Modified Thermodilution for Simultaneous Cardiac Output and Recirculation Assessment in Veno-venous Extracorporeal Membrane Oxygenation: A Prospective Diagnostic Accuracy Study.

BACKGROUND: Thermodilution is unreliable in veno-venous extracorporeal membrane oxygenation (VV-ECMO). Systemic oxygenation depends on recirculation fractions and ratios of extracorporeal membrane oxygenation (ECMO) flow to cardiac output. In a prospective in vitro simulation, this study assessed the diagnostic accuracy of a modified thermodilution technique for recirculation and cardiac output. The hypothesis was that this method provided clinically acceptable precision and accuracy for cardiac output and recirculation. METHODS: Two ECMO circuits ran in parallel: one representing a VV-ECMO and the second representing native heart, lung, and circulation. Both circuits shared the right atrium. Extra limbs for recirculation and pulmonary shunt were added. This study simulated ECMO flows from 1 to 2.5 l/min and cardiac outputs from 2.5 to 3.5 l/min with recirculation fractions (0 to 80%) and pulmonary shunts. Thermistors in both ECMO limbs and the pulmonary artery measured the temperature changes induced by cold bolus injections into the arterial ECMO limb. Recirculation fractions were calculated from the ratio of the areas under the temperature curve (AUCs) in the ECMO limbs and from partitioning of the bolus volume (flow based). With known partitioning of bolus volumes between ECMO and pulmonary artery, cardiac output was calculated. High-precision ultrasonic flow probes served as reference for Bland-Altman plots and linear mixed-effect models. RESULTS: Accuracy and precision for both the recirculation fraction based on AUC (bias, -5.4%; limits of agreement, -18.6 to 7.9%) and flow based (bias, -5.9%; limits of agreement, -18.8 to 7.0%) are clinically acceptable. Calculated cardiac output for all recirculation fractions was accurate but imprecise (RecirculationAUC: bias 0.56 l/min; limits of agreement, -2.27 to 3.4 l/min; and RecirculationFLOW: bias 0.48 l/min; limits of agreement, -2.22 to 3.19 l/min). Recirculation fraction increased bias and decreased precision. CONCLUSIONS: Adapted thermodilution for VV-ECMO allows simultaneous measurement of recirculation fraction and cardiac output and may help optimize patient management with severe respiratory failure.

Integral assessment of gas exchange during veno-arterial ECMO: accuracy and precision of a modified Fick principle in a porcine model.

Assessment of native cardiac output during extracorporeal circulation is challenging. We assessed a modified Fick principle under conditions such as dead space and shunt in 13 anesthetized swine undergoing centrally cannulated veno-arterial extracorporeal membrane oxygenation (V-A ECMO, 308 measurement periods) therapy. We assumed that the ratio of carbon dioxide elimination (V̇co2) or oxygen uptake (V̇o2) between the membrane and native lung corresponds to the ratio of respective blood flows. Unequal ventilation/perfusion (V̇/Q̇) ratios were corrected towards unity. Pulmonary blood flow was calculated and compared to an ultrasonic flow probe on the pulmonary artery with a bias of 99 mL/min (limits of agreement -542 to 741 mL/min) with blood content V̇o2 and no-shunt, no-dead space conditions, which showed good trending ability (least significant change from 82 to 129 mL). Shunt conditions led to underestimation of native pulmonary blood flow (bias -395, limits of agreement -1,290 to 500 mL/min). Bias and trending further depended on the gas (O2, CO2) and measurement approach (blood content vs. gas phase). Measurements in the gas phase increased the bias (253 [LoA -1,357 to 1,863 mL/min] for expired V̇o2 bias 482 [LoA -760 to 1,724 mL/min] for expired V̇co2) and could be improved by correction of V̇/Q̇ inequalities. Our results show that common assumptions of the Fick principle in two competing circulations give results with adequate accuracy and may offer a clinically applicable tool. Precision depends on specific conditions. This highlights the complexity of gas exchange in membrane lungs and may further deepen the understanding of V-A ECMO.

Perioperative Doppler ultrasound assessment of portal vein flow pulsatility in high-risk cardiac surgery patients: a multicentre prospective cohort study.

