Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better?

INTRODUCTION: Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. METHODS: We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). RESULTS: A total of 165 (median age 63 years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. CONCLUSION: Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.

A Mixed-Methods Evaluation of Patient Education Materials for Colorectal Cancer.

BACKGROUND: Patient education materials are created by professional organizations to inform patients about their disease and its treatment. However, it remains unclear if these materials are appropriate for patients. OBJECTIVE: This study aims to broadly evaluate the education materials for patients with colorectal cancer. DESIGN: Patient education materials from the National Comprehensive Cancer Network, the National Cancer Institute, and the American Society of Colon and Rectal Surgeons were assessed quantitatively by using 1) the Flesch-Kincaid readability formula and 2) the Patient Education Material Assessment Tool. The Patient Education Material Assessment Tool scores materials in 2 domains: understandability and actionability. These materials were further evaluated qualitatively via an exploratory focus group with patients and their caregivers (n = 5) and semi-structured interviews with board-certified/eligible colorectal surgeons (n = 10). SETTING: This study was conducted at academic centers and a regional professional society meeting. PARTICIPANTS: The mean patient age was 63. Most surgeons (8/10) practiced in an academic setting, and 4/10 were female. MAIN OUTCOME MEASURES: The primary outcomes measured were reading grade level and domain scores for the Patient Education Material Assessment Tool. Qualitative data were recorded, transcribed, and coded. Themes were generated through data interpretation and data reduction. RESULTS: Materials ranged from 7th to 11th grade reading level. National Comprehensive Cancer Network materials scored highest for understandability (92.2% ± 6.1%, mean ± SD), followed by National Cancer Institute (84.0% ± 6.6%) and American Society of Colon and Rectal Surgeons (82.2% ± 6.3%) materials. Actionability scores varied; the National Comprehensive Cancer Network materials scored 82.5% ± 1.7%, whereas the National Cancer Institute and American Society of Colon and Rectal Surgeons materials scored 23.3% ± 6.7% and 50.0% ± 8.2%. Critical gaps were identified in the content of these materials. Patients wanted more information about self-care, both emotional and physical. Specifically, patients sought details about postoperative bowel function. Whereas surgeons wanted information about the typical hospital course and recovery, all wanted materials to be customizable. LIMITATIONS: A limited number of materials were reviewed, and patient focus groups were exploratory. CONCLUSIONS: Commonly available printed education materials for colorectal cancer are written at a high reading grade level, vary in their usability, and neglect important details about postoperative recovery. See Video Abstract at http://links.lww.com/DCR/B535. EVALUACIN DE MTODOS MIXTOS DE MATERIALES EDUCATIVOS PARA PACIENTES SOBRE CNCER COLORECTAL: ANTECEDENTES:Los materiales educativos para pacientes son creados por organizaciones profesionales para informar a los pacientes sobre su enfermedad y su tratamiento. Sin embargo, no está claro si estos materiales son apropiados para los pacientes.OBJETIVO:Evaluar ampliamente los materiales para el cáncer colorrectal.DISEÑO:Los materiales educativos para pacientes de la Red Nacional Integral del Cáncer (NCCN), el Instituto Nacional del Cáncer (NCI) y la Sociedad Americana de Cirujanos de Colon y Recto (ASCRS) se evaluaron cuantitativamente utilizando (1) la fórmula de legibilidad de Flesch-Kincaid y (2) la herramienta de evaluación de material educativo para pacientes. La Herramienta de evaluación de materiales educativos para pacientes califica los materiales en dos dominios: comprensibilidad y viabilidad. Estos materiales fueron evaluados cualitativamente a través de un grupo de enfoque exploratorio con pacientes y sus cuidadores (n = 5) y entrevistas semiestructuradas con cirujanos colorrectales certificados o elegibles para certificación por el consejo (n = 10).ESCENARIO:Centros académicos y un encuentro regional de una sociedad profesional.PACIENTES:La edad media de los pacientes fue de 63 años. La mayoría de los cirujanos (8/10) practicaban en un entorno académico, y 4/10 eran mujeres.PRINCIPALES MEDIDAS DE RESULTADO:Nivel de grado de lectura y puntajes de dominios para la Herramienta de evaluación de materiales educativos para pacientes. Los datos cualitativos se registraron, transcribieron y codificaron. Los temas se generaron mediante la interpretación y la reducción de datos.RESULTADOS:Los materiales variaron desde el nivel de lectura del 7° al 11° grado. Los materiales de la NCCN obtuvieron la puntuación más alta en comprensibilidad (92.2 ± 6.1%, media ± DE), seguidos por los materiales de NCI (84.0 ± 6.6%) y ASCRS (82.2 ± 6.3%). Los puntajes de viabilidad variaron; Los materiales de NCCN obtuvieron una puntuación de 82.5 ± 1.7%, mientras que los materiales de NCI y ASCRS obtuvieron una puntuación de 23.3 ± 6.7% y 50.0 ± 8.2%, respectivamente. Se identificaron lagunas críticas en el contenido de estos materiales. Los pacientes querían más información sobre el autocuidado, tanto emocional como físico. Específicamente, los pacientes buscaron detalles sobre la función intestinal posoperatoria. Mientras que los cirujanos querían información sobre el curso hospitalario típico y la recuperación, y todos querían que los materiales fueran personalizables.LIMITACIONES:Se revisó una cantidad limitada de materiales y los grupos de enfoque de pacientes fueron exploratorios.CONCLUSIONES:Los materiales educativos impresos comúnmente disponibles para el cáncer colorrectal están escritos a un alto nivel de grado de lectura, varían en su usabilidad y omiten detalles importantes sobre la recuperación postoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B535.

