Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region.

BACKGROUND: Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE: This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN: This study was a retrospective, descriptive, and ecological study. SETTINGS: This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS: All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES: The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS: Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS: This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION: This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY: ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use.

INTRODUCTION: Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS: National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS: One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS: We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.

Surgical Site Infections in Colorectal Resections: What is the Cost?

INTRODUCTION: Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives. METHODS: Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC). RESULTS: Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI. CONCLUSIONS: SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.

Impact of Race and Ethnicity on Perioperative Outcomes During Hysterectomy for Endometriosis.

STUDY OBJECTIVE: To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals. PATIENTS: Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis. INTERVENTIONS: Compare perioperative complications based on patient race and ethnicity. MEASUREMENTS AND MAIN RESULTS: A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) compared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45). CONCLUSION: Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications.

Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky.

BACKGROUND: Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-d delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky. METHODS: The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of the last colonoscopy and the first specialist visit were identified through the claims. Bivariate and logistic regression analysis was performed to identify factors associated with delay to CRC specialist visit. RESULTS: A total of 3927 patients from 100 hospitals in Kentucky were included. Approximately, 19% of patients with CRC visited a specialist more than 14 d after CRC detection on colonoscopy. Delay to specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, P < 0.0001), low and moderate education level (OR 1.4 and 1.3, respectively, P = 0.0127), and stage I CRC (OR 1.5, P < 0.0001). There was a higher percentage of delay to specialist among Medicaid patients (44.0%) than Medicare (18.0%) and privately insured patients (18.8%). CONCLUSIONS: We identified Medicaid insurance, low education attainment, and early stage CRC diagnosis as independent risk factors associated with 14-d delay in seeking specialist care after CRC detection on colonoscopy.

Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery.

BACKGROUND: Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution. METHODS: This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher's exact tests, and continuous variables were compared using Mann-Whitney U tests. RESULTS: A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis. CONCLUSION: Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.

A Retrospective Review: Patient-Reported Preoperative Prescription Opioid, Sedative, or Antidepressant Use Is Associated with Worse Outcomes in Colorectal Surgery.

