnerabilidad social en los pacientes de cirugía colorrectal bajo programas de recuperación mejorados.OBJETIVO:Planteamos la hipótesis de que el aumento de la vulnerabilidad social se asocia con peores resultados antes de la implementación de la recuperación mejorada, pero después de la implementación, las disparidades en los resultados se reducirían.DISEÑO:Estudio de cohorte retrospectivo que utilizó regresión logística multivariable para identificar asociaciones de vulnerabilidad social y recuperación mejorada con los resultados.ESCENARIO:Base de datos institucional del Programa de Mejora Nacional de la Calidad de la Cirugía del American College of Surgeons.PACIENTES:Pacientes sometidos a cirugía colorrectal electiva (2010-2020). Programas de recuperación mejorada implementados en 2015. Aquellos que se adhieren a ≥70% de los componentes del programa de recuperación mejorada definidos como recuperación mejorada y todos los demás como recuperación no mejorada.MEDIDAS DE RESULTADO:Duración de la estancia hospitalaria, complicaciones y reingresos.RESULTADOS:De 1.523 pacientes, 589 (38,7%) estaban en el grupo de recuperación mejorada, con 732 (40,3%) pacientes en el tercio más bajo del índice de vulnerabilidad social, 498 (27,4%) en el tercio más alto, y no hubo diferencias en la distribución del índice vulnerabilidad social por grupo de recuperación mejorada. En el modelo multivariable, la vulnerabilidad social no se asoció con una mayor duración de la estancia hospitalaria, complicaciones o reingresos en ninguno de los grupos de recuperación mejorada. La raza negra se asoció con una mayor duración de la estadía tanto en el grupo de recuperación no mejorada (OR1,2, IC95% 1,1-1,3) como en el grupo de recuperación mejorada (OR1,2, IC95% 1,1-1,4). La adherencia a la recuperación mejorada se asoció con reducciones en las disparidades raciales en las complicaciones, ya que la raza negra se asoció con mayores probabilidades de complicaciones en el grupo de recuperación no mejorada (OR1,9, IC95% 1,2-3,0), pero no en el grupo de recuperación mejorada (OR0,8, IC95% 0,4-1,6).LIMITACIONES:No se evaluaron los detalles de los factores potenciales que afectan la adherencia al programa de recuperación mejorada y son el tema del trabajo actual de este equipo.CONCLUSIÓN:La alta vulnerabilidad social no se asoció con peores resultados entre los pacientes colorrectales con recuperación mejorada y sin recuperación mejorada. Una mayor adherencia al programa de recuperación se asoció con reducciones en las disparidades raciales en las tasas de complicaciones. Sin embargo, persisten disparidades en la duración de la estadía y es necesario trabajar para comprender los mecanismos subyacentes que impulsan estas disparidades. (Traducción-Dr. Felipe Bellolio ).

Development of a comprehensive survey to assess key socioecological determinants of health.

BACKGROUND: Although disparities in surgical outcomes are well-documented, our understanding of how socioecological factors drive these disparities remains limited. Comprehensive and efficient assessment tools are needed. This study's objective was to develop and assess the acceptability and feasibility of a comprehensive tool evaluating socioecological determinants of health in patients requiring colorectal surgery. METHODS: In the first phase, a comprehensive socioecological determinant of health assessment tool was developed. A review of validated socioecological health evaluation instruments was conducted, and a 2-step modified Delphi method addressed the length, clarity, appropriateness, and redundancy of each instrument. A comprehensive tool was then finalized. In the second phase, the tool was tested for acceptability and feasibility in adult patients requiring colorectal surgery using a theory-guided framework at 3 Alabama hospitals. Relationships between survey responses and measures of acceptability and feasibility were evaluated using results from initial pilot tests of the survey. RESULTS: In Phase 1, a modified Delphi process led to the development of a comprehensive tool that included 31 socioecological determinants of health (88 questions). Results of acceptability and feasibility were globally positive (>65%) for all domains. Overall, 83% of participants agreed that others would have no trouble completing the survey, 90.4% of respondents reported the survey was not burdensome, 97.6% of patients reported having enough time to complete the survey, and 80.9% agreed the survey was well-integrated into their appointment. CONCLUSION: An 88-item assessment tool measuring 31 socioecological determinants of health was developed with high acceptability and feasibility for patients who required colorectal surgery. This work aids in the development of research needed to understand and address surgical disparities.

