The Determinants of Inpatient Palliative Care Use in Patients With Pancreatic Cancer.

INTRODUCTION: Symptom burden management is a major goal of pancreatic cancer care given that most patients are diagnosed late. Early palliative care is recommended in addition to concurrent active treatment; however, disparities exist. We sought to determine the factors associated with inpatient palliative treatment among pancreatic cancer patients and compare treatment outcomes in terms of mortality, discharge disposition and resource utilization. METHODS: We conducted a retrospective study of 22,053 pancreatic cancers using the National Inpatient Sample (NIS) database (January - December 2020). Patient and hospital characteristics, mortality, discharge disposition, length of stay (LOS), hospital costs and charges were compared between pancreatic cancer patients based on palliative treatment. Multivariate regression was used to evaluate patient and hospital characteristics and outcomes associated with palliative treatment. RESULTS: A total number of 3839 (17.4%) patients received palliative care. Patients who received palliative care were more likely to be older, Medicaid insured, and nonobese. Patients were less likely to receive palliative care if they are males, Medicare insured, had a lower Charlson comorbidity score, or treated in Urban nonteaching hospitals. Patients who received palliative care displayed higher odds of in-hospital mortality and prolonged LOS. The adjusted additional mean hospital cost and charges in patients who received palliative care were lower by $1459, and $4222 respectively. CONCLUSIONS: Inpatient palliative treatment in pancreatic cancer patients is associated with an older age, a higher comorbidity burden, non-obesity, insurance status and urban teaching hospitals. Our study suggests that inpatient palliative treatment decreased hospital resource utilization without prolonging survival.

Endoscopic Retrograde Cholangiopancreatography Performed by Trainees Is Not Associated with Increased Immediate Adverse Events or Technical Failure Rates.

BACKGROUND/AIM: Training endoscopists to perform endoscopic retrograde cholangiopancreatography (ERCP) is critical to address the increasing patient population with pancreatobiliary diseases. Concerns remain about ERCP safety and success involving trainees. We compared the technical success and immediate adverse events between ERCP with and without trainee involvement. METHODS: Retrospective analysis of 28,271 ERCP procedures in a national sample of the United States over 12 years. Demographics, procedure and fluoroscopy time, visualization and cannulation of main structures, adverse events, and technical success rates were compared between ERCP with and without trainees. Categorical variables were compared using Pearson's chi-square test and continuous variables using a standard t-test. Univariate and multivariate regressions were performed adjusting for age, gender, ethnicity, US region, ASA class and clinical setting. RESULTS: Approximately 49.5% of ERCPs had a trainee involved. The ampulla was visualized in 97.4% with trainee vs. 97.3% without trainee involvement (P = 0.858). The common bile duct was visualized and cannulated in 90.4% with trainees vs. 91.7% without trainees involved (P < 0.001). The ERCP was incomplete in 5.9% of cases with trainees vs. 6.4% without trainees involved (P = 0.207). Trainee participation added 8.7 min to average procedure time (aOR: 1.02, P < 0.001) and 2.0 min to fluoroscopy time (aOR: 1.00, P = 0.796). Adverse events (aOR: 0.89, P = 0.704) and technical success (aOR: 0.83, P = 0.571) were similar in both groups. CONCLUSIONS: Trainee involvement leads to increased procedure duration but is not associated with increased immediate adverse events, or technical failure. Our study supports ERCP safety and success with trainee participation.

Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in the prone or supine position. We compared the technical success and other outcomes between these positions. METHODS: This was a retrospective cohort study using the Clinical Outcomes Research Initiative database. Demographics, procedure and fluoroscopy time, visualization of main structures, and technical success rates were compared between the supine and prone positions. Univariate and multivariate regressions were performed to adjust for age, sex, ethnicity and clinical setting. RESULTS: A total of 21,090 patients who underwent ERCP were included, of whom 1769 (8.4%) were supine and 19,321 (91.6%) were prone. The common bile duct (CBD) was visualized and cannulated in 89.1% of supine vs. 91.4% of prone positions (P=0.017), while the ampulla was visualized in 97.1% of supine vs. 97.7% of prone (P=0.414). The ERCP was incomplete in 10% of supine vs. 5% of prone cases (P<0.001). On multivariate analysis, supine position required shorter procedure times than prone (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.98-0.98; P<0.001). The supine position also yielded lower odds of CBD visualization and cannulation (aOR 0.63, 95%CI 0.44-0.91; P=0.011) and higher odds of an incomplete examination (aOR 1.84, 95%CI 1.46-2.30; P<0.001) vs. prone. CONCLUSIONS: The supine position leads to shorter procedures but is more likely to result in poorer visualization and cannulation of the CBD and an incomplete examination. This may reflect the technical difficulty of performing ERCP in the supine position for the endoscopist. Our study supports recommendations for an individualized ERCP approach.

Hospital robotic use for colorectal cancer care.

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review.

BACKGROUND: Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS: Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS: There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (ß = - 0.16, p < 0.001) and for each specialty (GS: ß = - 0.18, p < 0.001; CRS ß = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Impact of travel distance on quality outcomes in colorectal cancer.

OBJECTIVES: This study sought to examine the impact of distance traveled from place of residence to surgical facility for elective colorectal surgery on surgical outcomes, length of stay, and complication rate. STUDY DESIGN: Retrospective study. METHODS: Patients with colorectal cancer were identified from the Florida Inpatient Discharge Database. Distance traveled from primary residence to surgical facility was estimated using zip code. After adjusting for patient and hospital characteristics, multivariate regression models compared bypassed hospitals, the length of stay, and complication rates for patients traveling different distances to receive care. RESULTS: Patients residing in rural areas and in South (odds ratio [OR], 2.37; 95% CI, 1.55-3.63) and Central Florida (OR, 5.86; 95% CI, 3.86-8.89) were more likely to travel more than 50 miles for treatment. Teaching status of the hospital (OR, 9.99; 95% CI, 6.98-14.31), a hospital's availability of a colorectal surgeon (OR, 1.83; 95% CI, 1.45-2.31), and metastasized cancer (OR, 1.43; 95% CI, 1.17-1.82) influenced the patient's decision to travel farther for treatment. Length of stay was significantly higher for patients traveling farther (P < .0343). However, there was no significant difference in the rate of complications among the groups (those traveling 25-50 miles vs < 25 miles [P = .5766] and those traveling > 50 miles vs < 25 miles [P = .4516]). CONCLUSIONS: A greater number of patients travel more than 50 miles to the surgical facility at a later stage of disease. These patients do not significantly differ from those traveling less than 50 miles in their rates of complications; however, they stay longer at the surgical facility.

Factors associated with worse outcomes for colorectal neuroendocrine tumors in radical versus local resections.

BACKGROUND: Colorectal neuroendocrine tumors (NETs) are the most common NETs of the gastrointestinal tract. Due to the rarity, colorectal NETs are understudied and are not clearly understood. Our study sought to identify the factors associated with worse outcomes for colorectal NETs following resection. METHODS: We identified patients diagnosed with colorectal NETs [2004-2014] who underwent resection from the National Cancer Data Base. Non-NETs were excluded. Overall survival (OS) was evaluated using the Kaplan Meier method. Cox proportional hazards and logistic regression models were used to assess factors associated with radical versus local resection, OS and LOS. RESULTS: A total of 7,967 colon and 11,929 rectal NETs were analyzed. The majority of colon (93.4%) and rectal (89.1%) NETs underwent radical and local resection respectively. The 5-year OS was 69% and 92% for colon and rectal NETs respectively. Older age (OR 1.45, CI 1.37-1.53) and clinical stage 4 (OR 9.91, CI 4.56-21.52) were associated with higher odds for colonic radical resection. Lowest median income quartile (OR 1.41, CI 1.21-1.64) and African Americans (OR 1.26, CI 1.07-1.49) experienced higher mortality for colon and rectal NETs respectively. CONCLUSIONS: Racial minority and low-income patients experience worse outcomes for colorectal NETs following resection.

