Enteral contrast in the computed tomography diagnosis of appendicitis: comparative effectiveness in a prospective surgical cohort.

OBJECTIVE: Our goal was to perform a comparative effectiveness study of intravenous (IV)-only versus IV + enteral contrast in computed tomographic (CT) scans performed for patients undergoing appendectomy across a diverse group of hospitals. BACKGROUND: Small randomized trials from tertiary centers suggest that enteral contrast does not improve diagnostic performance of CT for suspected appendicitis, but generalizability has not been demonstrated. Eliminating enteral contrast may improve efficiency, patient comfort, and safety. METHODS: We analyzed data for adult patients who underwent nonelective appendectomy at 56 hospitals over a 2-year period. Data were obtained directly from patient charts by trained abstractors. Multivariate logistic regression was utilized to adjust for potential confounding. The main outcome measure was concordance between final radiology interpretation and final pathology report. RESULTS: A total of 9047 adults underwent appendectomy and 8089 (89.4%) underwent CT, 54.1% of these with IV contrast only and 28.5% with IV + enteral contrast. Pathology findings correlated with radiographic findings in 90.0% of patients who received IV + enteral contrast and 90.4% of patients scanned with IV contrast alone. Hospitals were categorized as rural or urban and by their teaching status. Regardless of hospital type, there was no difference in concordance between IV-only and IV + enteral contrast. After adjusting for age, sex, comorbid conditions, weight, hospital type, and perforation, odds ratio of concordance for IV + enteral contrast versus IV contrast alone was 0.95 (95% CI: 0.72-1.25). CONCLUSIONS: Enteral contrast does not improve CT evaluation of appendicitis in patients undergoing appendectomy. These broadly generalizable results from a diverse group of hospitals suggest that enteral contrast can be eliminated in CT scans for suspected appendicitis.

Diagnostic imaging and biopsy use among elderly medicare beneficiaries with hepatocellular carcinoma.

PURPOSE: Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general community. PATIENTS AND METHODS: This cohort study used Surveillance, Epidemiology, and End Results (SEER) -Medicare data (2002-2005) evaluating biopsy, imaging modalities (ultrasound, computed tomography [CT] scan, and/or magnetic resonance imaging [MRI]), and HCC risk factors. RESULTS: Of 3,696 patients, 1,197 (32.4%) underwent one or more biopsies, with no change in yearly biopsy rate (trend test, P = .64). Patients with tumors > 5 cm were most likely to receive biopsies (35.3%), with increasing rates of biopsy for larger tumors (P = .001). Patients who received biopsies underwent more imaging than those who did not (P < .001) and were more likely to have an HCC risk factor. Tumor size > 5 cm in the setting of a concurrent HCC risk factor increased the odds of biopsy. In 47.8% of patients, the diagnostic sequence was not consistent with contemporary evidence-based guidelines. CONCLUSIONS: Despite widespread availability and use of CT scan and MRI, one third of HCC patients undergo biopsy, suggesting a problem with the performance and/or quality of diagnostic imaging or that providers do not believe imaging alone is sufficient to establish the diagnosis. Understanding factors that drive biopsy use may help improve the care of patients with HCC.

Neoadjuvant chemotherapy in the Medicare cohort with advanced ovarian cancer.

OBJECTIVE: The value of neoadjuvant chemotherapy (NAC) for the treatment of advanced ovarian cancer has yet to be determined. While NAC may facilitate and simplify complete cytoreduction and reduce the risk of surgery, the delay of surgery related to NAC needs to be balanced against any potential benefit. METHODS: Surveillance, Epidemiology and End-Results (SEER) data linked to Medicare claims were used to identify 6844 women with treated stage III/IV epithelial ovarian cancer (1995-2005). Patients were classified by primary treatment (surgery (PDS) or chemotherapy), and the primary chemotherapy group was characterized as having NAC or palliative chemotherapy (PC) based on whether there was documentation that surgery was recommended. We compared surgical complications and survival between the groups. RESULTS: 4827 (71%) of women were treated with PDS, 958 received NAC (14%) and 1059 (15%) had PC. Only 577 (60%) of women with NAC underwent surgery and they had fewer ostomies (8.5% vs. 19.2%, p<0.001) and fewer infections, gastrointestinal and pulmonary complications than PDS (all p<0.01). Comparing NAC to PDS there was a 16% increase in the risk of death at 2years (RR 1.16, 95%CI 1.01-1.34) for women with stage III disease and a 15% reduction in the risk for women with stage IV disease (RR 0.85, 95%CI 0.73-0.99). CONCLUSIONS: NAC followed by surgery was associated with fewer surgical complications than PDS. The direction and magnitude of the difference in survival between women receiving NAC and those receiving PDS differed according to the stage of disease and follow up time.