What Are the Long-Term Changes to Bowel Function Patient-reported Outcomes After Elective Sigmoidectomy for Diverticular Disease?: Observational Study of Patients Undergoing Elective Sigmoidectomy for Diverticular Disease.

Objective: To evaluate long-term changes to bowel function after elective sigmoidectomy for diverticular disease. Background: For patients with diverticular disease, choosing surgery is often based on the presumption of improvement in preoperative symptoms. Our group previously reported bowel function does not change in the early perioperative period; however, studies of long-term outcomes are limited. Methods: This is an observational study of patients that underwent elective sigmoidectomy for diverticular disease and completed the Colorectal Functional Outcome (COREFO) questionnaire before surgery. Patients were stratified into two groups based on presence or absence of a preoperative symptomatic score (i.e., total COREFO ≥ 15). Long-term bowel function (>1 year from surgery) was assessed using the COREFO questionnaire via telephone or subsequent clinic visit. Paired t-tests compared mean preoperative scores to mean long-term scores. Results: Fifty-one patients met inclusion criteria (21 symptomatic, 30 asymptomatic). All symptomatic patients had uncomplicated disease, whereas 90% of asymptomatic patients had complicated disease. Median time from operation to questionnaire completion was 23 months (IQR = 13-34). Asymptomatic patients demonstrated impaired bowel function, predominantly driven by changes in the social impact domain. Symptomatic patients demonstrated improved bowel function, driven by changes in the incontinence, social impact, stool-related aspects, and need for medication domains. Conclusions: In the long-term after elective sigmoidectomy for diverticular disease, patients with symptomatic bowel function preoperatively improve substantially, while those with asymptomatic preoperative scores demonstrate statistically significant impairment. Patients determined to be symptomatic with patient-reported outcomes likely benefit long-term from sigmoid resection.Mini-Abstract: In this manuscript, long-term changes to patient-reported bowel function were assessed using a validated questionnaire after sigmoidectomy for diverticular disease. We found that in patients with symptomatic preoperative bowel function, long-term bowel function improved after elective resection. Alternatively, patients with asymptomatic preoperative bowel function demonstrated long-term impairment in bowel function.

