Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes.

Importance: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures: Center volume, changes in cost. Results: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.

Sex Disparities in Academic Productivity and Rank Among Abdominal Transplant Faculty in the United States.

BACKGROUND: The aim of this study was to examine sex differences in academic rank and productivity among members of the American Society of Transplant Surgeons in the United States. METHODS: Cross-sectional, focusing on current board-certified abdominal transplant surgeons in the United States. Demographic factors such as sex, region, and faculty rank were collected from institutional websites. Academic metrics, including H-index, total publications, and relative citation ratio, were collected from Scopus and iCite. RESULTS: We identified 536 surgeon members of the American Society of Transplant Surgeons with an academic institution. The majority were men (83%). Men were in practice longer than women (17.9 ± 11 vs 11.7 ± 9 years, P < .0001) and had higher academic metrics, including H-index (25.6 ± 20 vs16.4 ± 14, P < .0001) and total publications (110 ± 145 vs 58.8 ± 69, P < .0001). There was a significant difference in faculty appointments by sex (P < .05), with men showing evidence of increased academic advancement. After adjusting for academic rank, PhD status, and location of medical school and residency, women remained associated with a lower H-index on multivariate analysis (P < .01). CONCLUSION: Sex disparities in academic rank and achievement are present among transplant surgical faculty in the United States, and future efforts are needed to promote sex equity in transplant surgery academia.

Biophysiological stress and sleep deprivation among abdominal transplant surgery fellows: A prospective multi-institutional study using a wearable device.

BACKGROUND: Transplant surgery fellowship is physically and emotionally demanding. The objective of this study was to characterize biophysiological stress and sleep patterns among transplant surgery fellows. METHODS: Participating fellows wore a biophysical monitor over a 28-day period and completed biweekly surveys. Sleep patterns were dichotomized as normal or sleep deprived, and heart rate variability (HRV) was used to assess stress. RESULTS: Seventeen fellows participated. Fellows were frequently sleep deprived (43.9% of nights) and stress was near universal (87.2% of days). Burnout was reported by 2 fellows (11.8%). Only 4 fellows (23.5%) reported compliance with the Transplant Accreditation and Certification Council managed time policy; these fellows experienced fewer days of stress than non-compliant fellows (79.8% vs 89.2% p = 0.02). CONCLUSIONS: This is the first study to quantify sleep deprivation and stress among transplant fellows. Future work is needed to evaluate the effects of sleep deprivation, and stress on burnout and patient outcomes.

The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation.

OBJECTIVES: To develop a scalable metric which quantifies kidney transplant (KT) centers' performance providing equitable access to KT for minority patients, based on the individualized prelisting prevalence of end-stage renal disease (ESRD). BACKGROUND: Racial and ethnic disparities for access to transplant in patients with ESRD are well described; however, variation in care among KT centers remains unknown. Furthermore, no mechanism exists that quantifies how well a KT center provides equitable access to KT for minority patients with ESRD. METHODS: From 2013 to 2018, custom datasets from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESRD in each center's health service area. Markers of socioeconomic status and recipient outcomes were compared between high and low KTEI centers. RESULTS: A total of 249 transplant centers performed 111,959 KTs relative to 475,914 nontransplanted patients with ESRD. High KTEI centers performed more KTs for Black (105.5 vs 24, P <0.001), Hispanic (55.5 vs 7, P <0.001), and American Indian (1.0 vs 0.0, P <0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs 44, P <0.001), worse social deprivation (53 vs 46, P <0.001), and lower educational attainment (52 vs 43, P <0.001). While providing increased access to transplant for minority and low socioeconomic status populations, high KTEI centers had improved patient survival (hazard ratio: 0.86, 95% confidence interval: 0.77-0.95). CONCLUSIONS: The KTEI is the first metric to quantify minority access to KT incorporating the prelisting ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic patients with ESRD.

A National Assessment of T2 Staging for Intrahepatic Cholangiocarcinoma and the Poor Prognosis Associated with Multifocality.