BACKGROUND: Portal vein Doppler ultrasound pulsatility measured by transoesophageal echocardiography is a marker of the haemodynamic impact of venous congestion in cardiac surgery. We investigated whether the presence of abnormal portal vein flow pulsatility is associated with a longer duration of invasive life support and postoperative complications in high-risk patients. METHODS: In this multicentre cohort study, pulsed-wave Doppler ultrasound assessments of portal vein flow were performed during anaesthesia before initiation of cardiopulmonary bypass (before CPB) and after separation of cardiopulmonary bypass (after CPB). Abnormal pulsatility was defined as portal pulsatility fraction (PPF) ≥50% (PPF50). The primary outcome was the cumulative time in perioperative organ dysfunction (TPOD) requiring invasive life support during 28 days. Secondary outcomes included major postoperative complications. RESULTS: 373 patients, 71 (22.0%) had PPF50 before CPB and 77 (24.9%) after CPB. PPF50 was associated with longer duration of TPOD (median [inter-quartile range]; before CPB: 27 h [11-72] vs 19 h [8.5-42], P=0.02; after CPB: 27 h [11-61] vs 20 h [8-42], P=0.006). After adjusting for confounders, PPF50 before CPB showed significant association with TPOD. PPF50 after CPB was associated with a higher rate of major postoperative complications (36.4% vs 20.3%, P=0.006). CONCLUSIONS: Abnormal portal vein flow pulsatility before cardiopulmonary bypass was associated with longer duration of life support therapy after cardiac surgery in high-risk patients. Abnormal portal vein flow pulsatility after cardiopulmonary bypass separation was associated with a higher risk of major postoperative complications although this association was not independent of other factors. CLINICAL TRIAL REGISTRATION: NCT03656263.

Assessment of magnetic flux density properties of electromagnetic noninvasive phrenic nerve stimulations for environmental safety in an ICU environment.

Diaphragm weakness affects up to 60% of ventilated patients leading to muscle atrophy, reduction of muscle fiber force via muscle fiber injuries and prolonged weaning from mechanical ventilation. Electromagnetic stimulation of the phrenic nerve can induce contractions of the diaphragm and potentially prevent and treat loss of muscular function. Recommended safety distance of electromagnetic coils is 1 m. The aim of this study was to investigate the magnetic flux density in a typical intensive care unit (ICU) setting. Simulation of magnetic flux density generated by a butterfly coil was performed in a Berlin ICU training center with testing of potential disturbance and heating of medical equipment. Approximate safety distances to surrounding medical ICU equipment were additionally measured in an ICU training center in Bern. Magnetic flux density declined exponentially with advancing distance from the stimulation coil. Above a coil distance of 300 mm with stimulation of 100% power the signal could not be distinguished from the surrounding magnetic background noise. Electromagnetic stimulation of the phrenic nerve for diaphragm contraction in an intensive care unit setting seems to be safe and feasible from a technical point of view with a distance above 300 mm to ICU equipment from the stimulation coil.

Assessment of Right Heart Function during Extracorporeal Therapy by Modified Thermodilution in a Porcine Model.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation therapy is a growing treatment modality for acute cardiorespiratory failure. Cardiac output monitoring during veno-arterial extracorporeal membrane oxygenation therapy remains challenging. This study aims to validate a new thermodilution technique during veno-arterial extracorporeal membrane oxygenation therapy using a pig model. METHODS: Sixteen healthy pigs were centrally cannulated for veno-arterial extracorporeal membrane oxygenation, and precision flow probes for blood flow assessment were placed on the pulmonary artery. After chest closure, cold boluses of 0.9% saline solution were injected into the extracorporeal membrane oxygenation circuit, right atrium, and right ventricle at different extracorporeal membrane oxygenation flows (4, 3, 2, 1 l/min). Rapid response thermistors in the extracorporeal membrane oxygenation circuit and pulmonary artery recorded the temperature change. After calculating catheter constants, the distributions of injection volumes passing each circuit were assessed and enabled calculation of pulmonary blood flow. Analysis of the exponential temperature decay allowed assessment of right ventricular function. RESULTS: Calculated blood flow correlated well with measured blood flow (r2 = 0.74, P < 0.001). Bias was -6 ml/min [95% CI ± 48 ml/min] with clinically acceptable limits of agreement (668 ml/min [95% CI ± 166 ml/min]). Percentage error varied with extracorporeal membrane oxygenation blood flow reductions, yielding an overall percentage error of 32.1% and a percentage error of 24.3% at low extracorporeal membrane oxygenation blood flows. Right ventricular ejection fraction was 17 [14 to 20.0]%. Extracorporeal membrane oxygenation flow reductions increased end-diastolic and end-systolic volumes with reductions in pulmonary vascular resistance. Central venous pressure and right ventricular ejection fractions remained unchanged. End-diastolic and end-systolic volumes correlated highly (r2 = 0.98, P < 0.001). CONCLUSIONS: Adapted thermodilution allows reliable assessment of cardiac output and right ventricular behavior. During veno-arterial extracorporeal membrane oxygenation weaning, the right ventricle dilates even with stable function, possibly because of increased venous return.

Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

BACKGROUND: There is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC. METHODS: Clinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group. RESULTS: Of the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences ($37,391 vs $137,996). CONCLUSIONS: Since OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.

Variation in postacute care utilization after complex surgery.

BACKGROUND: Variation in use of postacute care (PAC), including skilled nursing facilities and inpatient rehabilitation, accounts for 73% of regional variation in Medicare spending. Studies of hospital variation in PAC use have typically focused on nonsurgical patients or have been limited to Medicare data. Consequently, there is no nationally representative data on how rates of postoperative discharge to PAC differ between hospitals. The purpose of this study was to explore hospital-level variation in PAC utilization after cardiovascular and abdominal surgery. MATERIALS AND METHODS: We evaluated 3,487,365 patients from the Nationwide Inpatient Sample and 60,666 from the Veterans Affairs health system, who had colorectal surgery, hepatectomy, pancreatectomy, coronary bypass, aortic aneurysm repair, and peripheral vascular bypass from 2008 to 2011. For each hospital, we calculated unadjusted and risk-adjusted observed-to-expected ratios for discharge to PAC facilities (skilled nursing or inpatient rehabilitation). RESULTS: A total of 631,199 (18%) non-veterans and 4744 (8%) veterans were discharged to PAC facilities. For veterans, 32% were ≥70 y old, and 98% were men. For non-veterans, 39% were ≥70, and 60% were men. Hospital rates of discharge to PAC facilities varied from 1% to 36% for veterans hospitals and from 1% to 59% for non-veteran hospitals. Risk-adjusted observed-to-expected ratios ranged from 0.10 to 4.15 for veterans and from 0.11 to 4.3 for non-veteran hospitals. CONCLUSIONS: There is substantial variation in PAC utilization and rates of home discharge after abdominal and cardiovascular surgery. To reduce variation, further research is needed to understand health systems factors that influence PAC utilization.

An assessment of repeat computed tomography utilization in the emergency department in the setting of blunt trauma.

PURPOSE: Computed tomography (CT) is a standard imaging modality utilized during the evaluation of trauma patients in the emergency department (ED). However, while it is common to utilize intravenous (IV) contrast as an adjunct, the use of multiple CT scans and how it impacts patient flow can lead to changes in patient management. Our objectives are to assess length of stay (LOS) and rates of acute kidney injury (AKI), when two CT scans of the abdomen/pelvis are performed compared to one CT scan. METHODS: Data of trauma hospital encounters were retrospectively collected during a 5-year period at a large, level 1 trauma center. Encounters were categorized into patients who received one or two CT scans of the abdomen/pelvis, as well as if they had received IV contrast or not. CT scan reads were extracted from chart records, and groups were compared. RESULTS: Of 5787 patient encounters, 5335 (93.4%) received IV contrast and 75 (1.3%) received two CT scans. Lower rates of AKI were associated with IV contrast (2.5 vs 12.5%). Receiving two CT scans was associated with increased rates of AKI (20.0 vs 3.0%; p < 0.0001), ICU admissions (88.0 vs 25.1%; p < 0.0001), and hospital LOS (21.9 vs 1.4 days; p < 0.0001). Of the repeat CT scans, 59.4% demonstrated no significant difference and did not require blood products or the operating room. CONCLUSION: Two CT scans performed during blunt trauma encounters demonstrated mixed benefit and were associated with an increased hospital LOS. Additionally, IV contrast was associated with lower rates of AKI.