Medicare costs for endovascular abdominal aortic aneurysm treatment in the Vascular Quality Initiative.

BACKGROUND: Reintervention after endovascular repair (EVR) of abdominal aortic aneurysms is common. However, the cumulative financial impact of reintervention after EVR on a national scale is poorly defined. Our objective was to describe the cost to Medicare for aneurysm treatment (EVR plus reinterventions) among a cohort of patients with known follow-up for 5 years after repair. METHODS: We identified patients who underwent EVR within the Vascular Quality Initiative who were linked to their respective Medicare claims file (n = 13,995). We excluded patients who underwent EVR after September 30, 2010, and those who had incomplete Medicare coverage (n = 12,788). The remaining cohort (n = 1207) had complete follow-up until death or 5 years (Medicare data available through September 30, 2015). We then obtained and compiled the corresponding Medicare reimbursement data for the index EVR hospitalization and all subsequent reinterventions. RESULTS: We studied 1207 Medicare patients who underwent EVR and had known follow-up for reinterventions for 5 years. The mean age was 76.2 years (±7.1 years), 21.6% of patients were female, and 91.1% of procedures were elective. The Kaplan-Meier reintervention rate at 5 years was 18%. Among patients who underwent reintervention, 154 (73.7%) had a single reintervention, 40 (19.1%) had two reinterventions, and 15 (7.2%) had three or more reinterventions. The median cost to Medicare for the index EVR hospitalization was $25,745 (interquartile range, $21,131-$28,774). The median cost for subsequent reinterventions was $22,165 (interquartile range, $17,152-$29,605). The cumulative cost to Medicare of aneurysm treatment (EVR plus reinterventions) increased in a stepwise fashion among patients who underwent multiple reinterventions, with each reintervention being similar in cost to the index EVR. CONCLUSIONS: The overall cost incurred by Medicare to reimburse for each reintervention after EVR is roughly the same as for the initial procedure itself, meaning that Medicare cost projections would be greater than $100,000 for any individual who undergoes an EVR with three reinterventions. The long-term financial impact of EVR must be considered by surgeons, patients, and healthcare systems alike as these cumulative costs may hinder the fiscal viability of an EVR-first therapeutic approach and highlight the need for judicious patient selection paradigms.

Medicare reimbursement of lower extremity bypass does not cover cost of care for most patients with critical limb ischemia.

OBJECTIVE: Lower extremity bypass surgery remains an important treatment option for patients with critical limb ischemia (CLI), but is resource intensive. We sought to evaluate the cost and Medicare reimbursement for lower extremity bypass surgery in patients with CLI. METHODS: Hospital cost accounting systems were queried for total technical and professional costs incurred and reimbursement received for patients with CLI undergoing lower extremity bypass at our center between 2011 and 2017. Patients were identified by assignment to Diagnosis-Related Group (DRG) 252, 253, or 254 (other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity, respectively). Additional clinical data were incorporated from the Vascular Quality Initiative clinical registry. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by DRG. We compared technical, professional, and total costs; reimbursement; and contribution margins across DRGs using univariate statistics and evaluated factors associated with total contribution margin using median quantile regression. RESULTS: We analyzed 68 patients with hemodynamically confirmed CLI (46% rest pain, 54% tissue loss), of whom 25% received a prosthetic graft. Mean age was 66.1 ± 11.6 years, 69% were male, 49% diabetic, 44% current smokers, and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex DRG 252 (median, $2490; interquartile range [IQR], -$1,621 to $10,080). In the majority of patients with less complex DRG 253 (median, -$3,100; IQR, -$8499 to $109) and DRG 254 (median, -$4902; IQR, -$9259 to $1059), reimbursement did not cover the cost of care. Both technical costs and professional costs varied significantly with the complexity of DRG. Although reimbursement from technical services increased alongside increasing complexity of DRG, there was insignificant variation in professional reimbursement as DRG complexity increased. On multivariable modeling, longer length of stay (-$2547 per additional day) and preoperative dialysis (-$5555) were significantly associated with negative margins. CONCLUSIONS: For the majority of patients with CLI, current Medicare reimbursement does not adequately cover the cost of providing care after open bypass surgery. As commercial insurers move toward Medicare reimbursement rates, more granular risk stratification profiles are needed to ensure open surgical care for patients with CLI remains financially sustainable.

