Escalation of Commitment in the Surgical ICU.

OBJECTIVES: Escalation of commitment is a business term that describes the continued investment of resources into a project even after there is objective evidence of the project's impending failure. Escalation of commitment may be a contributor to high healthcare costs associated with critically ill patients as it has been shown that, despite almost certain futility, most ICU costs are incurred in the last week of life. Our objective was to determine if escalation of commitment occurs in healthcare settings, specifically in the surgical ICU. We hypothesize that factors previously identified in business and organizational psychology literature including self-justification, accountability, sunk costs, and cognitive dissonance result in escalation of commitment behavior in the surgical ICU setting resulting in increased utilization of resources and cost. DESIGN: A descriptive case study that illustrates common ICU narratives in which escalation of commitment can occur. In addition, we describe factors that are thought to contribute to escalation of commitment behaviors. MAIN RESULTS: Escalation of commitment behavior was observed with self-justification, accountability, and cognitive dissonance accounting for the majority of the behavior. Unlike in business decisions, sunk costs was not as evident. In addition, modulating factors such as personality, individual experience, culture, and gender were identified as contributors to escalation of commitment. CONCLUSIONS: Escalation of commitment occurs in the surgical ICU, resulting in significant expenditure of resources despite a predicted and often known poor outcome. Recognition of this phenomenon may lead to actions aimed at more rational decision making and may contribute to lowering healthcare costs. Investigation of objective measures that can help aid decision making in the surgical ICU is warranted.

Association of high-volume hospitals with greater likelihood of discharge to home following colorectal surgery.

IMPORTANCE: Discharge disposition is a patient-centered quality metric that reflects differences in quality of life and recovery following surgery. The effect of hospital volume on quality of recovery measured by rates of successful discharge to home remains unclear. OBJECTIVE: To test the hypothesis that patients having colorectal surgery at high-volume hospitals would more likely be discharged to home rather than discharged to skilled rehabilitation facilities to complete recovery. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal analysis of 2008 hospital inpatient data to identify patients undergoing colorectal surgery who survived to discharge. The setting was the Nationwide Inpatient Sample, the largest all-payer inpatient care database, containing data from more than 1000 hospitals. Participants were 280,644 patients (≥ 18 years) who underwent colorectal resections for benign or malignant disease and survived to discharge. MAIN OUTCOMES AND MEASURES: The primary end point was discharge to home (with or without home health care) vs discharge to skilled facilities (skilled nursing, short-term recovery, or rehabilitation hospitals or other institutions). The secondary end point was discharge to home with home health care rather than to a skilled facility for patients with postdischarge care needs. Multiple logistic regression using robust standard errors was used to compute the odds ratios of each outcome based on hospital volume, while adjusting for other important variables. RESULTS: The odds of discharge to home vs discharge to skilled facilities were significantly greater in high-volume hospitals compared with low-volume hospitals (odds ratio, 2.09; 95% CI, 1.70-2.56), with an absolute increase of 9%. For patients with postdischarge care needs, high-volume hospitals were less likely than low-volume hospitals to use skilled facilities rather than home health care (odds ratio, 0.35; 95% CI, 0.27-0.45), with an absolute difference of 10%. CONCLUSIONS AND RELEVANCE: Patients having colorectal surgery at high-volume hospitals are significantly more likely to recover and return home after surgery than individuals having operations at low-volume hospitals. This study is the first step in a process of identifying which features of high-volume hospitals contribute toward desirable outcomes. Efforts to identify the reasons for improved recovery at high-volume hospitals can help lower-volume hospitals adopt beneficial practices.

Hand-assisted laparoscopy leads to efficient colorectal cancer surgery.

BACKGROUND: Laparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy. MATERIALS AND METHODS: We performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemar's tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care. RESULTS: Forty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01). CONCLUSIONS: HAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.

Disparities in the use of minimally invasive surgery for colorectal disease.

BACKGROUND: Morbidity and mortality rates for major surgical procedures are decreased in high-volume hospitals (HVH). Additionally, HVH are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS). Although HVH often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at HVH. METHODS: Laparoscopic and open colectomies performed at HVH were identified using the 2008 Nationwide Inpatient Sample database. ICD-9 codes were used to identify MIS colorectal resections. Multiple logistic regression including ethnic and socioeconomic variables were used to identify independent predictive factors for undergoing MIS. RESULTS: A total of 211,862 colorectal resections were performed at HVH in 2008. Only 16,637 (7.3%) colorectal resections were performed using MIS. When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo MIS than those in the lowest income groups. In addition, patients with Medicaid and uninsured patients were significantly less likely to undergo MIS compared to patients with private insurance. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH. CONCLUSION: There are significant socioeconomic disparities in the use of MIS for colorectal disease at HVH. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.

Minimally invasive surgery in colon cancer patients leads to improved short-term outcomes and excellent oncologic results.

