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BACKGROUND: Large Language Models (LLM; e.g., ChatGPT) may be used to assist clinicians and form the basis of future clinical decision support (CDS) for colon cancer. The objectives of this study were to (1) evaluate the response accuracy of two LLM-powered interfaces in identifying guideline-based care in simulated clinical scenarios and (2) define response variation between and within LLMs. METHODS: Clinical scenarios with "next steps in management" queries were developed based on National Comprehensive Cancer Network guidelines. Prompts were entered into OpenAI ChatGPT and Microsoft Copilot in independent sessions, yielding four responses per scenario. Responses were compared to clinician-developed responses and assessed for accuracy, consistency, and verbosity. RESULTS: Across 108 responses to 27 prompts, both platforms yielded completely correct responses to 36% of scenarios (n = 39). For ChatGPT, 39% (n = 21) were missing information and 24% (n = 14) contained inaccurate/misleading information. Copilot performed similarly, with 37% (n = 20) having missing information and 28% (n = 15) containing inaccurate/misleading information (p = 0.96). Clinician responses were significantly shorter (34 ± 15.5 words) than both ChatGPT (251 ± 86 words) and Copilot (271 ± 67 words; both p < 0.01). CONCLUSIONS: Publicly available LLM applications often provide verbose responses with vague or inaccurate information regarding colon cancer management. Significant optimization is required before use in formal CDS.
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BACKGROUND: Pancreatic cancer remains highly lethal and resection represents the only chance for cure. Although patients are counseled regarding short-term (0-3 months) mortality, little is known about mortality 3-6 months (intermediate-term) following surgery. We assessed predictors of intermediate-term mortality, evaluated hospital-level variation, and developed a nomogram to predict intermediate-term mortality risk. METHODS: Patients undergoing pancreatic cancer resection were identified from the National Cancer Database (2010-2020). Multivariable logistic regression identified predictors of intermediate-term mortality and assessed differences between short-term and intermediate-term mortality. Multinomial regression grouped by intermediate-term mortality quartiles evaluated hospital-level variation. A neural network model was constructed to predict intermediate-term mortality risk. All statistical tests were 2-sided. RESULTS: Of 45,297 patients, 3,974 (8.9%) died within 6-months of surgery of which 2,216 (5.1%) were intermediate-term. Intermediate-term mortality was associated with increasing T-category, positive nodes, lack of systemic therapy, and positive margins (all p < .05) compared with survival beyond 6-months. Compared with short-term, intermediate-term mortality was associated with treatment at high-volume hospitals, positive nodes, neoadjuvant systemic therapy, adjuvant radiotherapy, and positive margins (all p < .05). Median intermediate-term mortality rate per hospital was 4.5% (IQR 2.6-6.5). Highest quartile hospitals had decreased odds of treatment with neoadjuvant systemic therapy, neoadjuvant radiotherapy, and adjuvant radiotherapy (all p < .05). The neural network nomogram was highly accurate (Accuracy: 0.9499; AUC-ROC of 0.7531) in predicting individualized intermediate-term mortality risk. CONCLUSION: Nearly 10% of patients undergoing pancreatectomy for cancer died within 6-months of which half occurred in the intermediate-term. These data have real-world implications to improve shared decision-making when discussing curative-intent pancreatectomy.
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Subcutaneous injection of unfractionated heparin (UH) or low molecular weight heparin (LMWH) is frequently utilized for venous thromboembolism chemoprophylaxis. We previously discovered that nurses believe patients experience more pain with UH compared to the LMWH enoxaparin; however, no published studies that are appropriately powered exist comparing pain associated with subcutaneous chemoprophylaxis. Our objective was to assess if differences exist in pain associated with subcutaneous administration of UH and enoxaparin. We conducted an observational study of patients who underwent major abdominal surgery between 11/2017-4/2019. All patients received one of three prophylactic regimens: (1) UH only, (2) Initial dose of UH followed by enoxaparin, or (3) enoxaparin only. Of the 74 patients observed, 40 patients received UH followed by enoxaparin, 17 received UH only, and 17 received enoxaparin only. There was a significant difference in patients' mean perceived pain between subcutaneous UH and enoxaparin injections (mean post-injection pain after UH 3.3 vs. enoxaparin 1.5; p < 0.001). There was no significant difference in perceived pain for patients who received consecutive UH or enoxaparin injections. Differences in pain associated with different chemoprophylaxis agents may be an unrecognized driver of patient refusals of VTE chemoprophylaxis and may lead to worse VTE outcomes.
