Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries.

BACKGROUND: Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries. METHODS: A retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders. RESULTS: MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (ß coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001). CONCLUSIONS: MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.

The Predictive Performance of General Surgery Milestones on Post-Graduation Outcomes.

OBJECTIVE: To establish whether Accreditation Council for Graduate Medical Education Milestones predict future performance of general surgery trainees. SUMMARY BACKGROUND DATA: Milestones provide bi-annual assessments of trainee progress across six competencies. It is unknown whether the Milestones predict surgeon performance after the transition to independent practice. METHODS: We performed a retrospective cohort study of surgeons with complete Milestone assessments in the fourth and fifth clinical years who treated patients in acute care hospitals within Florida, New York, and Pennsylvania, 2015-2018. To account for the multiple ways in which the Milestone assessments might predict post-graduation outcomes, we included 120 Milestones features in our elastic net machine learning models. The primary outcome was risk-adjusted patient death or serious morbidity. RESULTS: 278 general surgeons were included in the study. Milestone assessments 6-months into the fourth clinical year displayed a normal score distribution while multicollinearity and low score discrimination at the final assessment period were detected. Individual Milestones features from the Patient Care, Professionalism, and Systems-based Practice domains were most predictive of patient-related outcomes. For example, surgeons with worse patient outcomes had significantly lower scores in Patient Care 3 when compared to surgeons with better patient outcomes (High DSM, yes: 2.86 vs. no: 3.04, P=0.011). CONCLUSIONS: The Milestones features that were most predictive of better patient outcomes related to intraoperative skills, ethical principles, and patient navigation and safety, measured 12-18 months prior to graduation. The development of a parsimonious set of evidence-based Milestones that better correlate with surgeon experience could enhance surgical education.

Key Issues in Surgical Residency Education: Recommendations of the Blue Ribbon II Committee Residency Education Subcommittee.

In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA) , the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee. The Subcommittee organized its work around prioritized themes including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement. Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion. It was recognized that coordinated efforts across existing organizational structures will be required, informed by dataset integration strategies that meaningfully measure educational and related patient outcomes.

Circulating microRNA as a Potential Biomarker for Skeletal Disease in Primary Hyperparathyroidism: A Case-control Study.

OBJECTIVE: The goal of this study was to characterize the microRNA (miRNA) expression signatures in patients with PHPT and identify miRNA biomarkers of bone homeostasis. SUMMARY BACKGROUND DATA: Primary hyperparathyroidism (PHPT) is associated with increased bone turnover and decreased bone mass. miRNA are markers of bone remodeling. METHODS: We performed a prospective case-control study of post-menopausal females with PHPT and control subjects matched for race, age, and BMD. We collected clinical and biochemical data, assessed BMD by dual-energy X-ray absorptiometry, and measured 27 serum miRNAs related to bone remodeling. We used linear regression to assess the correlation between miRNA levels, conventional biochemical markers and BMD. RESULTS: A total of 135 subjects were evaluated, including 49 with PHPT (discovery group), 47 control patients without PHPT, and an independent validation cohort of 39 PHPT patients. Of 27 miRNAs evaluated, nine (miR-335-5p, miR-130b-3p, miR-125b-5p, miR-23a-3p, miR-152-3p, miR-582-5p, miR-144-5p, miR-320a and miR-19b-3p) were differentially expressed in PHPT compared to matched control subjects. All nine differentially expressed miRNAs significantly correlated with levels of serum parathyroid hormone (PTH), and eight of the nine correlated with calcium levels. No differentially expressed miRNAs were consistently correlated with markers of BMD. Subjects with PHPT segregate from controls based on the signature of these nine miRNAs on principle component analysis. CONCLUSIONS: These data suggest that PHPT is characterized by a unique miRNA signature that is distinct from postmenopausal and idiopathic osteoporosis. Levels of specific miRNAs significantly correlate with PTH, suggesting that bone remodeling in PHPT may be mediated in part by PTH-induced changes in miRNA.

Surgeon and Surgical Trainee Experiences After Adverse Patient Events.

Importance: Adverse patient events are inevitable in surgical practice. Objectives: To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants: In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures: The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results: Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance: In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.

Revisiting the Relationship Between Tumor Size and Risk in Well-Differentiated Thyroid Cancer.