BACKGROUND: T2 intrahepatic cholangiocarcinoma (ICC) is defined as a solitary tumors with vascular invasion or multifocal tumors including satellite lesions, multiple lesions, and intrahepatic metastases. This study aimed to evaluate the prognosis associated with multifocal tumors. METHODS: The National Cancer Database was queried from 2004 to 2017 for patients with non-metastatic ICC. The patients were grouped based on T2 staging, multifocality, and lymph node involvement. RESULTS: The study enrolled and classified 4887 patients into clinical (c) stage groups as follows: 15.2% with solitary T2N0 (sT2N0) tumors, 21.3% with multifocal T2N0 (mT2N0) tumors, and 63.5% with node-positive (TxN1) disease. Patients with (c)sT2N0 tumors had higher rates of surgical resection than those with (c)mT2N0 or (c)TxN1 disease (33.5% vs 19.7% vs 15.0%; p < 0.01). Median overall survival (OS) was better for the patients with (c)sT2N0 tumors than for those with multifocal and node-positive disease (15.4 vs 10.4 vs 10.4 months; p < 0.01). On multivariate analysis, (c)sT2N0 tumors were associated with better OS than (c)mT2N0 tumors [hazard ratio (HR), 1.31; 95% confidence interval (CI), 1.17-1.46; p < 0.01] or (c)TxN1 disease (HR,1.41; 95% CI 1.28-1.56; p < 0.01). In a subset analysis based on pathologic (p) staging of patients who underwent surgical resection with regional lymphadenectomy, multivariate analysis demonstrated that (p)sT2N0 tumors were associated with better OS than (p)mT2N0 tumors (HR,1.40; 95% CI 1.03-1.92; p = 0.03) or (p)TxN1 disease (HR, 2.05; 95% CI 1.62-2.58; p < 0.01). CONCLUSIONS: Multifocal T2N0 ICC is associated with poor OS and has a disparate prognosis compared with solitary T2N0 disease, even among patients who undergo resection. Future staging criteria should account for the poor outcomes associated with multifocal ICC.

Cost-Effectiveness of Utilization of Hepatitis B Virus-Positive Liver Donors for HBV-Negative Transplant Recipients.

BACKGROUND: Utilization of hepatitis B virus (HBV)-infected donors represents an opportunity to expand the liver transplantation (LT) donor pool. However, benefits of accepting HBV-positive donors for HBV-negative candidates, potentially expanding the donor pool resulting in earlier transplantation, must be balanced with costs of lifelong antiviral therapy. The aim of this study was to evaluate cost-effectiveness of this strategy. METHODS: We developed a Markov model with two strategies, transplant with (1) a HBV-positive donor versus and (2) a HBV-negative donor for a HBV-negative LT candidate. A healthcare system perspective was utilized, effectiveness measured in quality-adjusted life-years, and costs in 2018 USD. RESULTS: In the base-case, the HBV-positive donor strategy is more effective (gain of 0.46 QALYs), but $26,159 more expensive, yielding an incremental cost-effectiveness ratio (ICER) of $57,389/QALY. However, increasing the candidate's Model for End-Stage Liver Disease score resulted in increasing cost-effectiveness, ICER of $69,507/QALY (MELD 6-10) to $47,385/QALY (MELD > 30). Results were most sensitive to antiviral cost and cost after first year of LT. In probabilistic sensitivity analysis, the HBV-positive strategy was always more effective but more expensive, with average ICER of $64,883/QALY. This strategy was highly cost-effective (ICER < $50,000/QALY) 21% of the time and cost < $100/000/QALY 94% of the time. CONCLUSIONS: Consideration of these donors must be individualized to each candidate's severity of liver disease, associated costs, and personal preferences that impact quality of life. Expansion of the donor pool to include HBV-positive donors for appropriate recipients may be a cost-effective policy and may provide significant benefit for individual patients.

Perioperative thrombelastography serves as an important assessment tool of transfusion requirements during liver transplantation.