A Comparison of Surgical Quality and Patient Satisfaction Indicators Between VA Hospitals and Hospitals Near VA Hospitals.

BACKGROUND: The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act established a community care program allowing veterans to receive care outside Veteran Affairs Medical Centers (VAMCs). We sought to compare patient safety and satisfaction indicators from VAMCs and surrounding non-VAMCs (non-VAs). METHODS: We identified VAMCs with at least one non-VA acute care hospital within 25 miles in three geographic regions (West/Southwest, New England, and Deep South). Children's, specialty, and critical access hospitals were excluded. Using publicly available Hospital Compare data, we analyzed VAMC and surrounding non-VA performance in postsurgical patient safety indicator (PSI) events and Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores and hospital star ratings. RESULTS: The 34 VAMCs performed better than 319 surrounding non-VAs in rates of wound dehiscence, accidental lacerations, and perioperative hemorrhage/hematoma as well as composite PSI rating (P < 0.05). VAMCs performed significantly better than non-VAs (18.0 versus 51.4 events per 1000 patients, P < 0.001) in composite surgery-specific PSIs. When comparing mean linear Hospital Consumer Assessment of Healthcare Providers and Systems score star ratings (1-5 scale), VAMCs had similar performance in overall hospital rating compared with non-VAs (3.28 versus 3.38, P = 0.48) and summary rating of hospital stays (2.87 versus 2.92, P = 0.69). When compiled patient satisfaction star ratings were compared, there was no difference (2.96 versus 2.97, P = 0.9). VAMCs performed worse than non-VAs in "would recommend" ratings (2.7 versus 3.13, P = 0.007). CONCLUSIONS: Across disparate regions, VAMCs match or outperform neighboring non-VAs in surgical quality metrics and patient satisfaction ratings. Veterans receiving surgical care at VAMCs may receive equivalent or better care than at non-VAs.

Gender Representation by Specialty Track at Surgical Meetings: The American and Australasian Experiences.

BACKGROUND: We compared the representation of women panelists at two large, general interest surgical meetings: the American College of Surgeons (ACS) Clinical Congress and Royal Australasian College of Surgeons (RACS) Scientific Congress. MATERIALS AND METHODS: We performed comprehensive analyses of panels and panelists at ACS and RACS meetings (2013-2018). Manual review was conducted to determine counts and proportions of invited panelists by gender. We made within- and between-meeting comparisons regarding gender representation by specialty track. Tracks were characterized after our review of meeting programs. RESULTS: There were 4542 panelists and 1390 panels at RACS from 2013 to 2018. At ACS, there were 3363 panelists over 693 panels. The specialty tracks with the highest proportion of men-only panels were transplant (75%) and cardiothoracic (63%) at ACS and cardiothoracic (83%) and multidisciplinary (81%) at RACS. The lowest proportions of men-only panels were in breast and pediatric surgery at ACS (5% and 11%, respectively) and breast and rural surgery at RACS (24% and 36%, respectively). At ACS, the highest proportions of women panelists were on panels in breast (63%) and endocrine surgery (48%) and in breast (44%) and rural surgery (33%) at RACS, while the lowest proportion of women panelists were in transplant (10%) and cardiothoracic (14%) at ACS and multidisciplinary (8%) and cardiothoracic (7%) at RACS. CONCLUSIONS: There is a persistent difference in gender representation at surgical meetings, particularly within certain subspecialties. Program chairs and committees could increase the proportion of women by focusing on who serves as panelists overall and within specialty tracks.