Racial Differences in Aging-Related Deficits Among Older Adults With Colorectal Cancer.

BACKGROUND: Despite the known influences of both race- and aging-related factors in colorectal cancer outcomes and mortality, limited literature is available on the intersection between race and aging-related impairments. OBJECTIVE: To explore racial differences in frailty and geriatric deficit subdomains among patients with colorectal cancer. DESIGN: Retrospective study using data from the Cancer and Aging Resilience Evaluation registry. SETTINGS: A comprehensive cancer center in the Deep South. PATIENTS: Older adults (aged ≥60 years) with colorectal cancer. MAIN OUTCOME MEASURES: Measure of frailty and geriatric assessment subdomains of physical function, functional status, cognitive complaints, psychological function, and health-related quality of life. RESULTS: Black patients lived in areas with a higher social vulnerability index compared to White patients (0.69 vs 0.49; p < 0.01) and had limited social support more often (54.5% vs 34.9%; p = 0.01). After adjustment for age, cancer stage, comorbidities, and social vulnerability index, Black patients were found to have a higher rate of frailty than White patients (adjusted OR 3.77; 95% CI, 1.76-8.18; p = 0.01). In addition, Black patients had more physical limitations (walking 1 block: adjusted OR 1.93; 95% CI, 1.02-3.69; p = 0.04), functional limitations (activities of daily living: adjusted OR 3.21; 95% CI, 1.42-7.24; p = 0.01), and deficits in health-related quality of life (poor global self-reported health: adjusted OR 2.45; 95% CI, 1.23-5.13; p = 0.01). Similar findings were shown after stratification by stage I to III vs IV. LIMITATIONS: Retrospective study at a single institution. CONCLUSIONS: Among older patients with colorectal cancer, Black patients were more likely to be frail than White patients, with deficits observed specifically in physical function, functional status, and health-related quality of life. Geriatric assessment may provide an important tool in addressing racial inequities in colorectal cancer. DIFERENCIAS RACIALES EN LOS DFICITS RELACIONADOS CON EL ENVEJECIMIENTO ENTRE ADULTOS MAYORES CON CNCER COLORRECTAL: ANTECEDENTES: A pesar de las influencias conocidas de los factores relacionados con la raza y el envejecimiento en los resultados y la mortalidad del cáncer colorectal, hay muy poca literatura sobre la intersección entre los impedimentos relacionados con la raza y el envejecimiento.OBJETIVO: El objetivo era explorar las diferencias raciales en los subdominios de fragilidad y déficit geriátrico entre los pacientes con cáncer colorectal.DISEÑO: Estudio retrospectivo utilizando datos del registro Cancer and Aging Resilience Evaluation.AJUSTES: Un centro oncológico integral en el Sur Profundo.PACIENTES: Adultos mayores (≥60 años) con cáncer colorrectal de raza Negra o Blanca.PRINCIPALES MEDIDAS DE RESULTADO: Medida compuesta de fragilidad y subdominios de evaluación geriátrica de función física, estado funcional, quejas cognitivas, función psicológica y calidad de vida relacionada con la salud.RESULTADOS: De los 304 pacientes incluidos, el 21,7% (n = 66) eran negros y la edad media era de 69 años. Los pacientes negros vivían en áreas con un índice de vulnerabilidad social (SVI) más alto en comparación con los pacientes blancos (SVI 0,69 vs 0,49; p < 0,01) y con mayor frecuencia tenían apoyo social limitado (54,5% vs 34,9%; p = 0,01). Después de ajustar por edad, estadio del cáncer, comorbilidades y SVI, los pacientes de raza negra tenían una mayor tasa de fragilidad en comparación con los pacientes de raza blanca (ORa 3,77, IC del 95%: 1,76-8,18; p = 0,01). Además, los pacientes negros tenían más limitaciones físicas (caminar 1 cuadra: ORa 1,93, IC 95% 1,02-3,69; p = 0,04), limitaciones funcionales (actividades de la vida diaria: ORa 3,21, IC 95% 1,42-7,24; p = 0,01 ) y déficits en la calidad de vida relacionada con la salud (mala salud global autoinformada: ORa 2,45, IC 95% 1,23-5,13; p = 0,01). Las quejas cognitivas y las funciones psicológicas no difirieron según la raza (p > 0,05). Se mostraron hallazgos similares después de la estratificación por estadio I-III frente a IV.LIMITACIONES: Estudio retrospectivo en una sola institución.CONCLUSIONES: Entre los pacientes mayores con cáncer colorrectal, los pacientes negros tenían más probabilidades que los pacientes blancos de ser frágiles, observándose déficits específicamente en la función física, el estado funcional y la calidad de vida relacionada con la salud. La evaluación geriátrica puede proporcionar una herramienta importante para abordar las desigualdades raciales en el cáncer colorrectal.

