Anorectal Sexual Function Index: Development and Validation of a Health-related Quality of Life Measure.

OBJECTIVE: To assess the reliability and validity of measuring receptive anal intercourse (RAI) sensation and associated satisfaction and bother. METHODS: Between July 2022 and January 2023, we conducted a survey on sensations during RAI among people with prostates (ie, cisgender men and transgender women). The survey content was developed based on our previous qualitative study. We assessed internal reliability and consistency through time. Sensations experienced during RAI were correlated with health-related quality-of-life measures to ensure construct validity. RESULTS: The final index contained four scales: pleasure (four items), pain (seven items), urinary (four items), and bowel (four items). Overall, 1084 individuals filled out the questionnaire. The internal consistency for all subscales was at or above 0.79. Scores tended to be stable across time with all test-retest coefficients at or above 0.72. Pleasure scores were inversely correlated with pain scores (r = -0.46). Pleasure was positively correlated with erections (r = 0.36) and orgasms (r = 0.44) during RAI, and sexual satisfaction (r = 0.39). Notable positive correlations for pain scores were with bowel scores (r = 0.49), internalized homophobia (r = 0.35), and prostatitis symptoms (r = 0.37). Urinary scores were moderately associated with IPSS scores (r = 0.22). Bowel scores were positively correlated with GI symptoms (r = 0.24), mental health symptoms (r = 0.28), and chronic prostatitis symptoms (r = 0.29). CONCLUSION: The results of the current study provide evidence that the Anorectal Sexual Function Index is both reliable and valid. The Anorectal Sexual Function Index may be a particularly useful health-related quality-of-life measure to assess outcomes regarding a host of urologic issues that may affect RAI.

Changes in surgical mortality during COVID-19 pandemic by patients' race, ethnicity and socioeconomic status among US older adults: a quasi-experimental event study model.

OBJECTIVES: To examine changes in the 30-day surgical mortality rate after common surgical procedures during the COVID-19 pandemic and investigate whether its impact varies by urgency of surgery or patient race, ethnicity and socioeconomic status. DESIGN: We used a quasi-experimental event study design to examine the effect of the COVID-19 pandemic on surgical mortality rate, using patients who received the same procedure in the prepandemic years (2016-2019) as the control, adjusting for patient characteristics and hospital fixed effects (effectively comparing patients treated at the same hospital). We conducted stratified analyses by procedure urgency, patient race, ethnicity and socioeconomic status (dual-Medicaid status and median household income). SETTING: Acute care hospitals in the USA. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 14 common surgical procedures from 1 January 2016 to 31 December 2020. MAIN OUTCOME MEASURES: 30-day postoperative mortality rate. RESULTS: Our sample included 3 620 689 patients. Surgical mortality was higher during the pandemic, with peak mortality observed in April 2020 (adjusted risk difference (aRD) +0.95 percentage points (pp); 95% CI +0.76 to +1.26 pp; p<0.001) and mortality remained elevated through 2020. The effect of the pandemic on mortality was larger for non-elective (vs elective) procedures (April 2020: aRD +0.44 pp (+0.16 to +0.72 pp); p=0.002 for elective; aRD +1.65 pp (+1.00, +2.30 pp); p<0.001 for non-elective). We found no evidence that the pandemic mortality varied by patients' race and ethnicity (p for interaction=0.29), or socioeconomic status (p for interaction=0.49). CONCLUSIONS: 30-day surgical mortality during the COVID-19 pandemic peaked in April 2020 and remained elevated until the end of the year. The influence of the pandemic on surgical mortality did not vary by patient race and ethnicity or socioeconomic status, indicating that once patients were able to access care and undergo surgery, surgical mortality was similar across groups.

Association of Frailty With Post-Operative Outcomes of Older Adults Undergoing Elective Ostomy Reversal.