BACKGROUND: Minimally invasive surgery (MIS) techniques are beneficial compared with open techniques. There is a paucity of data of the potential advantages of MIS in colon cancer surgery for veterans. Therefore, we hypothesize that use of MIS in colon cancer resections in a Veterans Affairs Medical Center will lead to improved short-term outcomes without compromising oncologic outcomes. METHODS: A retrospective analysis of a prospectively maintained database was performed. We compared surgical, short-term, and oncologic outcomes in MIS versus open surgery. RESULTS: MIS patients had significantly less blood loss, surgical time, days to return of bowel function, and hospital and intensive care unit stays. Also, they had a greater and more adequate lymphadenectomy, and were less likely to experience a postoperative complication. Survival analyses showed no difference in overall and disease-free survival. CONCLUSIONS: The use of MIS in colon cancer leads to improved short-term outcomes and similar oncologic outcomes when compared with open surgery.

Depression is associated with prolonged and complicated recovery following colorectal surgery.

BACKGROUND: There are little data regarding the impact of depression on outcomes after gastrointestinal surgery. We hypothesize that depression would be associated with prolonged hospital stay and changes in discharge disposition for patients undergoing colon and rectal surgery. METHODS: We identified 292,191 patients undergoing colon and rectal surgery using the 2008 Nationwide Inpatient Sample. We used multivariate regression to evaluate the effect of depression on length of stay and discharge disposition. RESULTS: A preoperative diagnosis of depression was present in 20,039 (6.9%) patients. Mean length of stay for those with depression (10.4 days, 95% confidence interval (CI) 10.04-10.76) was significantly longer than for patients without depression (9.64 days, 95% CI 9.48-9.81). After adjusting for cofounders, depression still predicted an increase in length of stay. Additionally, depressed patients were less likely to resume normal function at discharge, as 40% required either home health or time in a skilled facility following discharge from the acute care hospital. CONCLUSIONS: Among patients undergoing colorectal surgery, depression is associated with a significantly prolonged hospital stay and higher likelihood of requiring skilled nursing assistance after discharge. Further research into the mechanism underlying these differences and potential treatment strategies among depressed patients is warranted.

A multidisciplinary cancer center maximizes surgeons' impact.

BACKGROUND: Colorectal cancer patients require care across different disciplines. Integration of multidisciplinary care is critical to accomplish excellent oncologic results. We hypothesized that the establishment of a dedicated colorectal cancer center (CRCC) around specialty-trained surgeons will lead to increased multidisciplinary management and improved outcomes in colorectal cancer patients. METHODS: We analyzed data from three periods: a baseline group, a period after the recruitment of specialty-trained surgeons, and a period after the creation of a dedicated multidisciplinary cancer center. Data analyzed included surrogate markers of surgical oncologic care, multidisciplinary integration, and oncologic outcomes. RESULTS: Recruitment of specialized surgeons led to improvements in surgical oncologic care; the establishment of the CRCC resulted in further improvements in surgical oncologic care and multidisciplinary integration. CONCLUSION: Our study suggests that although the recruitment of specialty-trained surgeons in a high volume center leads to improvement in surgical oncologic care, it is the establishment of a multidisciplinary center around the surgeons that leads to integrated care and improvements in oncologic outcomes.

Minimally invasive surgery improves short-term outcomes in elderly colorectal cancer patients.

BACKGROUND: Minimally invasive surgery (MIS) for colorectal resection has been shown to improve short-term outcomes compared with open surgery in patients with colorectal cancer. Currently, there is a paucity of data demonstrating similar efficacy between MIS and open colorectal resection in the elderly population. We hypothesized that minimally invasive surgery provides improved short-term outcomes in elderly patients with colorectal cancer. METHODS: A review of 242 consecutive elderly (≥ 65 y of age) patients who underwent either open or MIS colorectal resection for adenocarcinoma at one institution was conducted. Short-term and oncologic outcomes were analyzed. Continuous variables were analyzed by the Mann-Whitney U test. Categorical variables were compared by χ(2) tests. Survival was compared by the Kaplan-Meier method using the log rank test for comparison. RESULTS: Of the 242 elderly patients with colorectal cancer (median American Society of Anesthesiology score (ASA) scores of 3), 80% (n = 195) of patients underwent open and 20% (n = 47) had MIS colorectal cancer resections. Patients undergoing MIS had a faster return of bowel function, decreased days to nasogastric tube removal, decreased days to flatus and bowel movement, and quicker advancement to clear liquid and regular diets. The overall length of hospital stay in the MIS group was decreased by 40% as well as a trend towards a 50% decrease in SICU stay. Additionally, there was 66% decrease in cardiac complications in the MIS group. When evaluating for oncologic adequacy as measured by number of lymph nodes and surgical resection margins, MIS surgery offered equivalent results as open resection. Furthermore, there was no significant difference in overall survival for MIS versus open colorectal surgery. CONCLUSION: Minimally invasive colorectal cancer resection leads to improved short-term outcomes as demonstrated by decreased length of hospital stay and faster return of bowel function. Additionally, there appears to be no difference in oncologic outcomes in the elderly. On the basis of our data, age alone should not be a contra-indication to laparoscopic colorectal cancer resection.