Spillover effects on health outcomes in low- and middle-income countries: a systematic review.

Background: Many interventions delivered to improve health may benefit not only direct recipients but also people in close physical or social proximity. Our objective was to review all published literature about the spillover effects of interventions on health outcomes in low-middle income countries and to identify methods used in estimating these effects. Methods: We searched 19 electronic databases for articles published before 2014 and hand-searched titles from 2010 to 2013 in five relevant journals. We adapted the Cochrane Collaboration's quality grading tool for spillover estimation and rated the quality of evidence. Results: A total of 54 studies met inclusion criteria. We found a wide range of terminology used to describe spillovers, a lack of standardization among spillover methods and poor reporting of spillovers in many studies. We identified three primary mechanisms of spillovers: reduced disease transmission, social proximity and substitution of resources within households. We found the strongest evidence for spillovers through reduced disease transmission, particularly vaccines and mass drug administration. In general, the proportion of a population receiving an intervention was associated with improved health. Most studies were of moderate or low quality. We found evidence of publication bias for certain spillover estimates but not for total or direct effects. To facilitate improved reporting and standardization in future studies, we developed a reporting checklist adapted from the CONSORT framework specific to reporting spillover effects. Conclusions: We found the strongest evidence for spillovers from vaccines and mass drug administration to control infectious disease. There was little high quality evidence of spillovers for other interventions.

Truth in Reporting: How Data Capture Methods Obfuscate Actual Surgical Site Infection Rates within a Health Care Network System.

BACKGROUND: Two systems measure surgical site infection rates following colorectal surgeries: the American College of Surgeons National Surgical Quality Improvement Program and the Centers for Disease Control and Prevention National Healthcare Safety Network. The Centers for Medicare & Medicaid Services pay-for-performance initiatives use National Healthcare Safety Network data for hospital comparisons. OBJECTIVE: This study aimed to compare database concordance. DESIGN: This is a multi-institution cohort study of systemwide Colorectal Surgery Collaborative. The National Surgical Quality Improvement Program requires rigorous, standardized data capture techniques; National Healthcare Safety Network allows 5 data capture techniques. Standardized surgical site infection rates were compared between databases. The Cohen κ-coefficient was calculated. SETTING: This study was conducted at Boston-area hospitals. PATIENTS: National Healthcare Safety Network or National Surgical Quality Improvement Program patients undergoing colorectal surgery were included. MAIN OUTCOME MEASURES: Standardized surgical site infection rates were the primary outcomes of interest. RESULTS: Thirty-day surgical site infection rates of 3547 (National Surgical Quality Improvement Program) vs 5179 (National Healthcare Safety Network) colorectal procedures (2012-2014). Discrepancies appeared: National Surgical Quality Improvement Program database of hospital 1 (N = 1480 patients) routinely found surgical site infection rates of approximately 10%, routinely deemed rate "exemplary" or "as expected" (100%). National Healthcare Safety Network data from the same hospital and time period (N = 1881) revealed a similar overall surgical site infection rate (10%), but standardized rates were deemed "worse than national average" 80% of the time. Overall, hospitals using less rigorous capture methods had improved surgical site infection rates for National Healthcare Safety Network compared with standardized National Surgical Quality Improvement Program reports. The correlation coefficient between standardized infection rates was 0.03 (p = 0.88). During 25 site-time period observations, National Surgical Quality Improvement Program and National Healthcare Safety Network data matched for 52% of observations (13/25). κ = 0.10 (95% CI, -0.1366 to 0.3402; p = 0.403), indicating poor agreement. LIMITATIONS: This study investigated hospitals located in the Northeastern United States only. CONCLUSIONS: Variation in Centers for Medicare & Medicaid Services-mandated National Healthcare Safety Network infection surveillance methodology leads to unreliable results, which is apparent when these results are compared with standardized data. High-quality data would improve care quality and compare outcomes among institutions.

Surgical follow-up costs disproportionately impact low-income patients.

