Associations of Demographic and Social Factors on Health-Related Quality-of-Life Changes Among Older Women With Breast or Gynecologic Cancer.

OBJECTIVES: To examine associations of sociodemographic factors and social limitations with health-related quality of life (HRQOL) from pre- to postdiagnosis in older female cancer survivors. SAMPLE & SETTING: 9,807 women aged 65 years or older with breast or gynecologic cancer from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey. METHODS & VARIABLES: Physical and mental HRQOL were assessed using the physical component summary (PCS) and mental component summary (MCS) of the Veterans RAND 12-Item Health Survey. Descriptive statistics and mixed-effects models for repeated measures were used. RESULTS: Social limitations were the only significant factor associated with changes in MCS scores. Race and ethnicity, rurality, and social interference were associated with significant decreases in PCS scores. IMPLICATIONS FOR NURSING: Nurses can assess mental and physical HRQOL after diagnosis and advocate for appropriate referrals. Oncology care should be tailored to cultural considerations, including race and ethnicity, rurality, and social support.

Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population.

BACKGROUND: As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS: We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS: We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS: We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.

Comparing super-utilizers and lower-utilizers among commercial- and Medicare-insured adults with sickle cell disease.

ABSTRACT: Sickle cell disease (SCD) is a rare but costly condition in the United States. Super-utilizers have been defined as a subset of the population with high health care encounters or expenditures. Although super-utilizers have been described in other disease states, little is known about super-utilizers among adults with SCD. This study aimed to characterize the differences in expenditures, overall health care encounters, and pain episode encounters between super-utilizers (top 10% expenditures) and lower-utilizers with SCD (high, top 10%-24.9%; moderate, 25%-49.9%; and low, bottom 50% expenditures). A retrospective longitudinal cohort of adults with SCD were identified using validated algorithms in MarketScan and Medicare claim databases from 2016 to 2020. Encounters and expenditures were analyzed from inpatient, outpatient, and emergency department settings. Differences in encounters and expenditures between lower-utilizers and super-utilizers were compared using logistic regression. Among super-utilizers, differences in encounters and expenditures were compared according to incidences of pain episode encounters. The study population included 5666 patients with commercial insurance and 8600 with Medicare. Adjusted total annual health care expenditure was 43.46 times higher for super-utilizers than for low-utilizers among commercial-insured and 13.37 times higher in Medicare-insured patients. Among super-utilizers, there were patients with few pain episode encounters who had higher outpatient expenditures than patients with a high number of pain episode encounters. Our findings demonstrate the contribution of expensive outpatient care among SCD super-utilizers, in which analyses of high expenditure have largely focused on short-term care. Future studies are needed to better understand super-utilizers in the SCD population to inform the effective use of preventive interventions and/or curative therapies.

Comparing Kidney Transplant Rates and Outcomes Among Adults With and Without Intellectual and Developmental Disabilities.

Importance: Improving equity in organ transplant access for people with intellectual and developmental disabilities (IDD) is a topic of social discourse in mainstream media, state legislation, and national legislation. However, few studies have compared evaluation rates, transplant rates, and outcomes among adults with and without IDD. Objective: To compare rates of kidney transplant and transplant-specific outcomes between propensity-score matched groups of adults with end-stage kidney disease (ESKD [also referred to as end-stage renal disease (ESRD)]) with and without co-occurring IDD. Design, Setting, and Participants: This retrospective cohort study included all Medicare inpatient and outpatient standard analytical files from 2013 through 2020. A total of 1 413 655 adult Medicare beneficiaries with ESKD were identified. Propensity-score matching was used to balance cohorts based on age, sex, race, follow-up duration, and Charlson Comorbidity Index. The matched cohorts consisted of 21 384 adults with ESKD (10 692 of whom had IDD) and 1258 kidney transplant recipients (629 of whom had IDD). Data were analyzed between June 1, 2022, and August 1, 2022. Exposure: IDD. Main Outcomes and Measures: Evaluation for kidney transplant, receipt of kidney transplant, perioperative complications, readmission, mortality, graft rejection, and graft failure. Results: Of the 21 384 propensity-score matched adults with ESKD, the median (IQR) age was 55 (43-65) years, 39.2% were male, 27.4% were Black, 64.1% were White, and 8.5% identified as another race or ethnicity. After propensity score matching within the ESKD cohort, 633 patients with IDD (5.9%) received a kidney transplant compared with 1367 of adults without IDD (12.8%). Adults with IDD were 54% less likely than matched peers without IDD to be evaluated for transplant (odds ratio, 0.46; 95% CI, 0.43-0.50) and 62% less likely to receive a kidney transplant (odds ratio, 0.38; 95% CI, 0.34-0.42). Among matched cohorts of kidney transplant recipients, rates of perioperative complications, readmission, and graft failure were similar for adults with and without IDD. Conclusions and Relevance: Using the largest cohort of adult kidney transplant recipients with IDD to date, the study team found that rates of evaluation and transplant were lower despite yielding equivalent outcomes. These data support consideration of adults with IDD for kidney transplant and underscore the urgent need for antidiscrimination initiatives to promote the receipt of equitable care for this population.