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Background and study aims Low-quality colonoscopy increases cancer risk but measuring quality remains challenging. We developed an automated, interactive assessment of colonoscopy quality (AI-CQ) using machine learning (ML). Methods Based on quality guidelines, metrics selected for AI development included insertion time (IT), withdrawal time (WT), polyp detection rate (PDR), and polyps per colonoscopy (PPC). Two novel metrics were also developed: HQ-WT (time during withdrawal with clear image) and WT-PT (withdrawal time subtracting polypectomy time). The model was pre-trained using a self-supervised vision transformer on unlabeled colonoscopy images and then finetuned for multi-label classification on another mutually exclusive colonoscopy image dataset. A timeline of video predictions and metric calculations were presented to clinicians in addition to the raw video using a web-based application. The model was externally validated using 50 colonoscopies at a second hospital. Results The AI-CQ accuracy to identify cecal intubation was 88%. IT ( P = 0.99) and WT ( P = 0.99) were highly correlated between manual and AI-CQ measurements with a median difference of 1.5 seconds and 4.5 seconds, respectively. AI-CQ PDR did not significantly differ from manual PDR (47.6% versus 45.5%, P = 0.66). Retroflexion was correctly identified in 95.2% and number of right colon evaluations in 100% of colonoscopies. HQ-WT was 45.9% of, and significantly correlated with ( P = 0.85) WT time. Conclusions An interactive AI assessment of colonoscopy skill can automatically assess quality. We propose that this tool can be utilized to rapidly identify and train providers in need of remediation.
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BACKGROUND: Venous thromboembolism (VTE) chemoprophylaxis is the standard of care after gastrointestinal (GI) cancer surgery; however, variation in risk based on pathologic factors (eg, stage and histology) is unclear. This study aimed to evaluate the association of pathologic factors with VTE after GI cancer surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program procedure targeted datasets were queried for patients who underwent colorectal, pancreatic, primary hepatic, and esophageal cancer surgery between 2017 and 2020. Disease-specific and pathologic factors associated with postoperative VTE were evaluated using multivariable logistic regression. RESULTS: Among 70,934 patients who underwent GI cancer surgery, the incidence rates of 30-day postoperative VTE were 3.3% for pancreatic cancer, 3.2% for esophageal cancer, 2.7% for primary hepatic, and 1.3% for colorectal cancer. T stage was associated with VTE for colorectal cancer (T4 vs T1; odds ratio [OR], 1.79; 95% CI, 1.24-2.60), pancreatic cancer (all T stages vs T1; P < .05), and primary hepatic cancer (T4 vs T1; OR, 2.80; 95% CI, 1.55-5.08). N stage was associated with VTE for colorectal cancer (N2 vs N0; OR, 1.33; 95% CI, 1.04-1.68) and pancreatic cancer (N2 vs N0; OR, 1.36; 95% CI, 1.03-1.81). M stage was associated with VTE for colorectal cancer (OR, 1.47; 95% CI, 1.17-1.85) and esophageal cancer (OR, 2.54; 95% CI, 1.24-5.19). Histologic subtype was not associated with VTE, except for pancreatic neuroendocrine tumors vs adenocarcinoma (OR, 1.34; 95% CI, 1.03-1.74). CONCLUSION: Pathologic factors were associated with higher 30-day VTE risk after GI cancer surgery. Acknowledging the association of pathologic factors on VTE is an important first step to considering a more tailored approach to chemoprophylaxis.