Acute Pancreatitis in Celiac Disease: Has the Inpatient Prevalence Changed and Is It Associated With Worse Outcomes?

OBJECTIVES: Studies suggest that adults diagnosed with celiac disease (CD) are at higher risk of developing acute pancreatitis (AP). The aim of this study is to explore the relationship between CD and AP in terms of inpatient prevalence, mortality, morbidity, and resource utilization in the past decade. METHODS: Retrospective cohort study using the Nationwide Inpatient Sample (2007-2016). The primary outcome was the occurrence of AP in CD patients. Secondary outcomes were the trend in AP cases in CD patients, and mortality, morbidity, length of stay, and total hospital charges and costs. RESULTS: Of 337,201 CD patients identified, 7372 also had AP. The mean age was 53 years, 71% were women. The inpatient prevalence of AP in CD was 2.2% versus 1.2% in non-CD cohort (P < 0.01). Patients with CD displayed increased odds of having AP (adjusted odds ratio, 1.92; P < 0.01). Patients with AP and CD displayed lower odds of morbidity and mortality than non-CD patients with AP. CONCLUSIONS: The inpatient prevalence of AP is higher in CD patients, and increased from 2007 to 2016. Patients with CD and AP displayed lower morbidity and mortality, which may suggest that they have a less severe form of AP or lower baseline comorbidity.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida.

BACKGROUND: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients.

BACKGROUND: Tranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA. METHODS: We retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery. RESULTS: There was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA. CONCLUSION: TXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.

Unusual Presentation of Recurrent Gallstone Ileus: A Case Report and Literature Review.

BACKGROUND: Gallstone ileus (GSI) is a rare form of small bowel obstruction (SBO) in patients with cholelithiasis, which is often poorly managed. Enhanced abdominal computed tomography (CT) with contrast is considered the most helpful diagnostic tool, as it is highly sensitive, specific, and accurate. We report an interesting case of recurrent GSI that was not detected by CT but diagnosed intraoperatively. CASE PRESENTATION: A 49-year-old female with a previous history of choledocholithiasis and ERCP presented to the emergency department following episodes of sudden cramping, epigastric pain, and nausea. An abdominal CT revealed evidence of SBO with clear evidence of GSI and a cholecystoduodenal fistula. Laparoscopic exploration of the small bowel revealed a large, calcified 3.5 cm × 3 cm gallstone with evidence of pressure necrosis; segmental bowel resection with stapled anastomosis was performed and patient recovered appropriately after surgery. Cholecystectomy was not performed due to multiple co-morbidities and absence of gallbladder stones. However, she presented two months later with signs and symptoms of SBO. A repeat abdominal CT showed dilated bowel with no clear transition point. This was suspected to be due to adhesions. After an initial conservative treatment which produced mild improvement, laparotomy was performed which revealed a second large non-calcified gallstone and necrotic small bowel with a pocket of abscess. CONCLUSION: The most sensitive diagnostic tool for GSI is enhanced abdominal CT but dilemma arises when GSI is not detected on CT. A high index of suspicion and further exploration are required in order not to miss other vital findings.

Variability between individual surgeons in route of hysterectomy for patients with endometrial cancer in Florida.

