Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery.

BACKGROUND: The impact of time to readmission (TTR) on post-discharge mortality has not been well examined. We sought to define the impact of TTR on postoperative mortality after liver or pancreas surgery. METHODS: A retrospective cohort analysis of liver and pancreas surgical patients was conducted using 2013-2015 Medicare Provider Analysis and Review database. Patients were subdivided into TTR groups: 1-5 days, 6-15, 15-30, 31-60, 61-90, and no readmission. The association of index complication, readmission causes, TTR, and mortality was assessed. RESULTS: Among 18,177 patients, a total of 4485 (24.7%) patients were readmitted within 90 days of discharge. Major causes for readmission differed across TTR groups. Patients readmitted within 1-15 days were more likely to be readmitted for postoperative infection compared with patients who had a late readmission (1-5 days: 63.1% vs. 6-15 days: 65.0% vs. 61-90 days: 39.3%; P < 0.001). In contrast, causes of late readmissions were more likely related to gastrointestinal complications (1-5 days: 28.9% vs. 61-90 days: 39.7%; P < 0.001). Compared with no readmission, 180-day mortality was highest among patients readmitted within 16-30 days (aOR 3.60; 95% CI 2.94-4.41). Among patients with index complications, patients who were readmitted within 1-5 days had a higher risk-adjusted 180-day mortality than late readmission (1-5 days: 37.3% vs. 61-90 days: 27.1%) (P < 0.001). CONCLUSIONS: Among patients who were readmitted, the incidence of mortality increased with TTR up to 60 days after discharge yet decreased thereafter. The relation of TTR and mortality was particularly pronounced among those patients who had an index complication. Future efforts should consider TTR when identifying specific approaches to decrease readmission.

Procedure-Specific Volume and Nurse-to-Patient Ratio: Implications for Failure to Rescue Patients Following Liver Surgery.

BACKGROUND: The effect of various hospital characteristics on failure to rescue (FTR) after liver surgery has not been well examined. We sought to examine the relationship between hospital characteristics and FTR after liver surgery. METHODS: The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was used to identify Medicare beneficiaries who underwent liver surgery. The effect of various hospital characteristics on FTR was compared among the highest mortality hospitals (HMH) and the lowest mortality hospitals (LMH). RESULTS: Among 4902 patients undergoing hepatectomy, patients treated at HMH had a higher risk of FTR (OR 3.08, 95% CI 2.03-4.66). Hospital factors such as total number of beds (OR 0.80, 95% 0.56-1.15), operating rooms (OR 0.81, 95% 0.57-1.14), and overall hospital surgical volume (OR 0.88, 95% 0.61-1.25) were not associated with FTR (all p > 0.05). In contrast, hospitals with a greater nurse-to-patient ratio had a markedly lower risk of FTR following a complication (OR 0.70, 95% CI 0.54-0.91; p = 0.007) (Table 3). As volume of liver operations and nurse-to-patient ratio decreased the risk of FTR increased (p > 0.001). After risk-adjusting for patient characteristics, both the effect of surgical volume (adjusted OR 0.66, 95% CI 0.46-0.94; p = 0.022) and nurse-to-patient ratio (adjusted OR 0.68, 95% CI 0.51-0.90; p = 0.008) remained strongly associated with FTR. CONCLUSION: FTR rates varied considerably among hospital performing hepatectomy. Higher procedure-specific hepatectomy volume, as well as a higher nurse-to-patient ratio, accounted for a reduction in the FTR rates. These data highlight the importance of not only procedure volume, but also adequate nurse staffing in reducing FTR and improving mortality following complex procedures such as hepatectomy.

A systematic review of the methods utilised to measure the relationship between cancer patients and oncologists: Implications for future research and practice.