BACKGROUND: Thrombelastography has become increasingly used in liver transplantation. The implications of thrombelastography at various stages of liver transplantation, however, remain poorly understood. Our goal was to examine thrombelastography-based coagulopathy profiles in liver transplantation and determine whether preoperative thrombelastography is predictive of transfusion requirements perioperatively. METHODS: A retrospective review of 364 liver transplantations from January 2013 to May 2017 at a single institution was performed. Patients were categorized as hypocoagulable or nonhypocoagulable based on their preoperative thrombelastography profile. The primary outcome was intraoperative transfusion requirements. RESULTS: Of patients undergoing liver transplantation, 47% (n = 170) were hypocoagulable and 53% (n = 194) were nonhypocoagulable preoperatively. Hypocoagulable patients had higher transfusion requirements compared to nonhypocoagulable patients, requiring more units of packed red blood cells (7 vs 4, P < .01), fresh frozen plasma (14 vs 8, P < .01), cryoprecipitate (2 vs 1, P < .01), platelets (3 vs 2, P < .01), and cell saver (3 vs 2 L, P < .01). Additionally, these patients were more likely to receive platelets and cryoprecipitate in the first 24 hours following liver transplantation (both P < .05). No differences were found between rates of intensive care unit length of stay, 30-day readmission, or mortality. CONCLUSION: Coagulation abnormalities are common among liver transplantation patients and can be identified using thrombelastography. Identification of a patient's coagulation state preoperatively aids in guiding transfusion during liver transplantation. This work serves to better direct clinicians during major surgery to improve perioperative resource utilization. Future prospective work should aim to identify specific thrombelastography values that may predict transfusion requirements.

The impact of opioid use on human and health care costs in surgical patients.

BACKGROUND: Preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear. METHODS: A single-center retrospective analysis was performed on surgical patients admitted with intestinal obstruction (2010-2014). Patients were grouped into active opioid and nonopioid user cohorts. Active opioid use was defined as having an opioid prescription overlapping the date of admission. Chronic opioid use was defined by duration of use ≥ 90 days. Admission or intervention due to opioid-related illness was determined through consensus decision of 2 independent, blinded clinicians. Primary end point was the effect of active opioid use on hospital resource utilization. RESULTS: During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 55 (18.6%) of these patients, with a median length of opioid use of 164 days (interquartile range 54-344 days). Average length of use was 164 days, with the majority of active users (n = 42, 76.4%) meeting criteria for chronic use. A subgroup analysis of active users demonstrated that opioid-related conditions were responsible for 10 admissions (18.2%) and 2 readmissions (3.6%). Among active users requiring surgical intervention, 3 procedures (21.4%) were due to opioid-related illnesses. Median hospital length of stay was 2 days longer (8 vs 6 days) and hospital costs were greater ($12,241 vs $8489) among active users (P < .05 each). CONCLUSION: Active opioid users are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and health care spending.

The road to academic surgical leadership: Characteristics and experiences of surgical chairpersons.

BACKGROUND: The evolving landscape of academic surgery demands leaders who are not only effective clinicians and researchers, but also administrators able to navigate complex hospital organizations, financial pressures in the era of quality measures, and inclusion of an increasingly diverse workforce. The aim of this study was to characterize achievements and assess perspectives in becoming a surgical chair in order to guide young surgeons in their career trajectories to surgical leadership. METHODS: A survey encompassing demographics, surgical training, nonmedical advanced degrees, academic advancement, and leadership experiences was sent via electronic mail to members of the American College of Surgeons Society of Surgical Chairs in December 2018. RESULTS: Of 191 Society of Surgical Chairs members, 52 (27.2%) completed the survey, with 6 (11.5%) women, 40 (76.9%) white, and the majority becoming chair between ages 46 and 60 (n = 39, 75.0%). Training beyond residency included fellowships (n = 41, 78.8%) and advanced nonmedical degrees (n = 15, 28.8%). Median H-index was 47 (range 10-120) with 126 (5-500) research publications, and grants received was 2 (0-38) for federal and 5 (0-43) for industry. Female chairs appear to have fewer nonmedical degrees (n = 1) and no difference in age at becoming chair (66.7% vs 79.6% between ages 46 and 60), H-index (26 [10-41] vs 49 [17-120]), or publications (93 [10-189] vs 150 [5,500]). Prior educational (n = 36, 69.2%) and clinical (n = 44, 84.6%) leadership roles were common, with 30 chairs (57.7%) having held both roles. Experiences which respondents felt have most helped them function as chair included serving as a clinical division director (n = 37, 71.2%), residency program director (n = 28, 53.8%), leadership courses (n = 28, 53.8%), a research career (n = 22, 42.3%), and being a vice/interim chair (n = 15, 28.8%). Personal traits felt to be most important in becoming a successful chair included being effective at communication (n = 37, 71.2%), collaborative (n = 35, 67.3%), trustworthy (n = 30, 57.7%), and a problem-solver (n = 27, 51.9%). CONCLUSION: Becoming a department surgical chair often involves not only surgical subspecialty expertise, but also nonmedical training and prior leadership roles, which help facilitate development of skills integral to navigating the collaborative and diverse nature of academic surgery in the current era.

