A preoperative prediction model for risk of multiple admissions after colon cancer surgery.

BACKGROUND: A subset of patients who undergo colon cancer surgery may be at a high risk of multiple subsequent admissions. We developed a simplified model to predict the preoperative risk of multiple postoperative admissions (MuAdm) among patients undergoing colon resection to aid in preoperative planning. METHODS: Patients aged ≥18 y with colon cancer who underwent elective surgical resection identified in discharge claims from California and New York (2008-2011) were included. The primary outcome, MuAdm, was defined as 2 or more admissions in the year following resection. Logistic regression models were developed to identify factors predictive of MuAdm. A weighted point system was developed using beta-coefficients (P < 0.05). A random sample of 75% of the data was used for model development, which was validated in the remaining 25% sample. RESULTS: A total of 14,780 patients underwent colon resection for cancer. Almost 30% had an admission in the year after index surgery and 9.8% had MuAdm. The significant predictors of MuAdm were higher Elixhauser comorbidity index score, metastatic disease, payer system, and the number of admissions in the year before surgery. Scores ranged from 0 to 8. Scores ≤1 had a 7% risk of MuAdm, and scores ≥6 had a >30% risk of MuAdm. CONCLUSIONS: In the year following discharge after resection of colon cancer, nearly 10% of patients are admitted 2 or more times. A simple, preoperative clinical model can prospectively predict the likelihood of multiple admissions in patients anticipating resection. This model can be used for preoperative planning and setting postoperative expectations more accurately.

Hospitalization in the Year Preceding Major Oncologic Surgery Increases Risk for Adverse Postoperative Events.

BACKGROUND: Hospitalization is associated with negative clinical effects that last beyond discharge. This study aimed to determine whether hospitalization in the year before major oncologic surgery is associated with adverse outcomes. METHODS: Patients 18 years of age or older with stomach, pancreas, colon, or rectal cancer who underwent resection in California and New York (2008-2010) were included in the study. Patients with hospitalization in the year prior to oncologic resection (HYPOR) were identified. Multivariable logistic regression was used to examine the association of prior hospitalization with the following adverse outcomes: inpatient mortality, complications, complex discharge needs, and 90-day readmission. Subset analysis by cancer type was performed. Outcomes based on temporal proximity of hospitalization to month of surgical admission were evaluated. RESULTS: Of 32,292 patients, 16.3% (n = 5276) were HYPOR. Patients with prior hospitalization were older (median age, 72 vs 67 years; p < 0.001) and had more comorbidities (Elixhauser Index ≥3, 86.5 vs 75.3%; p < 0.001). In the multivariable analysis, HYPOR was associated with complications (odds ratio [OR], 1.28; 95% confidence interval [CI] 1.18-1.40), complex discharge (OR, 1.44; 95% CI 1.34-1.55), and 90-day readmission (OR, 1.45; 95% CI 1.35-1.56). The interval from HYPOR to resection was not associated with adverse outcomes. CONCLUSIONS: Patients hospitalized in the year before oncologic resection are at increased risk for postoperative adverse events. Recent hospitalization is a risk factor that is easily ascertainable and should be used by clinicians to identify patients who may need additional support around the time of oncologic resection.

Outcomes of the 2021-2022 APDS General Surgery Recruitment Process Recommendations.

BACKGROUND: In recent years, mounting challenges for applicants and programs in resident recruitment have catapulted this topic into a top priority in medical education. These challenges span all aspects of recruitment-from the time an applicant applies until the time of the Match-and have widespread implications on cost, applicant stress, compromise of value alignment, and holistic review, and equity. In 2021-2022, the Association of Program Directors in Surgery (APDS) set forth recommendations to guide processes for General Surgery residency recruitment. OBJECTIVES: This work summarizes the APDS 2021-2022 resident recruitment process recommendations, along with their justification and program end-of-cycle program feedback and compliance. This work also outlines the impact of these data on the subsequent 2022-2023 recommendations. METHODS: After a comprehensive review of the available literature and data about resident recruitment, the APDS Task Force proposed recommendations to guide 2021-2022 General Surgery resident recruitment. Following cycle completion, programs participating in the categorical General Surgery Match were surveyed for feedback and compliance. RESULTS: About 122 of the 342 programs (35.7%) participating in the 2022 categorical General Surgery Match responded. Based on available data in advance of the cycle, recommendations around firm application and interview numbers could not be made. About 62% of programs participated in the first round interview offer period with 86% of programs limiting offers to the number of slots available; 95% conducted virtual-only interviews. Programs responded they would consider or strongly consider the following components in future cycles: holistic review (90%), transparency around firm requirements (88%), de-emphasis of standardized test scores (54%), participation in the ERAS Supplemental application (58%), single first round interview release period (69%), interview offers limited to the number of available slots (93%), 48-hour minimum interview offer response time (98%), operationalization of applicant expectations (88%), and virtual interviews (80%). There was variability in terms of the feedback regarding the timing of the single first round offer period as well as support for a voluntary, live site visit for applicants following program rank list certification. CONCLUSIONS: The majority of programs would consider implementing similar recommendations in 2022-2023. The greatest variability around compliance revolved around single interview release and the format of interviews. Future innovation is contingent upon the ongoing collection of data as well as unification of data sources involved in the recruitment process.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease.

BACKGROUND: Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients. METHODS: A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes. RESULTS: Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64). CONCLUSIONS: Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Wind, water, wound, walk--do the data deliver the dictum?

OBJECTIVE: To evaluate the teaching dictum "wind, water, wound, walk" in the modern surgical environment. DESIGN: A retrospective cohort study. SETTING: Hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program. PARTICIPANTS: We identified 11,137 patients enrolled in American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) who were older than 18 years; underwent a general surgical procedure; and developed a postoperative pneumonia (PNA, "wind"), urinary tract infection (UTI, "water"), surgical site infection (SSI, "wound"), or venous thromboembolic event (VTE, "walk") for inclusion in the study. Patients were excluded if they had an infection present at the time of surgery or were missing information on the time of diagnosis. RESULTS: The median day of diagnosis differed significantly according to occurrence type (median day of PNA = 5, UTI = 8, SSI = 11, and VTE = 9, p < 0.001). The sequence of occurrences diagnosed before discharge (median day of PNA = 4, UTI = 5, SSI = 7, and VTE = 5) differed from that of occurrences diagnosed following discharge (median day of PNA = 10, UTI = 14, SSI = 14, and VTE = 14). Within the predischarge and postdischarge subsets, the median day of diagnosis remained significantly different according to occurrence type (all p's < 0.001). CONCLUSIONS: The dictum should be taught as, "wind, water, walk, wound" to reflect the timing and progression of the diagnosis of PNA, UTI, VTE, and SSI. The dictum did not reflect the timing or sequence of the occurrences in the cohort diagnosed after discharge. Educators must teach trainees to apply the dictum in the appropriate patient setting. As surgical care changes, we must continue to reassess our educational pearls to ensure that they reflect the modern reality.