BACKGROUND: Prescription opioid, sedative, and antidepressant use has been on the rise. The effect of these medications on outcomes in colorectal surgery has not been established. OBJECTIVE: This study aimed to evaluate the impact of preoperative prescription opioid, sedative, and antidepressant use on postoperative outcomes following colorectal surgery. DESIGN: This study was a retrospective database and medical record review. SETTINGS: This study was conducted at University of Kentucky utilizing the local American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS: All patients ≥18 years of age who underwent colorectal resection for all indications, excluding trauma, between January 1, 2013, and December 31, 2016, were included. MAIN OUTCOME MEASURES: The primary outcomes measured were the rates of 30-day postoperative morbidity and mortality. RESULTS: Of 1201 patients, 30.2% used opioids, 18.4% used sedatives, and 28.3% used antidepressants preoperatively. Users of any medication class had higher ASA classification, rates of dyspnea, and severe chronic obstructive pulmonary disease than nonusers. Opioid users also had higher rates of ostomy creation, contaminated wound classification, prolonged operation time, and postoperative transfusion. Postoperatively, patients had higher rates of intra-abdominal infection (opioids: 21.5% vs 15.2%, p = 0.009; sedatives: 23.1% vs 15.7%, p = 0.01; antidepressants: 22.4% vs 15.0%, p = 0.003) and respiratory failure (opioids: 11.0% vs 6.3%, p = 0.007; sedatives: 12.2% vs 6.7%, p = 0.008; antidepressants: 10.9% vs 6.5%, p = 0.02). Reported opioid or sedative users had a prolonged hospital length of stay of 2 days (p < 0.001) compared with nonusers. After adjustment for all predictors of poor outcome, opioid and sedative use was associated with increased 30-day morbidity and mortality following colorectal procedures (OR, 1.43; 95% CI, 1.07-1.91 and OR, 1.48; 95% CI, 1.05-2.08). LIMITATIONS: This study was a retrospective review and a single-institution study, and it had unmeasured confounders. CONCLUSIONS: We identified that patient-reported prescription opioid and sedative use is associated with higher 30-day composite adverse outcomes in colorectal resections, highlighting the need for the evaluation of opioid and sedative use as a component of the preoperative risk stratification. See Video Abstract at http://links.lww.com/DCR/B226. REVISIÓN RETROSPECTIVA: EL USO DE OPIOIDES, SEDANTES O ANTIDEPRESORES EN EL PREOPERATORIO SE ASOCIAN CON MALOS RESULTADOS EN CIRUGÍA COLORECTAL: El uso de opioides, sedantes y antidepresores esta en aumento. No se ha establecido el efecto de estos medicamentos en los resultados de la cirugía colorrectal.Evaluar el impacto del uso preoperatorio de opioides, sedantes y antidepresores en los resultados después de una cirugía colorrectal.Base de datos retrospectiva y revisión de registros médicos.Este estudio se realizó en la Universidad de Kentucky utilizando la base de datos del Proyecto de Mejora de Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Todos los pacientes ≥ 18 años que se sometieron a una resección colorrectal por diversas indicaciones, excluyendo los traumas, entre el 1 de Enero de 2013 y el 31 de Diciembre de 2016.Tasas de morbilidad y mortalidad postoperatorias a los 30 días.De 1201 pacientes, 30.2% usaron opioides, 18.4% usaron sedantes y 28.3% usaron antidepresores antes de la cirugía. Los pacientes tratados con cualquiera de los medicamentos mencionados, presentaban un ASA mas elevado, tasas de disnea y EPOC mas graves en comparación con pacientes sin tratamiento previo. Los consumidores de opioides también tuvieron tasas más altas de creación de ostomías, clasificación mas alta de heridas contaminadas, un tiempo de operación prolongado y transfusión postoperatoria mayor. Después de la cirugía los pacientes que tuvieron tasas más altas de infección intraabdominal (opioides: 21.5% vs 15.2%, p = 0.009, sedantes: 23.1% vs 15.7%, p = 0.01, antidepresivos: 22.4% vs 15.0%, p = 0.003) e insuficiencia respiratoria (opioides: 11.0% vs 6.3%, p = 0.007, sedantes: 12.2% vs 6.7%, p = 0.008, antidepresivos: 10.9% vs 6.5%, p = 0.02). Los consumidores de opioides o sedantes tuvieron una estadía hospitalaria prolongada de más de 2 días (p <0.001) en comparación con los consumidores. Después de haber realizado el ajuste de todos los predictores de mal pronóstico, el uso de opioides y sedantes se asoció con una mayor morbilidad y mortalidad a los 30 días después de cirugía colorrectal (OR 1.43 [IC 95% 1.07-1.91] y OR 1.48 [IC 95% 1.05-2.08], respectivamente)Revisión retrospectiva, estudio de una sola institución, factores de confusión no evaluados.Identificamos que el consumo de opiáceos y sedantes recetados a los pacientes se asocian con resultados adversos complejos más allá de 30 días en casos de resección colorrectal, destacando la necesidad de su respectiva evaluación como componentes de la estratificación de riesgo preoperatorio. Consulte Video Resumen http://links.lww.com/DCR/B226. (Traducción-Dr. Xavier Delgadillo).

Increased Incidence of Surgical Site Infection in IBD Patients.

BACKGROUND: Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for. OBJECTIVE: This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection. DESIGN: The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012. OUTCOME MEASURES: The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection. RESULTS: The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity. LIMITATIONS: This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents. CONCLUSIONS: Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies.

INTRODUCTION: Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD). PURPOSE: To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis. METHODS: Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively. RESULTS: Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications. CONCLUSIONS: Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.