The association of social vulnerability with colorectal enhanced recovery program failure.

Background: Enhanced recovery programs (ERPs) improve outcomes, but over 20 % of patients fail ERP and the contribution of social vulnerability is unknown. This study aimed to characterize the association between social vulnerability and ERP adherence and failure. Methods: This was a retrospective cohort study of colorectal surgery patients between 2015 and 2020 utilizing ACS-NSQIP data. Patients who failed ERP (LOS > 6 days) were compared to patients not failing ERP. The CDC's social vulnerability index (SVI) was used to assess social vulnerability. Result: 273 of 1191 patients (22.9 %) failed ERP. SVI was a significant predictor of ERP failure (OR 4.6, 95 % CI 1.3-16.8) among those with >70 % ERP component adherence. SVI scores were significantly higher among patients non-adherent with 3 key ERP components: preoperative block (0.58 vs. 0.51, p < 0.01), early diet (0.57 vs. 0.52, p = 0.04) and early foley removal (0.55 vs. 0.50, p < 0.01). Conclusions: Higher social vulnerability was associated with non-adherence to 3 key ERP components as well as ERP failure among those who were adherent with >70 % of ERP components. Social vulnerability needs to be recognized, addressed, and included in efforts to further improve ERPs. Key message: Social vulnerability is associated with non-adherence to enhanced recovery components and ERP failure among those with high ERP adherence. Social vulnerability needs to be addressed in efforts to improve ERPs.

A socioecological qualitative analysis of barriers to care in colorectal surgery.

BACKGROUND: Although specific social determinants of health have been associated with disparities in surgical outcomes, there exists a gap in knowledge regarding the mechanisms of these associations. Gaining perspectives from multiple socioecological levels can help elucidate these mechanisms. Our study aims to identify social determinants of health that act as barriers or facilitators to surgical care among colorectal surgery stakeholders. METHODS: We recruited participants representing 5 socioecological levels: patients (individual); caregivers/surgeons (interpersonal); and leaders in hospitals (organizational), communities (community), and government (policy). Patients participated in focus groups, and the remaining participants underwent individual interviews. Semistructured interview guides were used to explore barriers and facilitators to surgical care at each socioecological level. Transcripts were analyzed by 3 coders in an inductive thematic approach with content analyses. The intercoder agreement was 93%. RESULTS: Six patient focus groups (total n = 18) and 12 key stakeholder interviews were conducted. The mean age of patients was 54.7 years, 66% were Black, and 61% were female. The most common diseases were colorectal cancer (28%), inflammatory bowel disease (28%), and diverticulitis (22%). Key social determinants of health impacting surgical care emerged at each level: individual (clear communication, mental stress), interpersonal (provider communication and trust, COVID-related visitation restrictions), organizational (multiple forms of contact, quality educational materials, scheduling systems, discrimination), community (community and family support and transportation), and policy (charity care, patient advocacy organizations, insurance coverage). CONCLUSION: Key social determinants of health-impacting care among colorectal surgery patients emerged at each socioecological level and may provide targets for interventions to reduce surgical disparities.

