Trajectory Analysis of Healthcare Utilization Before and After Major Surgery.

OBJECTIVE: To characterize patterns of healthcare utilization before and after surgery and determine any association with pre-operative frailty. SUMMARY BACKGROUND DATA: Frail patients experience worse post-operative outcomes and increased costs during the surgical encounter. Evidence is comparatively lacking for longer-term effects of frailty on post-operative healthcare utilization. METHODS: Retrospective, longitudinal cohort analysis of adult patients undergoing any elective surgical procedure following pre-operative frailty assessment with the Risk Analysis Index (RAI) from 02/2016-12/2020 at a large integrated healthcare delivery and financing system. Group-based trajectory modeling of claims data estimated distinct clusters of patients with discrete utilization trajectories. Multivariable regression predicted membership in trajectories of interest using preoperative characteristics, including frailty. RESULTS: Among 29,067 surgical encounters, four distinct utilization trajectories emerged in longitudinal data from the 12 months before and after surgery. All cases exhibited a surge in utilization during the surgical month, after which most patients returned to "low" [25,473 (87.6%)], "medium" [1,403 (4.8%)], or "high" [528 (1.8%)] baseline utilization states established before surgery. The fourth trajectory identified 1,663 (5.7%) cases where surgery occasioned a transition from "low" utilization before surgery to "high" utilization afterward. RAI score alone did not effectively predict membership in this transition group, but a multivariable model with other preoperative variables was effective (c=0.859, max re-scaled R-squared 0.264). CONCLUSIONS AND RELEVANCE: Surgery occasions the transition from low to high healthcare utilization for a substantial subgroup of surgical patients. Multivariable modeling may effectively discriminate this utilization trajectory, suggesting an opportunity to tailor care processes for these patients.

Non-inferiority of fragmented care for high-risk pediatric neuroblastoma patients: a single institution analysis.

Pediatric neuroblastoma (NB) patients receive multi-modal therapy and may experience care fragmented among multiple institutions with a significant travel burden, which has been associated with poor outcomes for some adult cancers. We hypothesized that fragmented care for pediatric NB patients is associated with inferior outcomes compared to treatment consolidated at one location. We reviewed paper and electronic records for pediatric NB patients who received ≥1 hematopoietic stem cell transplant (HSCT) at Duke from 1990-2017. Fragmented care was defined by treatment at >1 institution and grouped by 2 institutions vs. 3+ institutions. Distances were calculated using Google Maps. To compare all care groups, we used Fisher's Exact and Kruskal-Wallis tests for demographic and treatment characteristics, Kaplan-Meier for unadjusted overall survival (OS), and Cox proportional hazards for factors associated with OS. Of 127 eligible patients, 102 (80.3%) patients experienced fragmented care, with 17 treated at 3+ facilities. Kaplan-Meier analysis did not associate fragmented care with increased mortality (log-rank p = 0.13). With multivariate analysis, only earlier diagnostic decade and greater distance to HSCT remained significantly associated with worsened OS. In this single institutional study, we found fragmented care did not impact overall survival. Worsened overall survival was associated with increased travel distance for HSCT and further research should aim to improve supportive processes for patients undergoing HSCT for high-risk neuroblastoma.

Mobile Application to Identify Cancer Treatment-Related Financial Assistance: Results of a Randomized Controlled Trial.

PURPOSE: Insured patients with cancer face high treatment-related, out-of-pocket (OOP) costs and often cannot access financial assistance. We conducted a randomized, controlled trial of Bridge, a patient-facing app designed to identify eligible financial resources for patients. We hypothesized that patients using Bridge would experience greater OOP cost reduction than controls. METHODS: We enrolled patients with cancer who had OOP expenses from January 2018 to March 2019. We randomly assigned patients 1:1 to intervention (Bridge) versus control (financial assistance educational websites). Primary and secondary outcomes were self-reported OOP costs and subjective financial distress 3 months postenrollment. In post hoc analyses, we analyzed application for and receipt of financial assistance at 3 months postenrollment. We used chi-square, Mann-Whitney tests, and logistic regression to compare study arms. RESULTS: We enrolled 200 patients. The median age was 57 years (IQR, 47.0-63.0). Most patients had private insurance (71%), and the median household income was $62,000 in US dollars (USD) (IQR, $36,000-$100,000 [USD]). Substantial missing data precluded assessment of primary and secondary outcomes. In post hoc analyses, patients in the Bridge arm were more likely than controls to both apply for and receive financial assistance. CONCLUSION: We were unable to test our primary outcome because of excessive missing follow-up survey data. In exploratory post hoc analyses, patients who received a financial assistance app were more likely to apply for and receive financial assistance. Ultimately, our study highlights challenges faced in identifying measurable outcomes and retaining participants in a randomized, controlled trial of a mobile app to alleviate financial toxicity.

Examining the Effect of Travel Distance to Pediatric Cancer Centers and Rurality on Survival and Treatment Experiences: A Systematic Review.