Thirty-day mortality after primary cytoreductive surgery for advanced ovarian cancer in the elderly.

OBJECTIVE: To identify factors associated with increased 30-day mortality after advanced ovarian cancer debulking among elderly women. METHODS: A database linking Medicare records with the Surveillance, Epidemiology, and End Results (SEER) data was used to identify a cohort of 5,475 women aged 65 and older who had primary debulking surgery for stage III or IV epithelial ovarian cancer (diagnosed 1995-2005). Women were stratified by acuity of hospital admission. Multivariable analysis was performed to identify patient-related and treatment-related variables associated with 30-day mortality. RESULTS: Five thousand four hundred seventy-five women had surgery for advanced ovarian cancer, and the overall 30-day mortality was 8.2%. Women admitted electively had a 30-day mortality of 5.6% (251 of 4,517), and those admitted emergently had a 30-day mortality of 20.1% (168 of 835). Advancing age, increasing stage, and increasing comorbidity score were all associated with an increase in 30-day mortality (all P<.05) among elective admissions. A group of women at high risk admitted electively included those aged 75 or older with stage IV disease and women aged 75 or older with stage III disease and a comorbidity score of 1 or more. This group had an observed 30-day mortality of 12.7% (95% confidence interval 10.7%-14.9%). CONCLUSION: Age, cancer stage, and comorbidity scores may be helpful to stratify electively admitted patients based on predicted postoperative mortality. If validated in a prospective cohort, then these factors may help identify women who may benefit from alternative treatment strategies. LEVEL OF EVIDENCE: II.

Trends in treatment of advanced epithelial ovarian cancer in the Medicare population.

OBJECTIVE: Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy. METHODS: Using the Surveillance, Epidemiology and End-Results data we identified a cohort of 8211 women aged 65 and above with stage III/IV epithelial ovarian cancer diagnosed between 1995 and 2005. Receipt of chemotherapy or surgery was identified using Medicare claims. Logistic regression was used to evaluate factors associated with sequencing of treatment and the receipt of surgery. RESULTS: 3241 (39.1%) had surgery and at least 6 cycles of chemotherapy in either order. Surgery was performed initially in 4827 (58.8%) women and 3658/4827 (75.8%) had subsequent chemotherapy. 2017 (24.6%) had primary chemotherapy and 649/2017 (32.2%) of these women had subsequent surgery. Advanced age, African American race, stage IV disease, non-married status and increasing medical comorbidity were all associated with the failure to receive both surgery and at least 6 cycles of chemotherapy (all p<0.01). CONCLUSIONS: The majority of women with advanced ovarian cancer in the Medicare population do not receive both combination therapy with surgery and at least 6 cycles of chemotherapy. A large proportion of women are receiving chemotherapy as primary treatment for advanced ovarian cancer, and the majority of these patients do not have cancer-directed surgery.

Trends in the utilization and impact of radiofrequency ablation for hepatocellular carcinoma.

BACKGROUND: The incidence of hepatocellular carcinoma (HCC) is rising and radiofrequency ablation (RFA) appears to be increasingly used. The nationwide use and impact of RFA have not been well characterized. STUDY DESIGN: We performed an historical cohort study of US patients 18 years old and older, with a diagnosis of HCC (n = 22,103) using the national Surveillance, Epidemiology, and End Results (SEER) limited-use database (1998 to 2005). Main outcomes measures were receipt of different therapeutic interventions (ablation, RFA, resection, or transplantation) and adjusted 1- and 2-year survivals. RESULTS: A total of 4,924 (22%) patients underwent any intervention, with a 93% increase over the 8-year study period (trend test, p < 0.001). RFA accounted for 43% of this increase. Despite increased use of therapeutic interventions, 1- and 2-year survival rates did not improve over time for patients in the study cohort (48% and 34%, 52% and 37%, 50% and 36%; in 1998, 2002, and 2004, respectively; p = 0.31). Among patients with solitary lesions, adjusted 1- and 2-year survivals remained stable over time after transplantation (97% and 94%, 95% and 89%, 94% and 86% in 1998, 2002, and 2004, respectively; p = 0.99) and RFA (86% and 64%, 76% and 54%, in 2002 and 2004, respectively; p = 0.97), but improved after resection (83% and 71%, 91% and 84%, 97% and 94% in 1998, 2002, and 2004, respectively; p = 0.03). CONCLUSIONS: Use of interventions for the treatment of HCC, and specifically RFA, have markedly increased over time. Because increased use of RFA among patients with potentially resectable disease is likely to occur, and because of a lack of high-level evidence supporting expanded indications, continued evaluation of the indications for RFA and subsequent outcomes among US patients is warranted.