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Neoplasias Gastrointestinais , Complicações Pós-Operatórias , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle , Feminino , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pessoa de Meia-Idade , Idoso , Neoplasias Gastrointestinais/cirurgia , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/patologia , Incidência , Fatores de Risco , Estadiamento de Neoplasias , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Neoplasias Hepáticas/cirurgia , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/patologia , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/complicações , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Although outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as "treat-and-release" encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors. METHODS: Using the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission. RESULTS: Of the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia-related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3-1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1-1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3-3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1-2.2). We observed no associations between these factors and the odds of readmission. CONCLUSION: Emergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.
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Pacientes Ambulatoriais , Tireoidectomia , Adulto , Estados Unidos/epidemiologia , Humanos , Tireoidectomia/efeitos adversos , Medicaid , Florida/epidemiologia , Serviço Hospitalar de Emergência , Readmissão do Paciente , Estudos RetrospectivosRESUMO
Purpose: Breast ultrasound suffers from low positive predictive value and specificity. Artificial intelligence (AI) proposes to improve accuracy, reduce false negatives, reduce inter- and intra-observer variability and decrease the rate of benign biopsies. Perpetuating racial/ethnic disparities in healthcare and patient outcome is a potential risk when incorporating AI-based models into clinical practice; therefore, it is necessary to validate its non-bias before clinical use. Approach: Our retrospective review assesses whether our AI decision support (DS) system demonstrates racial/ethnic bias by evaluating its performance on 1810 biopsy proven cases from nine breast imaging facilities within our health system from January 1, 2018 to October 28, 2021. Patient age, gender, race/ethnicity, AI DS output, and pathology results were obtained. Results: Significant differences in breast pathology incidence were seen across different racial and ethnic groups. Stratified analysis showed that the difference in output by our AI DS system was due to underlying differences in pathology incidence for our specific cohort and did not demonstrate statistically significant bias in output among race/ethnic groups, suggesting similar effectiveness of our AI DS system among different races (p>0.05 for all). Conclusions: Our study shows promise that an AI DS system may serve as a valuable second opinion in the detection of breast cancer on diagnostic ultrasound without significant racial or ethnic bias. AI tools are not meant to replace the radiologist, but rather to aid in screening and diagnosis without perpetuating racial/ethnic disparities.
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PURPOSE: Cancer staging is the foundation for all cancer management decisions. For real-time use, stage must be embedded in the electronic health record as a discrete data element. The objectives of this quality improvement (QI) initiative were to (1) identify barriers to utilization of an existing discrete cancer staging module, (2) identify health information technology (HIT) solutions to support discrete capture of cancer staging data, and (3) increase capture across the oncology enterprise in our diverse health system. METHODS: Six sigma QI methodologies were used to define barriers and solutions to improve discrete cancer staging. Design thinking principles informed solution development to test prototypes. Two multidisciplinary teams of disease-specific clinicians within GI and genitourinary conducted phased testing pilots to determine health system solutions. Solutions were expanded to all oncology specialties across our health system. RESULTS: Baseline average discrete staging capture across our health system was 31%. Poor workflow efficiency, limited accountability, and technical design gaps were key barriers to timely, complete staging. Implementation of more than 25 design enhancements to a HIT solution and passive user alerts led to a postimplementation capture rate of 58% across 55 outpatient clinics involving more than 400 clinicians. CONCLUSION: We identified key barriers to discrete data capture and designed solutions through iterative use of QI methodologies and disease-specific pilots. After implementation, discrete capture of cancer staging nearly doubled across our diverse health system. This approach is scalable and transferable to other initiatives to develop and implement clinically relevant HIT solutions across a diverse health system.
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BACKGROUND AND OBJECTIVES: Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. METHODS: Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. RESULTS: Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. CONCLUSIONS: ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.
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Procedimentos Cirúrgicos do Sistema Digestório , Readmissão do Paciente , Humanos , Estados Unidos , Idoso , Alta do Paciente , Assistência ao Convalescente , Medicare , Serviço Hospitalar de Emergência , Estudos RetrospectivosRESUMO
INTRODUCTION: In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. METHODS: ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). RESULTS: Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. DISCUSSION: The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.
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BACKGROUND: Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN: Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS: There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS: Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.