BACKGROUND: Surgical procedures have significant costs at the national level, but the financial burden on patients is equally important. Patients' out-of-pocket costs for surgery and surgical care include not only direct medical costs but also the indirect cost of lost wages and direct nonmedical costs including transportation and childcare. We hypothesized that the nonmedical costs of routine postoperative clinic visits disproportionately impact low-income patients. MATERIALS AND METHODS: This was a cross-sectional study performed in the postoperative acute care surgery clinic at a large, urban county hospital. A survey containing items about social, demographic, and financial data was collected from ambulatory patients. Nonmedical costs were calculated as the sum of transportation, childcare, and lost wages. Costs and cost to income ratios were compared between income strata. RESULTS: Ninety-seven patients responded to the survey of which 59 reported all items needed for cost calculations. The median calculated cost of a clinic visit was $27 (interquartile range $18-59). Components of this cost were $16 ($14-$20) for travel, $22 ($17-$50) for childcare among patients requiring childcare, and $0 ($0-$30) in lost wages. Low-income patients had significantly higher (P = 0.0001) calculated cost to income ratios, spending nearly 10% of their monthly income on these costs. CONCLUSIONS: The financial burden of routine postoperative clinic visits is significant. Consistent with our hypothesis, the lowest income patients are disproportionately impacted, spending nearly 10% of their monthly income on costs associated with the clinic visit. Future cost-containment efforts should examine alternative, lower cost methods of follow-up, which reduce financial burden.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE: To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND: TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS: A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS: TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS: TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Renewed assessment of the stapled anastomosis with the increasing role of laparoscopic colectomy for colon cancer.

INTRODUCTION: Stapled gastrointestinal anastomosis has gained wide adoption among the surgical community for its ease, speed, and its applicability in laparoscopic surgery. Over the last decade, with the increase in laparoscopic techniques in colon surgery, anastomotic stapling has become the technique of choice for colon cancer surgery at our center. This abstract assesses whether the increasing adoption of anastomotic stapling affected the rate of anastomotic leaks and duration of surgery. METHODS: All patients surgically treated for colon cancer with a primary bowel anastomosis from 2004 through 2011 were included (n = 998). Duration of stay, surgery, and postoperative complication rates was compared between hand-sewn and stapled anastomosis. RESULTS: The number of stapled anastomoses grew significantly from 45.8% in 2004-2007 to 80.3% in 2008-2011 (p < 0.001), and an increasing portion of those is performed in laparoscopic procedures (29.8 to 43.3%; p = 0.01). Surgeries using stapled anastomosis initially took longer, but a decreasing trend (2004-2007: 147.5 min to 2007-2011: 124 min; p < 0.001) along with an increasing duration in hand-sewn surgeries (94-118.5 min; p < 0.01) meant stapled procedures became shorter than hand-sewn procedures by 2009. Complication rates did not differ significantly between groups, with stapled anastomoses having lower percentages of anastomotic leaks (1.6 vs. 2.4%; p = 0.38). By the second half of our research period, the median admission for patients with stapled anastomoses was two days shorter (4 vs. 6 days; p < 0.001), independently of the chosen approach. CONCLUSION: Stapled anastomoses did not increase anastomotic leak rates. If anything, leak rates appeared slightly lower. In addition, stapled anastomoses significantly shortened operation duration. With the benefit of being a tool that facilitates minimally invasive surgery, it is a safe way to improve efficiency, reduce costs, and promote faster and better recovery.

Sonographic patterns of lung consolidation in mechanically ventilated patients with and without ventilator-associated pneumonia: a prospective cohort study.

PURPOSE: Thoracic ultrasound (TUS) has been successfully used in the diagnosis of community-acquired pneumonia. Little is known about its diagnostic potential in ventilator-associated pneumonia (VAP). The purpose of this study was to systematically describe the morphology and temporal changes of sonographic patterns in mechanically ventilated patients and to evaluate the diagnostic performance characteristics of TUS-based VAP diagnoses. MATERIALS AND METHODS: Patients who were placed on invasive ventilation for reasons other than pneumonia and who were considered at risk for the development of VAP received daily TUS examinations while being closely monitored for the development of pneumonia. RESULTS: Fifty-seven patients were studied. The incidence of VAP was 21.1%. Sonographic patterns of reduced or absent lung aeration were found in 64.2% of examinations. The sonographic pattern of lung consolidation with either dynamic or static air bronchograms was 100% sensitive and 60% specific for VAP in those patients who developed clinical signs and symptoms compatible with pneumonia. The pretest and posttest probabilities were 0.38 and 0.6, respectively. CONCLUSIONS: Sonographic patterns of abnormal aeration are frequently observed in mechanically ventilated patients. If sonographic lung consolidation with either static or dynamic air bronchograms is absent, VAP is highly unlikely. The presence of these sonographic patterns in patients with signs and symptoms suggestive of pneumonia significantly increases the probability of VAP.