Longitudinal Spending on Endovascular and Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Endovascular repair (EVR) has replaced open surgery as the procedure of choice for patients requiring elective abdominal aortic aneurysm (AAA) repair. Long-term outcomes of the 2 approaches are similar, making the relative cost of caring for these patients over time an important consideration. METHODS AND RESULTS: We linked Medicare claims to Vascular Quality Initiative registry data for patients undergoing elective EVR or open AAA repair from 2004 to 2015. The primary outcome was Medicare's cumulative disease-related spending, adjusted to 2015 dollars. Disease-related spending included the index operation and associated hospitalization, surveillance imaging, reinterventions (AAA-related and abdominal wall procedures), and all-cause admissions within 90 days. We compared the incidence of disease-related events and cumulative spending at 90 days and annually through 7 years of follow-up. The analytic cohort comprised 6804 EVR patients (median follow-up: 1.85 years; interquartile range: 0.82-3.22 years) and 1889 open repair patients (median follow-up: 2.62 years; interquartile range: 1.13-4.80 years). Spending on index surgery was significantly lower for EVR (median [interquartile range]: $25 924 [$22 280-$32 556] EVR versus $31 442 [$24 669-$40 419] open; P<0.001), driven by a lower rate of in-hospital complications (6.6% EVR versus 38.0% open; P<0.001). EVR patients underwent more surveillance imaging (1.8 studies per person-year EVR versus 0.7 studies per person-year open; P<0.001) and AAA-related reinterventions (4.0 per 100 person-years EVR versus 2.1 per 100 person-years open; P=0.041). Open repair patients had higher rates of 90-day readmission (12.9% EVR versus 17.8% open; P<0.001) and abdominal wall procedures (0.6 per 100 person-years EVR versus 1.5 per 100 person-years open; P<0.001). Overall, EVR patients incurred more disease-related spending in follow-up ($7355 EVR versus $2706 open through 5 years). There was no cumulative difference in disease-related spending between surgical groups by 5 years of follow-up (-$33 EVR [95% CI: -$1543 to $1476]). CONCLUSIONS: We observed no cumulative difference in disease-related spending on EVR and open repair patients 5 years after surgery. Generalized recommendations about which approach to offer elective AAA patients should not be based on relative cost.

A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Patients who undergo endovascular aneurysm repair (EVAR) often require reintervention after the index repair. The long-term rate of reintervention and how this has changed with newer device technology are poorly understood. Therefore, we performed a systematic review and meta-analysis of the available literature to determine long-term freedom from reintervention after EVAR and the change in reintervention rates over time. METHODS: We performed a systematic review of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials and observational studies that documented the rate of reintervention after EVAR. We performed a meta-analysis of Kaplan-Meier freedom from reintervention at each year after EVAR. We used linear regression to evaluate change in reintervention rate over time with newer device technology. RESULTS: We included a total of 30 studies (randomized trials, n = 3; observational studies, n = 27) comprising 32,126 patients in this review and meta-analysis. Studies ranged in the implantation date of the EVAR device from 1996 to 2014. The probability of freedom from reintervention was 81% (95% confidence interval [CI], 77%-85%) at 5 years, 70% (95% CI, 65%-76%) at 10 years, and 64% (95% CI, 46%-79%) at 14 years. Linear regression demonstrated an improvement in freedom from reintervention when results were stratified by the year of device implantation. At 1 year, estimated freedom from reintervention improved from 90% in 1998 to 94% in 2008 (n = 26 studies; R2 = 0.11; P = .10). At three years, estimated freedom from reintervention improved from 77% in 1998 to 90% in 2008 (n = 26 studies; R2 = 0.27; P = .006). At 5 years, estimated freedom from reintervention improved from 68% in 1998 to 81% in 2008 (n = 22 studies; R2 =0.12; P = .12). At 7 years, estimated freedom from reintervention improved from 51% in 1998 to 86% in 2011 (n = 22 studies; R2 = 0.40; P = .015). CONCLUSIONS: EVAR patients remain at risk for reintervention indefinitely, and therefore lifelong surveillance is imperative. Encouragingly, reintervention rates have improved over time, with newer devices exhibiting lower rates. Reintervention rate remains an important metric for new devices and registries.