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Hospitais , Melhoria de Qualidade , Humanos , Illinois/epidemiologia , Benchmarking , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologiaRESUMO
PURPOSE: To evaluate the feasibility, effectiveness, and outcomes of percutaneous cholecystostomy drain internalization in patients with calculous cholecystitis who were not surgical candidates. MATERIALS AND METHODS: Percutaneous cystic duct interventions were attempted in 17 patients (with the intent to place dual cholecystoduodenal stents) who were deemed unfit for surgery and had previously undergone percutaneous cholecystostomies for acute calculous cholecystitis. Baseline demographics, technical success, time from percutaneous cholecystostomy to internalization (dual cholecystoduodenal stent placement), stent patency duration, and adverse event rates were evaluated. RESULTS: Fifteen (88%) of 17 procedures to cross the cystic duct were technically successful. Of these 17 patients, 13 (76%) underwent successful placement of dual cholecystoduodenal stents. Two of these 13 patients (who had successful dual cholecystoduodenal stent placement) needed repeat percutaneous cholecystostomy drains (1 patient had stent migration leading to recurrent cholecystitis, and the other had a perihepatic biloma). The 1-year patency rate was 77% (95% CI, 47%-100%). CONCLUSIONS: Dual cholecystoduodenal stent placement in nonsurgical patients is a technically feasible treatment option with the goal to remove percutaneous cholecystostomy drains.
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Colecistite Aguda , Colecistite , Colecistostomia , Humanos , Ducto Cístico/diagnóstico por imagem , Colecistite/terapia , Colecistite/cirurgia , Drenagem/efeitos adversos , Drenagem/métodos , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Colecistite Aguda/diagnóstico por imagem , Colecistite Aguda/cirurgia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: Evidence for neoadjuvant therapy (NAT) in extrahepatic cholangiocarcinoma (eCCA) is limited. Our objectives were to: (1) characterize treatment trends, (2) identify factors associated with receipt of NAT, and (3) evaluate associations between NAT and postoperative outcomes. METHODS: Retrospective cohort study of the National Cancer Database (2004-2017). Multivariable logistic regression assessed associations between NAT and postoperative outcomes. Stratified analysis evaluated differences between surgery first, neoadjuvant chemotherapy, and neoadjuvant chemoradiation (CRT). RESULTS: Among 8040 patients, 417 (5.2%) received NAT. NAT increased during the study period 2.9%-8.4% (p < 0.001). Factors associated with receipt of NAT included age <50 (vs. >75, odds ratio [OR] 4.32, p < 0.001) and stage 3 disease (vs. 1, OR 1.68, p = 0.01). Compared with surgery first, patients who received NAT had higher odds of R0 resection (OR 1.49, p = 0.01) and lower 30-day mortality (OR 0.51, p = 0.04). On stratified analysis, neoadjuvant chemotherapy was not associated with differences in any outcomes. However, neoadjuvant CRT was associated with improvement in R0 resection (OR 3.52, <0.001) and median survival (47.8 vs. 25.3 months, log-rank < 0.001) compared to surgery first. CONCLUSIONS: NAT, particularly neoadjuvant CRT, was associated with improved postoperative outcomes. These data suggest expanding the use of neoadjuvant CRT for eCCA.
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Neoplasias dos Ductos Biliares , Colangiocarcinoma , Neoplasias Pancreáticas , Humanos , Terapia Neoadjuvante , Neoplasias Pancreáticas/cirurgia , Estudos Retrospectivos , Colangiocarcinoma/cirurgia , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/patologiaRESUMO
INTRODUCTION: With widespread adoption of enhanced recovery protocols and a push toward shorter length of stay (LOS) following colon surgery, the extent to which complications have shifted to the post-discharge setting is unknown. The objectives of this study were to (1) characterize changes in LOS and post-discharge complications over time and (2) evaluate risk factors associated with post-discharge complications. METHODS: Patients who underwent elective colon resection from 2012 to 2018 were identified from the ACS NSQIP Colectomy-Targeted Dataset. Changes in LOS and the proportion of post-discharge complications were evaluated over time, and predictors of post-discharge complications were assessed using multivariable logistic regression. RESULTS: Of the 98,136 patients who underwent colon resection, median LOS decreased from 5 days in 2012 to 4 days in 2018. Overall, 30-day complication rate was 21.5%, which decreased during the study period (25.8 to 19.1%, p < 0.001). Of the 13 individual complications evaluated, 4 demonstrated a significant increase in the proportion of post-discharge events including overall SSI (55.8 to 63.3%, p = 0.002), superficial SSI (57.3 to 75.7%, p < 0.001), wound disruption (46.0 to 62.1%, p = 0.047), and UTI (41.5 to 62.7%, p < 0.001). Factors associated with the development of any post-discharge complication included female sex, ASA III/IV/V, dependent functional status, and higher BMI. Intraoperative factors included wound class, operation time, and approach. CONCLUSIONS: Although LOS and 30-day complications decreased over time, the proportion of events occurring post-discharge increased for several complications. We identified specific factors associated with post-discharge complications which emphasize the importance of a patient monitoring program to early identify and manage post-discharge complications.