BACKGROUND: Ostomy reversal is a common surgical procedure; however, it is not without associated risks. Patient selection for this elective procedure is therefore critically important. Elderly patients represent a growing population and a substantial proportion of patients that present for evaluation after ostomy creation due to the most common etiologies. This study aims to assess the impact of frailty on the outcomes of ostomy reversal among older adults. METHODS: Patients ≥65 years who underwent ostomy reversal from 2015 to 2019 were identified in the NSQIP database. Frailty was calculated using the 5-item Modified Frailty Index (MFI). Multivariate regression was performed to evaluate the association of frailty with post-operative 30-day mortality, 30-day serious complications, discharge to a facility, and 30-day readmission. RESULTS: A total of 13,053 patients were included, of which 18.7% were frail (MFI ≥ 2). Patients who underwent colostomy reversal had higher rates of serious complications (P < .0001) and discharge to facility (P < .0001) compared to other reversals. In multivariate analysis, frailty was associated with increased odds of serious complications (OR 1.52, 95% CI 1.31-1.77), discharge to facility (OR 2.14, 95% CI 1.79-2.57), and readmission (OR 1.23, 95% CI 1.04-1.46), but not mortality. Frail patients had predicted probabilities 1.4 times higher for serious complications and 1.7-2.2 times greater for discharge to facility than non-frail patients. CONCLUSIONS: Among older adults undergoing elective ostomy reversal, frailty is independently associated with increased odds of 30-day serious complications, discharge to facility, and 30-day readmission. As a potentially modifiable risk factor, identification of frailty offers the opportunity for shared decision-making and prehabilitation.

"It's Incapacitated Me in so Many Ways": Older Adults' Lived Experience With Postoperative Symptoms at Home After Major Elective Surgery.

OBJECTIVE: This qualitative study aimed to explore the challenges faced by older adults regarding the postoperative symptom experience after major elective surgery. BACKGROUND: Although extensively studied in oncology settings, the impact of postoperative symptom burden remains largely underexplored in elective major surgery among older adults. METHODS: We employed convenience sampling to recruit adults aged 65 years or above undergoing major elective surgery at the University of California, San Francisco. Semistructured interviews regarding the surgical experience were conducted at 1 and 3 months postoperatively. An inductive qualitative approach was used to identify emerging themes. Symptoms revealed by participants during interviews were also captured. RESULTS: Nineteen participants completed a 1-month postoperative interview, and 17 additionally completed a 3-month interview. Three themes emerged: (1) postoperative symptoms significantly impacted valued life activities and psychosocial well-being, (2) participants felt "caught off guard" by the intensity and duration of postoperative symptoms, and (3) participants expressed the need for additional support, resources, and education on symptom management. The most frequently mentioned symptoms were postoperative pain (n=12, 63.1%), gastrointestinal discomfort (n=8, 42.1%), and anxiety/stress (n=8, 42.1%) at 1-month postsurgery compared with pain and depression (both n=6, 35.3%) at 3 months. CONCLUSIONS: Study participants were surprised by the negative impact of postoperative symptoms on their psychosocial well-being and ability to engage in valued life activities. Symptom burden is an important patient-reported outcome that should be assessed postoperatively. Interventions to minimize postoperative symptom burden in older adults could optimize quality of life and participation in meaningful activities during surgical recovery.

Surgical Informed Consent: A Scoping Review of Physician-facing Decision Support Tools.

Objectives: Physician-facing decision support tools facilitate shared decision-making (SDM) during informed consent, but it is unclear whether they are comprehensive in the domains they measure. In this scoping review, we aimed to (1) identify the physician-facing tools used during SDM; (2) assess the patient-centered domains measured by these tools; (3) determine whether tools are available for older adults and for use in various settings (elective vs. emergent); and (4) characterize domains future tools should measure. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews, Embase, Medline, and Web of Science were queried for articles published between January 2000 and September 2022. Articles meeting inclusion criteria underwent title and abstract review. Eligible studies underwent data abstraction by two reviewers. Results: Of 4365 articles identified, 160 were eligible. Tools to aid in surgical SDM focus on elective procedures (79%) and the outpatient setting (71%). Few tools are designed for older adults (5%) or for nonelective procedures (9%). Risk calculators were most common, followed by risk indices, prognostic nomograms, and communication tools. Of the domains measured, prognosis was more commonly measured (85%), followed by alternatives (28%), patient goals (36%), and expectations (46%). Most tools represented only one domain (prognosis, 33.1%) and only 6.7% represented all four domains. Conclusions and Implications: Tools to aid in the surgical SDM process measure short-term prognosis more often than patient-centered domains such as long-term prognosis, patient goals, and expectations. Further research should focus on communication tools, the needs of older patients, and use in diverse settings.

