Association Between Racial and Socioeconomic Disparities and Hospital Performance in Treatment and Outcomes for Patients with Colon Cancer.

BACKGROUND: Disparities in colon cancer care and outcomes by race/ethnicity, socioeconomic status (SES), and insurance are well recognized; however, the extent to which inequalities are driven by patient factors versus variation in hospital performance remains unclear. We sought to compare disparities in care delivery and outcomes at low- and high-performing hospitals. METHODS: We identified patients with stage I-III colon adenocarcinoma from the 2012-2017 National Cancer Database. Adequate lymphadenectomy and timely adjuvant chemotherapy administration defined hospital performance. Multilevel regression models evaluated disparities by race/ethnicity, SES, and insurance at the lowest- and highest-performance quartile hospitals. RESULTS: Of 92,573 patients from 704 hospitals, 45,982 (49.7%) were treated at 404 low-performing hospitals and 46,591 (50.3%) were treated at 300 high-performing hospitals. Low-performing hospitals treated more non-Hispanic (NH) Black, Hispanic, low SES, and Medicaid patients (all p < 0.01). Among low-performing hospitals, patients with low versus high SES (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82-0.92), and Medicare (OR 0.90, 95% CI 0.85-0.96) and Medicaid (OR 0.88, 95% CI 0.80-0.96) versus private insurance, had decreased odds of receiving high-quality care. At high-performing hospitals, NH Black versus NH White patients (OR 0.83, 95% CI 0.72-0.95) had decreased odds of receiving high-quality care. Low SES, Medicare, Medicaid, and uninsured patients had worse overall survival at low- and high-performing hospitals (all p < 0.01). CONCLUSION: Disparities in receipt of high-quality colon cancer care occurred by SES and insurance at low-performing hospitals, and by race at high-performing hospitals. However, survival disparities by SES and insurance exist irrespective of hospital performance. Future steps include improving low-performing hospitals and identifying mechanisms affecting survival disparities.

Evaluation of emergency department treat-and-release encounters after major gastrointestinal surgery.

BACKGROUND AND OBJECTIVES: Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. METHODS: Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. RESULTS: Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. CONCLUSIONS: ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.

National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection.

INTRODUCTION: Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications. METHODS: Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation. RESULTS: Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3 d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4 d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1 d to 8.5% for LOS ≥5 d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P < 0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P = 0.070). CONCLUSIONS: Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.

Initial Assessment of the Effect of ProvenCare on Lung Cancer Surgical Quality.

BACKGROUND: ProvenCare is a joint initiative of the American College of Surgeons Commission on Cancer, Geisinger, and The Society of Thoracic Surgeons (STS) to standardize evidence-based practices in the delivery of surgical lung cancer care. This study compares outcomes of ProvenCare patients with the STS Database. METHODS: Best practice elements were agreed on through expert consensus meetings. ProvenCare elements were used to direct care. Compliance was monitored while clinical outcomes were collected within the STS General Thoracic Surgery Database (GTSD). ProvenCare patient outcomes were compared with outcomes in all other STS GTSD patients. Univariable and multivariable logistic regression models compared morbidity and mortality. RESULTS: A total of 2026 patients at 23 ProvenCare hospitals were compared with 71 565 control patients at 311 hospitals from 2010 to 2016. ProvenCare patients were more likely to receive guideline-recommended staging evaluations and more likely to have mediastinal staging performed during resection (63.4% vs 49.4%; P < .001). There was no difference in 30-day mortality (1.4% vs 1.3% lobectomy [P = .84]; 3.4% vs 2.0% all other resections [P = .054]) or STS indicator complications (10.8% vs 9.9% lobectomy [P = .21]; 9.2% vs 9.4% all other resections [P = .92]). When controlling for patient-level clinical and demographic risk factors, the likelihood of perioperative morbidity and mortality was not significantly different (odds ratio [OR], 1.07 [95% CI, 0.77-1.47] lobectomy; OR, 0.97 [95% CI, 0.62-1.50] all other resections). CONCLUSIONS: Variability in preoperative evaluation of patients with lung cancer represents an opportunity to improve quality of care. ProvenCare increased use of guideline-recommended preoperative processes, which may improve cancer outcomes and survival, without resulting in differences in short-term surgical outcomes.

Entrustable Professional Activity-Based Summative Performance Assessment in the Surgery Clerkship.

OBJECTIVE: The objectives of this study were to 1) assess the performance Entrustable Professional Activities (EPAs) when integrated into the summative assessment of third-year medical students on the surgery clerkship and 2) to compare EPAs to traditional clinical performance assessment tools. DESIGN: EPA assessments were collected prospectively from a minimum of 4 evaluators at the completion of each surgical clerkship rotation from November 2019 to June 2019. Overall EPA-based clinical performance scores were calculated as the sum of the mean EPA score from each evaluator. A rating of overall clinical performance called the clinical performance appraisal (CPA) was also collected. EPA ratings were compared to the CPA score, National Board of Medical Examiners exam score, objective structured clinical exam scores, and final clerkship grade. SETTING: Northwestern Memorial Hospital, a tertiary care teaching institution in Chicago, IL. RESULTS: Overall, 446 evaluations (111 students) were included in the analysis. The aggregate EPA scores ranged from 11.6-24.0 (mean 19.9 ± 2.0), and the CPA scores ranged from 4.4-9.0 (mean 7.6 ± 0.7). The variance among learners in EPA scores was significantly higher than CPA scores (p < 0.001). The aggregate EPA scores correlated well with CPA scores (Spearman's rho 0.803) but had lesser, positive correlations with the objective structured clinical exam (rho 0.153) and National Board of Medical Examiners (rho 0.265) scores. When all EPA scores were included in ordinal logistic regression, only EPA 6, oral presentation of patients, was independently associated with students' final grades (OR: 10.05, 95%CI 1.41-71.80; p = 0.02). CONCLUSION: Integration of EPAs for use in clinical performance assessment of medical students is feasible within a surgery clerkship. Compared to a global clinical performance assessment, EPA-based assessment provided better discrimination of clinical performance among learners. Use of EPAs may better identify advanced learners and those that need additional time.