Gender and ethnic disparities in colon cancer presentation and outcomes in a US universal health care setting.

OBJECTIVE: Access to care is a pillar of U.S. healthcare reform and could potentially challenge existing ethnic and gender disparities in care. We present a snapshot of these disparities in surgical colon cancer patients in the largest public hospital in Massachusetts, a state leading in providing universal healthcare, to indicate potential changes that might result from universal care access. METHODS: All surgical colon cancer patients at Massachusetts General Hospital (2004-2011) were included. Baseline characteristics, perioperative, and long-term outcomes were compared. RESULTS: Among 1,071 patients, the 110 (10.3%) minority patients presented with more comorbid (mean Charlson score 0.84 vs. 0.71; P = 0.039), metastatic (21.8% vs. 14%; P = 0.026), and node-positive disease (50% vs. 38.8%; P = 0.014). Women (n = 521; 48.6%) had less screening diagnoses (overall: 17.8% vs. 22.6%; P = 0.049, screening age: 26.4% vs. 32.7%; P = 0.036) with subsequently higher rates of metastatic disease on pathology (11.3% vs. 7.1%, P = 0.02). Multivariate adjustment for baseline staging makes outcome disparities no longer statistically significant. CONCLUSIONS: Significant gender and ethnic disparities subsist at baseline despite long-standing low-threshold healthcare access, although seemingly mitigated by enrollment into high-level care, empowering equal chances for underprivileged groups. The outcomes are also a reminder that universal healthcare will not be a panacea for the deeply rooted and dynamic causes of presentation inequalities.

Association of high-volume hospitals with greater likelihood of discharge to home following colorectal surgery.

IMPORTANCE: Discharge disposition is a patient-centered quality metric that reflects differences in quality of life and recovery following surgery. The effect of hospital volume on quality of recovery measured by rates of successful discharge to home remains unclear. OBJECTIVE: To test the hypothesis that patients having colorectal surgery at high-volume hospitals would more likely be discharged to home rather than discharged to skilled rehabilitation facilities to complete recovery. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal analysis of 2008 hospital inpatient data to identify patients undergoing colorectal surgery who survived to discharge. The setting was the Nationwide Inpatient Sample, the largest all-payer inpatient care database, containing data from more than 1000 hospitals. Participants were 280,644 patients (≥ 18 years) who underwent colorectal resections for benign or malignant disease and survived to discharge. MAIN OUTCOMES AND MEASURES: The primary end point was discharge to home (with or without home health care) vs discharge to skilled facilities (skilled nursing, short-term recovery, or rehabilitation hospitals or other institutions). The secondary end point was discharge to home with home health care rather than to a skilled facility for patients with postdischarge care needs. Multiple logistic regression using robust standard errors was used to compute the odds ratios of each outcome based on hospital volume, while adjusting for other important variables. RESULTS: The odds of discharge to home vs discharge to skilled facilities were significantly greater in high-volume hospitals compared with low-volume hospitals (odds ratio, 2.09; 95% CI, 1.70-2.56), with an absolute increase of 9%. For patients with postdischarge care needs, high-volume hospitals were less likely than low-volume hospitals to use skilled facilities rather than home health care (odds ratio, 0.35; 95% CI, 0.27-0.45), with an absolute difference of 10%. CONCLUSIONS AND RELEVANCE: Patients having colorectal surgery at high-volume hospitals are significantly more likely to recover and return home after surgery than individuals having operations at low-volume hospitals. This study is the first step in a process of identifying which features of high-volume hospitals contribute toward desirable outcomes. Efforts to identify the reasons for improved recovery at high-volume hospitals can help lower-volume hospitals adopt beneficial practices.