Health care utilization among surgically treated Medicare beneficiaries with lung cancer.

BACKGROUND: Markers of increased health care utilization are surrogates for adverse events, and one such metric--prolonged length of stay greater than 14 days (PLOS)--was recently endorsed as a provider-level performance measure. METHODS: This is a cohort study (1992 through 2002) aimed to describe increased health care utilization among 21,067 operated lung cancer patients using the Surveillance, Epidemiology, and End-Results-Medicare database. Increased utilization was defined by PLOS, discharge to an institutional care facility (ICF), or readmission within 30 days. RESULTS: Twelve percent of patients had a PLOS, 13% were discharged to an ICF, and 15% were readmitted. In multivariate analyses, factors associated with a higher odds ratio of PLOS, discharge to ICF, or readmission included age older than 80 years, increasing comorbidity index, not being married, and pneumonectomy (all p < 0.05). Relative to patients living in the West, those in the Midwest or South had a higher odds ratio of PLOS and readmission but a lower odds ratio of discharge to an ICF (all p < 0.05). Adjusted rates of PLOS decreased significantly with time, whereas adjusted ICF and readmission rates increased (all p < 0.01). Patients who required increased utilization had higher adjusted 2.5-year mortality rates compared with those who did not (PLOS, 42% versus 20%; ICF, 32% versus 20%; readmission, 33% versus 19%; all p < 0.001). CONCLUSIONS: Baseline health status and nonclinical factors were associated with increased utilization, nonuniform trends in utilization were observed with time, and increased utilization was associated with worse long-term outcomes. These findings have implications for quality-improvement initiatives that measure increased health care utilization as a surrogate for provider performance.

Risk tolerance and bile duct injury: surgeon characteristics, risk-taking preference, and common bile duct injuries.

BACKGROUND: Little is known about surgeon characteristics associated with common bile duct injury (CBDI) during laparoscopic cholecystectomy (LC). Risk-taking preferences can influence physician behavior and practice. We evaluated self-reported differences in characteristics and risk-taking preference among surgeons with and without a reported history of CBDI. STUDY DESIGN: A mailed survey was sent to 4,100 general surgeons randomly selected from the mailing list of the American College of Surgeons. Surveys with a valid exclusion (retired, no LC experience) were considered responsive, but were excluded from data analysis. RESULTS: Forty-four percent responded (1,412 surveys analyzed), 37.7% reported being the primary surgeon when a CBDI occurred, and 12.9% had more than one injury. Surgeons reporting an injury were slightly older (52.8 +/- 9.0 years versus 51.3 +/- 9.8 years; p < 0.004) and in practice longer (20.8 +/- 9.7 years versus 18.9 +/- 10.5 years; p < 0.001). Surgeons not reporting a CBDI were more likely trained in LC during residency (63.3% versus 55.4% injuring) as compared with surgeons reporting a CBDI, who were more likely trained at an LC course (29.8% versus 38.2%). Surgeons in academic practice or who work with residents had lower reported rates of CBDI (7.9% versus 14.5% [academics]; 18.7% versus 25.0% [residents]). Mean risk score was 12.4 +/- 4.4 (range 6 to 30 [30 = highest]) with a similar average between those who did (12.2 +/- 4.5) and did not (11.9 +/- 4.4) report a CBDI (p < 0.23). Compared with surgeons in the lowest three deciles of risk score, relative risk for CBDI among surgeons in the upper three deciles was 17% greater (p = 0.07). CONCLUSIONS: More years performing LC and certain practice characteristics were associated with an increased rate of CBDI. The impact of extremes of risk-taking preference on surgical decision making can be an important part of decreasing adverse events during LC and should be evaluated.

Safety and efficacy of video-assisted versus conventional lung resection for lung cancer.