Variability in blood transfusions after pancreaticoduodenectomy: A national analysis of the University HealthSystem Consortium.

BACKGROUND: Variability in blood use after pancreaticoduodenectomy and the associated impact on readmission, mortality, and cost is not well understood at the national level. METHODS: The University HealthSystem Consortium database was queried for all pancreaticoduodenectomies performed between the years 2011-2013 (n = 9,582). Patients were grouped according to transfusion requirements into none (0 units, 64%), low (1-2 units, 15%), medium (3-5 units, 13%), and high (>5 units, 8%). Multivariable analyses were used to determine predictors of increased transfusions, readmission, in-hospital mortality, and cost. RESULTS: Of the patients undergoing pancreaticoduodenectomy, 36% received blood perioperatively. Patients with high transfusion requirements were less often white, more often male, and had a higher severity of illness (all P < .01). High transfusion requirements correlated with higher readmission rates (OR 1.23, P = .03), cost (RR 1.84, P < .01), length of stay (18 vs. 13 vs. 10 vs. 8 days, P < .01), and in-hospital mortality (12.5% vs. 3.1% vs. 0.5% vs. 0.4%, P < .01). Higher-volume surgeons demonstrated lower transfusion requirements (OR 0.61, P < .01). CONCLUSION: Significant variability exists nationally in transfusion practices for patients undergoing pancreaticoduodenectomy, which may be driven most by severity of illness and surgeon volume. Efforts to reduce such variability could lead to improved outcomes and healthcare cost savings.

The Importance of Safety-Net Hospitals in Emergency General Surgery.

INTRODUCTION: Safety-net hospitals provide care to an inherently underprivileged patient population. These hospitals have previously been shown to have inferior surgical outcomes after complex, elective procedures, but little is known about how hospital payer-mix correlates with outcomes after more common, emergent operations. METHODS: The University HealthSystem Consortium database was queried for all emergency general surgery procedures performed from 2009 to 2015. Emergency general surgery was defined as the seven operative procedures recently identified as contributing most to the national burden. Only urgent and emergent admissions were included (n = 653,305). Procedure-specific cohorts were created and hospitals were grouped according to safety-net burden. Multivariate analyses were done to study the effect of safety-net burden on hospital outcomes. RESULTS: For all seven emergency procedures, patients at hospitals with a high safety-net burden were more likely to be young and black (p < 0.01 each). Patients at high-burden hospitals had similar severity of illness scores to those at other hospitals. Compared with lower burden hospitals, in-hospital mortality rates at high-burden hospitals were similar or lower in five of seven procedures (p = NS or < 0.01, respectively). After adjusting for patient factors, high-burden hospitals had similar or lower odds of readmission in six of seven procedures, hospital length of stay in four of seven procedures, and cost of care in three of seven procedures (p = NS or < 0.01, respectively). CONCLUSION: Safety-net hospitals provide emergency general surgery services without compromising patient outcomes or incurring greater healthcare resources. These data may help inform the vital role these institutions play in the healthcare of vulnerable patients in the USA.

Impact of Preoperative Opioid Use After Emergency General Surgery.

