Impact of advance care planning consults on advance directives completion.

OBJECTIVES: Advance care planning (ACP) consults have been credited with increasing the likelihood that patients will receive desired care at the end of life, including reduced hospitalization and spending. We aimed to investigate whether implementation of ACP consults leads to improved advance directive (AD) completion rates. STUDY DESIGN: Retrospective case-control evaluation. METHODS: Chart review was conducted among patients in hematology/oncology and primary care to compare AD completion rates of patients in each clinical area offered ACP consults between July 1, 2017, and June 30, 2018, and those not offered ACP consults prior to July 1, 2017. RESULTS: Completed ADs increased from historic rates of 1% to 65.9% of primary care patient records. Among hematology/oncology patients offered consults, completed ADs were present in 28.1% of patient records compared with historic rates of 3%. CONCLUSIONS: Patients offered ACP consults had significantly higher AD completion rates than those without consults in both primary care and hematology/oncology practices. The difference in ACP consult attendance between the primary care and hematology/oncology groups clearly suggests that further improvements can be made to assist patients in accessing AD education and completion support.

Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study.

OBJECTIVE: Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid). METHODS: The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use. RESULTS: A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05). CONCLUSIONS: In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting.

OBJECTIVE: Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. METHODS: For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. RESULTS: A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. CONCLUSIONS: These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery.

OBJECTIVE: Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions. METHODS: The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type. RESULTS: The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid). CONCLUSIONS: In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Functional Outcomes and Health-Related Quality of Life Before and After Primary Total Knee Replacement for Patients From Diverse Geographic Regions.

BACKGROUND: The purpose of this study was to investigate whether patient-reported knee function and health status before and after primary total knee replacement (TKR) at an academic medical center differs among patients from diverse geographic regions. METHODS: We assessed patient-reported outcomes (PROs) as measured by the Oxford Knee Score (OKS) and EuroQoL-5D (EQ-5D) in 2855 TKR patients at preprimary and one year postprimary TKR procedure between January 1, 2012 and June 30, 2014. We compared the demographic characteristics, response rates, and changes in OKS, EQ-5D, and EQ visual analog scale among local, regional, and national patient groups. Patient- or hospital-related predictors of the postoperative scores were identified after controlling for preoperative scores on the PRO measures. RESULTS: Local patients had more comorbid conditions. Groups were similar in clinical outcomes such as length of stay at hospital, complication, and reoperation rates. Local, regional, and national patients had similar response rates and reported a similar level of knee function and health-related quality of life before and after TKR. Eighty nine percent had clinically important improvement on OKS, 69% on EQ-5D index, and 28% EQ visual analog scale, and there were no differences among groups in the proportions of clinically meaningful change. Better postoperative PRO scores were associated with older age, shorter hospital stay, fewer comorbidities, nonsmoking status, fewer complications, and private health insurance. CONCLUSION: Some patient characteristics such as comorbidities were greater in the local patient cohort versus the national cohort. Nevertheless, clinical outcomes and PROs were comparable across all geographic tiers.

Screening for Diabetic Retinopathy with a Nonmydriatic Ultra-Wide-Field Retina Camera by Family Medicine Physicians.