Risk of catheter-associated deep venous thrombosis in inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease confers a hypercoagulable state. A large number of these patients require central venous access in the form of peripherally inserted central catheters for long-term intravenous therapies. Our clinical observations suggested that these patients had a higher incidence of catheter-associated deep venous thrombosis than that of the general population. OBJECTIVE: The aim of this study was to examine the relationship between IBD and catheter-associated deep venous thrombosis. DESIGN: A retrospective chart review was conducted of all patients who underwent peripherally inserted central catheter line placement between 2009 and 2011. SETTING: This study was performed at a single-institution tertiary referral center. PATIENTS: All patients who underwent peripherally inserted central catheter line placement were identified. OUTCOME MEASURES: The risk of catheter-associated deep venous thrombosis in IBD patients was assessed. This risk was compared with known risk factors such as malnutrition, malignancy, diabetes mellitus, and tobacco use. Multivariate analysis was performed. Catheter size, indication for placement, and vein location of catheter-associated deep venous thrombosis were identified in the IBD population. RESULTS: There were 7179 peripherally inserted central catheter lines placed during the study period; the overall incidence of catheter-associated deep venous thrombosis was 2.1% (148/7179). The incidence of catheter-associated deep venous thrombosis among patients with IBD was 6.8% (9/132). The incidence of catheter-associated deep venous thrombosis among non-IBD patients was 1.9% (139/7047) (relative risk, 3.5; 95% CI, 1.8-6.6; p < 0.001). The incidence of catheter-associated deep venous thrombosis was increased for patients with malnutrition (4.8%, 30/628, p < 0.001) and increasing age (95% CI, 1.01-1.12; p = 0.02). There was no increased incidence of catheter-associated deep venous thrombosis for patients with diabetes mellitus (1.6%, 25/1574, p < 0.14), malignancy (2.8%, 30/1041, p = 0.06), or tobacco use (1.6%, 31/1938, p = 0.10). After multivariate analysis, IBD, malnutrition, and increasing age were found to be significant risk factors for the development of catheter-associated deep venous thrombosis. LIMITATIONS: The inability to track the number of catheter days, the inaccuracy of administrative data, the lack of outpatient follow-up, and the small number of events in the study cohort were limitations of this study. CONCLUSIONS: This is the first study to demonstrate IBD as an independent risk factor to the development of catheter-associated deep venous thrombosis. The placement of a peripherally inserted central catheter line in IBD should be utilized selectively.

Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization.

BACKGROUND: Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD). METHODS: The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption. RESULTS: Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion. CONCLUSION: In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.

Age and Medicare Insurance are Barriers to Telemedicine Access-A Quality Improvement Project.

BACKGROUND: Telehealth use has had widespread expansion and adoption over the past two years. This study aims to evaluate access to telehealth essentials (TE) using a novel metric. METHODS: This single institute study surveyed outpatient surgical patients to determine their access to TE. Generalized linear mixed models were used to determine the relationship of demographic and county-level variables on access to four TE. RESULTS: 138 patients were surveyed. Sixty-six (47.8%) were from Appalachian Kentucky. In the survey cohort, 122 (88.4%) had smart phones, 109 (80.7%) had devices with video messaging capabilities, 106 (80.9%) had cellular reception, and 112 (82.4%) had access to WiFi. Increasing age and Medicare insurance were the most consistent predictors of lack of access to TE. CONCLUSION: Rural Appalachian Kentucky has access to TE. Telehealth has the potential to decrease the healthcare inequity in rural populations, but incompletely address this inequity for the aging population.

A Review of Quality Improvement Process Measures for Colorectal Surgery in the United States Using the American College of Surgeons National Surgical Quality Improvement Program Database - Have We Made Progress?

Numerous guidelines have been published regarding Enhanced Recovery Programs (ERP) following colorectal surgery over the past decade. Participation in these guidelines at a national level is unclear. We hypothesize that the adaptation of ERP for patients undergoing elective colorectal surgery is limited but the use of quality improvement measures has increased and while outcomes have improved over the past several years. A total of 86 402 patients were evaluated undergoing elective colectomy between 2013-2018 using the ACS-NSQIP database. Over a 5-year period, there was a significant increase in the use of quality improvement process measures: mechanical and oral bowel preparation and minimally invasive approach. During this time, there was a significant decrease in overall perioperative morbidities (P <.001). These encouraging results from a large national database suggest that evidence-based, quality improvement guidelines are being embraced and that overall outcomes for patients undergoing elective colectomy are improving.

Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients.

INTRODUCTION: Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes. METHODS: After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2. RESULTS: 1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population. CONCLUSIONS: Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative.

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Endoscopic stricturotomy with pulsed argon plasma and balloon dilation for refractory benign colorectal strictures: a case series.