OBJECTIVE: We sought to evaluate the use of video-assisted thoracoscopy among patients with lung cancer and its safety and effectiveness relative to conventional resection. METHODS: A cohort study (1994-2002) was conducted by using the Surveillance, Epidemiology, and End-Results Medicare database. Video-assisted thoracoscopy and conventional resection were hypothesized to be equivalent in terms of risks of death. Equivalency was defined by a confidence interval of 0.72 to 1.28 for the odds of 30-day death and 0.89 to 1.11 for the hazard of death, corresponding to a difference of no more than 1% for 30-day mortality and 5% for 5-year survival, respectively. RESULTS: Among 12,958 patients who underwent segmentectomy or lobectomy (mean age, 74 +/- 5 years), 6% underwent video-assisted thoracoscopy. The use of video-assisted thoracoscopy increased from 1% to 9% between 1994 and 2002. Compared with those who underwent conventional resection, patients who underwent video-assisted thoracoscopy more frequently had smaller tumors (P < .001) and stage I disease (P = .03), underwent lymphadenectomy (P < .001), and were cared for by higher-volume surgeons (P < .001) and at higher-volume hospitals (P < .001). After adjusting for differences in patient, cancer, management, and provider characteristics, the odds of early death were not significantly different between patients undergoing video-assisted thoracoscopy and those undergoing conventional resection, although equivalency was not demonstrated (adjusted odds ratio, 0.93; 95% confidence interval, 0.57-1.50). The hazard of death was equivalent for video-assisted thoracoscopy and conventional resection (adjusted hazard ratio, 0.99; 95% confidence interval, 0.90-1.08). CONCLUSIONS: Video-assisted thoracoscopy was uncommonly used to manage lung cancer, although its use has increased over time. Video-assisted thoracoscopy and conventional resection were equivalent in terms of long-term survival.

Surgeon specialty and long-term survival after pulmonary resection for lung cancer.

BACKGROUND: Long-term outcomes and processes of care in patients undergoing pulmonary resection for lung cancer may vary by surgeon type. Associations between surgeon specialty and processes of care and long-term survival have not been described. METHODS: A cohort study (1992 through 2002, follow-up through 2005) was conducted using Surveillance, Epidemiology, and End-Results-Medicare data. The American Board of Thoracic Surgery Diplomates list was used to differentiate board-certified thoracic surgeons from general surgeons (GS). Board-certified thoracic surgeons were designated as cardiothoracic surgeons (CTS) if they performed cardiac procedures and as general thoracic surgeons (GTS) if they did not. RESULTS: Among 19,745 patients, 32% were cared for by GTS, 45% by CTS, and 24% by GS. Patient age, comorbidity index, and resection type did not vary by surgeon specialty (all p > 0.10). Compared with GS and CTS, GTS more frequently used positron emission tomography (36% versus 26% versus 26%, respectively; p = 0.005) and lymphadenectomy (33% versus 22% versus 11%, respectively; p < 0.001). After adjustment for patient, disease, and management characteristics, hospital teaching status, and surgeon and hospital volume, patients treated by GTS had an 11% lower hazard of death compared with those who underwent resection by GS (hazard ratio, 0.89; 99% confidence interval, 0.82 to 0.97). The risks of death did not vary significantly between CTS and GS (hazard ratio, 0.94; 99% confidence interval, 0.88 to 1.01) or GTS and CTS (hazard ratio, 0.94; 99% confidence interval, 0.87 to 1.03). CONCLUSIONS: Lung cancer patients treated by GTS had higher long-term survival rates than those treated by GS. General thoracic surgeons performed preoperative and intraoperative staging more often than GS or CTS.

Racial disparities among patients with lung cancer who were recommended operative therapy.

HYPOTHESIS: Health care system and provider biases and differences in patient characteristics are thought to be prevailing factors underlying racial disparities. The influence of these factors on the receipt of care would likely be mitigated among patients who are recommended optimal therapy. We hypothesized that there would be no significant evidence of racial disparities among patients with early-stage lung cancer who are recommended surgical therapy. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of patients in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stage I or II lung cancer between January 1, 1992, and December 31, 2002 (follow-up through December 31, 2005). MAIN OUTCOME MEASURES: Receipt of lung resection and overall survival. RESULTS: Among 17,739 patients who were recommended surgical therapy (mean [SD] age, 75 [5] years; 89% white, 6% black), black patients less frequently underwent resection compared with white patients (69% vs 83%, respectively; P < .001). After adjustment, black race was associated with lower odds of receiving surgical therapy (odds ratio = 0.43; 99% confidence interval, 0.36-0.52). Unadjusted 5-year survival rates were lower for black patients compared with white patients (36% vs 42%, respectively; P < .001). After adjustment, there was no significant association between race and death (hazard ratio = 1.03; 99% confidence interval, 0.92-1.14) despite a 14% difference in receipt of optimal therapy. CONCLUSIONS: Even among patients who were recommended surgical therapy, black patients underwent lung resection less often than white patients. Unexpectedly, racial differences in the receipt of optimal therapy did not appear to affect outcomes. These findings suggest that distrust, beliefs and perceptions about lung cancer and its treatment, and limited access to care (despite insurance) might have a more dominant role in perpetuating racial disparities than previously recognized.