Relationship between pelvic sensations and lifetime exposure to receptive anal intercourse among people with prostates.

BACKGROUND: Despite the negative stigma on receptive anal intercourse (RAI), this behavior has a positive influence on individuals' sexual and relationship health. No large studies have previously looked at specific sensations experienced during RAI and how these sensations may change with experience. AIM: In this study we aimed to quantify commonly reported pelvic sensations during RAI and determine whether their presentation changes with increasing experience of RAI. METHODS: An internet survey was conducted on sensations felt during RAI among people with prostates from July 2022-January 2023. The survey content was developed based on a mixed-methods qualitative study and inquired about demographic and sexual histories as well as sensations (pleasure, pain, urinary, and bowel) experienced during RAI. We used descriptive statistics to describe demographic and sexual histories. All data were stratified by lifetime exposure to RAI. OUTCOMES: The primary outcomes assessed included the quantification of both the primary sensations experienced during RAI and the associated bother. RESULTS: In total, 975 participants completed the survey. The median age was 32 (range 18-78) years. The average age of first participation in RAI was 21 ± 6.6 years. Most respondents were having sex at least once a week (65%). Nine percent of respondents reported fewer than 10 experiences with RAI, 26% reported 11-50 RAI experiences, 32% reported 51-200 experiences, 16% reported 201-500 experiences, and 18% reported >500 experiences. As the number of experiences with RAI increased (from <10 to >500 exposures), the reported frequency of pleasurable sensation increased from 41% to 92% (P < .0001), whereas severe insertional pain and symptoms of bowel urgency decreased from 39% to 13% and from 21% to 6%, respectively (P < .0001). Urinary urgency sensation did not differ by lifetime RAI experience. CLINICAL IMPLICATIONS: Lifetime RAI exposure can be readily assessed and correlates not only with pelvic sensation but also many other aspects of sexual health. These results imply that the etiology of dissatisfaction with pleasure or anodyspareunia during RAI may differ by lifetime RAI exposure. STRENGTHS AND LIMITATIONS: This is the first study to our knowledge to assess pelvic sensations experienced during RAI among a large sample of individuals. This is a cross-sectional study, and we cannot conclude how pelvic sensations change over time among individuals. Internet-based participants may not be representative of clinical populations. CONCLUSION: Lifetime exposure to RAI is positively associated with pleasure and is negatively associated with pain and bowel urgency. Pelvic sensations experienced during RAI appear to be dependent on lifetime RAI exposure history regardless of age.

Prospective Correlation of Magnetic Resonance Tumor Regression Grade With Pathologic Outcomes in Total Neoadjuvant Therapy for Rectal Adenocarcinoma.

PURPOSE: Total neoadjuvant therapy (TNT) is a newly established standard treatment for rectal adenocarcinoma. Current methods to communicate magnitudes of regression during TNT are subjective and imprecise. Magnetic resonance tumor regression grade (MR-TRG) is an existing, but rarely used, regression grading system. Prospective validation of MR-TRG correlation with pathologic response in patients undergoing TNT is lacking. Utility of adding diffusion-weighted imaging to MR-TRG is also unknown. METHODS: We conducted a multi-institutional prospective imaging substudy within NRG-GI002 (ClinicalTrials.gov identifier: NCT02921256) examining the ability of MR-based imaging to predict pathologic complete response (pCR) and correlate MR-TRG with the pathologic neoadjuvant response score (NAR). Serial MRIs were needed from 110 patients. Three radiologists independently, then collectively, reviewed each MRI for complete response (mriCR), which was tested for positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity with pCR. MR-TRG was examined for association with the pathologic NAR score. All team members were blinded to pathologic data. RESULTS: A total of 121 patients from 71 institutions met criteria: 28% were female (n = 34), 84% White (n = 101), and median age was 55 (24-78 years). Kappa scores for T- and N-stage after TNT were 0.38 and 0.88, reflecting fair agreement and near-perfect agreement, respectively. Calling an mriCR resulted in a kappa score of 0.82 after chemotherapy and 0.56 after TNT reflected near-perfect agreement and moderate agreement, respectively. MR-TRG scores were associated with pCR (P < .01) and NAR (P < .0001), PPV for pCR was 40% (95% CI, 26 to 53), and NPV was 84% (95% CI, 75 to 94). CONCLUSION: MRI alone is a poor tool to distinguish pCR in rectal adenocarcinoma undergoing TNT. However, the MR-TRG score presents a now validated method, correlated with pathologic NAR, which can objectively measure regression magnitude during TNT.

Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN: The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS: Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS: This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

Atlas of the receptive anal sex experience among people with prostates.

BACKGROUND: Receptive anal intercourse (RAI) is commonly practiced among individuals of all sexual orientations. However, negative stigmatization by society and health care professionals leads to the underreporting or this practice. AIM: We sought to assess and describe the subjective role of the prostate as a pleasure center in participants with diverse RAI experiences. The secondary aim was to describe nonprostatic areas within the anorectal region that produce erotic sensation and/or pain. METHODS: The exploratory sequential multimethod study design included focus groups and semistructured interviews with 30 individuals with prostates who had engaged in RAI. We used graphic elicitation of natal male anatomy to enhance visualization and assess participant perspectives. OUTCOMES: The main outcome of interest was the identification of anatomic locations of erogenous sensation and pain during RAI. RESULTS: Among the participants (median age 38, range 24-77 years), most participants (90%) identified as cisgender male. Three major themes emerged within the motivations for RAI, including (1) deriving intrinsic pleasure, (2) providing both pleasure for a partner and a way to improve intimacy/connection, and (3) an inability to be the insertive partner due to physical or mental challenges. The data suggest that the anorectal region produces a variety of erogenous sensations which participants find pleasurable. Overall, 2 major areas of erogenous sensation occur along the anterior rectal wall and within the anus. Within the context of RAI, 2 distinct categories of pain emerged, including pain with insertion and pain at other times. CLINICAL IMPLICATIONS: Understanding where erogenous sensation originates for each individual may predict sexual functioning after various surgical interventions. Timing and location of pain may aid in further characterizing anodyspareunia. STRENGTHS AND LIMITATIONS: Our study utilized a sequential design (from focus groups to interviews) with diverse RAI experiences, especially regarding age, geographic location, and prostate pathology. We included individuals of diverse gender identities, but too few to evaluate these groups independently from cisgender men. CONCLUSION: People with prostates experience pleasure in multiple areas during RAI. Contrary to some lay literature, the prostate region is not the subjective pleasure center for all individuals. Timing and location of pain during RAI may inform areas for intervention. Providing a language for pleasure and pain during RAI may improve communication between not only sexual partners but also clinicians and patients.

Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons.

BACKGROUND: Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. METHODS: An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. RESULTS: The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. CONCLUSION: Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.

Public Opinions About Surgery in Older Adults: A Thematic Analysis.

OBJECTIVE: To examine public opinions of surgery in older adults. BACKGROUND: Increasing numbers of older adults are undergoing surgery. National healthcare organizations recognize the increased risks of postoperative complications and mortality in the older surgical population and have made efforts to improve the care of older adults undergoing surgery through hospital-level programs. However, limited research has explored the opinions and responses of the wider U.S. public regarding surgery in older adults. METHODS: We performed a qualitative, thematic analysis of reader comments posted in response to online newspaper articles relating to surgery in older adults. Articles were published in 2019-2020 and targeted for a popular press audience. RESULTS: Nine hundred eight reader comments posted in response to 6 articles relating to surgery in older adults were identified. Articles were published in online editions of print newspapers with a digital circulation between 1.3 and 5.7 million subscribers. Three themes were identified: (1) wariness/distrust towards healthcare: including general distrust of medicine and distrust of surgery, (2) problems experienced: ineffective communication and unrealistic expectations, and (3) recommended solutions: the need for multidisciplinary teams and patient-centered communication. CONCLUSIONS: Overall, the public viewed surgery in older adults with wariness/distrust due to ineffective communication and unrealistic expectations. Specialized surgical care tailored to the unique needs of older adults is needed. The public perspective suggests that U.S. health systems should strongly consider adopting programs that provide care to meet the unique needs of older adults undergoing surgery and ultimately improve both patient outcomes and their surgical experience.