PURPOSE: Diabetic retinopathy (DR) is the leading cause of blindness among working-aged adults aged 20 to 74 years. Despite professional association guidelines that recommend yearly screening for DR, only about 60% of Americans with diabetes mellitus (DM) receive annual examinations. The purpose of this 2-phase study was to determine the ability of family medicine (FM) physicians to accurately interpret retinal images of patients with DM. METHODS: Five FM physicians received a 1-hour lecture on DR by a retinal specialist after which the physicians were shown 30 ultrawide-field retina images and asked to determine whether the images contained signs of DR (phase 1). PATIENTS: Patients with DM who had not received an eye examination within the past year underwent nonmydriatic retinal photography in a FM clinic (phase 2). The 5 FM physicians were asked to evaluate the images for signs of DR and the images were simultaneously sent to a retinal specialist for independent interpretation. The diagnoses of the FM physicians and retina specialist were compared. Patients were informed of their results and were asked to complete a brief telephone survey regarding their experience with the screening process. RESULTS: Thirty retina images, 5 with DR and 25 without DR, were included in the postlecture assessment. Each of the 30 images was reviewed by all 5 FM physicians. Of the 5 images with DR, 3 were correctly diagnosed by all 5 FM physicians, 1 was correctly diagnosed by 4, and 1 was accurately diagnosed by 3. Overall accuracy for the 5 FM physicians was 100%, 100%, 100%, 97%, and 87%. Among the 34 patients included in phase 2, 3 (8%) were diagnosed with DR by the retinal specialist but 8 (24%) were diagnosed with DR by the FM physicians. Of the 3 patients with DR confirmed by the retinal specialist, only 1 was detected by the FM physicians (sensitivity, 33%; 95% CI, 1% to 91%). Of the 31 patients without DR as determined by the retinal specialist, 24 were accurately diagnosed by the FM physicians (specificity, 77%; 95% CI, 59% to 90%). The screening procedure was considered easy/efficient by 28 of 31 (90%) respondents. CONCLUSION: To improve early detection of DR new screening methods should be considered. FM physicians were able to accurately identify DR on postlecture images but were not as accurate when evaluating images taken from patients in the FM clinic. Patients found the screening process to be easy and efficient. This study was limited by the small sample size, particularly the limited number of DR cases. Future studies that include cases with a wide variation of DR severity are needed to determine the accuracy of FM physicians at detecting DR in a clinical setting.

Do safety-net hospitals provide equitable care after decompressive surgery for acute cauda equina syndrome?

INTRODUCTION: Safety-net hospitals provide care to a substantial share of disadvantaged patient populations. Whether disparities exist between safety-net hospitals and their counterparts in performing emergent neurosurgical procedures has not yet been examined. OBJECTIVE: We used the Nationwide Inpatient Sample (NIS), a national all-payer inpatient healthcare database, to determine whether safety-net hospitals provide equitable care after decompressive surgery for acute cauda equina syndrome (CES). METHODS: The NIS from 2002 to 2011 was queried for patients with a diagnosis of acute CES who received decompressive surgery. Hospital safety-net burden was designated as low (LBH), medium (MBH), or high (HBH) based on the proportion of inpatient admissions that were billed as Medicaid, self-pay, or charity care. Etiologies of CES were classified as degenerative, neoplastic, trauma, and infectious. Significance was defined at p < 0.01. RESULTS: A total of 5607 admissions were included in this analysis. HBHs were more likely than LBHs to treat patients who were Black, Hispanic, on Medicaid, or had a traumatic CES etiology (p < 0.001). After adjusting for patient, hospital, and clinical factors treatment at an HBH was not associated with greater inpatient adverse events (p = 0.611) or LOS (p = 0.082), but was associated with greater inflation-adjusted admission cost (p = 0.001). DISCUSSION: Emergent decompressive surgery for CES performed at SNHs is associated with greater inpatient costs, but not greater inpatient adverse events or LOS. Differences in workflows at SNHs may be the drivers of these disparities in cost and warrant further investigation.

Hospital robotic use for colorectal cancer care.

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.

Adverse Events Detection Through Global Trigger Tool Methodology: Results From a 5-Year Study in an Italian Hospital and Opportunities to Improve Interrater Reliability.

OBJECTIVE: Global Trigger Tool (GTT) has been proposed as a low-cost method to detect adverse events (AEs). The validity of the methodology has been questioned because of moderate interrater agreement. Continuous training has been suggested as a means to improve consistency over time. We present the main findings of the implementation of the Italian version of the GTT and evaluate efforts to improve the interrater reliability over time. METHODS: The Italian version of the GTT was developed and implemented at the San Bonifacio Hospital, a 270-bed secondary care acute hospital in Verona, Italy. Ten clinical records randomly selected every 2 weeks were reviewed from 2009 to 2014. Two-stage interrater reliability assessment between team members was conducted on 2 subsamples of 50 clinical records before and after the implementation of specific review rules and staff training. RESULTS: Among 1320 medical records reviewed, a total of 366 AEs were found with at least 1 AE on 20.2% of all discharges, 27.7 AEs/100 admissions, and 30.6 AEs/1000 patient-days. Adverse events with harm score E and F were respectively 58.2% (n = 213) and 38.8% (n = 142). First round interrater reliability was comparable with other international studies. The interrater agreement improved significantly after intervention (κ interrater I = 0.52, κ interrater II = 0.80, P < 0.001). CONCLUSIONS: Despite the improvements in the interrater consistency, overall results did not show any significant trend in AEs over time. Future studies may be directed to apply and adapt the GTT methodology to more specific settings to explore how to improve its sensitivity.

