Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

BACKGROUND: The local treatment of extremity sarcomas usually is predicated on a decision between limb salvage and amputation. The manner in which surgical options are presented in the context of shared decision-making may influence this decision. In a population of "simulated" patients-survey respondents presented with a mock clinical vignette and then asked to choose between treatments-we assessed cognitive bias by deliberate alteration of the subjective presentation of the same objective information. QUESTIONS/PURPOSES: (1) Will the manner in which information is presented to a simulated patient, in the setting of treatment for a bone sarcoma, bias their decision regarding pursuing amputation versus limb salvage? (2) At the time of decision-making, will a simulated patient's personal background, demographics, or mood affect their ultimate decision? METHODS: Survey respondents (Amazon MTurk platform) were presented with mock clinical vignettes simulating a sarcoma diagnosis and were asked to choose between amputation and limb salvage. Specific iterations were designed to assess several described types of cognitive bias. These scenarios were distributed, using anonymous online surveys, to potential participants aged 18 years or older. Recruitment was geographically restricted to individuals in the United States. Overall, 404 respondents completed the survey. The average age of respondents was 33 years (SD 1.2 years), 60% were male and 40% were female. In all, 12% of respondents worked in healthcare. Each respondent also completed questions regarding his or her demographics and his or her current mood. Associations between the type of bias presented and the respondent's choice of limb salvage versus amputation were examined. Independent sample t-tests were used to compare means. Statistical significance was defined as p < 0.05. RESULTS: When amputation was presented as an option to mitigate functional loss (framing bias), more patients chose it than when limb salvage was presented as means for increased functional gains (23% [23 of 100] versus 10% [12 of 118], odds ratio [OR], 2.26; p = 0.010). Older simulated patients were more likely to choose limb salvage when exposed to framing bias versus younger patients (mean age 33 years versus 30 years, p = 0.02). Respondents who were employed in healthcare more commonly chose amputation versus limb salvage when exposed to framing bias (24% [eight of 35] versus 9% [17 of 183]; OR, 2.46; p = 0.02). Those who chose amputation were more likely to score higher on scales that measured depression or negative affect. CONCLUSIONS: Shared decision-making in orthopaedic oncology represents a unique circumstance in which several variables may influence a patient's decision between limb salvage and amputation. Invoking cognitive bias in simulated patients appeared to affect treatment decisions. We cannot be sure that these findings translate to the experience of actual sarcoma patients; however, we can conclude that important treatment decisions may be affected by cognitive bias and that patient characteristics (in this study, age, healthcare profession, and mood) may be associated with an individual's susceptibility to cognitive bias. We hope these observations will assist providers in the thoughtful delivery of highly charged information to patients facing difficult decisions, and promote further study of this important concept. LEVEL OF EVIDENCE: Level III, economic and decision analyses.

Stress Urinary Incontinence Surgery in Washington State Before and After Introduction of the Mesh Midurethral Sling.

OBJECTIVES: Mesh midurethral slings (MUSs) are safe, effective treatments for female stress urinary incontinence (SUI), but many companies have ceased production because of controversies surrounding transvaginal mesh. To determine if introduction of MUS has increased the complication rate associated with SUI surgery, we compared women undergoing SUI surgery in the MUS era to those who had surgery prior its introduction. METHODS: This was a retrospective cohort study of a statewide hospital discharge database. Stress urinary incontinence surgeries from 1987 to 1996 and 2007 to 2013 were identified using International Classification of Diseases, Ninth Revision codes. RESULTS: A total of 30,723 SUI surgeries were performed during the study periods. After 2006, slings accounted for 91.8% of SUI surgeries. Patients were older (54.5 vs 53.0 years, P < 0.001) and sicker (22.6% vs 9.7% had ≥1 comorbid condition, P < 0.0001). Blood transfusion was more common in the MUS era (1.2% vs 0.4%, P < 0.001) however, other complications were either similar between groups or less common in the MUS era including 30-day readmission (2.5% vs 2.4%, P = 0.543), reoperation for urinary retention (0.1% vs 0.2%, P < 0.0375), and wound infection (0.1% vs 0.5%, P < 0.001), despite more concomitant prolapse surgeries (69.0 vs 26.9%, P < 0.001) and hysterectomies (53.0 vs 35.4%, P < 0.001) in the MUS era. Hospital stays were shorter after 2006 (1.0 vs 3.0 days, P < 0.001), and fewer women required reoperation for SUI within 2 years (0.5% vs 1.8%, P < 0.001). CONCLUSIONS: Following introduction of MUS, women who underwent SUI surgery were slightly older with more medical comorbidities yet did not appear to experience increased surgical complications. Fewer women underwent reoperation for recurrent SUI, and hospital stays were shorter, suggesting an improvement in care. This study supports the continued availability and use of MUSs.