Management of symptomatic cholelithiasis: a systematic review.

BACKGROUND: Symptomatic cholelithiasis is a common surgical disease and accounts for half of the over one million cholecystectomies performed in the USA annually. Despite its prevalence, only one prior systematic review has examined the evidence around treatment strategies and it contained a narrow scope. The goal of this systematic review was to analyze the clinical effectiveness of treatment options for symptomatic cholelithiasis, including surgery, non-surgical therapies, and ED pain management strategies. METHODS: Literature search was performed from January 2000 through June 2020, and a narrative analysis was performed as studies were heterogeneous. RESULTS: We identified 12 publications reporting on 10 trials (9 randomized controlled trials and 1 observational study) comparing treatment methods. The studies assessed surgery, observation, lithotripsy, ursodeoxycholic acid, electro-acupuncture, and pain-management strategies in the emergency department. Only one compared surgery to observation. CONCLUSION: This work presents the existing data and underscores the current gap in knowledge regarding treatment for patients with symptomatic cholelithiasis. We use these results to suggest how future trials may guide comparisons between the timing of surgery and watchful waiting to create a set of standardized guidelines. Providing appropriate and timely treatment for symptomatic cholelithiasis is important to streamline care for a costly and prevalent disease. TRIAL REGISTRATION: PROSPERO Protocol Number: CRD42020153153.

Identifying vulnerable populations with symptomatic cholelithiasis at risk for increased health care utilization.

BACKGROUND: Gallstones are a common problem in the United States with many patients suffering from symptomatic cholelithiasis (SC). Patients with SC may first present to the emergency department ED) and are often discharged for elective follow-up; however, it is unknown what system and patient factors are associated with increased risk for ED revisits. This study aimed to assess longitudinal ED utilization and cholecystectomy for patients with SC and identify patient, geographic, and hospital characteristics associated with ED revisits, specifically race/ethnicity and insurance status. METHODS: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Emergency department revisits and cholecystectomy after discharge were examined using logistic regression, clustering standard errors by hospital. Models adjusted for patient, geographic, and hospital variables using census and hospital administrative data. RESULTS: Cohort included 34,427 patients who presented to the ED with SC and were discharged. There were 18.8% of the patients that had one or more biliary-related ED revisits within 1 year. In fully adjusted models, non-Hispanic Black patients had higher odds for any ED revisit (adjusted odds ratio 1.23; 95% confidence interval, 1.09-1.39) and for two more ED revisits (adjusted odds ratio 1.48; 95% confidence interval, 1.20-1.82). Insurance type was also associated with ED revisits. CONCLUSION: Non-Hispanic Black patients experienced higher utilization of health care resources for SC after adjusting for other patient, geographic and hospital variables. Strategies to mitigate these disparities may include the development of standardized protocols regarding the follow-up and education for SC. Implementation of such strategies can ensure equitable treatment for all patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Delay to Surgery for Patients with Symptomatic Cholelithiasis: Retrospective Analysis of an Administrative California Database after Discharge from the Emergency Department.

BACKGROUND: Timely receipt of surgery should be available for all patients. Few studies have examined differences in the treatment of symptomatic cholelithiasis (SC), a common surgical problem, based on race/ethnicity or insurance status. This study aimed to identify differences in repeat emergency department (ED) use and wait time to cholecystectomy for SC. STUDY DESIGN: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Repeat ED use and wait time to elective and nonelective cholecystectomy after ED discharge were examined using logistic and negative binomial regression models. RESULTS: The final cohort analyzed 13,596 patients who underwent cholecystectomy within 1 year from index ED visit for SC. In adjusted analysis, non-Hispanic Black patients had higher odds for repeat ED use for biliary-related conditions before elective surgery and experienced longer waits for cholecystectomy (across several measures of wait times) compared with non-Hispanic White patients. Similar findings were seen for Medicaid and self-pay compared with privately insured patients. For example, self-pay patients had more than double the odds of experiencing repeat ED use while waiting for elective cholecystectomy compared with privately insured patients (adjusted odds ratio 2.49, 95% CI 1.88-3.31). CONCLUSION: Patients with SC receiving cholecystectomy within 1 year from index ED visit were more likely to have repeat ED use and longer waits to surgery based on their race/ethnicity and insurance status, even after adjusting for other measures of access. We identify a vulnerable population at risk for differences in treatment for a common surgical pathology.