Multi-modality mediastinal staging for lung cancer among medicare beneficiaries.

INTRODUCTION: The use of noninvasive and invasive diagnostic tests improves the accuracy of mediastinal staging for lung cancer. It is unknown how frequently multimodality mediastinal staging is used, or whether its use is associated with better health outcomes. METHODS: A cohort study was conducted using Surveillance, Epidemiology, and End Results-Medicare data (1998-2005). Patients were categorized as having undergone single (computed tomography [CT] only), bi- (CT and positron emission tomography or CT and invasive staging), or tri-modality (CT, positron emission tomography, and invasive staging) staging. RESULTS: Among 43,912 subjects, 77%, 21%, and 2% received single, bi-, and tri-modality staging, respectively. The use of single modality staging decreased over time from 90% in 1998 to 67% in 2002 (p-trend <0.001), whereas the use of bi- and tri-modality staging increased from 10% to 30% and 0.4% to 5%, respectively. After adjustment for differences in patient characteristics, the use of a greater number of staging modalities was associated with a lower risk of death (bi- versus single modality: hazard ratio [HR] 0.58, 99% confidence interval [CI] 0.56-0.60; tri- versus single modality: HR 0.49, 99% CI 0.45-0.54; tri- versus bi-modality: HR 0.85, 99% CI 0.77-0.93). These associations were maintained even after excluding stage IV patients or adjustment for stage. CONCLUSIONS: The use of multimodality mediastinal staging increased over time and was associated with better survival. Stage migration and unmeasured patient and provider characteristics may have affected the magnitude of these associations. Cancer treatment guidelines should emphasize the potential relationship between staging procedures and outcomes, and health care policy should encourage adherence to staging guidelines.

Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To evaluate negative appendectomy (NA) and the relationship of NA and computed tomography (CT) and/or ultrasound (US). SUMMARY BACKGROUND INFORMATION: NA may be influenced by the use and accuracy of preoperative CT/US. The Surgical Care and Outcomes Assessment Program (SCOAP) gathers chart-abstracted process of care data (such as CT/US accuracy) for general surgical procedures (including appendectomy) at most Washington State hospitals. METHODS: We determined the prevalence of NA and CT/US concordance at the 15 SCOAP hospitals with >50 consecutive patients undergoing appendectomy (2006-2007). RESULTS: The number of patients who underwent urgent appendectomies was 3540. The percentage of patients who had imaging (CT-91%) was 86% (women-89%, men-83%). The use of imaging ranged across hospitals from 56% to 97%. There was 91% agreement between imaging and pathology report findings (92.3%-CT and 82.4%-US). The overall rate of NA was 6% (women-8%, men-4%). The prevalence of NA was 9.8% among patients having no imaging, 8.1% among those having an US, and 4.5% in those having a CT. Among patients with NA, CT/US was obtained in 75%; correct in 10% and incorrect or ambiguous in 65%. Higher rates of NA were correlated with lower rates of CT/US concordance (r = -0.57). There was no significant difference in rates of perforation between those with (17%) and without (15%) imaging (P = 0.2). There were significant increases in the use of CT/US and decreases in NA over the time period (P < 0.01). CONCLUSIONS: The prevalence of NA at SCOAP hospitals decreased significantly. Variation in NA between hospitals was linked closely to CT/US accuracy suggesting CT/US accuracy should be considered a measure of quality in the care of patients with presumed appendicitis.

Reoperation for urinary incontinence.