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Assistência ao Convalescente , Alta do Paciente , Colectomia/efeitos adversos , Colo/cirurgia , Feminino , Humanos , Tempo de Internação , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos RetrospectivosRESUMO
PURPOSE: Unresectable intrahepatic cholangiocarcinoma (ICC) signifies a poor prognosis with limited treatment options beyond systemic chemotherapy. This study's purpose was to evaluate the safety, efficacy, and potential for downstaging to resection of yttrium-90 (Y90) radioembolization for treatment of unresectable ICC. MATERIALS AND METHODS: From 2004 to 2020, 136 patients with unresectable ICC were treated with radioembolization at a single institution. Retrospective review was performed of a prospectively collected database. Outcomes were (1) biochemical and clinical toxicities, (2) local tumor response, (3) time to progression, and (4) overall survival (OS) after Y90. Univariate/multivariate survival analyses were performed. A subgroup analysis was performed to calculate post-resection recurrence and OS in patients downstaged to resection after Y90. RESULTS: Grade 3+ clinical and biochemical toxicities were 7.6% (n = 10) and 4.9% (n = 6), respectively. Best index lesion response was complete response in 2 (1.5%), partial response in 42 (32.1%), stable disease in 82 (62.6%), and progressive disease in 5 (3.8%) patients. Median OS was 14.2 months. Solitary tumor (P < 0.001), absence of vascular involvement (P = 0.009), and higher serum albumin (P < 0.001) were independently associated with improved OS. Eleven patients (8.1%) were downstaged to resection and 2 patients (1.5%) were bridged to transplant. R0-resection was achieved in 8/11 (72.7%). Post-resection median recurrence and OS were 26.3 months and 39.9 months, respectively. CONCLUSION: Y90 has an acceptable safety profile and high local disease control rates for the treatment of unresectable ICC. Downstaging to resection with > 3 years survival supports the therapeutic role of Y90 for unresectable ICC. LEVEL OF EVIDENCE: Level 3, single-arm single-center cohort study.
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Neoplasias dos Ductos Biliares , Colangiocarcinoma , Embolização Terapêutica , Neoplasias Hepáticas , Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos/patologia , Colangiocarcinoma/cirurgia , Estudos de Coortes , Seguimentos , Humanos , Neoplasias Hepáticas/terapia , Estudos Retrospectivos , Resultado do Tratamento , Radioisótopos de Ítrio/uso terapêuticoRESUMO
BACKGROUND: Adherence to bundled interventions can reduce surgical site infection (SSI) rates; however, predictors of successful implementation are poorly characterized. We studied the association of patient and hospital characteristics with adherence to a colorectal SSI reduction bundle across a statewide surgical collaborative. STUDY DESIGN: A 16-component colorectal SSI reduction bundle was introduced in 2016 across a statewide quality improvement collaborative. Bundle adherence was measured for patients who underwent colorectal operations at participating institutions. Multivariable mixed-effects logistic regression models were constructed to estimate associations of patient and hospital factors with bundle adherence and quantify sources of variation. RESULTS: Among 2,403 patients at 35 hospitals, a median of 11 of 16 (68.8%, interquartile range 8 to 13) bundle elements were completed. The likelihood of completing 11 or more elements was increased for obese patients (56.8% vs 51.5%, odds ratio [OR] 1.39, 95% CI 1.05 to 1.86, p = 0.022) but reduced for underweight patients (31.0% vs 51.5%, OR 0.51, 95% CI 0.26 to 1.00, p = 0.048) compared with patients with a normal BMI. Lower adherence was noted for patients treated at safety net hospitals (n = 9 hospitals, 24.4% vs 54.4%, OR 0.08, 95% CI 0.01 to 0.44, p = 0.004). The largest proportion of adherence variation was attributable to hospital factors for six bundle elements, surgeon factors for no elements, and patient factors for nine elements. CONCLUSION: Adherence to an SSI reduction bundle is associated with patient BMI and hospital safety net status. Quality improvement groups should consider institutional traits for optimal implementation of SSI bundles. Safety net hospitals may require additional focus to overcome unique implementation barriers.