Association of County-level Upward Economic Mobility with Stage at Diagnosis and Receipt of Treatment Among Patients Diagnosed with Pancreatic Adenocarcinoma.

OBJECTIVE: Determining the impact of county-level upward economic mobility on stage at diagnosis and receipt of treatment among Medicare beneficiaries with pancreatic adenocarcinoma. SUMMARY BACKGROUND DATA: The extent to which economic mobility contributes to socioeconomic disparities in health outcomes remains largely unknown. METHODS: Pancreatic adenocarcinoma patients diagnosed in 2004-2015 were identified from the SEER-Medicare linked database. Information on countylevel upward economic mobility was obtained from the Opportunity Atlas. Its impact on early-stage diagnosis (stage I or II), as well as receipt of chemotherapy or surgery was analyzed, stratified by patient race/ethnicity. RESULTS: Among 25,233 patients with pancreatic adenocarcinoma, 37.1% (n = 9349) were diagnosed at an early stage; only 16.7% (n = 4218) underwent resection, whereas 31.7% (n = 7996) received chemotherapy. In turn, 10,073 (39.9%) patients received any treatment. Individuals from counties with high upward economic mobility were more likely to be diagnosed at an earlier stage (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.25), as well as to receive surgery (OR 1.58, 95% CI 1.41-1.77) or chemotherapy (OR 1.51, 95% CI 1.39-1.63). White patients and patients who identified as neither White or Black had increased odds of being diagnosed at an early stage (OR 1.12, 95% CI 1.02-1.22 and OR 1.35, 95% CI 1.02-1.80, respectively) and of receiving treatment (OR 1.73, 95% CI 1.59-1.88 and OR 1.49, 95% CI 1.13-1.98, respectively) when they resided in a county of high vs low upward economic mobility. The impact of economic mobility on stage at diagnosis and receipt of treatment was much less pronounced among Black patients (high vs low, OR 1.28, 95% CI 0.96-1.71 and OR 1.30, 95% CI 0.99-1.72, respectively). CONCLUSIONS: Pancreatic adenocarcinoma patients from higher upward mobility areas were more likely to be diagnosed at an earlier stage, as well as to receive surgery or chemotherapy. The impact of county-level upward mobility was less pronounced among Black patients.

Pancreatogenic Diabetes after Partial Pancreatectomy: A Common and Understudied Cause of Morbidity.

BACKGROUND: Partial pancreatic resection is a known risk factor for new-onset pancreatogenic diabetes mellitus (P-DM). The long-term incidence of P-DM and its clinical impact after partial pancreatic resection remains unknown. The primary objective of this study is to determine the long-term incidence of P-DM and its clinical impact after partial pancreatic resection. STUDY DESIGN: The Medicare 100% Standard Analytic File (2013 to 2017) was queried for all patients who underwent partial pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy). The primary outcome was the development of postoperative P-DM after surgery. RESULTS: Among 4,255 patients who underwent a pancreaticoduodenectomy or distal pancreatectomy, with a median follow-up of 10.8 months, the incidence of P-DM was 20.3% (n=863) and occurred at a median of 3.6 months after surgery. For patients with at least a 3-year follow-up, 32.2% of patients developed P-DM. Risk factors for developing P-DM included male sex (odds ratio [OR] 1.32, 95% CI 1.13 to 1.54), undergoing a distal pancreatectomy (OR 1.98, 95% CI 1.68 to 2.35), having a malignant diagnosis (OR 1.65, 95% CI 1.34 to 2.04), a family history of diabetes (OR 2.06, 95% CI 1.43 to 2.97; all p < 0.001), and being classified as prediabetic in the preoperative setting (OR 1.57, 95% CI 1.18 to 2.08; p = 0.002). Patients who developed P-DM were more commonly readmitted within 90 days of surgery and had higher postoperative healthcare expenditures in the year after surgery ($24,440 US dollars vs $16,130 US dollars; both p < 0.001) vs patients without P-DM. CONCLUSIONS: Approximately 1 in 5 Medicare beneficiaries who undergo a pancreatic resection develop P-DM after pancreatic resection. Appropriate screening and improved patient education should be conducted for these patients, in particular, for those with identified risk factors.