INTRODUCTION: The patient-physician relationship is a critical component of patient-centred health care. The patient-oncologist relationship is particularly important due to the uncertainties that surround treatment of cancer. The goal of the current review was to summarise current methodological approaches to studying the relationship between cancer patients and oncologists. METHODS: A systematic review using PsychInfo, Ebsco, PubMed and Google Scholar was performed using combinations and variations of the MESH terms: "relationship," "doctor-patient," and "oncology." The included studies explicitly measured the "relationship" as an independent or dependent variable. Data were extracted and analysed. RESULTS: The 13 studies included in the review were published from 2004 to 2018. There was little agreement between studies on the definition of the patient-oncologist relationship. Trust was most frequently measured, but methods varied. Most studies evaluated the patient perspective (n = 10). The few studies that considered the oncologist perspective did not measure their perception of the relationship. CONCLUSIONS: The current review demonstrates that current approaches used to assess the patient-oncologist relationship are inconsistent. These differences may limit our understanding of patient needs in current research and practice. Future research should focus on the use of a relational lens as a theoretical framework to assess the patient-oncologist relationship.

The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database.

BACKGROUND AND OBJECTIVES: Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90-day readmission after hepato-pancreatic (HP) procedures. METHODS: The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HP procedures between 2010 and 2014. Patients were stratified according to benign versus malignant HP diagnoses and as index (same hospital as operation) versus non-index (different hospital) readmissions. RESULTS: Among the 41 059 patients who underwent HP procedures, 26 563 (65%) underwent a liver resection while 14 496 (35%) pancreatic resection. Among all patients, 11 902 (29%) had a benign diagnosis versus 29 157 (71%) who had a cancer diagnosis. Overall 90-day readmission was 22% (n = 8 998) with a slight increase in readmissions among patients with a malignant (n = 6 655;23%) versus benign (n = 2 343;20%) diagnosis (P < 0.001). Readmission to an index hospital was more common (n = 7 316 81%) versus a non-index hospital (n = 1 682 19%). Non-index hospital readmissions were more frequent among patients with malignant HP diagnoses (OR, 1.41;P = 0.001). CONCLUSIONS: Up to one in four patients were readmitted after HP surgery. Late readmission was more common among patients with a cancer-diagnosis. While most readmissions occurred at the index hospital, 19% of all readmissions occurred at a non-index hospital and were more frequent among patients with malignant diagnoses.

Preoperative prognostic nutritional index predicts survival of patients with intrahepatic cholangiocarcinoma after curative resection.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is an aggressive malignancy. We sought to examine the association between preoperative prognostic nutritional index (PNI) and long-term overall survival among patients with ICC who underwent curative-intent resection. METHODS: Patients who underwent hepatectomy for ICC between 1990 and 2015 were identified using an international multi-institutional database. Clinic-pathological characteristics and long-term outcomes of patients with PNI ≥ 40 and <40 were compared using univariable and multivariable analyses. RESULTS: Among 637 patients, 53 patients had PNI < 40 (8.3%) and 584 patients had PNI ≥ 40 (91.7%). While there was no difference between PNI groups with regard to tumor size (P = .87), patients with PNI < 40 were more likely to have multifocal disease (PNI < 40, n = 16, 30.2% vs PNI ≥ 40, n = 65, 11.1%; P < 0.001), poorly differentiated or undifferentiated ICC (PNI < 40, n = 13, 25.5% vs PNI ≥ 40, n = 75, 13.1%; P = 0.020) and T2/T3/T4 disease vs patients with PNI ≥ 40 (PNI < 40, n = 38, 71.7% vs PNI ≥ 40, n = 265, 45.4%; P < 0.001). Patients with PNI ≥ 40 had better OS vs patients with PNI < 40 (5-year OS: PNI ≥ 40: 47.5%, 95% CI, 42.2 to 52.6% vs PNI < 40: 24.6%, 95% CI, 12.1 to 39.6%; P < 0.001). On multivariable analysis, PNI < 40 remained associated with increase risk of death (HR, 1.71; 95% CI, 1.15 to 2.53; P = 0.008). CONCLUSION: A low preoperative PNI was associated with a more aggressive ICC phenotype. After controlling for these factors, PNI remained independently associated with a markedly worse prognosis.

Changes in intracuff pressure of cuffed endotracheal tubes while positioning for adenotonsillectomy in children.