Translating coding lists in administrative claims-based research for cardiovascular procedures.

BACKGROUND: To effectively use administrative claims for healthcare research, clinical events must be inferred from coding data according to validated algorithms. In October 2015, the United States transitioned from the International Classification of Diseases Ninth Revision (ICD-9) to the Tenth Revision (ICD-10). We describe our method to derive new ICD-10 codes for outcomes after vascular procedures from our prior, validated ICD-9 codes. METHODS: We began with validated ICD-9 coding lists known to represent outcomes after lower extremity revascularization, thoracic aortic endograft placement, abdominal aortic aneurysm reintervention, and carotid revascularization. We used the publicly available general equivalence mapping tools to derive corresponding ICD-10 codes for each of the ICD-9 codes in our current lists. The resulting lists were then manually reviewed by multiple authors to ensure clinical relevance for appropriate event detection. Clinically nonrelevant and duplicated codes were removed. RESULTS: A total of 475 ICD-9 codes were translated to ICD-10 with a 98-fold increase (n = 46,630) in the total number of codes. Overall, we found that 77% of codes (n = 35,833) were either duplicated or not clinically relevant upon manual review. For example, for thoracic aortic endograft placement, 97 ICD-9 codes mapped to 14,661 ICD-10 codes in total. A total of 890 codes were removed as duplicates and 9035 codes were removed during manual clinical review. The resultant, reviewed list contained 4736 ICD-10 codes representing a 49-fold increase from the initial ICD-9 list. Findings were similar across the other procedures studied. CONCLUSIONS: ICD-10 has expanded the number of codes necessary to describe outcomes after vascular procedures. More than 75% of the codes obtained using the general equivalence mapping database were either duplicated or not clinically relevant. Manual review of codes by researchers with clinical knowledge of the procedures is imperative.

Characterizing Reimbursements for Medicare Patients Receiving Endovascular Abdominal Aortic Aneurysm Repair at Vascular Quality Initiative Centers.

BACKGROUND: Endovascular aortic aneurysm repair (EVR) has a major financial impact on health care systems. We characterized reimbursement for index EVR hospitalizations among Medicare beneficiaries having surgery at Vascular Quality Initiative (VQI) centers. METHODS: We linked Medicare claims to VQI clinical registry data for patients undergoing EVR from 2003 to 2015. Analysis was limited to patients fully covered by fee-for-service Medicare parts A and B in the year of their operation and assigned a corresponding diagnosis-related group for EVR. The primary outcome was Medicare's reimbursement for inpatient hospital and professional services, adjusted to 2015 dollars. We performed descriptive analysis of reimbursement over time and univariate analysis to evaluate patient demographics, clinical characteristics, procedural variables, and postoperative events associated with reimbursement. This informed a multilevel regression model used to identify factors independently associated with EVR reimbursement and quantify VQI center-level variation in reimbursement. RESULTS: We studied 9,403 Medicare patients who underwent EVR at VQI centers during the study period. Reimbursements declined from $37,450 ± $9,350 (mean ± standard deviation) in 2003 to $27,723 ± $10,613 in 2015 (test for trend, P < 0.001). For patients experiencing a complication (n = 773; 8.2%), mean reimbursement for EVR was $44,858 ± $23,825 versus $28,857 ± $9,258 for those without complications (P < 0.001). Intestinal ischemia, new dialysis requirement, and respiratory compromise each doubled Medicare's average reimbursement for EVR. After adjusting for diagnosis-related group, several patient-level factors were independently associated with higher Medicare reimbursement; these included ruptured abdominal aortic aneurysm (+$2,372), additional day in length of stay (+$1,275), and being unfit for open repair (+$501). Controlling for patient-level factors, 4-fold variation in average reimbursement was seen across VQI centers. CONCLUSIONS: Reimbursement for EVR declined between 2003 and 2015. We identified preoperative clinical factors independently associated with reimbursement and quantified the impact of different postoperative complications on reimbursement. More work is needed to better understand the substantial variation observed in reimbursement at the center level.