The win ratio: A novel approach to define and analyze postoperative composite outcomes to reflect patient and clinician priorities.

BACKGROUND: The "win ratio" (WR) is a novel statistical technique that hierarchically weighs various postoperative outcomes (eg, mortality weighted more than complications) into a composite metric to define an overall benefit or "win." We sought to use the WR to assess the impact of social vulnerability on the likelihood of achieving a "win" after hepatopancreatic surgery. METHODS: Individuals who underwent an elective hepatopancreatic procedure between 2013 and 2017 were identified using the Medicare database, which was merged with the Center for Disease Control and Prevention's Social Vulnerability Index. The win ratio was defined based on a hierarchy of postoperative outcomes: 90-day mortality, perioperative complications, 90-day readmissions, and length of stay. Patients matched based on procedure type, race, sex, age, and Charlson Comorbidity Index score were compared and assessed relative to win ratio. RESULTS: Among 32,557 Medicare beneficiaries who underwent hepatectomy (n = 11,621, 35.7%) or pancreatectomy (n = 20,936, 64.3%), 16,846 (51.7%) patients were male with median age of 72 years (interquartile range 68-77) and median Charlson Comorbidity Index of 3 (interquartile range 2-8), and a small subset of patients were a racial/ethnic minority (n = 3,759, 11.6%). Adverse events associated with lack of a postoperative optimal outcome included 90-day mortality (n = 2,222, 6.8%), postoperative complication (n = 8,029, 24.7%), readmission (n = 6,349, 19.5%), and length of stay (median: 7 days, interquartile range 5-11). Overall, the patients from low Social Vulnerability Index areas were more likely to "win" with a textbook outcome (win ratio 1.07, 95% confidence interval 1.01-1.12) compared with patients from high social vulnerability counties; in contrast, there was no difference in the win ratio among patients living in average versus high Social Vulnerability Index (win ratio 1.04, 95% confidence interval 0.98-1.10). In assessing surgeon volume, patients who had a liver or pancreas procedure performed by a high-volume surgeon had a higher win ratio versus patients who were treated by a low-volume surgeon (win ratio 1.21, 95% confidence interval 1.16-1.25). In contrast, there was no difference in the win ratio (win ratio 1.01, 95% confidence interval 0.97-1.06) among patients relative to teaching hospital status. CONCLUSION: Using a novel statistical approach, the win ratio ranked outcomes to create a composite measure to assess a postoperative "win." The WR demonstrated that social vulnerability was an important driver in explaining disparate postoperative outcomes.

Telehealth Utilization Among Surgical Oncology Patients at a Large Academic Cancer Center.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth within medicine. Data on sociodemographic and clinical characteristics associated with telehealth utilization among cancer surgical patients have not been well-defined. METHODS: Cancer patients who had a surgical oncology visit at the James Cancer Hospital in March 2020-May 2021 were included. Patient demographic and clinical characteristics were recorded; access to modern information technology was measured using the Digital Divide Index (DDI). A logistic regression model was used to assess odds of receiving a telehealth. RESULTS: Among 2942 patients, median DDI was 18.2 (interquartile range 17.4-22.1). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.98 per 10-year increase), sex (male vs. female: OR 1.83, 95% CI 1.45-2.32), cancer type (pancreatic vs. breast: OR 9.19, 95% CI 6.38-13.23; colorectal vs. breast: OR 5.31, 95% CI 3.71-7.58), insurance type (Medicare vs. Medicaid: OR 1.58, 95% CI 1.04-2.41) and county of residence (distant vs. neighboring: OR 1.33, 95% CI 1.06-1.66) were associated with increased odds of receiving a telehealth visit. Patients from high DDI counties were not less likely to receive telehealth visits versus patients from low DDI counties (OR 1.15, 95% CI 0.85-1.57). CONCLUSIONS: Several patient sociodemographic and clinical characteristics had an impact on the likelihood of receiving a telehealth visit versus an in-person visit, suggesting that telehealth may not be equally accessible to all surgical oncology patients.

A novel machine learning approach to identify social risk factors associated with textbook outcomes after surgery.