BACKGROUND: When using cuffed endotracheal tubes (cETTs), changes in head and neck position can lead to changes in intracuff pressure. AIM: The aim of this study was to assess the combined effect of neck extension, shoulder roll placement, and Crowe-Davis retractor use during adenotonsillectomy on the intracuff pressure of cETTs in children. METHODS: Patients <18 years of age undergoing adenotonsillectomy under general anesthesia following the placement of a cETT were included in the study. After inflation of the cuff to seal the trachea, using the leak test, baseline intracuff pressure was recorded and then continuously monitored. After neck extension, placement of a shoulder roll, insertion of the Crow-Davis retractor, suspension from a Mayo stand, and positioning for surgery, the intracuff pressure was recorded again. RESULTS: The study cohort included 84 patients, ranging in age from 0.9 to 17 years (5.7 ± 3.9 years). In 46 patients (54.8%), the intracuff pressure increased from baseline after positioning for adenotonsillectomy. In 12 of these patients (14.3%), the intracuff pressure was >30 cm H2O. The intracuff pressure decreased in 28 patients (33.3%), while no change was noted in 10 patients (11.9%). Overall, the general trend was an increase in intracuff pressure from 15.9 ± 7.8 cm H2O to 18.9 ± 11.6 cm H2O. CONCLUSION: Both increases and decreases in the intracuff pressure may occur following positioning of the pediatric patient for adenotonsillectomy. An increase in intracuff pressure may result in a higher risk of damage to the tracheal mucosa. A decrease in the intracuff pressure can result in an air leak resulting in inadequate ventilation, increased risk of aspiration, and even predispose to airway fire if oxygen-enriched gases are used. Continuous intracuff pressure monitoring or rechecking the intracuff pressure after positioning for adenotonsillectomy may be indicated.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

The Association Between Patient Satisfaction and Patient-Reported Health Outcomes.

OBJECTIVE: Although patient satisfaction is increasingly used to rate hospitals, it is unclear how patient satisfaction is associated with health outcomes. We sought to define the relationship of self-reported patient satisfaction and health outcomes. DESIGN: Retrospective cross-sectional analysis using regression analyses and generalized linear modeling. SETTING: Utilizing the Medical Expenditure Panel Survey Database (2010-2014), patients who had responses to survey questions related to satisfaction were identified. PARTICIPANTS: Among the 9166 patients, representing 106 million patients, satisfaction was rated as optimal (28.2%), average (61.1%), and poor (10.7%). Main Outcome Measures: We sought to define the relationship of self-reported patient satisfaction and health outcomes. RESULTS: Patients who were younger, male, black/African American, with Medicaid insurance, as well as patients with lower socioeconomic status were more likely to report poor satisfaction (all P < .001). In the adjusted model, physical health score was not associated with an increased odds of poor satisfaction (1.42 95% confidence interval [CI]: 0.88-2.28); however, patients with a poor mental health score or ≥2 emergency department visits were more likely to report poor overall satisfaction (3.91, 95% CI: 2.34-6.5; 2.24, 95% CI: 1.48-3.38, respectively). CONCLUSION: Poor satisfaction was associated with certain unmodifiable patient-level characteristics, as well as mental health scores. These data suggest that patient satisfaction is a complex metric that can be affected by more than provider performance.

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: Analysis of Practice Patterns of Intermountain HealthCare.