Benign strictures of the colon and rectum affect a sizable portion of patients who have an underlying inflammatory disease or who have undergone recent surgery. Etiologies include inflammatory bowel disease (IBD), post-surgical ischemia, anastomotic strictures, non-steroidal anti-inflammatory drugs (NSAIDs), and complicated diverticulitis. Refractory colorectal strictures are very difficult to manage and often require repeated and different treatment options. We report a novel technique using argon plasma coagulation (APC) with endoscopic balloon dilation (EBD) as a safe and effective treatment modality for refractory benign colorectal strictures. Four patients with symptomatic benign colorectal strictures were referred for endoscopic treatment. In all cases (two females and two males; average age 62 years), the endoscopic and radiographic assessment showed significant strictures (diameter, 4-13 mm). The stricture was secondary to Crohn's disease in one patient and anastomotic strictures in the other three patients. Endoscopic stricturotomy through fulguration and tissue destruction using argon plasma at 1.5 liters/minute, effect 2, and 40 watts was performed, followed by EBD. All patients were treated by one advanced endoscopist. The primary outcomes were the efficiency and safety of endoscopic stricturotomy with pulsed argon plasma and balloon dilation. The resolution of stricture was achieved in all patients. No complications were reported. We believe that combined APC with EBD is a safe and effective technique in the treatment of benign colonic stricture.

Impact of the Affordable Care Act Medicaid Expansion on Reimbursement in Emergency General Surgery.

BACKGROUND: Kentucky had one of the nation's largest increases in insurance coverage with the Affordable Care Act's (ACA) Medicaid expansion, quadrupling the proportion of Kentuckians with insurance coverage. This study compares reimbursement rates for surgical procedures performed by emergency general surgery (EGS) services at the University of Kentucky (UK) before and after Medicaid expansion in January 2014. METHODS: This IRB-approved, single-institution study retrospectively evaluated all patients undergoing surgical treatment by our EGS team from 1/1/2011 to 12/31/2016. We queried operative records for the most frequently performed procedures by the EGS service. We reviewed patient electronic medical records and hospital financial records to identify insurance status, diagnosis codes, and expected hospital reimbursements, based on UK Hospital's procedure/payer accounting models. RESULTS: Four thousand six hundred ninety-three patient procedures met inclusion criteria; 46.5% of these came before ACA expansion and 53.5% after expansion. The most frequent procedures performed were incision and drainage, laparoscopic appendectomy, laparoscopic cholecystectomy, and exploratory laparotomy. After ACA expansion, the proportion of patients with Medicaid nearly doubled (19.8% vs. 35.6%, p < 0.001). Concomitantly, there was a more than fivefold decrease in the uninsured patient population after expansion (23.3% vs. 4.6%, p < 0.001), and mean hospital reimbursement increased for laparoscopic appendectomy (13.7%, p < 0.001), laparoscopic cholecystectomy (50.7%, p < 0.001), and incision and drainage (70.2%, p < 0.001). CONCLUSION: After ACA expansion, there was a sustained decrease in proportion of uninsured patients and a concomitant sustained increase in proportion of patients with access to Medicaid services in the EGS operative population, leading to increased mean hospital reimbursements and decreased patient financial burden.

Abdominal Wall Thickness is a Predictor for Surgical Site Infections in Patients Undergoing Colorectal Operations.

BACKGROUND: Surgical site infections (SSIs) are an established complication following colorectal operations, with rates up to 30% reported in the literature. Obesity is a known risk factor for SSI; however, body mass index (BMI), body fat percentage, waist-hip ratio, or abdominal circumference are imperfect measures. The purpose of our study was to determine whether abdominal wall thickness (AWT) is predictive of SSI. METHODS: We queried our American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database for patients (age ≥18 years) undergoing a colectomy at the University of Kentucky (UK) from January 1, 2013 to December 31, 2018. The exclusion criteria included patients with open abdomens or the lack of preoperative computed tomography (CT) within 3 months of their operation. AWT was measured at the level of the anterior superior iliac spine (ASIS) on abdominal CT. SSI was defined by superficial SSI, deep SSI, and wound dehiscence. RESULTS: Of 1261 patients enrolled, 52.2% were female, with an average age of 57.4 years. More patients had laparoscopic operations (51%), and the median length of stay was 7 days. Our study demonstrated an SSI rate of 9.4% and a 30-day readmission rate of 11%. The overall mean AWT was 2.6 cm (range .1-13.1), and patients with the highest AWT quintile were more likely to develop an SSI than the lowest quintile (12% vs. 5%). After controlling for risk factors and confounders, the odds of an SSI were 3.6 times higher for patients with the highest AWT than patients with the lowest AWT. CONCLUSIONS: Among colorectal surgery patients, AWT is an independent risk factor predictive for SSI.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky.

BACKGROUND: Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality. METHODS: The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots. RESULTS: A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001). CONCLUSIONS: Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery.

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure (P = 0.037) and a higher wound class (P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure (P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI (P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.