Effectiveness of a Medical vs Revascularization Intervention for Intermittent Leg Claudication Based on Patient-Reported Outcomes.

Importance: Intermittent claudication (IC) is the most common presentation of infrainguinal peripheral artery disease. Both medical and revascularization interventions for IC aim to increase walking comfort and distance, but there is inconclusive evidence of the comparative benefit of revascularization given the possible risk of limb loss. Objective: To compare the effectiveness of a medical (walking program, smoking cessation counseling, and medications) vs revascularization (endovascular or surgical) intervention for IC in the community, focusing on outcomes of greatest importance to patients. Design, Setting, and Participants: Longitudinal (12-month follow-up) prospective observational cohort study conducted between July 3, 2011, and November 5, 2014, at 15 clinics associated with 11 hospitals in Washington State. Participants were 21 years or older with newly diagnosed or established IC. Interventions: Medical or revascularization interventions. Main Outcomes and Measures: Primary end points were 12-month change scores on the distance, speed, and stair-climb domains of the Walking Impairment Questionnaire (score range, 0-100). Secondary outcomes were change scores on the Walking Impairment Questionnaire pain domain (score range, 0-100), Vascular Quality of Life Questionnaire (VascuQol) (score range, 1-7), European Quality of Life-5 Dimension Questionnaire (EQ-5D) (score range, 0-1), and Claudication Symptom Instrument (CSI) (score range, 0-4). Results: A total of 323 adults were enrolled, with 282 (87.3%) in the medical cohort. At baseline, the mean duration of disease was longer for participants in the medical cohort, while those in the revascularization cohort reported more severe disease. Other characteristics were well balanced. At 12 months, change scores in the medical cohort reached significance for the following 3 outcomes: speed (5.9; 95% CI, 0.5-11.3; P = .03), VascuQol (0.28; 95% CI, 0.08-0.49; P = .008), and EQ-5D (0.038; 95% CI, 0.011-0.066; P = .006). In the revascularization cohort, there were significant improvements in the following 7 outcomes: distance (19.5; 95% CI, 7.9-31.0; P = .001), speed (12.1; 95% CI, 1.4-22.8; P = .03), stair climb (11.4; 95% CI, 1.3-21.5; P = .03), pain (20.7; 95% CI, 11.0-30.4; P < .001), VascuQol (1.10; 95% CI, 0.80-1.41; P < .001), EQ-5D (0.113; 95% CI, 0.067-0.159; P < .001), and CSI (-0.63; 95% CI, -0.96 to -0.31; P < .001). Relative improvements (percentage changes) at 12 months in the revascularization cohort over the medical cohort were observed as follows: distance (39.1%), speed (15.6%), stair climb (9.7%), pain (116.9%), VascuQol (41%), EQ-5D (18%), and CSI (13.5%). Conclusions and Relevance: Among patients with IC, those in the revascularization cohort had significantly improved function (Walking Impairment Questionnaire), better health-related quality of life (VascuQol and EQ-5D), and fewer symptoms (CSI) at 12 months compared with those in the medical cohort, providing important information to inform treatment strategies in the community.

Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes.

OBJECTIVE: To study the association between diabetes status, perioperative hyperglycemia, and adverse events in a statewide surgical cohort. BACKGROUND: Perioperative hyperglycemia may increase the risk of adverse events more significantly in patients without diabetes (NDM) than in those with diabetes (DM). METHODS: Using data from the Surgical Care and Outcomes Assessment Program, a cohort study (2010-2012) evaluated diabetes status, perioperative hyperglycemia, and composite adverse events in abdominal, vascular, and spine surgery at 53 hospitals in Washington State. RESULTS: Among 40,836 patients (mean age, 54 years; 53.6% women), 19% had diabetes; 47% underwent a perioperative blood glucose (BG) test, and of those, 18% had BG ≥180 mg/dL. DM patients had a higher rate of adverse events (12% vs 9%, P < 0.001) than NDM patients. After adjustment, among NDM patients, those with hyperglycemia had an increased risk of adverse events compared with those with normal BG. Among NDM patients, there was a dose-response relationship between the level of BG and composite adverse events [odds ratio (OR), 1.3 for BG 125-180 (95% confidence interval (CI), 1.1-1.5); OR, 1.6 for BG ≥180 (95% CI, 1.3-2.1)]. Conversely, hyperglycemic DM patients did not have an increased risk of adverse events, including those with a BG 180 or more (OR, 0.8; 95% CI, 0.6-1.0). NDM patients were less likely to receive insulin at each BG level. CONCLUSIONS: For NDM patients, but not DM patients, the risk of adverse events was linked to hyperglycemia. Underlying this paradoxical effect may be the underuse of insulin, but also that hyperglycemia indicates higher levels of stress in NDM patients than in DM patients.

Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards.

BACKGROUND: The Leapfrog Group established a minimum hospital case volume of 13 for esophageal resection in a response to known improved outcomes in larger volume centers. The aim of this study was to evaluate variation in short-term outcomes among hospitals that met the Leapfrog volume criteria. METHODS: Using the Washington State Comprehensive Hospital Abstract Reporting System, a retrospective cohort design evaluated all patients (≥18 years) undergoing esophageal resection for any diagnosis since the introduction of Leapfrog standards (2000 to 2007). The main outcome measures were hospital stay, readmissions within 30 days of discharge, discharge to an institutional care facility, operative reinterventions, and 90-day mortality. RESULTS: A total of 1,505 adult Washington state residents underwent esophageal resection without complex reconstruction (1,352 elective [89.8%]). Of 45 hospitals reporting at least one procedure, 5 (11%) met Leapfrog volume standards. Leapfrog hospitals accounted for 62% of the total elective volume. Overall, elective patients at Leapfrog hospitals had a lower adjusted risk of death compared with those at hospitals that did not meet criteria (odds ratio 0.50, p = 0.02). Across the different Leapfrog hospitals there was over fivefold variation in 90-day mortality (1.7% to 10.2%), 2.5-fold variation in reinterventions (8% to 20%), and fourfold variation in discharges to an institutional care facility (5.3% to 19.8%). Length of stay and readmission rate varied less. CONCLUSIONS: Although referral to high-volume centers has been an important advance for complex surgical procedures, there is still a substantial degree of variability in outcomes among hospitals that met Leapfrog volume criteria for esophagectomy. Metrics such as process, individual surgeon volume, and risk-adjusted outcome measures may yield further opportunities for quality improvement that extend beyond hospital volume-based assessments.

A critical evaluation of the impact of Leapfrog's evidence-based hospital referral.

BACKGROUND: Evidence-based hospital referral (EBHR) is a Leapfrog group quality metric based primarily on hospital procedural volume. It has yet to be determined if EBHR has led to regionalized surgical care and whether it has improved patient outcomes. STUDY DESIGN: We conducted a before and after cohort study of 13,157 adults (1994 to 2007) who underwent pancreatic or esophageal resection or abdominal aortic aneurysm (AAA) repair in Washington State. Adjusted mortality, readmission, and complication rates were assessed before and after EBHR was introduced. RESULTS: Hospitals meeting an EBHR volume metric in any year ranged from 2 to 6. Comparing before and after 2001 (2004 for pancreatic resection), the proportion of patients treated at hospitals meeting the EBHR volume metric for a given procedure increased for pancreatic (59.4% vs 75.7%, p < 0.001) and esophageal resection (41.5% vs 59.2%, p < 0.001), but was similar for AAA repair (16.3% vs 17.6%, p = 0.13). In general, rates of adverse events were lower at hospitals meeting an EBHR volume metric. However, across Washington State and at non-EBHR centers, rates of mortality, readmission, and complications generally did not improve in the 7 years after introduction of the EBHR initiative. CONCLUSIONS: Although a greater proportion of pancreatic or esophageal resections were performed at hospitals meeting a given EBHR volume metric in the 7 years after Leapfrog, this shift had a negligible impact on outcomes across Washington State. It remains to be determined why regionalization for AAA repair has not occurred and why regionalization trends in pancreatic and esophageal surgery have not had the intended impact of improving overall safety outcomes.

Impact of advancing age on abdominal surgical outcomes.