Psychosocial Outcomes Following Adolescent Metabolic and Bariatric Surgery: a Systematic Review and Meta-Analysis.

BACKGROUND: Metabolic and bariatric surgery is an effective strategy to curb the natural history of obesity progression and improve psychosocial status in the short term for adolescents with severe obesity. The medium- and long-term psychosocial impact of bariatric surgery in this population is not established. METHODS: We searched MEDLINE (Ovid), EMBASE, Web of Science, PsycInfo, and the Cochrane Libraries through October 2017 for reports of weight loss surgery (roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding) on adolescents with severe obesity (age ≤ 21 years) having ≥ 6 months of follow-up. The primary outcome for inclusion in systematic review was use of a validated quality of life (QoL) or other psychosocial instrument at baseline and postoperatively. We used standardized mean difference (SMD) and random-effects modeling to provide summary estimates across different instruments. RESULTS: We reviewed 5155 studies, of which 20 studies met inclusion criteria for qualitative synthesis. There were 14 studies and 9 unique cohorts encompassing 573 patients which were eligible for meta-analysis regarding postoperative change in QoL. Across surgical procedures, there was significant improvement in QoL of 1.40 SMD (95% confidence interval 0.95 to 1.86; I2 = 89%; p < 0.001) at last follow-up (range 9-94 months). Trends in QoL improvement demonstrated the greatest improvement at 12 months; however, significant improvement was sustained at longest follow-up of 60+ months. CONCLUSIONS: Weight loss surgery is associated with sustained improvement in QoL for adolescents with severe obesity across surgical procedures. Long-term data for psychosocial outcomes reflecting other mental health domains is lacking.

Helmet use is associated with higher Injury Severity Scores in alpine skiers and snowboarders evaluated at a Level I trauma center.

BACKGROUND: There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types, and injury severity among skiers and snowboarders. METHODS: The trauma registry at a Northeast American College of Surgeons Level I trauma center was queried by International Classification of Diseases Codes-9th or 10th Revision for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (Injury Severity Score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use. RESULTS: Seven hundred twenty-one patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p < 0.001), but the rate of any head injury did not significantly change (49% to 43%, p = 0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.30-3.11), intracranial hemorrhage (OR, 1.81; 95% CI, 1.10-2.96), chest injury (OR, 1.66; 95% CI, 1.05-2.61), and/or lumbosacral spine injury (OR, 1.84; 95% CI, 1.04-3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR, 0.51; 95% CI, 0.30-0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR, 0.30; 95% CI, 0.14-0.64). More patients who hit a stationary object were helmeted compared with those who fell from standing height onto snow (70% vs. 56% respectively, p < 0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR, 2.80; 95% CI, 1.79-4.38). CONCLUSION: Helmeted skiers and snowboarders evaluated at a Level I trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared with unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high-impact injury, regardless of helmet use. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Trends in Gender Representation at the American College of Surgeons Clinical Congress and the Academic Surgical Congress: A Mixed Picture of Progress.

BACKGROUND: There has been increasing attention to gender inequity in speakers at professional meetings. The aim of this study was to evaluate temporal trends in representation of women at the Academic Surgical Congress (ASC) and American College of Surgeons Clinical Congress (CC), 2 prominent general interest, national surgical meetings. STUDY DESIGN: We reviewed ASC (2014-2019) and CC (2013-2018) meeting programs to determine counts and proportions of invited panelists and moderators by gender, including the frequency of men-only panels. We conducted trend analyses to assess for temporal change in gender representation and univariate tests of association between different measures of gender representation. RESULTS: The overall proportions of women panelists were 35% (ASC) and 28% (CC). There was a significant increase in the proportion of women panelists over the study period at the CC (23% to 34%, p = 0.007) but not at the ASC (37% to 36%, p = 0.79). The proportion of men-only panels decreased significantly over time at the CC (38% to 23%, p = 0.04), but not at the ASC (23% to 17%, p = 0.50), while the proportion of moderators at the ASC increased significantly (31% to 43%, p = 0.01), but not at the CC (29% to 37%, p = 0.40). CONCLUSIONS: Women remain in the minority of panelists and moderators at the ASC and CC meetings, and approximately 1 in 5 panels are composed entirely of men. Although progress has been made at both meetings, ongoing and deliberate attention is needed to ensure continued progress toward the goal of equitable gender representation in academic surgery.

Evaluating Patient-Reported Outcomes in Inguinal Hernia Clinical Trials.

BACKGROUND: Patient-reported outcomes (PROs) are increasingly reported in the literature and are subsequently relied on for clinical decision-making. In 2013, CONSORT (Consolidated Standards of Reporting Trials) added 5 guidelines for reporting PROs in randomized controlled trials, the PRO extensions. Adherence to the extensions among inguinal hernia trials is unknown. METHODS: A comprehensive review of the literature was performed to find RCTs evaluating inguinal hernia repair. Inclusion criteria were RCTs evaluating surgical management of inguinal hernia that included PROs as primary or secondary outcomes, published from January, 2014 through July, 2018. Exclusion criteria were nonelective repairs, age <18 y, or articles unavailable in English. Two researchers graded the articles for compliance with the extensions. RESULTS: We identified 1548 articles, 78 of which met inclusion criteria. Four articles (5%) met all 5 extensions, whereas five (6%) did not meet any of the extensions. The extension requiring "identification of the PROs in the abstract as a primary or secondary outcome" was most commonly satisfied (83%), whereas that requiring the article "reference PRO instrument validity" was least satisfied (23%). Pain was the most frequently studied PRO and a visual analog scale was the most frequently used instrument. CONCLUSIONS: Inguinal hernia trials demonstrate poor adherence to the PRO extensions. PRO data from these trials have been published widely; however, the lack of standardization in reporting calls into question the generalizability of these findings. Further education about these guidelines is necessary to improve PRO reporting and ensure optimal patient-centered care based on high quality evidence.

A multi-center analysis of readmission after cardiac surgery: Experience of The Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Readmissions after cardiac surgery are common and associated with increased morbidity, mortality and cost of care. Policymakers have targeted coronary artery bypass grafting to achieve value-oriented health care milestones. We explored the causes of readmission following cardiac surgery among a regional consortium of hospitals. METHODS: Using administrative data, we identified patients readmitted to the same institution within 30 days of cardiac surgery. We performed standardized review of readmitted patients' medical records to identify primary and secondary causes of readmission. We evaluated causes of readmission by procedure and tested for univariate associations between characteristics of readmitted patients and nonreadmitted patients in our clinical registry. RESULTS: Of 2218 cardiac surgery patients, 272 were readmitted to the index hospital within 30 days for a readmission rate of 12.3%. Median time to readmission was 9 days (interquartile range 4-16 days) and only 13% of patients were evaluated in-office before readmission. Readmitted patients were more likely to have had valve surgery (31.3% vs 22.7%) than patients not readmitted. Readmitted patients were also more likely to have preoperative creatinine more than or equal to 2 mg/dL (P = .015) or congestive heart failure (CHF) (P = .034), require multiple blood transfusions or sustained inotropic support (P < .001), and experience postoperative atrial fibrillation (P = .022) or renal insufficiency (P < .001). Infection (26%), pleural or pericardial effusion (19%), arrhythmia (16%), and CHF (11%) were the most common primary etiologies leading to readmission. CONCLUSIONS: Ensuring early follow-up for high-risk patient groups while improving early detection and management of the principal drivers of readmission represent promising targets for decreasing readmission rates.