Racial disparities in postoperative outcomes persist for patients with inflammatory bowel disease under a colorectal enhanced recovery program.

INTRODUCTION: Enhanced recovery programs (ERPs) reduce racial disparities in surgical outcomes for general colorectal surgery populations. It is unclear, however, if disparities in IBD populations are impacted by ERPs. METHODS: Retrospective study comparing IBD patients undergoing major elective colorectal operations before (2006-2014) and after (2015-2021) ERP implementation using ACS-NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes (complications and readmissions) by logistic regression. RESULTS: Of 466 IBD patients, 47% were pre-ERP and 53% were ERP patients. In multivariable analysis stratified by ERP period, Black race was associated with increased odds of complications in the pre-ERP (OR 3.6, 95%CI 1.4-9.3) and ERP groups (OR 3.1 95%CI 1.3-7.6). Race was not a predictor of LOS or readmission in either group. High social vulnerability was associated with increased odds of readmission pre-ERP (OR 15.1, 95%CI 2.1-136.3), but this disparity was mitigated under ERPs (OR 1.4, 95%CI 0.4-5.6). CONCLUSION: While ERPs mitigated some disparities by social vulnerability, racial disparities persist in IBD populations even under ERPs. Further work is needed to achieve surgical equity for IBD patients.

The University of Alabama at Birmingham Surgery Community Network: Tackling the Challenges of Rural Surgery.

Over the past 5 years, The University of Alabama at Birmingham (UAB) Department of Surgery has taken a keen interest in the practice of surgery in rural Alabama and has established the UAB surgery community network. Our goal is to improve the delivery of surgical care in rural areas through active recruitment of rural surgeons, the development of research around rural surgery practice, and the expansion of a surgery network throughout the state. Here, we will present the challenges faced by rural surgery, our early work to address these challenges, and offer a plan for moving forward.

Improving surgical patient education materials using informational design with visual elements.

Patient education materials (PEMs) serve as a foundation for educating patients and families across all surgical fields but are often not understandable. The National Institute of Health (NIH) recommends that PEMs be written at a grade 6-7 reading level; however, most current materials exceed that measure.3 Lack of understandable and appropriate surgical PEMs compounds the difficulties that low health literacy patients face with resultant poor surgical outcomes.2,3 The challenge for surgeons is to adequately educate patients pre-operatively and post-operatively on the complexities of surgery. Another challenge is to compact decades of education and training into an easy-to-understand medium for patients. To address this challenge, many physicians have utilized visual aids to improve PEM efficacy. While visual aids are a critical piece of education materials, they must be designed intentionally to be effective. The most important consideration is that the PEM communicates the information clearly to users. With this in mind, we created a framework for productive utilization of visual aids by integrating the C.A.R.P. graphic design technique into an existing surgical PEM to enhance communication and understandability.

Healthcare Disparities and Colorectal Cancer.

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Small Bowel Crohn's Disease Recurrence is Common After Total Proctocolectomy for Crohn's Colitis.

BACKGROUND: Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era. OBJECTIVE: The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at four hospitals within a single healthcare system. PATIENTS: Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019. MAIN OUTCOME MEASURES: Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence. RESULTS: In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age <18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0). LIMITATIONS: The study was limited by its retrospective design and lack of consistent follow-up on all patients. CONCLUSIONS: Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762. RECURRENCIA FRECUENTE DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUS DE LA PROCTOCOLECTOMA TOTAL POR COLITIS DE CROHN: ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad <18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).