BACKGROUND: Identifying social determinants of health has become a priority for many researchers, health care providers, and payers. The vast amount of patient and population-level data available on social determinants creates, however, both an opportunity and a challenge as these data can be difficult to synthesize and analyze. METHODS: Medicare beneficiaries who underwent 1 of 4 common operations between 2013 and 2017 were identified. Using a machine learning algorithm, the primary independent variable, surgery social determinants of health index, was derived from 15 common, publicly available social determents of health measures. After development of a surgery social determinants of health index, multivariable logistic regression was used to estimate the association of this index with textbook outcomes, as well as the component metrics of textbook outcomes. RESULTS: A novel surgery social determinants of health index was developed with factor component weights that varied relative to their impact on postoperative outcomes. Factors with the highest weight in the algorithm relative to postoperative outcomes were the proportion of noninstitutionalized civilians with a disability and persons without high school diploma, while components with the lowest weights were the proportion of households with more people than rooms and persons below poverty. Overall, an increase in surgery social determinants of health index was associated with 6% decreased odds (95% confidence interval: 0.93-0.94) of achieving a textbook outcome. In addition, an increase in surgery social determinants of health index was associated with increased odds of each of the individual components of textbook outcome; ranging from 3% increased odds (95% confidence interval: 1.03-1.04) for 90-day readmission to 10% increased odds (95% confidence interval: 1.09-1.11) for 90-day mortality. Further, there was 6% increased odds (95% confidence interval: 1.05-1.07) of experiencing a complication and 7% increased odds (95% confidence interval: 1.06-1.07) of having an extended length of stay. Minority patients from a high surgery social determinants of health index had 38% lower odds (95% confidence interval: 0.60-0.65) of achieving a textbook outcome compared with White/non-Hispanic patients from a low surgery social determinants of health index area. CONCLUSION: Using a machine learning approach, we developed a novel social determents of health index to predict the probability of achieving a textbook outcome after surgery.

Financial Impact of Out-of-Pocket Costs Among Patients Undergoing Resection for Colorectal Carcinoma.

INTRODUCTION: Little is known about the societal burden of cancer surgical care in terms of out-of-pocket (OOP) costs. The current study sought to define OOP costs incurred by patients undergoing colorectal cancer resection. METHODS: Privately insured patients undergoing colorectal cancer resection between 2013 and 2017 were identified from the IBM MarketScan database. Total and OOP costs were calculated within 1 year prior to and 1 year post surgery. A multivariable linear regression model was used to estimate total OOP costs relative to patient demographic and clinical characteristics. RESULTS: Among 10,935 patients, 7289 (66.7%) had primary colon cancer while 3643 (33.3%) had rectal cancer. Median total costs were US$93,967 (IQR US$51027-168,251). Median OOP costs were US$4417 (IQR US$2519-6943), or 4.5% (IQR 2.2-8.1%) of total costs. OOP costs varied over the course of patient care; specifically, median OOP costs in the preoperative period were US$432 (IQR US$130-1452) versus US$2146 (IQR US$851-3525) in the perioperative period and US$969 (IQR US$327-2239) in the postoperative period. On multivariable analysis, receipt of chemotherapy (+US$1368, 95%CI +US$1211 to +US$1525) or radiotherapy (+US$842, 95% CI +US$626 to +US$1059) was associated with higher total OOP costs. Patients with a health maintenance organization (HMO) (-US$2119, 95% CI -US$2550 to -US$1689) or a point-of-service plan (-US$938, 95% CI -US$1385 to -US$491) had lower total OOP costs than patients with comprehensive insurance. In contrast, patients with a consumer-driven or a high-deductible health plan had considerably higher total OOP costs than patients with comprehensive insurance (+US$1400, 95% CI +US$972 to +US$1827 and +US$3243, 95% CI +US$2767 to +US$3717, respectively). CONCLUSIONS: Privately insured colorectal cancer patients undergoing surgical resection pay a median of US$4417 in OOP costs, or 4.5% of total costs. OOP costs varied with receipt of chemotherapy or radiotherapy, region of residence, and insurance plan type.

Fragmentation of practice: The adverse effect of surgeons moving around.

BACKGROUND: Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome. METHOD: Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis. RESULTS: Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05). CONCLUSION: Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Is Hospital Occupancy Rate Associated With Postoperative Outcomes Among Patients Undergoing Hepatopancreatic Surgery?