OBJECTIVE(S): The objective of the study was to describe the rate and associated factors of reoperation for urinary incontinence. STUDY DESIGN: A cohort study using Washington state hospitalization records from 1987 to 2005 of inpatient urinary incontinence surgeries. The cumulative reoperation rate was estimated for the entire cohort and by procedure. Cox regression was used to estimate the hazard of reoperation. RESULTS: A total of 41,705 women underwent either a sling or retropubic colposuspension (Burch); 1895 underwent reoperation for urinary incontinence (8.6%; 95% confidence interval, 7.8-9.5%), a rate of 5.5 per 1000 woman-years. Women undergoing Burch had a lower reoperation rate than those undergoing slings (4.2 vs 6.7 per 1000 woman-years; P < .001). Concomitant hysterectomy was associated with a lower reoperation rate for Burch and sling repairs (5.4-2.9 and 7.7-4.2 per 1000 woman-years). CONCLUSION(S): Reoperation for urinary incontinence occurs commonly in the general population. The variable reoperation rate observed should be further investigated, given current trends toward increased Sling use.

Trends in the operative management and outcomes of T4 lung cancer.

BACKGROUND: This study describes temporal trends and variables in the operative management and outcomes of patients with T4 lung tumors in the general community. METHODS: Surveillance, Epidemiology, and End-Results-Medicare data were used for a cohort study (1992 to 2002) of patients with stage IIIB lung cancer defined by T4 tumors. Patient characteristics, tumor size, nodal status, use of staging modalities, extent of resection, multi-modality therapy, and provider volume were examined. Follow-up death data were available through 2005. RESULTS: Among 13,077 cases of T4 lung tumors, 1177 patients (9%) underwent resection. Over time, use of mediastinoscopy (20%) did not change (p = 0.49); mediastinal lymphadenectomy increased from 10% to 29% (p < 0.001) and neoadjuvant therapy from 4% to 8% (p = 0.04). Five-year survival rates increased from 15% to 35% (p < 0.001). A higher hazard of death was associated with increasing age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00 to 1.03), comorbidity index of 3 vs 0 (HR, 1.66; 95% CI 1.24 to 2.21), tumor size 3 cm or more (HR, 1.55; 95% CI, 1.30 to 1.84), N2/N3 nodes (HR, 1.67; 95% CI, 1.40 to 1.98), and sublobar resection (HR, 1.55; 95% CI, 1.26 to 1.90). Mediastinal lymphadenectomy had a significantly lower hazard of death (HR, 0.78; 95% CI, 0.64 to 0.95). Improvements in overall survival over time persisted after adjustment for these factors (p = 0.007). CONCLUSIONS: Temporal changes in the operative management of T4 tumors coincided with improvements in long-term survival. Our findings corroborate prior work and practice guidelines supporting operative therapy for select patients with T4 lung cancer.

Surgeon knowledge, behavior, and opinions regarding intraoperative cholangiography.

BACKGROUND: The risk of common bile duct injury during laparoscopic cholecystectomy (LC) is 50% to 70% lower when an intraoperative cholangiogram (IOC) is used, and this effect is exaggerated among less experienced surgeons. Routine IOC is not universal, and barriers to its use, including surgeon knowledge, behavior, and attitudes, should be understood in developing quality-improvement interventions aimed at increasing IOC use. STUDY DESIGN: There were 4,100 general surgeons randomly selected from the American College of Surgeons who were mailed a survey about IOC. Surveys with a valid exclusion (retired, no LC experience) were considered responsive but were excluded from data analysis. RESULTS: Forty-four percent responded, with 1,417 surveys analyzed (mean age 51.8+/-9.6 years; 89.2% men; 55.3% private practice). Twenty-seven percent of respondents defined themselves as routine IOC users and 91.3% of routine users reported IOC use in more than 75% of LCs performed. Academic surgeons were less often routine users compared with nonacademics (15% versus 30%; p < 0.001). Selective users were more often low-volume (less than 20 LC/year) surgeons (8% versus 15%) as compared with routine users, who were more often high-volume (more than 100 LC/year) surgeons (27% versus 20%). Routine users had more favorable and accurate opinions about IOC (less costly and more protective of injury) than did selective users. Thirty-nine percent of routine users thought IOC decreased the risk of common bile duct injury by at least half compared with 10% of selective users. CONCLUSIONS: Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement interventions aimed at broader IOC use.

Management of pleural space infections: a population-based analysis.

OBJECTIVE: Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management strategies and their associated outcomes. METHODS: A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004. RESULTS: Four thousand four hundred twenty-four patients (age, 57.1 +/- 18.6 years; 67% male; comorbidity index, 1.1 +/- 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 (P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 +/- 17.6 years vs 61.5 +/- 18.6 years, P < .001) and had a lower comorbidity index (0.8 +/- 1.6 vs 1.4 +/- 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management. CONCLUSIONS: The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.