The SHARED Project: A Novel Approach to Engaging African American Men to Address Lung Cancer Disparities.

Black men are disproportionately impacted by lung cancer morbidity and mortality. Low-dose helical computed tomography (LDCT) lung cancer screening has demonstrated benefits for reducing lung cancer deaths by identifying cancers at earlier, more treatable stages. Despite the known benefits, LDCT screening is underutilized in black men. Studies in racially heterogeneous populations have found correlations between screening behaviors and factors such as physician trust, physician referral, and a desire to reduce the uncertainty of not knowing if they had lung cancer; yet little is known about the factors that specifically contribute to screening behaviors in black men. Community engagement strategies are beneficial for understanding barriers to health-care engagement. One community engagement approach is the citizen scientist model. Citizen scientists are lay people who are trained in research methods; they have proven valuable in increasing communities' knowledge of the importance of healthy behaviors such as screening, awareness of research, building trust in research, and improving study design and ethics. This paper proposes an intervention, grounded in community-based participatory research approaches and social network theory, to engage black men as citizen scientists in an effort to increase lung cancer screening in black men. This mixed-methods intervention will examine the attitudes, behaviors, and beliefs of black men related to uptake of evidence-based lung cancer screening.

COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy.

BACKGROUND: We compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy. METHODS: This is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches. RESULTS: Open approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups. CONCLUSION: Minimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

BACKGROUND: Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy. METHODS: Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression. RESULTS: A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers. CONCLUSIONS AND RELEVANCE: Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.

Nationwide Assessment of Robotic Lobectomy for Non-Small Cell Lung Cancer.

BACKGROUND: Robotic lobectomy has been described for non-small cell lung cancer (NSCLC). Our objectives were to (1) evaluate the use of robotic lobectomy over time, (2) identify factors associated with its use, and (3) assess outcomes after robotic lobectomy compared with other surgical approaches. METHODS: Stage I to IIIA NSCLC patients were identified from the National Cancer Data Base (2010 to 2012). Trends in robotic lobectomy were assessed over time, and multivariable logistic regression models were developed to identify factors associated with its use. Propensity-matched cohorts were constructed to compare postoperative outcomes after robotic lobectomy with thoracoscopic and open lobectomy. RESULTS: Lobectomy was performed in 62,206 patients by open (n = 45,527), thoracoscopic (n = 12,990), or robotic (n = 3,689) procedures at 1,215 hospitals. Between 2010 and 2012, robotic lobectomy significantly increased, from 3.0% to 9.1% (p < 0.001). Academic (odds ratio, 1.55; 95% confidence interval, 1.04 to 2.33) and high-volume hospitals (odds ratio, 1.49; 95% confidence interval, 1.04 to 2.14) were associated with increased use of robotic lobectomy. Length of stay was shorter in robotic lobectomy compared with open lobectomy (6.1 vs 6.9 days; p < 0.001). Fewer lymph nodes (9.9 vs 10.9; p < 0.001) and 12 or more nodes were examined less frequently (32.0% vs 35.6%; p = 0.005) in robotic resections than in thoracoscopic resections. There was no difference between robotic and open or robotic and thoracoscopic lobectomy patients in margin positivity, 30-day readmission, and deaths at 30 and 90 days. CONCLUSIONS: Robotic lobectomies have significantly increased in stage I to IIIA NSCLC patients, with outcomes similar to other approaches. Additional studies are needed to determine if this technology offers potential advantages compared with video-assisted thoracoscopic operations.

A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014.

BACKGROUND: During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents' career paths, training, and perceptions changed during this period. METHODS: The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors' Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. RESULTS: During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p = 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p = 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). CONCLUSIONS: With the evolution in CTS over the last decade, residents' training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.

Health care and socioeconomic impact of falls in the elderly.

BACKGROUND: Elderly falls are associated with long hospital stays, major morbidity, and mortality. We sought to examine the fate of patients ≥75 years of age admitted after falls. METHODS: We reviewed all fall admissions in 2008. Causes, comorbidities, injuries, procedures, mortality, readmission, and costs were analyzed. RESULTS: Seven hundred eight patients ≥75 years old were admitted after a fall, with 89% being simple falls. Short-term mortality was 6%. Male sex, atrial fibrillation, acute myocardial infarction, congestive heart failure (CHF), intracranial hemorrhage, hospital-acquired pneumonia, trigger events, Clostridium difficile, and intubation were predictors of death (P < .05). Thirty-day readmission occurred in 14%; CHF, craniotomy, and acute renal failure were predictive. The median cost of hospitalization was $11,000 with cardiac disease, anemia, major orthopedic and neurosurgical procedures, pneumonia, and intubation as predictive. CONCLUSIONS: Simple falls in the elderly have high morbidity, mortality, and costs. Methodologies for prevention are warranted and should be studied intensively.

Assessment of left ventricular global and segmental systolic function with transesophageal echocardiography.

The evaluation of LV global and segmental systolic function is a primary application for perioperative TEE. Although the practical techniques customarily used for these applications have limitations, they afford direct measures of function not otherwise available to the clinician in the operating room or intensive care setting.