OBJECTIVE: To define the association between hospital occupancy rate and postoperative outcomes among patients undergoing hepatopancreatic (HP) resection. SUMMARY BACKGROUND DATA: Previous studies have sought to identify hospital-level characteristics associated with optimal surgical outcomes and decreased expenditures. The present study utilized a novel hospital quality metric coined "occupancy rate" based on publicly available data to assess differences in postoperative outcomes among Medicare beneficiaries undergoing HP procedures. METHODS: Medicare beneficiaries who underwent an elective HP surgery between 2013 and 2017 were identified. Occupancy rate was calculated and hospitals were categorized into quartiles. Multivariable logistic regression was utilized to assess the association between occupancy rate and clinical outcomes. RESULTS: Among 33,866 patients, the majority underwent a pancreatic resection (58.5%; n = 19,827), were male (88.4%; n = 7,488), or white (88.4%; n = 29,950); median age was 72 years [interquartile range (IQR): 68-77] and median Charleston Comorbidity Index was 3 (IQR 2-8). Hospitals were categorized into quartiles based on hospital occupancy rate (cutoffs: 48.1%, 59.4%, 68.2%). Most patients underwent an HP operation at a hospital with an above average occupancy rate (n = 20,865, 61.6%), whereas only a small subset of patients had an HP procedure at a low occupancy rate hospital (n = 1,218, 3.6%). On multivariable analysis, low hospital occupancy rate was associated with increased odds of a complication [(OR) 1.35, 95% confidence interval (CI) 1.18-1.55) and 30-day mortality (OR 1.58, 95% CI 1.27-1.97). Even among only high-volume HP hospitals, patients operated on at hospitals that had a low occupancy rate were at markedly higher risk of complications (OR 1.42, 95% CI 1.03-1.97), as well as 30 day morality (OR 2.20, 95% CI 1.27-3.83). CONCLUSIONS: Among Medicare beneficiaries undergoing an elective HP resection, more than 1 in 4 hospitals performing HP surgeries utilized less than half of their beds on average. There was a monotonic relationship between hospital occupancy rate and the odds ofexperiencing a complication, as well as 30-day mortality, independent of other hospital level characteristics including procedural volume.

Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer.

BACKGROUND: Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors. RESULTS: Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively. CONCLUSIONS: Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery.

BACKGROUND: Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery. METHODS: Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined. RESULTS: Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]FPC vs 72 years [interquartile range: 68-77]non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]FPC vs 3 [interquartile range: 2-8]non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]FPC vs 51.3 [interquartile range: 27.9-69.4]non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84). CONCLUSION: Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

The impact of social vulnerability subthemes on postoperative outcomes differs by racial/ethnic minority status.

INTRODUCTION: Social vulnerability is an important driver of disparate surgical outcomes, however the extent to which certain types of vulnerability impact outcomes is poorly understood. METHODS: Medicare beneficiaries 65 years or older who underwent one of four operations were identified. Multivariable mixed-effects logistic regression was used to measure the association of four social vulnerability subthemes from the social vulnerability index (SVI) were assessed relative to the likelihood to achieve a textbook outcome (TO). RESULTS: Among 579,846 Medicare beneficiaries, median age was 74 years and most patients (536,455,92.5%) were White/non-Hispanic. On multivariable analysis, the overall impact of the composite SVI metric on the odds to achieve a postoperative TO was lower among White/non-Hispanic patients (Δ25%ile SVI:OR:0.98,95%CI:0.97-0.98) compared with ethnic/minority patients (Δ25%ile SVI:OR:0.93,95%CI:0.91-0.94). Increasing vulnerability in the subthemes of socioeconomic status (Δ25%ile SVI:ethnic/minority:OR:0.92, 95%CI:0.91-0.94) and household composition (Δ25%ile SVI:ethnic/minority:OR:0.92,95%CI:0.91-0.94) was associated with a greater likelihood not to achieve a TO among minority patients. CONCLUSIONS: Worsening SES and household compositions & disability had a detrimental effect on odds of TO following surgery with the most pronounced effect on non-White minority patients.

Patterns of health care utilization among Medicare beneficiaries diagnosed with pancreatic adenocarcinoma.