Neuro R2 score: Predicting high-risk neurologic readmissions within 30 days.

OBJECTIVE: To evaluate clinical and demographic factors of patients with neurologic disorders to determine which patient characteristics are significant for predicting 30-day hospital readmissions to develop a readmission risk predictor specific to patients with neurologic disorders. METHODS: We performed a retrospective single-center chart review for all patients admitted to the Department of Neurology or neurologic intensive care unit from January 1, 2013, to December 31, 2017. Clinical and demographic factors were analyzed to determine the association with readmission. Multivariable logistic regression analysis was performed and validated to develop a simple tool (Neuro R2 score) for predicting patients with neurologic disorders at high risk for hospital readmission. RESULTS: After removal of planned readmissions and patients who died in the hospital, the records of 4,876 patients with 314 (6.4%) readmission events were analyzed. The strongest predictors for readmission were Charlson disease count (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.06-1.35, p = 0.005), urgent or emergent admission (OR 1.50, 95% CI 1.04-2.17, p = 0.031), discharge to rehabilitation (OR 1.66, 95% CI 1.16-2.35, p = 0.005), cancer (OR 1.70, 95% CI 1.15-2.50, p = 0.007), brain tumor (OR 1.82, 95% CI 1.08-3.09, p < 0.03), cerebrovascular disease (OR 2.18, 95% CI 1.53-3.11, p < 0.001), and discharge to skilled nursing facility (OR 2.43, 95% CI 1.65-3.57, p < 0.001). CONCLUSIONS: The Neuro R2 score was developed to predict readmission risk, specifically in patients with neurologic disorders. Future research could include further validation of this readmission risk tool and strategies to reduce readmission in patients with the highest risk.

Impact of Patient Stage and Disease Characteristics on the proposed Radiation Oncology Alternative Payment Model (RO-APM).

PURPOSE: The proposed Radiation Oncology Alternative Payment Model (RO-APM) released on July 10, 2019, represents a dramatic shift from fee-for-service (FFS) reimbursement in radiation therapy (RT). This study compares historical revenue at Mayo Clinic to the RO-APM and quantifies the effect that disease characteristics may have on reimbursement. METHODS AND MATERIALS: FFS Medicare reimbursements were determined for patients undergoing RT at Mayo Clinic from 2015 to 2016. Disease categories and payment episodes were defined as per the RO-APM. Average RT episode reimbursements were reported for each disease site, except for lymphoma and metastases, and stratified by stage and disease subcategory. Comparisons with RO-APM reimbursements were made via descriptive statistics. RESULTS: A total of 2098 patients were identified, of whom 1866 (89%) were categorized per the RO-APM; 840 (45%) of those were aged >65 years. Breast (33%), head and neck (HN) (14%), and prostate (11%) cancer were most common. RO-APM base rate reimbursements and sensitivity analysis range were lower than historical reimbursement for bladder (-40%), cervical (-34%), lung (-28%), uterine (-26%), colorectal (-24%), upper gastrointestinal (-24%), HN (-23%), pancreatic (-20%), prostate (-16%), central nervous system (-13%), and anal (-10%) and higher for liver (+24%) and breast (+36%). Historical reimbursement varied with stage (stage III vs stage I) for breast (+57%, P < .01), uterine (+53%, P = .01), lung (+50%, P < .01), HN (+24%, P = .01), and prostate (+13%, P = .01). Overall, for patients older than 65 years of age, the RO-APM resulted in a -9% reduction in total RT reimbursement compared with historical FFS (-2%, -15%, and -27% for high, mid, and low adjusted RO-APM rates). CONCLUSIONS: Our findings indicate that the RO-APM will result in significant reductions in reimbursement at our center, particularly for cancers more common in underserved populations. Practices that care for socioeconomically disadvantaged populations may face significant reductions in revenue, which could further reduce access for this vulnerable population.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida.

BACKGROUND: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

Impact of Psychiatric Comorbidities on Health Care Costs Among Patients With Cancer.

