Disparities in Perioperative Use of Patient Engagement Technologies - Not All Use is Equal.

OBJECTIVE: To determine the association of patient-level characteristics on the use of a patient engagement technology during the perioperative period. SUMMARY OF BACKGROUND DATA: As implementation of patient engagement technologies continues to grow, it remains unclear who uses, and not uses, these technologies. Existing literature suggests significant disparities in usage of other technologies by patient age, race, sex, and geographic location, however, have yet to characterize patient usage of patient engagement technologies. METHODS: This is a retrospective cohort study of patients undergoing elective surgery by a colorectal surgeon between January 2018 and March 2020 who enrolled in a patient engagement technology at a single institution. Patients enrolled received educational content, healthcare reminders, patient reported outcome (PRO) surveys, and health checks preoperatively, in-hospital, and for 30-days postdischarge. The primary outcome was patient activation of the patient engagement technology. Secondary outcomes were completion of at least 1 PRO survey, 1 in-hospital health check, and 1 postdischarge health check. RESULTS: Of 549 patients who enrolled in the patient engagement technology, 473 (86.2%) activated. On multivariable stepwise regression, female patients [odds ratio (OR) 2.4, confidence interval (CI) 1.4-4.0, P = 0.001] and privately insured patients (OR 2.0, CI 1.1-3.8, P = 0.03) were more likely to activate. Black patients were less likely to activate (OR 0.5, CI 0.3-0.9, P = 0.02). Once activated, privately insured patients were more likely to complete PRO surveys (OR 2.3, CI 1.2-4.3, P = 0.01), in-hospital health checks (OR 2.4, CI 1.4-4.1, P = 0.002), and postdischarge health checks (OR 1.9, CI 1.1 -3.3, P < 0.001) than uninsured patients. Black patients were less likely to complete PRO surveys (OR 0.4, CI 0.3-0.7, P = 0.001) and in-hospital health checks (OR 0.6, CI 0.4-0.9, P = 0.03) than White patients. CONCLUSIONS: Use of a patient engagement technology in the perioperative period differs significantly by sex, race/ethnicity, and insurance status. These technologies may not be used equally by all patients, which should be considered during implementation of interventions to improve surgical outcomes.

Disparities in Surgical Timing and Guideline-Adherent Staging Work-Up for Colon Cancer.

BACKGROUND: Expedited or delayed surgery for colon cancer without appropriate work-up increases mortality risk. We sought to identify what patient, social, and hospital factors were associated with timely, guideline-adherent work-up for colon cancer. METHODS: Retrospective analysis of 19,046 patients in the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare administrative claims who underwent elective surgery for colon cancer between 2010 and 2015 was performed. Primary outcome was receipt of complete preoperative work-up (colonoscopy, imaging, tumor marker evaluation) and timely surgery within 60 days of diagnosis. Patients were stratified into four groups: (1) adherent; (2) early surgery (< 30 days) with incomplete work-up; (3) surgery between 30 and 60 days with incomplete work-up; and (4) late surgery (> 60 days) with/without work-up. Characteristics were compared and multinomial logistic regression was performed. RESULTS: Overall, 46.2% of patients received adherent care, 33.1% had early surgery and inadequate work-up, 10.3% had appropriately timed surgery but incomplete work-up, and 10.4% underwent late surgery. Multivariable analysis demonstrated that older, female, Black, and unmarried patients as well as patients living in areas with higher rates of poverty were more likely to receive non-adherent care. A greater proportion of patients at teaching hospitals received complete work-up (57.6% vs. 49.5%) but also underwent late surgery (12.4% vs. 8.6%) compared with non-teaching hospitals. CONCLUSIONS: Patient, societal, and hospital factors impact whether patients receive guideline-adherent colon cancer care. Interventions are needed to improve access to timely and guideline-adherent cancer care as a possible mechanism to combat surgical disparities.

Cost-benefit analysis of a patient engagement technology (PET) in cardiac, thoracic, and colorectal surgery.

BACKGROUND: Patient engagement technologies (PETs) guide patients through perioperative care, but little is known about their costs-benefits. METHODS: Retrospective cohort study of patients undergoing elective colorectal, cardiac, thoracic surgery 2015-2020. PET was implemented 2018. Patients were propensity-matched in pre-PET, PET, non-PET groups. Costs of surgical encounter and 30 days post-discharge, mortality, length-of-stay, readmissions, complications, satisfaction were compared. RESULTS: Overall, 4,373 patients underwent surgery and 607 (13.9%) patients enrolled in the PET. PET patients did not have increased costs in any specialty. Colorectal PET patients' variable costs of surgical encounter were $102 lower than non-PET, $1495 lower than pre-PET (p = 0.03). Thoracic PET patients' total costs of surgical encounter were $9224 lower than non-PET, $2187 lower than pre-PET (p = 0.03). Thoracic PET patients had lower mean LOS (2.4 days, 5.1 non-PET, 3.1 pre-PET, p = 0.03). PET patient satisfaction ranged 86.0%-97.8%. CONCLUSIONS: Use of a PET did not increase costs and was associated with benefits for patients undergoing elective surgery.

The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery.

BACKGROUND: Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system. METHODS: Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs). RESULTS: 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs. CONCLUSIONS: Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.

Implications of Hospital Volume on Costs Following Esophagectomy in the United States.

BACKGROUND: With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy. METHODS: The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality. RESULTS: In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001). CONCLUSIONS: This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.

Racial Disparities After Stoma Construction Exist in Time to Closure After 1 Year but Not in Overall Stoma Reversal Rates.

INTRODUCTION: Conflicting data exist on racial disparities in stoma reversal (SR) rates. Our aim was to investigate the role of race in SR rates, and time to closure, in a longitudinal, racially diverse database. METHODS: All adult patients (>18 years) who received an ileostomy or colostomy from 1999 to 2016 at a single institution were identified. Primary outcomes were SR rates and time to closure. Failure to reverse and time to closure was modeled using Cox regression. Kaplan-Meier survival curves, stratified by race, were generated for time to closure and hazard ratios (HRs) calculated. RESULTS: Of 770 patients with stomas, 65.6% of patients underwent SR; 76.6% were white and 23.4% were black. On adjusted analysis, race did not predict overall SR rates or time to closure if performed less than 1 year. Instead, significant predictors for failure in SR included age, insurance status, end colostomy/ileostomy, and loop colostomy (p < 0.05). Predictors of delay in time to closure included insurance, end colostomy/ileostomy, and loop colostomy (p < 0.05). In patients who underwent reversal after 1 year, black race was an independent predictor of time to closure (HR 0.21, 95% CI 0.07-0.63, p < 0.05). CONCLUSION: SR rates were equal between black and white patients. Disparities in time to closure existed only for black patients if reversed more than 1 year after index stoma construction. While equitable outcomes were achieved for most patients, further investigation is necessary to understand stoma disparities after 1 year.

Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery.

OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on racial disparities in postoperative length of stay (pLOS) after colorectal surgery. BACKGROUND: Racial disparities in surgical outcomes exist. We hypothesized that ERAS would reduce disparities in pLOS between black and white patients. METHODS: Patients undergoing ERAS in 2015 were 1:1 matched by race/ethnicity, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. After stratification by race/ethnicity, expected pLOS was calculated using the American College of Surgeons National Surgical Quality Improvement Project Risk Calculator. Primary outcome was the observed pLOS and observed-to-expected difference in pLOS. Secondary outcomes were National Surgical Quality Improvement Project postoperative complications including 30-day readmissions and mortality. Adjusted sensitivity analyses on pLOS were also performed. RESULTS: Of 420 patients (210 ERAS and 210 pre-ERAS) examined, 28.3% were black. Black and white patients were similar in age, body mass index, sex, American Anesthesia Association class, and minimally invasive approaches. Within the pre-ERAS group, black patients stayed a mean of 2.7 days longer than expected compared with white patients (P < 0.05). Overall, ERAS patients had a significantly shorter pLOS (5.7 vs 8 days) and observed-to-expected difference (-0.7 vs 1.4 days) compared with pre-ERAS patients (P < 0.01). In the ERAS group, disparities in pLOS were reduced with no differences in readmissions or mortality between black and white patients. On sensitivity analyses, race/ethnicity remained a significant predictor of pLOS among pre-ERAS patients, but not for ERAS patients. CONCLUSIONS: ERAS eliminated racial differences in pLOS between black and white patients undergoing colorectal surgery. Reduced pLOS occurred without increases in mortality, readmissions, and most postoperative complications. ERAS may provide a practical approach to reducing disparities in surgical outcomes.

The influence of fellowship training on the practice of pancreatoduodenectomy.