Accessing pediatric cancer treatment remains problematic for rural families or those living at increased distances from specialized centers. Rural adult cancer patients or those living far removed from treatment may present with later stage disease, receive different treatments than their closer counterparts, and experience worsened survival. While the financial and psychosocial strain of increased travel is well documented, effects of travel distance on similar outcomes for pediatric cancer patients remain ill-defined. We conducted a systematic review to synthesize literature examining the effect of travel distance and/or rurality (as a proxy for distance) on pediatric cancer treatment experiences and survival outcomes. Included studies examined travel distance to specialized centers or rural status for patients above 21 years of age. Studies were excluded if they focused on financial or quality of life outcomes. We analyzed 24 studies covering myriad malignancies and outcomes, including location of care, clinical trial participation, and likelihood of receiving specialized treatments such as stem cell transplants or proton beam therapy. Most were retrospective, and 9 were conducted outside the United States. While some studies suggest rural patients may experience worsened survival and those traveling furthest may experience shorter hospitalization times/rates, the available evidence does not uniformly assert negative effects of increased distance.

The patient experience of ABVD treatment in Hodgkin lymphoma: a retrospective cohort study of patient-reported distress.

PURPOSE: Psychological distress is prevalent in Hodgkin lymphoma (HL). Many patients, regardless of prognosis, receive ABVD chemotherapy as first-line treatment, but few studies have specifically examined the nature of distress during this shared treatment experience. METHODS: We conducted a retrospective study of patient-reported distress in HL patients receiving ABVD treatment at a single tertiary care facility. Distress was measured using the National Comprehensive Cancer Network Distress Thermometer and Problem List (PL). We used descriptive statistics and generalized estimating equations to assess the prevalence of distress and specific problem items during treatment and associations with patient- and disease-related factors. RESULTS: We collected data from 50 patients comprising 467 unique encounters, with 369/467 (79.0%) reporting a distress thermometer score. Median distress score was 2 (IQR: 0-5), but actionable distress (distress thermometer ≥4) was noted for 118/369 (32.0%) encounters. Actionable distress was only related to having a prior cancer, which conferred lower odds of actionable distress (OR 0.23, 95% CI 0.07-0.74, p=0.01) Physical and emotional problems were reported for 287/369 (77.8%) and 125/369 (33.9%) visits, respectively. Female patients had greater odds of both physical (OR 3.17, 95% CI 1.32-7.66, p=0.01) and emotional (OR 3.31, 95% CI 1.25-8.73, p=0.02) problems. CONCLUSION: ABVD treatment is associated with a high frequency of actionable distress, with physical and emotional problems acting as primary drivers. Female patients may be particularly vulnerable, while cancer survivors may be uniquely resilient. These findings demonstrate the need to thoroughly screen for and appropriately tailor distress management strategies for HL patients during treatment with ABVD.

Impact of Chronic Obstructive Pulmonary Disease on Postoperative Complication Rates, Ambulation, and Length of Hospital Stay After Elective Spinal Fusion (≥3 Levels) in Elderly Spine Deformity Patients.

OBJECTIVE: To investigate the impact that chronic obstructive pulmonary disease (COPD) has on postoperative complication rates, ambulation, and hospital length of stay for elderly spinal deformity patients after elective spinal fusion (≥3 levels). METHODS: The medical records of 559 elderly (≥60 years old) spine deformity patients undergoing elective spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 60 patients with COPD (10.7%) and 499 patients without COPD (89.3%). Patient demographics, comorbidities, postoperative complications, ambulatory status, and readmission rates were collected. The primary outcomes investigated in this study were complication rates and length of hospital stay. RESULTS: Demographics and comorbidities were similar between groups, with a difference in proportion of smokers (COPD group: 25.0% vs. no COPD group: 9.6%, P = 0.0004). The median number of fusion levels (P = 0.840), operative time (P = 0.842), estimated blood loss (P = 0.336), and incidences of durotomy (P = 0.258) was similar between both cohorts. The COPD cohort experienced a higher rate of postoperative fever (10.0% vs. 3.0%, P = 0.007) and pneumonia (5.0% vs. 0.4%, P = 0.0004), respectively. There was a significant difference in the number of feet walked on the first day of ambulation after surgery (COPD group: 58.6 ± 78.4 vs. no COPD group: 84.0 ± 102.8, P = 0.040). Length of hospital stay was significantly longer in the COPD cohort than the no COPD cohort (7.7 ± 6.4 vs. 6.0 ± 4.0 days, respectively; P = 0.0498). CONCLUSIONS: Our study demonstrates that elderly patients with COPD have increased lengths of stay and higher rates of postoperative pneumonia after spinal fusion. This determination identifies a potentially modifiable risk factor for increased utilization of health care resources.

Preoperative Hemoglobin Level is Associated with Increased Health Care Use After Elective Spinal Fusion (≥3 Levels) in Elderly Male Patients with Spine Deformity.