Multidisciplinary clinics for colorectal cancer may not provide more efficient coordination of care.

BACKGROUND: This retrospective study compares a multidisciplinary clinic (MDC) to standard care for time to treatment of colorectal cancer. METHODS: We queried our institutional ACS-NSQIP database for patients undergoing surgery for colorectal cancer from 2017 to 2020. Patients were stratified by initial clinic visit (MDC vs control). Primary endpoint was the time to start treatment (TST), either neoadjuvant therapy or surgery, from the date of diagnosis by colonoscopy. RESULTS: A total of 405 patients were evaluated (115 MDC, 290 Control). TST from diagnosis was not significantly shorter for the MDC cohort (MDC 30 days, Control 37 days; p = 0.07) even when stratified by type of initial treatment of neoadjuvant therapy (MDC 30, Control 34 days; p = 0.28) or surgery (MDC 32.5 days, Control 38 days; p = 0.35). CONCLUSION: Implementation of an MDC provides insignificant reduction in delay to start treatment for colorectal cancer patients as compared to standard care colorectal surgery clinics. CLASSIFICATION: Colorectal.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease.

BACKGROUND: Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients. METHODS: This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes. RESULTS: Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients. CONCLUSIONS: Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery.

BACKGROUND: Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system. METHODS: Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs). RESULTS: 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs. CONCLUSIONS: Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.

Emotional Intelligence and Burnout in Surgical Residents: A 5-Year Study.

OBJECTIVE: We sought to characterize the interactions of burnout with internal and external factors over the past 5 years for surgery residents at our institution. We hypothesized that burnout levels would be consistent among years, inversely related to emotional intelligence (EI) and job resources, and directly related to disruptive behaviors. DESIGN: General surgery residents at a single institution were invited to complete a survey each year from 2015 to 2019 that included a combination of the 22-item Maslach-Burnout Inventory, 30-item trait EI questionnaire, as well as focused questions assessing disruptive behaviors (8 items), job resources (8 items), and demographic characteristics. Burnout was defined as scoring high in depersonalization (≥ 10 points) or emotional exhaustion (≥ 27 points). Student's t tests and Wilcoxon tests were used to compare continuous variables; chi-square and Fisher's exact tests were used to compare categorical variables, as appropriate. Spearman's rho was used to calculate correlation. A logistic regression and separate linear regression model were constructed to assess relation of variables to burnout. SETTING: The general surgery residency program at the University of Alabama at Birmingham, Birmingham, Alabama, a large tertiary care academic center. RESULTS: An average of 47 surveys were completed each year, for a total of 236 (response rate 81%). One hundred seventeen (58.5%) met criteria for burnout. Burnout rates each year ranged from 68% to 53%, with the lowest value occurring in 2019. Incidence of burnout was lowest among the postgraduate year (PGY) 1 class and highest among the PGY5 class (38% versus 64%, p = 0.02). Individuals without burnout had higher scores for EI overall (5.7 versus 5.3, p < 0.001) as well as in each of its 4 subcomponents (p < 0.001). Individuals who were subjected to disruptive behaviors, particularly others taking credit for work and public humiliation, were more likely to experience burnout (p = 0.02). Those with burnout also had significantly lower scores in each of the 4 domains of the Job Resources model (p < 0.01). On multivariate logistic regression, increasing PGY level remained a significant predictor of burnout risk. Each of the sub-domains of EI and jobs resources inversely corelated with burnout, while disruptive behaviors directly correlated with burnout. ON subsequent multivariable linear regression, resident well-being and professional development remained independent predictors of lower burnout scores. CONCLUSIONS: Burnout is prevalent among trainees at our institution, but a trend toward improvement has been shown over 5 years. Burnout rates increase each year of surgical training beyond PGY2. Factors that mitigate burnout include resident well-being and professional development. Disruptive behaviors lead to increase burnout rates.