Minimally invasive surgery is underutilized for colon cancer.

BACKGROUND: The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication. METHODS: The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ(2) tests and dependent t tests, and Cramer's V was used to measure the strength of association. RESULTS: A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers. CONCLUSIONS: Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.

The VA is critical to academic development.

BACKGROUND: A principal responsibility for surgical chairs is the development of academic programs. This has been challenging in light of the current economic downturn, declining reimbursement, and changes in funding. The aim of this study was to determine the importance that surgical chairs place on the US Department of Veterans Affairs (VA) regarding their ability to develop academic programs. METHODS: A Web-based survey was constructed and the link sent to 122 university-based surgical department chairs in the United States in 2009 to evaluate previous and current VA affiliations as well as attitudes associated with academic program development. RESULTS: A total of 58 of 122 surveys (47.5%) were completed. Seventy percent of surgical chairs received some of their training at VA facilities, and 65% have held VA appointments. Although only 62% of programs were affiliated with VA centers, 91% of chairs believed that VA affiliations were important for their training programs. Additionally, 91% felt that the VA was a good place for faculty development. Finally, 78% indicated that the opportunity to obtain VA research funding is important for academic faculty development. CONCLUSION: Academic program development is an important part of a chair's responsibilities. The overwhelming majority of surgical chairs view a VA affiliation as an important resource in building academic surgical programs.

Ethnic disparities are reduced in VA colon cancer patients.

BACKGROUND: Inequalities in access to care have been hypothesized to be the cause of ethnic disparities in colon cancer. The aim of this study was to determine if ethnic disparities in the outcomes of colon cancer patients exist in a system with equal access. METHODS: A review of 214 consecutive patients who underwent elective colon resection for adenocarcinoma at 1 institution was conducted. Statistical analysis was performed using independent t tests and χ² tests. The Kaplan-Meier method was used for survival estimates. RESULTS: Of the 214 patients who underwent colon cancer resection, 38% (n = 82) were African American, while 62% (n = 132) were Caucasian. There was no significant difference in the stage of disease at presentation and between the mean times from diagnosis to surgical resection for African American and Caucasian patients. Also, there were no differences in survival. CONCLUSION: There does not appear to be a disparity in outcomes for colon cancer patients where equal access to medical care exists. This is based on findings of equal stages at presentation, time to referral, and survival among groups.

Establishment of a minimally invasive surgery program leads to decreased inpatient cost of care in veterans with colon cancer.

BACKGROUND: The objective of this study was to evaluate the establishment of a minimally invasive surgery program on the cost of care at the investigators' institution. It was hypothesized that a minimally invasive surgery program would decrease overall inpatient treatment costs for veterans with colon cancer. METHODS: All patients who were admitted for colon cancer surgery in fiscal year 2009 were included in this study. The main outcome measures were inpatient treatment cost and length of stay. RESULTS: The median inpatient cost incurred in the laparoscopic colectomy group was 33% ($6,000, P < .01) less than the in open colectomy group. The median length of hospital stay and operative time were also shorter by 31% (3.5 days, P < .05) and 37% (108 minutes, P < .01), respectively, in the laparoscopic colectomy group. CONCLUSIONS: In this study, colon cancer patients who underwent minimally invasive surgery for colon cancer experienced shorter hospital stay and operative times, which resulted in lower overall inpatient treatment cost.

Waist circumference predicts increased complications in rectal cancer surgery.

BACKGROUND: The impact of obesity on development of postoperative complications after gastrointestinal surgery remains controversial. This may be due to the fact that obesity has been calculated by body mass index, a measure that does not account for fat distribution. We hypothesized that waist circumference, a measure of central obesity, would better predict complications after high-risk gastrointestinal procedures. METHODS: Retrospective review of an institutional cancer database identified consecutive cases of men undergoing elective rectal resections. Waist circumference was calculated from preoperative imaging. RESULTS: From 2002 to 2009, 152 patients with mean age 65.2 ± 0.75 years and body mass index 28.0 ± 0.43 kg/m(2) underwent elective resection of rectal adenoma or carcinoma. Increasing body mass index was not significantly associated with risk of postoperative complications including infection, dehiscence, and reoperation. Greater waist circumference independently predicted increased risk of superficial infections (OR 1.98, 95% CI 1.19-3.30, p < 0.008) and a significantly greater risk of having one or more postoperative complications (OR 1.56, 95% CI 1.04-2.34, p < 0.034). CONCLUSIONS: Waist circumference, a measure of central obesity, is a better predictor of short-term complications than body mass index and can be used to identify patients who may benefit from more aggressive infection control and prevention.