BACKGROUND: Preoperative exposure to narcotics has recently been associated with poor outcomes after elective major surgery, but little is known as to how preoperative opioid use impacts outcomes after common, emergency general surgical procedures (EGS). METHODS: A high-volume, single-center analysis was performed on patients who underwent EGS from 2012 to 2013. EGS was defined as the seven emergent operations that account for 80% of the national burden. Preoperative opioid use was defined as having an active opioid prescription within 7 days prior to surgery. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days after discharge. RESULTS: A total of 377 patients underwent EGS during the study period. Preoperative opioid use was present in 84 patients (22.3%). Preoperative opioid users had longer hospital LOS (10.5 vs 6 days), higher costs of care ($25,331 vs $11,454), and higher 30-day readmission rates (22.6 vs 8.2%) compared with opioid-naïve patients (p < 0.001 each). After covariate adjustment, preoperative opioid use was predictive of LOS (RR 1.19 [1.01-1.41]) and 30-day hospital readmission (OR 2.69 [1.25-5.75]) (p < 0.05 each). Total direct cost was not different after modeling. Preoperative opioid users required more narcotic refills compared with opioid-naïve patients (5 vs 0 refills, p < 0.001). After discharge, 15.4% of opioid-naïve patients met criteria for chronic opioid use, vs 77.4% in preoperative opioid users (p < 0.001). CONCLUSIONS: Preoperative opioid use is associated with greater resource utilization after emergency general surgery, as well as vastly different postoperative opioid prescription patterns. These findings may help to inform the impact of preoperative opioid use on patient care, and its implications on hospital and societal cost.

Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals.

BACKGROUND: Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS: The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS: Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION: For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.

Cost of achieving equivalent outcomes in sicker patients after liver transplant.

BACKGROUND: We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS: Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS: Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION: Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.

Surviving rectal cancer: examination of racial disparities surrounding access to care.

BACKGROUND: The aim of this study was to evaluate whether survival differences are attributable to disproportionate access to stage-specific rectal cancer treatment recommended by the National Comprehensive Care Network. METHODS: A retrospective analysis of the National Cancer Data Base between 1998 and 2006 was performed. A series of Kaplan-Meier survival analyses were used to compare 5-y survival among race cohorts. Propensity score matching was used to compare Caucasian and African American patients who received the same treatment by accounting for covariates. RESULTS: 5-y overall survival in African Americans was 50.7% versus 56.2% in Caucasians (P < 0.001). In patients with stage I-III disease, 5-y survival was 58.7% in African Americans versus 63.1% in Caucasians (P < 0.001). Analysis of patients receiving surgery for stage I-III disease, revealed a 61.1% 5-y survival in African Americans versus 65.8% in Caucasians (P < 0.001). Propensity score matching did not eliminate the racial disparity. The median survival for Caucasian patients was 109.6 mo as compared to 85.8 mo for African Americans (P < 0.001). CONCLUSIONS: These data show that access to standard care appears to decrease but not eliminate the survival differences between African Americans and Caucasians with rectal cancer.

Opportunities to Improve Care of Hepatocellular Carcinoma in Vulnerable Patient Populations.

BACKGROUND: Hepatocellular carcinoma (HCC) patients with Medicaid or no health insurance have inferior survival compared with privately insured patients. Safety-net hospitals that care for these patients are often criticized for their inferior outcomes. We hypothesized that HCC survival was related to appropriate surgical management. STUDY DESIGN: The American College of Surgeons National Cancer Database was queried for patients diagnosed with HCC (n = 111,481) from 1998 to 2010. Hospitals were stratified according to safety-net burden, defined as the percentage of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared with lower-burden hospitals with regard to patient demographics, cancer presentation, surgical management, and survival. RESULTS: Patients at safety-net hospitals were less often white, had less income and education, but presented with similar stage HCC. Safety-net hospital patients were less likely to receive surgery (odds ratio 0.77; p < 0.01), and among curable patients (stages 1 and 2) who underwent surgical intervention, liver transplantation and resection were performed less often at safety-net hospitals than at other hospitals (50.7% vs 66.7%). Procedure-specific mortality rates were also higher at safety net hospitals (p < 0.01). However, multivariate analysis adjusting for cancer stage and type of surgery revealed similar survival for safety-net hospital patients who had surgery and survived for longer than 30 days (p = 0.73). CONCLUSIONS: Vulnerable patients with HCC are commonly treated at safety-net hospitals, are less likely to receive curative surgery, and have worse short-term outcomes. However, safety-net patients who can endure liver surgery have a similar prognosis as patients at nonsafety-net hospitals. Providing equal access to surgery may improve survival for vulnerable populations of HCC patients.

Case mix-adjusted cost of colectomy at low-, middle-, and high-volume academic centers.

BACKGROUND: Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. METHODS: All patients undergoing colectomy (n = 90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. RESULTS: Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P < .01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P < .01). CONCLUSION: Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers.