High-Flow Nasal Cannula Versus Noninvasive Ventilation as Initial Treatment in Acute Hypoxia: A Propensity Score-Matched Study.

IMPORTANCE: Patients presenting to the emergency department (ED) with hypoxemia often have mixed or uncertain causes of respiratory failure. The optimal treatment for such patients is unclear. Both high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are used. OBJECTIVES: We sought to compare the effectiveness of initial treatment with HFNC versus NIV for acute hypoxemic respiratory failure. DESIGN SETTING AND PARTICIPANTS: We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with HFNC or NIV within 24 hours of arrival to the University of Michigan adult ED from January 2018 to December 2022. We matched patients 1:1 using a propensity score for odds of receiving NIV. MAIN OUTCOMES AND MEASURES: The primary outcome was major adverse pulmonary events (28-d mortality, ventilator-free days, noninvasive respiratory support hours) calculated using a win ratio. RESULTS: A total of 1154 patients were included. Seven hundred twenty-six (62.9%) received HFNC and 428 (37.1%) received NIV. We propensity score matched 668 of 1154 (57.9%) patients. Patients on NIV versus HFNC had lower 28-day mortality (16.5% vs. 23.4%, p = 0.033) and required noninvasive treatment for fewer hours (median 7.5 vs. 13.5, p < 0.001), but had no difference in ventilator-free days (median [interquartile range]: 28 [26, 28] vs. 28 [10.5, 28], p = 0.199). Win ratio for composite major adverse pulmonary events favored NIV (1.38; 95% CI, 1.15-1.65; p < 0.001). CONCLUSIONS AND RELEVANCE: In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with NIV compared with HFNC was associated with lower mortality and fewer composite major pulmonary adverse events calculated using a win ratio. These findings underscore the need for randomized controlled trials to further understand the impact of noninvasive respiratory support strategies.

Cutaneous Squamous Cell Carcinoma Outcomes in Solid Organ Transplant Recipients: A Matched Retrospective Cohort Study.

BACKGROUND: Solid organ transplant recipients with cutaneous squamous cell carcinoma (CSCC) have an increased risk of poor outcomes. However, a recent study demonstrated that immunosuppression is not an independent risk factor for these poor outcomes after controlling for primary tumor stage. OBJECTIVE: To evaluate whether transplant status is an independent risk factor for poor outcomes in CSCC. MATERIALS AND METHODS: A database of CSCCs treated at an academic center over 10 years was used to perform a retrospective cohort study comparing the risk of poor outcomes (local recurrence, regional and distant metastases, and disease-specific death) in solid organ transplant recipients and controls. Subjects were matched on age, tumor stage, sex, tumor site, and time to poor outcome. RESULTS: There were 316 tumors from 78 transplant patients and 316 tumors from 262 controls. On multivariate analysis, tumor stage and location on the head and neck were predictive of poor outcomes. There was no significant difference in the risk of poor outcomes in the transplant group versus the control group. CONCLUSION: Transplant status was not an independent risk factor for poor squamous cell carcinoma outcomes after controlling for stage, age, sex, site, and time to poor outcome.

Performance of Staging Systems for Non-Head and Neck Cutaneous Squamous Cell Carcinoma.

BACKGROUND: The performance of staging systems in non-head and neck cutaneous squamous cell carcinomas has not been well established. OBJECTIVE: To evaluate the performance of the American Joint Committee on Cancer 8th Edition and Brigham and Women's Hospital staging systems in non-head and neck squamous cell carcinomas. MATERIALS AND METHODS: Eligible tumors were identified and staged from an existing retrospective database. Cumulative incidence function curves of any poor outcome were generated. Distinctiveness, sensitivity, specificity, positive and negative predictive value, and concordance index were calculated. RESULTS: 1,042 primary tumors were included, with 38 resulting in any poor outcome and 16 in any major poor outcome. High-stage tumors represented 2.2% and 3.5% of tumors; these accounted for 10/38 of the poor outcomes (26.3%) and 8/16 of the major poor outcomes (50%). High-stage tumors predicted major poor outcomes with a sensitivity of 0.5 and specificity of 0.99 for the Brigham and Women's Hospital system, and a sensitivity of 0.5 and specificity of 0.97 for the American Joint Committee on Cancer 8th edition system. The concordance index for both was 0.74. CONCLUSION: Current staging systems can be used to predict poor outcomes in cutaneous squamous cell carcinomas off the head and neck.

High-flow nasal cannula vs non-invasive ventilation in acute hypoxia: Propensity score matched study.

RATIONALE: The optimal treatment for early hypoxemic respiratory failure is unclear, and both high-flow nasal cannula and non-invasive ventilation are used. Determining clinically relevant outcomes for evaluating non-invasive respiratory support modalities remains a challenge. OBJECTIVES: To compare the effectiveness of initial treatment with high-flow nasal cannula versus non-invasive ventilation for acute hypoxemic respiratory failure. METHODS: We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with high-flow nasal cannula or non-invasive ventilation within 24 hours of Emergency Department arrival (1/2018-12/2022). We matched patients 1:1 using a propensity score for odds of receiving non-invasive ventilation. The primary outcome was major adverse pulmonary events (28-day mortality, ventilator-free days, non-invasive respiratory support hours) calculated using a Win Ratio. MEASUREMENTS AND MAIN RESULTS: 1,265 patients met inclusion criteria. 795 (62.8%) received high-flow oxygen and 470 (37.2%) received non-invasive ventilation. We propensity score matched 736/1,265 (58.2%) patients. There was no difference between non-invasive ventilation vs high-flow nasal cannula in 28-day mortality (17.7% vs 23.1%, p=0.08) or ventilator-free days (median [Interquartile Range]: 28 [25, 28] vs 28 [13, 28], p=0.50), but patients on non-invasive ventilation required treatment for fewer hours (median 7 vs 13, p< 0.001). Win Ratio for composite major adverse pulmonary events favored non-invasive ventilation (1.26, 95%CI 1.06-1.49, p< 0.001). CONCLUSIONS: In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with non-invasive ventilation was superior to high-flow nasal cannula for major pulmonary adverse events. Evaluation of composite outcomes is important in the assessment of respiratory support modalities.

Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women.

Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.

Two interventions to promote cervical, breast, and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test were evaluated by rural women who received them as part of the randomized trial. Participants who received the tailored interactive digital video disc (DVD; n = 266) or the DVD plus telephone-based patient navigation (PN; n = 276) were interviewed by phone about their engagement and satisfaction with the interventions. All participants reported receiving the DVD and 93.0% viewed it. Most agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to get screened. Almost all women in the DVD+PN group, 98.2% (n = 268) talked with the navigator. The most common cancer screenings discussed with navigators were colorectal (86.8%), followed by breast (71.3%) and cervical (57.5%). The average length of encounters with the navigators was 22.2 minutes; navigators spent 21.7 additional minutes on coordinating activities. Barriers discussed were similar across screening tests. The most common were related to the healthcare provider/system, lack of knowledge, forgetfulness/too much bother, and personal issues. This study provided important information about receipt, uptake, and satisfaction with two behavioral interventions, along with challenges encountered that may impact results.

Reliability of a Wearable Motion Tracking System for the Clinical Evaluation of a Dynamic Cervical Spine Function.

Neck pain is a common cause of disability worldwide. Lack of objective tools to quantify an individual's functional disability results in the widespread use of subjective assessments to measure the limitations in spine function and the response to interventions. This study assessed the reliability of the quantifying neck function using a wearable cervical motion tracking system. Three novice raters recorded the neck motion assessments on 20 volunteers using the device. Kinematic features from the signals in all three anatomical planes were extracted and used as inputs to repeated measures and mixed-effects regression models to calculate the intraclass correlation coefficients (ICCs). Cervical spine-specific kinematic features indicated good and excellent inter-rater and intra-rater reliability for the most part. For intra-rater reliability, the ICC values varied from 0.85 to 0.95, and for inter-rater reliability, they ranged from 0.7 to 0.89. Overall, velocity measures proved to be more reliable compared to other kinematic features. This technique is a trustworthy tool for evaluating neck function objectively. This study showed the potential for cervical spine-specific kinematic measurements to deliver repeatable and reliable metrics to evaluate clinical performance at any time points.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes.

Importance: Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. Objective: To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. Design, Setting, and Participants: This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. Main Outcomes and Measures: Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. Results: A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. Conclusions and Relevance: In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

The association of upward economic mobility with textbook outcomes among patients undergoing general and cardiovascular surgery.

BACKGROUND: While disadvantaged neighborhoods may be associated with worse outcomes and earlier death, the relationship between economic opportunity and surgical outcomes remains unexplored. METHODS: Medicare beneficiaries who underwent AAA, CABG, colectomy or cholecystectomy were identified and stratified into quintiles based on upward economic mobility. Risk-adjusted probability of adverse postoperative outcomes were examined relative to economic mobility. RESULTS: Among 1,081,745 Medicare beneficiaries (age: 75.5 years, female: 43.0%, White: 91.3%), risk-adjusted 30-day postoperative mortality decreased in a stepwise fashion from 6.0%(5.9-6.1) in the lowest quintile of upward economic mobility to 5.3%(5.2-5.4) in highest upward economic mobility (lowest vs. highest economic mobilityobility OR:1.14 (95%CI:1.11-1.17)). Similar associations were noted for postoperative complications (OR:1.04, 95%CI:1.02-1.06), extended length-of-stay (OR:1.07, 95%CI:1.06-1.09), and 30-day readmission (OR:1.04, 95%CI:1.02-1.05). Black beneficiaries had a higher risk of post-operative mortality across upward economic mobility quintiles except within the highest upward mobility group (referent, White patients, OR:0.93, 95%CI:0.79-1.09, p=0.355). CONCLUSION: Economic upward mobility was associated with post-operative outcomes. Race-based differences were mitigated at the highest levels of upward economic mobility, highlighting the importance of socioeconomics as a health equity lever.

Machine Learning Approach to Stratifying Prognosis Relative to Tumor Burden after Resection of Colorectal Liver Metastases: An International Cohort Analysis.

BACKGROUND: Assessing overall tumor burden on the basis of tumor number and size may assist in prognostic stratification of patients after resection of colorectal liver metastases (CRLM). We sought to define the prognostic accuracy of tumor burden by using machine learning (ML) algorithms compared with other commonly used prognostic scoring systems. STUDY DESIGN: Patients who underwent hepatectomy for CRLM between 2001 and 2018 were identified from a multi-institutional database and split into training and validation cohorts. ML was used to define tumor burden (ML-TB) based on CRLM tumor number and size thresholds associated with 5-year overall survival. Prognostic ability of ML-TB was compared with the Fong and Genetic and Morphological Evaluation scores using Cohen's d. RESULTS: Among 1,344 patients who underwent resection of CRLM, median tumor number (2, interquartile range 1 to 3) and size (3 cm, interquartile range 2.0 to 5.0) were comparable in the training (n = 672) vs validation (n = 672) cohorts; patient age (training 60.8 vs validation 61.0) and preoperative CEA (training 10.2 ng/mL vs validation 8.3 ng/mL) was also similar (p > 0.05). ML empirically derived optimal cutoff thresholds for number of lesions (3) and size of the largest lesion (1.3 cm) in the training cohort, which were then used to categorize patients in the validation cohort into 3 prognostic groups. Patients with low, average, or high ML-TB had markedly different 5-year overall survival (51.6%, 40.9%, and 23.1%, respectively; p < 0.001). ML-TB was more effective at stratifying patients relative to 5-year overall survival (low vs high ML-TB, d = 2.73) vs the Fong clinical (d = 1.61) or Genetic and Morphological Evaluation (d = 0.84) scores. CONCLUSIONS: Using a large international cohort, ML was able to stratify patients into 3 distinct prognostic categories based on overall tumor burden. ML-TB was noted to be superior to other CRLM prognostic scoring systems.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery.

BACKGROUND: There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery. METHODS: Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome. RESULTS: Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4. CONCLUSION: Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.

Surgeon Strategies to Patient-Centered Decision-making in Cancer Care: Validation and Applications of a Conceptual Model.

We sought to construct and validate a model of cancer surgeon approaches to patient-centered decision-making (PCDM) and compare applications of that model relative to surgical specialties. Ten PCDM strategies were assessed using a cross-sectional survey administered online to 295 board-certified cancer surgeons. Structural equation modeling was used to empirically validate and compare approaches to PCDM. Within the full sample, 7 strategies comprised a latent construct labeled, "physical & emotional accessibility," associated with surgeon approaches to PCDM (ß = 0.37, p < .05). Three individual strategies were included: "expectations (Q4)" (ß = 0.52, p < .05), "decision preferences (Q5) (ß = 0.47, p < .05), and "access medical information (Q3)" (ß = 0.75). Surgical specialties for subgroup analysis were classified as general/other (67.6%) or hepato-pancreato-biliary and upper gastrointestinal (HPB/UGI) (34.2%). For general/other surgeons, 7 individual strategies composed the model of surgeon approaches to PCDM, with "time (Q6) (ß = 0.70, p < .001) and "therapeutic relationship building (Q9)" (ß = 0.69, p < .001) being the strongest predictors. The HPB/UGI model included 2 latent constructs labeled "physical accessibility" (ß = 0.72, p < .05) and "creating a decision-making dialogue" (ß = 0.62) as well as the individual strategy, "effective communication (Q8)" (ß = 0.51, p < .05). Although models of surgeon PCDM varied, there were 4 overlapping strategies, including effective communication. Tailoring models of PCDM may improve surgeon uptake and thus, overall patient satisfaction with their cancer care.

Rural hospitals are not associated with worse postoperative outcomes for colon cancer surgery.

PURPOSE: We sought to determine whether colorectal cancer surgery can be done safely at rural hospitals. The current study compared outcomes among rural patients who underwent colon resection at rural and nonrural hospitals. METHODS: Medicare beneficiaries who underwent colon resection for cancer between 2013 and 2017 were identified using the Medicare Inpatient Standard Analytic Files. Patients and hospitals were designated as rural based on rural-urban continuum codes. Risk-adjusted postoperative outcomes and hospitalization spending were compared among patients undergoing resection at rural versus nonrural hospitals. RESULTS: Among 3,937 patients who resided in a rural county and underwent colon resection for cancer, mean age was 76.3 (SD: 7.1) years and 1,432 (36.4%) patients underwent operative procedure at a rural hospital. On multivariable analyses, no differences in postoperative outcomes were noted among Medicare beneficiaries undergoing colon resection for cancer at nonrural versus rural hospitals. Specifically, the risk-adjusted probability of experiencing a postoperative complication at a nonrural hospital was 15.4% (95% CI: 14.1%-16.8%) versus 16.3% (95% CI: 14.2%-18.3%) at a rural hospital (OR 1.08, 95% CI: 0.85-1.38); 30-day mortality (nonrural: 2.9%, 95% CI: 2.2-3.6 vs rural: 3.5%, 95% CI: 2.4-4.5) was also comparable. In addition, price standardized, risk-adjusted expenditures were similar at nonrural ($18,610, 95% CI: $18,037-$19,183) and rural ($19,010, 95% CI: $18,630-$19,390) hospitals. CONCLUSION: Among rural Medicare beneficiaries who underwent a colon resection for cancer, there were no differences in postoperative outcomes among nonrural versus rural hospitals. These findings serve to highlight the importance of policies and practice guidelines that secure safe, local surgical care, allowing rural clinicians to accommodate strong patient preferences while delivering high-quality surgical care.

Reliability of a Wearable Motion System for Clinical Evaluation of Dynamic Lumbar Spine Function.

Background: Low back pain is the leading cause of disability worldwide. Subjective assessments are often used to assess extent of functional limitations and treatment response. However, these measures have poor sensitivity and are influenced by the patient's perception of their condition. Currently, there are no objective tools to effectively assess the extent of an individual's functional disability and inform clinical decision-making. Objective: The purpose of this study was to evaluate the reliability of a wearable motion system based on Inertial Measurement Unit (IMU) sensors for use in quantifying low back function. Methods: Low back motion assessments were conducted by 3 novice raters on 20 participants using an IMU-based motion system. These assessments were conducted over 3 days with 2 days of rest in between tests. A total of 37 kinematic parameters were extracted from the low back motion assessment in all three anatomical planes. Intra-rater and inter-rater reliability were assessed using Intraclass Correlation Coefficients (ICCs) calculated from repeated measures, mixed-effects regression models. Results: Lumbar spine-specific kinematic parameters showed moderate to excellent reliability across all kinematic parameters. The ICC values ranged between 0.84-0.93 for intra-rater reliability and 0.66 - 0.83 for inter-rater reliability. In particular, velocity measures showed higher reliabilities than other kinematic variables. Conclusion: The IMU-based wearable motion system is a valid and reliable tool to objectively assess low back function. This study demonstrated that lumbar spine-specific kinematic metrics have the potential to provide good, repeatable metrics to assess clinical function over time.

Optimal hepatic surgery: Are we making progress in North America?

BACKGROUND: The aim of this analysis was to determine whether optimal outcomes have increased in recent years. Hepatic surgery is high risk, but regionalization and minimally invasive approaches have evolved. Best practices also have been defined with the goal of improving outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried. Analyses were performed separately for partial (≤2 segments), major (≥3 segments), and all hepatectomies. Optimal hepatic surgery was defined as the absence of mortality, serious morbidity, need for a postoperative invasive procedure or reoperation, prolonged length of stay (<75th percentile) or readmission. Tests of trend, χ2, and multivariable analyses were performed. RESULTS: From 2014 to 2018, 17,082 hepatectomies, including 11,862 partial hepatectomies and 5,220 major hepatectomies, were analyzed. Minimally invasive approaches increased from 25.6% in 2014 to 29.6% in 2018 (P < .01) and were performed more frequently for partial hepatectomies (34.2%) than major hepatectomies (14.4%) (P < .01). Operative time decreased from 220 minutes in 2014 to 208 minutes in 2018 (P < .05) and was lower in partial hepatectomies (189 vs 258 minutes for major hepatectomies) (P < .01). Mortality (0.7%) and length of stay (4 days) were lower for partial hepatectomies compared with major hepatectomies (1.9%; 6 days), and length of stay decreased for both partial hepatectomies (5 days in 2014 to 4 days in 2018) and major hepatectomies (6 days in 2014 to 6 days in 2018) (all P < .01). Postoperative sepsis (2.9% in 2014 and 2.4% in 2018), bile leaks (6% in 2014 and 4.8% in 2018), and liver failure (3.7% in 2014 and 3.3% in 2018) decreased for all patients (<.05). On multivariable analyses, overall morbidity decreased for major hepatectomies (OR 0.95, 95% CI 0.91-0.99) and all hepatectomies (OR 0.97, 95% CI 0.94-0.99, both P < .01), and optimal hepatic surgery increased over time for partial hepatectomies (OR 1.05, 95% CI 1.02-1.09) and all hepatectomies (OR 1.04, 95% CI 1.02-1.07, both P < .01). CONCLUSION: Over a 5-year period in North America, minimally invasive hepatectomies have increased, while operative time, postoperative sepsis, bile leaks, liver failure, and prolonged length of stay have decreased. Optimal hepatic surgery has increased for partial and all hepatectomies and is achieved more often in partial than in major resections.

Healthcare provider self-reported observations and behaviors regarding their role in the spiritual care of cancer patients.

PURPOSE: The provision of spiritual care by an interprofessional healthcare team is an important, yet frequently neglected, component of patient-centered cancer care. The current study aimed to assess the relationship between individual and occupational factors of healthcare providers and their self-reported observations and behaviors regarding spiritual care in the oncologic encounter. METHODS: A cross-sectional survey was administered to healthcare providers employed at a large Comprehensive Cancer Center. Pearson's chi-square test and logistic regression were used to determine potential associations between provider factors and their observations and behaviors regarding spiritual care. RESULTS: Among the participants emailed, 420 followed the survey link, with 340 (80.8%) participants completing the survey. Most participants were female (82.1%) and Caucasian (82.6%) with a median age was 35 years (IQR: 31-48). Providers included nurses (64.7%), physicians (17.9%), and "other" providers (17.4%). There was a difference in provider observations about discussing patient issues around religion and spirituality (R&S). Specifically, nurses more frequently inquired about R&S (60.3%), while physicians were less likely (41.4%) (p = 0.028). Also, nurses more frequently referred to chaplaincy/clergy (71.8%), while physicians and other providers more often consulted psychology/psychiatry (62.7%, p < 0.001). Perceived barriers to not discussing R&S topics included potentially offending patients (56.5%) and time limitations (47.7%). CONCLUSION: Removing extrinsic barriers and understanding intrinsic influences can improve the provision of spiritual care by healthcare providers.

Intrapersonal Factors Impact Advance Care Planning Among Cancer Patients.

BACKGROUND: Cancer patients infrequently engage in advance care planning processes. Establishing preferences for future medical treatment without advance care planning may not be patient-centered, as it fails to consider important factors that influence these important decisions. OBJECTIVE: The purpose of this study was to assess the influence of patient intrapersonal factors including race, religion, level of depression, and cancer stage on overall preferences for future medical treatment, including the presence of a (DNR), power of attorney, and advance directive. DESIGN: A retrospective chart review design was used. Patients were included who were diagnosed with cancer at The Ohio State University James Comprehensive Cancer Center from 01/2015 to 08/2019. RESULTS: A total of 3,463 patients were included. Median age was 59 years (IQR: 49, 67) and the majority of the patients was female (88.7%). Compared with no religious preference, patients who identified as religious had 61% higher odds (95%CI: 1.08-2.40) of having a DNR and approximately 30% higher odds of having a power of attorney (95%CI: 1.08-1.62) or advance directive (95%CI: 1.02-1.64). Patients with clinically relevant depression had more than twice the odds of having a DNR versus patients with no/lower levels of clinical depression (OR: 2.08; 95%CI: 1.40-3.10). White patients had higher odds of having a power of attorney (OR: 1.57; 95%CI: 1.16-2.13) and an advance directive (OR: 3.10; 95% CI: 1.95-4.93) than African-American/Black patients. CONCLUSIONS: Understanding the factors that affect preferences for future medical treatment is necessary for medical professionals to provide proper care and support to patients diagnosed with cancer and their families.

County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA.

INTRODUCTION: Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer. METHODS: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level. RESULTS: Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy. CONCLUSION: Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.

The religious/spiritual beliefs and needs of cancer survivors who underwent cancer-directed surgery.

OBJECTIVE: We sought to characterize patients' preferences for the role of religious and spiritual (R&S) beliefs and practices during cancer treatment and describe the R&S resources desired by patients during the perioperative period. METHOD: A cross-sectional survey was administered to individuals who underwent cancer-directed surgery. Data on demographics and R&S beliefs/preferences were collected and analyzed. RESULTS: Among 236 participants, average age was 58.8 (SD = 12.10) years; the majority were female (76.2%), white (94.1%), had a significant other or spouse (60.2%), and were breast cancer survivors (43.6%). Overall, more than one-half (55.9%) of individuals identified themselves as being religious, while others identified as only spiritual (27.9%) or neither (16.2%). Patients who identified as religious wanted R&S integrated into their care more often than patients who were only spiritual or neither (p < 0.001). Nearly half of participants (49.6%) wanted R&S resources when admitted to the hospital including the opportunity to speak with an R&S leader (e.g., rabbi; 72.1%), R&S texts (64.0%), and journaling materials (54.1%). Irrespective of R&S identification, 68.0% of patients did not want their physician to engage with them about R&S topics. SIGNIFICANCE OF RESULTS: Access to R&S resources is important during cancer treatment, and incorporating R&S into cancer care may be especially important to patients that identify as religious. R&S needs should be addressed as part of the cancer care plan.