The Association of Frailty With Outcomes for Older Adults Undergoing Appendectomy.

BACKGROUND: Frailty is a potential modifiable predictor of surgical outcomes in older adults. The impact of frailty following appendectomy, a common urgent operation, is unknown for older adults. The study aim was to assess if frailty is associated with worse perioperative outcomes after appendectomy in older adults. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2016 to 2018 and identified patients 65 and older who underwent appendectomy for acute appendicitis. We identified frailty as a Modified Frailty Index (MFI) score ≥2. Multivariate logistic regression was used to assess the association of frailty with 30-day mortality, serious complications, readmission, and discharge to facility. RESULTS: Five thousand seven hundred twenty-eight older adults underwent appendectomy, of which 29.1% were 75 or older, 53.3% female, 74.9% non-Hispanic White, and 17.1% frail. Frail patients experienced worse outcomes: mortality (frail: 1.0% vs non-frail: .3%, P = .001), serious complications (14.2% vs 8.0%, P = <.0001), and discharge to facility (9.3% vs 2.3%, P < .0001). On multivariate logistic regression, frailty was associated with increased mortality (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.28-8.66), serious complications (OR 1.51; 95% CI: 1.17-1.93), and discharge to facility (OR 2.80; 95% CI: 2.00-3.93). Frailty was not significantly associated with readmission (P = .180). CONCLUSIONS: Frailty is associated with worse postoperative outcomes following appendectomy in older adults. As frailty is potentially modifiable, it should be routinely assessed and utilized in perioperative optimization and counseling, especially with respect to patient-centered outcomes.

Demographic Differences Among US Department of Veterans Affairs Patients Referred for Genetic Consultation to a Centralized VA Telehealth Program, VA Medical Centers, or the Community.

Importance: Telehealth enables access to genetics clinicians, but impact on care coordination is unknown. Objective: To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models. Design, Setting, and Participants: This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined. Exposures: Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA). Main Outcomes and Measures: Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral. Results: In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model. Conclusions and Relevance: In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.

Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care.

OBJECTIVE: Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients. SUMMARY OF BACKGROUND DATA: PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery. METHODS: We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion. RESULTS: After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care. CONCLUSIONS: This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.

Symptomatic Cholelithiasis: Do Minority Patients Experience Delays to Surgery?

BACKGROUND: Cholecystectomy is one of the most common surgeries and the majority are performed to treat symptomatic cholelithiasis (SC). While surgery is often elective, poor access or delays in care may lead to urgent cases, which are potentially associated with higher complication rates. This study aims to determine if minority patients with SC have higher rates of urgent cholecystectomy and postoperative complications. MATERIALS AND METHODS: Analysis of patients undergoing cholecystectomy for SC utilizing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2017 to 2019. Primary outcome was acuity of cholecystectomy (i.e., urgent versus elective). Secondary outcomes were any post-operative complication and length of stay. RESULTS: Patients who underwent cholecystectomy for SC between 2017 to 2019 (N: 13,390) were analyzed. Hispanic and non-Hispanic Black patients had higher odds of undergoing urgent surgery as compared to non-Hispanic White patients, and Hispanics had over twice the odds (adjusted odds ratio (aOR), 2.16; 95% CI 1.93-2.43), adjusting for age, sex, and comorbidities. Having urgent surgery was associated with higher odds for developing any postoperative complication and experiencing longer length of stay. After adjusting for urgency of surgery, Non-Hispanic Black and Asian patients were at risk for higher postoperative length of stay. CONCLUSIONS: Hispanic and non-Hispanic Black patients were more likely to undergo urgent cholecystectomy as compared to non-Hispanic White patients for SC. Urgent surgery was independently associated with a higher complication rate and longer length of stay. Further characterization of the delays to surgery that lead to these differences are critical to prevent further treatment disparities.