BACKGROUND: Measures of health care use such as length of hospital stay (LOS) are used as proxies for quality of care after spine surgery. Accordingly, hospitals and health systems are investing considerable resources into the preoperative identification of patients at risk for prolonged LOS. This study aims to investigate the impact of preoperative level on outcomes and LOS after spinal fusion. METHODS: The medical records of 204 elderly (≥60 years) male patients undergoing elective spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. The lower hemoglobin (Hgb) level was designated as <13.5 g/dL. We identified 83 (40.7%) patients with preoperative lower Hgb levels and 121 (59.3%) with normal levels (low Hgb, n = 83; normal Hgb, n = 121). The primary outcomes investigated were complications and LOS. RESULTS: Demographics and comorbidities were similar between both groups, with mean Hgb levels being 12.3 ± 0.9 g/dL and 14.9 ± 1.0 g/dL for the low and normal cohorts, respectively. The lower Hgb cohort experienced higher rates of postoperative delirium (21.7% vs. 5.8%; P = 0.0007), non-wound infections (6.0% vs. 0.0%; P = 0.006), and hematoma formation (3.6% vs. 0.0%; P = 0.035). There was a significant difference in LOS between the cohorts, with the low Hgb cohort experiencing approximately a 2-fold increase (low Hgb, 8.1 ± 5.9 days vs. normal Hgb, 4.8 ± 2.5 days; P < 0.0001). Preoperative Hgb and hematocrit levels negatively correlated with LOS (Hgb, R = -0.388, P < 0.001 and Hct, R = -0.2883, P < 0.001). CONCLUSIONS: Our study shows that elderly male patients with lower preoperative Hgb levels have increased LOS and postoperative delirium after spinal fusion. Moreover, preoperative Hgb levels negatively correlate with LOS.

Pediatric traumatic brain injury at Mbarara Regional Referral Hospital, Uganda.

BACKGROUND: In Uganda, TBI constitute the majority of neurosurgical admissions and deaths specially in the pediatric population. This study aims to determine the factors associated with poor outcome among pediatric TBI cases at a major referral hospital in western Uganda. METHODS: This study was conducted at Mbarara Regional Referral Hospital (MRRH) in western Uganda. All pediatric neurosurgical cases between 2012 and 2015 were reviewed. In-hospital mortality and discharge GCS were the main outcomes of interest. Multivariable logistic regression with backward elimination was used to determine the factors significantly associated with outcome. RESULTS: A total of 381 pediatric TBI patients were admitted to MRRH between 2012 and 2015. The mean age was 8.6 (SD 5.6) with a male predominance (62.0%). The most common mechanism of injury overall was RTI, which was responsible for 71% of all TBI cases. In the multivariable logistic regression model, admission GCS < 13 was a strong predictor of poor outcome and in-hospital mortality compared to admission GCS ≥ 13, with patients demonstrating an odds ratio of 30 (95%CI: 7-132) and OR of 18 (95%CI: 4-79), respectively. CONCLUSION: Given the lack of published literature on pediatric TBI in LMICs, this study was the first to describe and evaluate risk factors associated with TBI severity among pediatric patients at a major referral hospital in western Uganda. Injury severity on admission was the only variable found to be significantly associated with discharge outcome. This study ultimately highlights the need for more effective preventative measures to decrease admission severity.

Relationship Among Koenig Depression Scale and Postoperative Outcomes, Ambulation, and Perception of Pain in Elderly Patients (≥65 Years) Undergoing Elective Spinal Surgery for Adult Scoliosis.

BACKGROUND: The aim of this study was to assess whether the Koenig Depression Scale (KDS) can identify depressed elderly patients undergoing elective spine surgery for deformity at risk for inferior postoperative outcomes including complication rates, ambulation ability, and patient-reported outcomes. METHODS: The medical records of 92 elderly patients (≥65 years) undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were reviewed for this study. Preoperative baseline depression was assessed using the validated KDS that was administered by a board-certified geriatrician. KDS is made up of 11 questions with a maximum of 11 points (No-Depression = KDS <4, Depression = KDS ≥4). The primary outcomes of this study were complication rates, duration of hospital stay, ambulation ability, and follow-up visual analog scale (VAS) scores at 6 weeks, 3 months, and 6 months after hospital discharge. RESULTS: Of the 92 patients, 20 of them (21.7%) were found to have a KDS ≥4. Baseline demographics and comorbidities were similar between both cohorts. Intraoperative variables and complications were similar between both cohorts. There were no significant differences in postoperative complications including length of hospital stay. There was no significant difference in ambulation abilities including preoperative gait speed (P = 0.38), days from operation to ambulation (P = 0.86), steps on first day of ambulation (P = 0.57), and steps before hospital discharge (P = 0.35). There was no significant difference between the cohorts in VAS scores at baseline (P = 0.19), 6 weeks (P = 0.91), 3 months (P = 0.58), and 6 months (P = 0.97) after hospital discharge. CONCLUSIONS: Our study found no difference in complication rates, ambulation abilities, and follow-up VAS scores between patients with and without depression using preoperative KDS.