OBJECTIVE: To describe the population-level risk of adverse outcomes among older adults undergoing common abdominal surgical procedures. DESIGN: Retrospective, population-based cohort study. SETTING: Washington State hospital discharge database. PARTICIPANTS: A total of 101 318 adults 65 years or older who underwent common abdominal procedures such as cholecystectomy, colectomy, and hysterectomy from 1987 through 2004. MAIN OUTCOME MEASURES: Ninety-day rates of postsurgical morbidity and mortality. RESULTS: The 90-day cumulative incidence of complications was 17.3%, with a 90-day mortality rate of 5.4%. Advancing age was associated with increasing frequency of complications (65-69 years, 14.6%; 70-74 years, 16.1%; 75-79 years, 18.8%; 80-84 years, 19.9%; 85-89 years, 22.6%; and >or=90 years, 22.7%; trend test, P < .001) and mortality (65-69 years, 2.5%; 70-74 years, 3.8%; 75-79 years, 6.0%; 80-84 years, 8.1%; 85-89 years, 12.6%; and >or=90 years, 16.7%; trend test, P < .001). After adjusting for demographic, patient, and surgical characteristics as well as hospital volume, the odds of early postoperative death increased considerably with each advance in age category. These associations were found among patients with both cancer and noncancer diagnoses and for both elective and nonelective admissions (trend test, P < .001). CONCLUSIONS: Among older adults, the risk of complications and early death after commonly performed abdominal procedures is greater than previously reported. These rates should be considered in ongoing quality improvement initiatives and may be helpful when counseling patients regarding abdominal operations.

The significance of discharge to skilled care after abdominopelvic surgery in older adults.

CONTENT: Older adults frequently undergo abdominopelvic surgical operations, yet the risk and significance of postoperative discharge disposition has not been well characterized. OBJECTIVE: To describe the population-level risk of discharge to institutional care facilities and its impact on survival among older patients who undergo common abdominopelvic surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, population-based cohort study, using the Washington State hospital discharge database for 89,405 adults aged 65 and older who underwent common abdominopelvic procedures (cholecystectomy, colectomy, hysterectomy/oophorectomy, and prostatectomy) between 1987 and 2004. MAIN OUTCOME MEASURES: Discharge location and short-term and long-term mortality. RESULTS: Advancing age was associated with discharge to an institutional care facility (ICF) after surgery [age, 65-69 (3.3%); 70-74 (5.7%); 75-79 (10.8%); 80-84 (20.6%); 85-89 (31.8%); 90+ (43.9%); trend test, P < 0.001). Postoperative complications were also associated with discharge to an ICF (21.9% vs. 8.9%, P < 0.001). Patients discharged to an ICF after surgery had higher 30-day (4.3% vs. 0.4%), 90 day (12.6% vs. 1.4%), and 1-year mortality (22.2% vs. 5.9%) in comparison with those discharged home with self-care (P < 0.001). Compared with similarly aged adults discharged home, patients discharged to an ICF had 4 times higher 1-year mortality (odds ratio = 3.9; 95% confidence interval = 3.6-4.2). Of patients who died after discharge to an ICF, the majority died either at the ICF (53.7%) or on a subsequent hospital admission (31.0%). CONCLUSIONS: Advancing age and postoperative complications are associated with the risk of discharge to an ICF after abdominopelvic operations. Patients discharged to an ICF are much more likely to die within the first postoperative year and ICF disposition should be considered as either a marker of debility and/or a component of patient decline. These findings may be helpful while counseling patients regarding the expected outcomes of ICF placement after surgical intervention.

Temporal trends in the management of potentially resectable lung cancer.

BACKGROUND: Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time. METHODS: This investigation was a cohort study of tumor-registry data linked to Medicare claims. RESULTS: Between 1992 and 2002, 24,030 patients--mean age 75 +/- 6 years, 55% men--were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97). CONCLUSIONS: Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.

Lower extremity angioplasty for claudication: a population-level analysis of 30-day outcomes.

OBJECTIVE: With the increased availability of lower extremity percutaneous transluminal angioplasty (PTA), the conventional, non-interventional management of claudication may be evolving. This study evaluated changes in the use and short-term outcomes of PTA among patients with claudication and other manifestations of peripheral arterial disease (PAD). METHODS: A retrospective cohort study was conducted using the linked Washington State hospital discharge database (CHARS). Cases included all patients undergoing inpatient lower extremity PTA from 1997 to 2004. Patients with claudication were compared with those having PTA for other lower extremity diagnoses. The main outcome measures were readmission, reintervention (angiography, angioplasty/stent, surgical revascularization, or amputation), and death