Introduction: Large tumor size is associated with poorer outcomes in well-differentiated thyroid cancer, yet it remains unclear whether size >4 cm alone confers increased risk, independent of other markers of aggressive disease. The goal of this study was to assess the relationship between tumor size, other high-risk histopathological features, and survival in well-differentiated thyroid cancer and to evaluate the significance of 4 cm as a cutoff for management decisions. Methods: Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2015) and categorized by tumor size (i.e., small [≤4 cm] or large [>4 cm]) and presence of high-risk histopathological features (e.g., extrathyroidal extension). First, propensity score matching was used to identify patients who were similar across all other observed characteristics except for small versus large tumor size, and a multivariable Cox proportional hazards model was used to estimate the relationship between tumor size and survival. Second, we assessed whether the presence of high-risk features demonstrates conditional effects on survival based on the presence of tumor size >4 cm using an interaction term. Finally, additional models assessed the relationship between incremental 1 cm increases in tumor size and survival. Analyses were repeated using a validation cohort from the Surveillance, Epidemiology, and End Results Program (2008-2013). Results: Of 193,133 patients in the primary cohort, 7.9% had tumors >4 cm, and 30% had at least one high-risk feature. After matching, tumor size >4 cm was independently associated with worse survival (HR 1.63, p < 0.001). However, tumor size >4 cm and one or more other high-risk features together yielded worse survival than either size >4 cm alone (MMD: 0.70, p < 0.001) or other high-risk features alone (MMD: 0.49, p < 0.001). When assessed in 1 cm increments, the largest increases in hazard of death occurred at 2 cm and 5 cm, not 4 cm. Results from the validation cohort were largely consistent with our primary findings. Conclusions: Concomitant high-risk features confer worse survival than large tumor size alone, and a 4 cm cutoff is not associated with the greatest increase in risk. These findings support a more nuanced approach to tumor size in the management of well-differentiated thyroid cancer.

The influence of primary language on postoperative stroke outcomes.

BACKGROUND: Language barriers have the potential to influence acute stroke outcomes. Thus, we examined postoperative stroke outcomes among non-English primary language speakers. METHODS: Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2016-2019), we conducted a retrospective cohort study of adults diagnosed with a postoperative stroke in Michigan, Maryland, and New Jersey. Patients were classified by primary language spoken: English (EPL) or non-English (n-EPL). The primary outcome was hospital length-of-stay. Secondary outcomes included stroke intervention, feeding tube, tracheostomy, mortality, cost, disposition, and readmission. Propensity-score matching and post-match regression were used to quantify outcomes. RESULTS: Among 3078 postoperative stroke patients, 6.2 â€‹% were n-EPL. There were no differences in length-of-stay or secondary outcomes, except for higher odds of feeding tube placement (OR 1.95, 95 â€‹% CI 1.10-3.47, p â€‹= â€‹0.0227) in n-EPL. CONCLUSIONS: Postoperative stroke outcomes were comparable by primary language spoken. However, higher odds of feeding tube placement in n-EPL may suggest differences in patient-provider communication.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes.

OBJECTIVE: To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA: It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS: Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS: We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS: Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Modern Trends for Primary Hyperparathyroidism: Intervening on Less Biochemically Severe Disease.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is defined by autonomous parathyroid hormone secretion, which has broad physiologic effects. Parathyroidectomy is the only cure and is recommended for patients demonstrating symptomatic disease and/or end organ damage. However, there may be a benefit to intervening before the development of complications. We sought to characterize institutional trends in the biochemical and symptomatic presentation of PHPT and the associated cure and complication rates. METHODS: We performed a retrospective cohort study of 1087 patients undergoing parathyroidectomy for PHPT, evaluating patients at 2-year intervals between 2002 and 2019. We identified signs and symptoms of PHPT based on the 2016 American Association of Endocrine Surgery Guidelines. Trends were evaluated with Kruskal Wallis, Chi-square tests, and Fisher's exact tests. RESULTS: Patients with PHPT are presenting with lower parathyroid hormone (P = 0.0001) and calcium (P = 0.001) in the current era. Parathyroidectomy is more commonly performed for borderline guideline concordant patients with osteopenia (40.2%) and modest calciuria (median 246 mg/dL/24 h). 93.7% are cured, with no difference over time or between groups by guideline concordance. CONCLUSIONS: Parathyroidectomy is increasingly performed for patients who demonstrate modest bone and renal dysfunction. Patients experience excellent cure rates and rarely experience postoperative hypocalcemia, suggesting a role for broader surgical indications.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer.

BACKGROUND: This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). METHODS: Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. RESULTS: Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 â€‹cm were more likely in men (vs. women: OR 2.47, p â€‹< â€‹0.001) and Hispanic patients (vs. White patients: OR 1.52, p â€‹= â€‹0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p â€‹= â€‹0.002; Hispanic: OR 1.44, p â€‹= â€‹0.038) and experienced longer time to surgery (Black: HR 0.66, p â€‹< â€‹0.001; Hispanic: HR 0.71, p â€‹< â€‹0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p â€‹= â€‹0.022). CONCLUSIONS: Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

Belonging in Surgery: A Validated Instrument and Single Institutional Pilot.