BACKGROUND: There has been a proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches. METHODS: Surveys were distributed to members of GI surgical societies. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD). RESULTS: Surveys were completed by 889 surgeons, 84.1% of whom had completed fellowship training. Fellowship completion was associated with a primarily HPB or surgical oncology-focused practice (p < 0.001), and greater median annual PD volume (p = 0.030). Transplant and HPB fellowship-trained respondents were more likely to have high-volume (≥20) annual practice (p = 0.005 and 0.029, respectively). Regarding putative fistula mitigation strategies, HPB-trained surgeons were more likely to use stents, biologic sealants, and autologous tissue patches (p = 0.007, <0.001 and 0.001, respectively). Surgical oncology trainees reported greater autologous patch use (p = 0.003). HPB fellowship-trained surgeons were less likely to routinely use intraperitoneal drainage (p = 0.036) but more likely to utilize early (POD ≤ 3) drain amylase values to guide removal (p < 0.001). Finally, HPB fellowship-trained surgeons were more likely to use the Fistula Risk Score in their practice (29 vs. 21%, p = 0.008). CONCLUSION: Fellowship training correlated with significant differences in surgeon experience, operative approach, and use of available fistula mitigation strategies for PD.

Modeling the Temporal Evolution of Postoperative Complications.

Post-operative complications have a significant impact on patient morbidity and mortality; these impacts are exacerbated when patients experience multiple complications. However, the task of modeling the temporal sequencing of complications has not been previously addressed. We present an approach based on Markov chain models for characterizing the temporal evolution of post-operative complications represented in the American College of Surgeons National Surgery Quality Improvement Program database. Our work demonstrates that the models have significant predictive value. In particular, an inhomogenous Markov chain model effectively predicts the development of serious complications (coma longer than a day, cardiac arrest, myocardial infarction, septic shock, renal failure, pneumonia) and interventional complications (unplanned re-intubation, longer than 2 days on a ventilator and bleeding transfusion).

Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience.

BACKGROUND: The American Board of Surgery and the American Board of Colorectal Surgery requirements for certification include 80 and 140 colonoscopic procedures, respectively. However, little data support the attainment of colonoscopic competency. The aim of this retrospective study is to report the colonoscopy learning experience for colorectal surgery fellows at a single high-volume training program. MATERIAL AND METHODS: A prospective database recorded the experience of six colorectal fellows over two consecutive academic years. Univariate, moving average curves, and change point analysis were used to assess learning curve trends over time. Screening colonoscopy competency was defined by a significant reduction in total procedure time and 80% cecal intubation rate within 35 min. RESULTS: From 2004 to 2006, a total of 2904 screening colonoscopies were performed, including 1498 (52%) by fellows (mean 249 procedures per fellow). The mean procedure time for fellows was 30.2 ± 15 min. Procedure time decreased significantly up to 120 procedures but not thereafter. Overall, fellows' total procedure time decreased by 7.6 min over the course of the year (P < 0.0001); 66% of fellows were able to complete 80% of the procedure in 40 min in the last 2 mo of training. The combined learning curve of all the fellows and the change point analysis showed a significant change occurs at 94 procedures. Using the moving average curve, we have shown 114 procedures are needed to achieve 80% completion rate in 35 min in majority of the fellows. CONCLUSIONS: Colorectal surgery fellows were observed to achieve screening colonoscopy competency approximately between 94 and 114 procedures. In the era of working time restrictions, prospective documentation of individual trainee performance may allow tailored training based on observed competency.

Mortality by stage for right- versus left-sided colon cancer: analysis of surveillance, epidemiology, and end results--Medicare data.

PURPOSE: Recent studies have reported increased mortality for right-sided colon cancers but had limited adjustment for patient characteristics and conflicting results by stage. We examined the relationship between colon cancer location (right- v left-side) and 5-year mortality by stage. PATIENTS AND METHODS: We identified Medicare beneficiaries from 1992 to 2005 with American Joint Commission on Cancer stages I to III primary adenocarcinoma of the colon who underwent surgery for curative intent through Surveillance, Epidemiology, and End Results (SEER) -Medicare data. Adjusted hazard ratios (HRs) and 95% CIs for predictors of all-cause 5-year mortality were obtained by using Cox proportional hazards regression. RESULTS: Of 53,801 patients, 67% had right-sided colon cancer. Patients with right-sided cancer were more likely to be older, to be women, to be diagnosed with a more advanced stage, and to have more poorly differentiated tumors. Adjusted Cox regression showed no significant difference in mortality between right- and left-sided cancers for all stages combined (HR, 1.01; 95% CI, 0.98 to 1.04; P = .598) or for stage I cancers (HR, 0.95; 95% CI, 0.88 to 1.03; P = .211). Stage II right-sided cancers had lower mortality than left-sided cancers (HR, 0.92; 95% CI, 0.87 to 0.97; P = .001), and stage III right-sided cancers had higher mortality (HR, 1.12; 95% CI, 1.06 to 1.18; P < .001). CONCLUSION: When analysis was adjusted for multiple patient, disease, comorbidity, and treatment variables, no overall difference in 5-year mortality was seen between right- and left-sided colon cancers. However, within stage II disease, right-sided cancers had lower mortality; within stage III, right-sided cancers had higher mortality.

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.