BACKGROUND: Care patterns among patients diagnosed with pancreatic adenocarcinoma remain poorly defined. METHODS: Cluster analysis was performed on patients with pancreatic adenocarcinoma to assess time from diagnosis to death spent in different care settings (home self-care-dominant[HSC], acute in-hospital care-dominant[ACS], hospice care-dominant[HC] or mixed home and hospice care[MHH]). RESULTS: Among 32,816 patients, most belonged to the HSC group (n = 13,459, 41%), followed by MHH (n = 9,091, 28%), ACS (n = 5,737, 18%) and HC (n = 4,529, 14%). Only about 1 in 3 patients in the HSC (n = 4,028, 30%) or ACS (n = 2,206, 35%) received hospice services for at least one week before death. 16% of patients (n = 5,188) died in the hospital, which was most common among ACS patients (n = 1,640, 29%). Median daily expenditures varied according to health care utilization (HSC, $44.6, IQR 12.3-130.1 vs MHH, $162.3, IQR 60.5-351.9 vs ACS, $489.7, IQR 243.2-856.8 vs HC, $306.1, IQR 132.3-580.0; p < 0.001). CONCLUSIONS: Pancreatic adenocarcinoma patients differed with regards to health care utilization, hospice use and expenditures following diagnosis.

Trends in Textbook Outcomes over Time: Are Optimal Outcomes Following Complex Gastrointestinal Surgery for Cancer Increasing?

BACKGROUND: The use of composite measures like "textbook outcome" (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer. METHODS: Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time. RESULTS: Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p < 0.001). The proportion of patients achieving a textbook outcome increased over time for all patients (2004-2007, 53.3% vs. 2008-2011, 56.5% vs. 2012-2016, 60.1%) (5-year increase: OR 1.16 95%CI 1.13-1.18) (p < 0.001). Survival at 1-year following pancreatic, liver, or colon resection for cancer had improved over time among both patients who did and did not achieve a postoperative TO. TO was independently associated with a marked reduction in hazard of death (HR 0.44, 95%CI 0.43-0.45). The association of TO and survival was consistent among patients stratified by procedure. CONCLUSION: Less than two-thirds of patients undergoing complex gastrointestinal surgery for a malignant indication achieved a TO. The likelihood of achieving a TO increased over time and was associated with improved survival.

Impact of hospital quality on surgical outcomes in patients with high social vulnerability: Association of textbook outcomes and social vulnerability by hospital quality.

BACKGROUND: We sought to define the impact of high- versus low-quality hospitals on the risk of adverse outcomes among patients undergoing hepatopancreatic surgery relative to social vulnerability. Social vulnerability is an important factor associated with risk of adverse postoperative outcomes. METHODS: Patients from 2013 to 2017 were identified from the Medicare Inpatient Standard Analytic File. Hospital quality was determined by calculating risk-adjusted probability to achieve a textbook outcome. The Social Vulnerability Index was used to categorize patients. Risk-adjusted probability of mortality, morbidity, and textbook outcome was examined across varying social vulnerability indices stratified by low-, average-, and high-quality hospitals. RESULTS: Among 27,000 patients who underwent a pancreatectomy (67%) or hepatectomy (33%%), median patient age was 72 years, 48% were female, and 89% were White; mean Social Vulnerability Index was 49. Risk-adjusted 90-day mortality (odds ratio: 1.32, 95% CI: 1.20-1.59, P = .004) and postoperative complications (odds ratio: 1.12, 95% confidence interval: 1.00-1.24, P = .044) were both higher among beneficiaries from the highest social vulnerability counties versus the lowest counties. At low-quality hospitals, patients from the highest vulnerability counties had 70% higher odds of mortality (odds ratio: 1.70, 95% confidence interval: 1.16-2.48, P = .007), 31% higher odds of overall morbidity odds ratio: 1.31, 95% confidence interval: 1.05-2.63, P = .013), and 19% lower odds of achieving a textbook outcome (odds ratio: 0.81, 95% confidence interval: 0.66-0.99, P = .035)-all of which were markedly worse compared with outcomes achieved at high-quality hospitals. CONCLUSION: Among patients with increased social vulnerability, outcomes were considerably better at high-quality hospitals. Referral of socially vulnerable patients to high-quality hospitals represents an important opportunity to ensure optimal outcomes after complex surgery.

Patient Social Vulnerability and Hospital Community Racial/Ethnic Integration: Do All Patients Undergoing Pancreatectomy Receive the Same Care Across Hospitals?

OBJECTIVE: The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy. BACKGROUND: The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined. METHODS: Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed. RESULTS: Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11). CONCLUSION: Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.

Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery.

BACKGROUND: Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. METHODS: The Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. RESULTS: Among 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194-1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04-6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39-30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11-1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04-1.13), nonelective surgery (HR 1.19, 95%CI 1.14-1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05-1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29-6.61) and non-cancer patients (HR 6.98, 95%CI 6.37-7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08-28.02), as well as non-cancer (HR 30.81, 95%CI 27.01-35.15) patients. CONCLUSIONS: Patients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1-2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.