OBJECTIVES: Minimally invasive surgery (MIS) was designated as a quality measure for endometrial cancer in 2014. However, national database analyses demonstrate that laparotomy is still performed for this indication. This study aims to assess the route of hysterectomy performed by gynecologic surgeons who manage endometrial cancer in the state of Florida. MATERIALS AND METHODS: All patients in Florida who were diagnosed with endometrial cancer (both ICD-9 Code 182.0 and ICD-10 Code C54.10), and who received a related surgical procedure from 2014 to 2016 were included. Eligible patients were identified using the Florida Inpatient Discharge Dataset, the Florida Ambulatory and Emergency Discharge Dataset, the Hospital Compare dataset, and the Healthcare Cost Report Information System. The primary surgeon was identified using their national provider identifier (NPI) number. Each surgeon's overall operative volume, MIS volume, and percentage of MIS procedures were collected. RESULTS: Hysterectomy for endometrial cancer was performed in 6086 patients; 4959 (81.5%) underwent MIS and 1127 (18.5%) had an abdominal approach. Hysterectomy for endometrial cancer was performed by 368 providers in Florida (range of 2-244 surgeries). The percentage of MIS to total hysterectomies for providers who performed 1-10 cases was 72.1%; 11-25 cases was 40.9%; 26-100 cases was 80.1%; and more than 100 cases was 86.1%. Variation in operative route exists amongst low- and high-volume providers. CONCLUSIONS: Statewide databases can be used to identify surgical trends for policy purposes. These findings support the referral of patients with endometrial cancer to surgeons with high MIS volumes.

Surgical Care for Women with Endometrial Cancer in Florida.

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings.

BACKGROUND: Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings. METHODS: This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded. RESULTS: Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d). CONCLUSIONS: Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Trends in the Use of Laparoscopy and Robotics for Colorectal Cancer in Florida.

Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.

Disparities in elective surgery for diverticulitis: Identifying the gap in care.

BACKGROUND: Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications. METHODS: The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models. RESULTS: Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons. CONCLUSIONS: Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Insight Into Health Care Services: A Characterization of Emergency Room Visits and Economic Hazards in the United States.

OBJECTIVE: This study explores the impact of economic hazard areas on hospital-based emergency departments to determine whether economically hazardous environments, characterized by the change of population, income per capita, and unemployment rate, experience a higher number of emergency room visits than areas of lower rated economic hazard risk in the United States. METHOD: A cross-sectional design was used of a nationally constructed data set of hospital-based emergency departments of over 6,000 hospitals in the United States. We identified our quality outcome measure as the emergency room visits rate within a hospital service area. We created the variable by dividing the number of emergency room visits by the population of the hospital services area in which the emergency room was located. RESULTS: Results indicate that there is a difference in the incident rate ratio of emergency room visits between environments considered to be experiencing greater amounts of hazard, compared to lower amounts of hazard. CONCLUSION: Hospital administrators and health policy-makers need to work in conjunction to focus efforts on public safety as a key objective in the delivery of emergency medical care. One crucial effort that hospital administrators need to focus on is improving emergency room capacity and efficiency as part of the disaster preparedness plan (Disaster Med Public Health Prep. 2019;13:470-475).

Disparities in minimally invasive surgery for colorectal cancer in Florida.

BACKGROUND: The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida. METHODS: Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach. RESULTS: Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001). CONCLUSIONS: Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.

Predictors of palliative treatment in stage IV colorectal cancer.

BACKGROUND: Palliative treatment may be associated with prolonged survival and improved quality of life, but remains underutilized in stage IV colorectal (CRC). We examined a national cohort of stage IV CRC patients to determine the factors associated with palliative treatment. METHODS: Stage IV CRC patients, classified based on their survival length (<6 months, 6-24 months, and 24 + months), were analyzed using the American College of Surgeons National Cancer Data Base (2004-2013). Multivariable analysis was performed to evaluate factors associated with palliative treatment. RESULTS: Of 85,981 patients analyzed, 10.9% received palliative treatment. For 6-24 months survival, a more recent year of diagnosis, Medicaid, uninsured status, Mountain and Pacific regions were associated with higher odds of palliative treatment. For those who survived < 6months, older patients had lower odds, while academic centers and residence > 20 miles from treating institutions were associated with increased likelihood of palliative treatment. CONCLUSIONS: Palliative treatment in stage IV CRC is associated with a more recent year of diagnosis, Medicaid, academic centers, Mountain and Pacific regions of the US.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS.

OBJECTIVE: The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL. METHODS: Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality). RESULTS: Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes. CONCLUSION: Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery. ABBREVIATIONS: HbA1c = glycated hemoglobin A1c; IQR = interquartile range.