OBJECTIVE: The aim of this study was to develop and validate an instrument to measure Belonging in Surgery among surgical residents. BACKGROUND: Belonging is the essential human need to maintain meaningful relationships and connections to one's community. Increased belongingness is associated with better well-being, job performance, and motivation to learn. However, no tools exist to measure belonging among surgical trainees. METHODS: A panel of experts adapted a belonging instrument for use among United States surgery residents. After administration of the 28-item instrument to residents at a single institution, a Cronbach alpha was calculated to measure internal consistency, and exploratory principal component analyses were performed. Multiple iterations of analyses with successively smaller item samples suggested the instrument could be shortened. The expert panel was reconvened to shorten the instrument. Descriptive statistics measured demographic factors associated with Belonging in Surgery. RESULTS: The overall response rate was 52% (114 responses). The Cronbach alpha among the 28 items was 0.94 (95% CI: 0.93-0.96). The exploratory principal component analyses and subsequent Promax rotation yielded 1 dominant component with an eigenvalue of 12.84 (70% of the variance). The expert panel narrowed the final instrument to 11 items with an overall Cronbach alpha of 0.90 (95% CI: 0.86, 0.92). Belonging in Surgery was significantly associated with race (Black and Asian residents scoring lower than White residents), graduating with one's original intern cohort (residents who graduated with their original class scoring higher than those that did not), and inversely correlated with resident stress level. CONCLUSIONS: An instrument to measure Belonging in Surgery was validated among surgical residents. With this instrument, Belonging in Surgery becomes a construct that may be used to investigate surgeon performance and well-being.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons.

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons. Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender. Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience. Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons. Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals. Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Perceived Implications of Compensation Structure for Academic Surgical Practice: A Qualitative Study.

This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care.

OBJECTIVE: Thyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy. METHODS: We identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy. RESULTS: A total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000. CONCLUSIONS: Overall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

The effect of Section 1557 of the Affordable Care Act on surgical outcomes in non-English primary language speakers.

BACKGROUND: In 2016, Section 1557 mandated use of qualified language interpreter services. We examined the effect of Section 1557 on surgical outcomes. METHODS: Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2013-2020), we performed a difference-in-differences analysis of adult surgical patients (Maryland, New Jersey). The exposure was implementation of Section 1557 (pre-period: 2013-2015; post-period: 2017-2020). The treatment group was non-English primary language speakers (n-EPL). The comparison group was English primary language speakers (EPL). Outcomes included length-of-stay, postoperative complications, mortality, discharge disposition, and readmissions. RESULTS: Among 2,298,584 patients, 198,385 (8.6%) were n-EPL. After implementation of Section 1557, n-EPL saw no difference in readmission rates but did experience significantly higher rates of mortality (+0.43%, p â€‹= â€‹0.049) and non-routine discharges (+1.81%, p â€‹= â€‹0.031) in Maryland, and higher rates of post-operative complications (+0.31%, p â€‹= â€‹0.001) in both states, compared to pre-Section 1557. CONCLUSIONS: Contrary to our hypothesis, Section 1557 did not improve surgical outcomes for n-EPL.

An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment.

BACKGROUND: This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT). METHODS: Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy. RESULTS: Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p â€‹= â€‹0.03; 90d readmission:+7.1%, p â€‹= â€‹0.776). CONCLUSIONS: In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.

Inefficiencies of care in hub and spoke healthcare systems: A multi-state cohort study.

BACKGROUND: Complex surgical care is often centralized to one high volume (hub) hospital within a system. The benefit of this centralization in common operations is unknown. METHODS: Using the Healthcare Cost and Utilization Project's State Inpatient Databases, adult general surgical patients within hospital systems in 13 states (2016-2018) were identified. Risk-adjusted logistic regression estimated the odds of death or serious morbidity (DSM) and prolonged length of stay (LOS) at hubs relative to other system hospitals (spokes). RESULTS: We identified 122,895 patients across 43 hub-and-spoke systems. Hubs completed 83.2 â€‹% of complex and 59.6 â€‹% of common operations. For complex operations, odds of DSM were significantly lower in hubs (OR: 0.80; 95 â€‹% CI [0.65, 0.98]). For common operations, odds of DSM were similar between hubs and spokes, while odds of prolonged LOS were greater at hubs (OR 1.19; 95 â€‹% CI [1.16,1.24]). CONCLUSIONS: While hub hospitals had lower odds of DSM for complex operation, they had higher odds of prolonged length of stay for common operations. This finding shows an opportunity for improved system efficiency.

The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis.

BACKGROUND: Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort. METHODS: We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort. RESULTS: Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001). CONCLUSION: Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.