BACKGROUND: Psychiatric disorders are common in cancer patients and impact outcomes. Impact on cancer care cost needs study to develop business case for psychosocial interventions. OBJECTIVE: To evaluate the impact of preexisting psychiatric comorbidities on total cost of care during 6 months after cancer diagnosis. METHODS: This retrospective cohort study examined patients diagnosed with cancer between January 1, 2009, and December 31, 2014, at one National Cancer Institute-designated cancer center. Patients who received all cancer treatment at the study site (6598 of 11,035 patients) were included. Patients were divided into 2 groups, with or without psychiatric comorbidity, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Total costs of care during the first 6 months of treatment were based on standardized costs adjusted to 2014 dollars, determined by assigning Medicare reimbursement rates to professional billed services and applying appropriate cost-to-charge ratios. Quantile regression models with covariate adjustments were developed to assess the effect of psychiatric comorbidity across the distribution of costs. RESULTS: Six hundred ninety-eight (10.6%) of 6598 eligible patients had at least one psychiatric comorbidity. These patients had more nonpsychiatric Elixhauser comorbidities (mean 4 vs. 3). Unadjusted total cancer care costs were higher for patients with psychiatric comorbidity (mean [standard deviation]: $51,798 [$74,549] vs. $32,186 [$45,240]; median [quartiles]: $23,871 [$10,705-$57,338] vs. $19,073 [$8120-$38,230]). Quantile regression models demonstrated that psychiatric comorbidity had significant incremental effects at higher levels of cost: 75th percentile $8629 (95% confidence interval: $3617-13,642) and 90th percentile $42,586 (95% confidence interval: $25,843-59,330). CONCLUSIONS: Psychiatric comorbidities are associated with increased total cancer costs, especially in patients with very high cancer care costs, representing an opportunity to develop mitigation strategies.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings.

BACKGROUND: Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings. METHODS: This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded. RESULTS: Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d). CONCLUSIONS: Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Disparities in elective surgery for diverticulitis: Identifying the gap in care.

BACKGROUND: Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications. METHODS: The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models. RESULTS: Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons. CONCLUSIONS: Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment.

BACKGROUND: Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success. OBJECTIVE: To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions. DESIGN: Retrospective cohort. PATIENTS: A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013. SETTING: Midwest primary care practice in an integrated health system. INTERVENTION: Enrollment in a CTP during acute hospitalization. MEASUREMENTS: The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare. RESULTS: The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission. CONCLUSIONS: No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

Disparities in minimally invasive surgery for colorectal cancer in Florida.

BACKGROUND: The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida. METHODS: Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach. RESULTS: Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001). CONCLUSIONS: Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS.

OBJECTIVE: The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL. METHODS: Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality). RESULTS: Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes. CONCLUSION: Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery. ABBREVIATIONS: HbA1c = glycated hemoglobin A1c; IQR = interquartile range.

Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program.

CONTEXT: Identifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. OBJECTIVES: The objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. METHODS: This is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. RESULTS: No significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268-$25,234). CONCLUSION: The Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.

ERAS protocol validation in a propensity-matched cohort of patients undergoing colorectal surgery.

PURPOSE: Enhanced recovery after surgery (ERAS) provides many benefits. However, important knowledge gaps with respect to specific components of enhanced recovery after surgery remain because of limited validation data. The aim of the study was to validate a mature ERAS protocol at a different hospital and in a similar population of patients. METHODS: This is a retrospective analysis of patients undergoing elective colorectal surgery from 2009 through 2016. Patients enrolled in ERAS are compared with those undergoing the standard of care. Patient demographic characteristics, length of stay, pain scores, and perioperative morbidity are described. RESULTS: Patients (1396) were propensity matched into two equal groups (ERAS vs non-ERAS). No significant difference was observed for age, Charlson Comorbidity Index, American Society of Anesthesiologists score, body mass index, sex, operative approach, and surgery duration. Median length of stay in ERAS and non-ERAS groups was 3 and 5 days (P < .001). Mean pain scores were lower in the ERAS group, measured at discharge from the postanesthesia unit (P < .001), on postoperative day 1 (P = .002) and postoperative day 2 (P = .02) but were identical on discharge. CONCLUSIONS: This ERAS protocol was validated in a similar patient population but at a different hospital. ERAS implementation was associated with an improved length of stay and pain scores similar to the original study. Different than most retrospective studies, propensity score matching ensured that groups were evenly matched. To our knowledge, this study is the only ERAS validation study in a propensity-matched cohort of patients undergoing elective colorectal surgery.