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Neoplasias Colorretais , Cirurgia Colorretal , Hospitais , Humanos , Melhoria de Qualidade , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
BACKGROUND: Screening colonoscopy effectiveness depends on procedure quality; however, knowledge about colonoscopy quality in rural and underserved areas is limited. This study aimed to describe the characteristics and quality of colonoscopy and to examine predictors of colonoscopy quality at rural and underserved hospitals. METHODS: Adults undergoing colonoscopy from April 2017 to March 2019 at rural or underserved hospitals across the Illinois Surgical Quality Improvement Collaborative were prospectively identified. The primary outcome was colorectal adenoma detection, and secondary outcomes included bowel preparation adequacy, cecum photodocumentation, and withdrawal time. Performance was benchmarked against multisociety guidelines, and multivariable logistic regression was used to examine patient, physician, and procedure characteristics associated with adenoma detection. RESULTS: In total, 4217 colonoscopy procedures were performed at 8 hospitals, including 1865 screening examinations performed by 19 surgeons, 9 gastroenterologists, and 2 family practitioners. Physician screening volume ranged from 2 to 218 procedures (median 50; IQR 23-74). Adenoma detection occurred in 26.6% of screening procedures (target: ≥ 25%), 90.7% had adequate bowel preparation (target: ≥ 85%), 93.1% had cecum photodocumentation (target: ≥ 95%), and mean withdrawal time was 8.1 min (target: ≥ 6). Physician specialty was associated with adenoma detection (gastroenterologists: 36.9% vs. surgeons: 22.5%; OR 2.30, 95% CI 1.40-3.77), but adequate bowel preparation (OR 1.15, 95% CI 0.76-1.73) and cecum photodocumentation (OR 1.56, 95% CI 0.91-2.69) were not. CONCLUSION: Colonoscopies performed at rural and underserved hospitals meet many quality metrics; however, quality varied widely. As physicians are scarce in rural and underserved areas, individualized interventions to improve colonoscopy quality are needed.
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Adenoma , Neoplasias Colorretais , Adenoma/diagnóstico , Adenoma/cirurgia , Adulto , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/métodos , Humanos , Programas de Rastreamento/métodos , Área Carente de Assistência MédicaRESUMO
COVID-19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID-19 or other large-scale disruptions in cancer care.
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COVID-19/prevenção & controle , Neoplasias Colorretais/terapia , Atenção à Saúde/normas , Terapia Combinada , Atenção à Saúde/métodos , Atenção à Saúde/organização & administração , Humanos , Illinois , Telemedicina/métodos , Telemedicina/organização & administração , Telemedicina/normasRESUMO
BACKGROUND: Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE: The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN: This was a post-hoc analysis of a prospective cohort study. SETTING: This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. PATIENTS: Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. INTERVENTIONS: The intervention was a 16-element colorectal surgical site infection reduction bundle. MAIN OUTCOME MEASURES: Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS: Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS: The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION: Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . DESEMPAQUETANDO PAQUETES EVALUACIN DE LA ASOCIACIN DE ELEMENTOS INDIVIDUALES DEL PAQUETE DE REDUCCIN DE INFECCIONES DEL SITIO QUIRRGICO COLORRECTAL CON LAS TASAS DE INFECCIN EN UNA COLABORACIN ESTATAL: ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).