BACKGROUND: The ideal management of common bile duct (CBD) stones remains controversial, whether with single-stage management using laparoscopic CBD exploration (LCBDE) during laparoscopic cholecystectomy, or with 2-stage management using preoperative or postoperative ERCP. We wished to elucidate the practice patterns within our health system, which includes both large urban referral centers and small rural critical access hospitals. STUDY DESIGN: We conducted a retrospective data analysis from our 22-hospital, not-for-profit, integrated healthcare system. All patients with a diagnosis of choledocholithiasis who underwent laparoscopic cholecystectomy (LC) and either ERCP or LCBDE for duct clearance between 2008 and 2013 were included. Demographic data, along with disease-specific characteristics and outcomes, were collected and compared. RESULTS: During the study period, 37,301 patients underwent LC. Of these, 1,961 (5.3%) met inclusion criteria. Single-stage management with LC+LCBDE was performed in 28% of patients, and the remaining 72% underwent 2-stage management with ERCP (73% postoperative ERCP, 27% preoperative). Mean total number of procedures was lowest in the LC+LCBDE group vs the post-cholecystectomy ERCP group vs the preoperative ERCP group (mean 1.4 vs 2.1 vs 2.3; p < 0.05). Hospital charges were also lower in the LC+LCBDE group vs post-cholecystectomy ERCP vs preoperative ERCP groups ($9,000 vs $10,800 vs $14,200; p < 0.05). Single-stage vs two-stage management varied greatly between hospitals (from 0% to 93%). CONCLUSIONS: Single-stage management of CBD stones resulted in the fewest procedures and lower hospital charges without an increase in complications. Single-stage management (LC+LCBDE) of CBD stones is underused and can offer better value in today's cost-constrained environment.

Influence of English proficiency on patient-provider communication and shared decision-making.

BACKGROUND: The number of patients in the United States (US) who speak a language other than English is increasing. We evaluated the impact of English proficiency on self-reported patient-provider communication and shared decision-making. METHODS: The 2013-2014 Medical Expenditure Panel Survey database was utilized to identify respondents who spoke a language other than English. Patient-provider communication (PPC) and shared decision-making (SDM) scores from 4-12 were categorized as "poor" (4-7), "average" (8-11), and "optimal." The relationship between PPC, SDM, and English proficiency was analyzed. RESULTS: Among 13,880 respondents, most were white (n = 10,281, 75%), age 18-39 (n = 6,677, 48%), male (n = 7,275, 52%), middle income (n = 4,125, 30%), and born outside of the US (n = 9,125, 65%). English proficiency was rated as "very well" (n = 7,221, 52%), "well" (n = 2,378, 17%), "not well" (n = 2,820, 20%), or "not at all" (n = 1,463, 10%). On multivariable analysis, patients who rated their English as "well" (OR 1.73, 95% CI 1.37-2.18) or "not well" (OR 1.53, 95% CI 1.10-2.14) were more likely to report "poor" PPC (both P < .01). Similarly, SDM was more commonly self-reported as "poor" among patients who reported English proficiency as "not well" (OR 1.31, 95% CI 1.04-1.65, P = .02). CONCLUSION: Decreased English proficiency was associated with worse self-reported patient-provider communication and shared decision-making. Attention to patients' language needs is critical to patient satisfaction and improved perception of care.

Impact of Post-Discharge Disposition on Risk and Causes of Readmission Following Liver and Pancreas Surgery.

BACKGROUND: The relationship between the post-discharge settings and the risk of readmission has not been well examined. We sought to identify the association between discharge destinations and readmission rates after liver and pancreas surgery. METHODS: The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was reviewed to identify liver and pancreas surgical patients. Patients were subdivided into three groups based on discharge destination: home/self-care (HSC), home with home health assistance (HHA), and skilled nursing facility (SNF). The association between post-acute settings, readmission rates, and readmission causes was assessed. RESULTS: Among 15,141 liver or pancreas surgical patients, 60% (n = 9046) were HSC, 26.9% (n = 4071) were HHA, and 13.4% (n = 2024) were SNF. Older, female patients and patients with ≥ 2 comorbidities, ≥ 2 previous admissions, an emergent index admission, an index complication, and ≥ 5-day length of stay were more likely to be discharged to HHA or SNF compared to HSC (all P < 0.001). Compared to HSC, HHA and SNF patients had a 34 and a 67% higher likelihood of 30-day readmission, respectively. The HHA and SNF settings were also associated with a 33 and a 69% higher risk of 90-day readmission. There was no association between discharge destination and readmission causes. CONCLUSION: Among liver and pancreas surgical patients, HHA and SNF patients had a higher risk of readmission within 30 and 90 days. There was no difference in readmission causes and discharge settings. The association between discharge setting and the higher risk of readmission should be further evaluated as the healthcare system seeks to reduce readmission rates after surgery.

Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan.

INTRODUCTION: The Affordable Care Act established a Center for Medicare/Medicaid Services based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas. We sought to assess the impact of the Affordable Care Act Surgery Incentive Payment on surgical procedures performed in Health Professional Shortage Areas. METHODS: Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006, and December 31, 2015, were used to categorize hospitals according to Health Professional Shortage Area location. A difference-in-differences analysis measured the effect of the Surgery Incentive Payment on year-to-year differences for inpatient and outpatient surgical procedures by hospital type pre- (2006-2010) versus post- (2011-2015) Surgery Incentive Payment implementation. RESULTS: Among 409 unique hospitals that performed surgical procedures for at least 1 year of the study period, 2 performed surgery in a designated Health Professional Shortage Area. The two Health Professional Shortage Area -designated hospitals were located in a rural area, were non-teaching hospitals, and had 196 and 202 hospital beds, respectively. After the enactment of the Surgery Incentive Payment, while non- Health Professional Shortage Areas had only a modest relative decrease in total inpatient procedures (Pre-Surgery Incentive Payment: 4,666,938 versus Post-Surgery Incentive Payment: 4,451,612; Δ-4.6%), the proportional decrease in inpatient surgical procedures at Health Professional Shortage Area hospitals was more marked (Pre-Surgery Incentive Payment: 25,830 versus Post-Surgery Incentive Payment: 21,503; Δ-16.7%). In contrast, Health Professional Shortage Area hospitals proportionally had a greater increase in total outpatient procedures (Pre-Surgery Incentive Payment: 17,840 versus Post-Surgery Incentive Payment: 22,375: Δ+25.4%) versus non- Health Professional Shortage Area hospitals (Pre-Surgery Incentive Payment: 5,863,300 versus Post-Surgery Incentive Payment: 6,156,138; Δ+4.9%). Based on the difference-in-differences analysis, the increase in the trend of surgical procedures at Health Professional Shortage Area hospitals was much more notable after Surgery Incentive Payment implementation (Δ+75.2%). CONCLUSION: The Medicare Surgery Incentive Payment program was associated with an increase in the number of surgical procedures performed at Health Professional Shortage Area hospitals relative to non-Health Professional Shortage Area hospitals during the study period, reversing the trend from negative to positive.

Variation in costs among surgeons and hospitals in Pediatric tympanostomy tube placement.

OBJECTIVES/HYPOTHESIS: 1) Identify the major expenses for outpatient pediatric tympanostomy tube placement in a multihospital network. 2) Compare differences for variations in costs among hospitals and surgeons. METHODS: An observational cohort study in a multihospital network using a standardized activity-based accounting system to determine hospital costs for tympanostomy tube placement from February 2011 to January 2015. Children aged 6 months to less than 3 years old who underwent same-day surgery (SDS) for tympanostomy tubes at 15 hospital facilities were included. Subjects with additional procedures were excluded. Hospital costs were subdivided into categories including operating room (OR), SDS preoperative, SDS postoperative, postanesthesia care unit, anesthesia, pharmacy, and OR supplies. RESULTS: The study cohort included 5,623 patients undergoing tympanostomy tube placement by 67 surgeons. Mean cost per surgery was $769 ± $3. Significant variations (P < 0.001) in mean cost per procedure were identified by hospital (range $1212 ± $38 to $509 ± $11) and by surgeon (range $1330 ± $75 to $660 ± $11). Operating room and SDS preoperative were the greatest expenditures; each category accounted for over 30% of overall costs. Pharmacy costs and OR costs were some of the major drivers of cost variation among surgeons. CONCLUSION: This study demonstrates that OR and SDS preoperative costs accounted for the greatest expenditure in tympanostomy tube placement, and significant variation exists among surgeons and hospitals within a multihospital network. Further research is needed to elucidate factors accounting for such variation in cost and the overall impact on patient outcomes. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1935-1939, 2016.