A Comparison of Spatial and Phenotypic Immune Profiles of Pancreatic Ductal Adenocarcinoma and Its Precursor Lesions.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease with a 5-year survival rate of 12.5%. PDAC predominantly arises from non-cystic pancreatic intraepithelial neoplasia (PanIN) and cystic intraductal papillary mucinous neoplasm (IPMN). We used multiplex immunofluorescence and computational imaging technology to characterize, map, and compare the immune microenvironments (IMEs) of PDAC and its precursor lesions. We demonstrate that the IME of IPMN was abundantly infiltrated with CD8+ T cells and PD-L1-positive antigen-presenting cells (APCs), whereas the IME of PanIN contained fewer CD8+ T cells and fewer PD-L1-positive APCs but elevated numbers of immunosuppressive regulatory T cells (Tregs). Thus, immunosuppression in IPMN and PanIN seems to be mediated by different mechanisms. While immunosuppression in IPMN is facilitated by PD-L1 expression on APCs, Tregs seem to play a key role in PanIN. Our findings suggest potential immunotherapeutic interventions for high-risk precursor lesions, namely, targeting PD-1/PD-L1 in IPMN and CTLA-4-positive Tregs in PanIN to restore immunosurveillance and prevent progression to cancer. Tregs accumulate with malignant transformation, as observed in PDAC, and to a lesser extent in IPMN-associated PDAC (IAPA). High numbers of Tregs in the microenvironment of PDAC went along with a markedly decreased interaction between CD8+ T cells and cancerous epithelial cells (ECs), highlighting the importance of Tregs as key players in immunosuppression in PDAC. We found evidence that a defect in antigen presentation, further aggravated by PD-L1 expression on APC, may contribute to immunosuppression in IAPA, suggesting a role for PD-L1/PD-1 immune checkpoint inhibitors in the treatment of IAPA.

Payer-Negotiated Price Variation and Relationship to Surgical Outcomes for the Most Common Cancers at NCI-Designated Cancer Centers.

BACKGROUND: Federal rules mandate that hospitals publish payer-specific negotiated prices for all services. Little is known about variation in payer-negotiated prices for surgical oncology services or their relationship to clinical outcomes. We assessed variation in payer-negotiated prices associated with surgical care for common cancers at National Cancer Institute (NCI)-designated cancer centers and determined the effect of increasing payer-negotiated prices on the odds of morbidity and mortality. MATERIALS AND METHODS: A cross-sectional analysis of 63 NCI-designated cancer center websites was employed to assess variation in payer-negotiated prices. A retrospective cohort study of 15,013 Medicare beneficiaries undergoing surgery for colon, pancreas, or lung cancers at an NCI-designated cancer center between 2014 and 2018 was conducted to determine the relationship between payer-negotiated prices and clinical outcomes. The primary outcome was the effect of median payer-negotiated price on odds of a composite outcome of 30 days mortality and serious postoperative complications for each cancer cohort. RESULTS: Within-center prices differed by up to 48.8-fold, and between-center prices differed by up to 675-fold after accounting for geographic variation in costs of providing care. Among the 15,013 patients discharged from 20 different NCI-designated cancer centers, the effect of normalized median payer-negotiated price on the composite outcome was clinically negligible, but statistically significantly positive for colon [aOR 1.0094 (95% CI 1.0051-1.0138)], lung [aOR 1.0145 (1.0083-1.0206)], and pancreas [aOR 1.0080 (1.0040-1.0120)] cancer cohorts. CONCLUSIONS: Payer-negotiated prices are statistically significantly but not clinically meaningfully related to morbidity and mortality for the surgical treatment of common cancers. Higher payer-negotiated prices are likely due to factors other than clinical quality.

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study.

INTRODUCTION: Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS: We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS: Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS: Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.

Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks.

Importance: Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. Objective: To quantify low-volume surgery and associated outcomes within hospital networks. Design, Setting, and Participants: This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Exposure: Receipt of surgery in a low-volume hospital within a network. Main Outcomes and Measures: Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). Results: In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Conclusions and Relevance: Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.

Optimizing care delivery in expanding health systems: Views from clinical leaders.

INTRODUCTION: In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored. METHODS: Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis. RESULTS: Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality. CONCLUSIONS: Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.

Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study.

BACKGROUND: The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. METHODS: In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. RESULTS: We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. CONCLUSIONS: Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.

Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.

BACKGROUND: Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. METHODS: A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes. RESULTS: In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001). CONCLUSIONS: The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.

Hospital performance in a statewide commercial insurer episode-based incentive program.

OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

The combined effect of race, dual-eligibility and neighborhood deprivation on medicare spending after cancer surgery.

INTRODUCTION: Disparities in clinical outcomes following high-risk cancer operations are well documented, but, whether these disparities contribute to higher Medicare spending is unknown. METHODS: Using 100% Medicare claims, White and Black beneficiaries undergoing complex cancer surgery between 2016 and 2018 with dual eligibility status and census tract Area Deprivation Index score were included. Linear regression was used to assess the association of race, dual-eligibility, and neighborhood deprivation on Medicare payments. RESULT: Overall, 98,725 White(93.5%) and 6900 Black(6.5%) patients were included. Black beneficiaries were more likely to live in the most deprived neighborhoods(33.4% vs. 13.6%; P < 0.001) and be dual-eligible(26.6% vs. 8.5%; P < 0.001) compared to White beneficiares. Overall, Medicare spending was higher for Black compared to White patients($27,291 vs. 26,465; P < 0.001). Notably, when comparing Black dual-eligible patients living in the most deprived neighborhoods to White non-dual eligible patients living in the least deprived spending($29,507 vs. $25,596; abs diff $3911; P < 0.001). CONCLUSION: In this study, Medicare spending was significantly higher for Black patients undergoing complex cancer operations compared to White patients due to higher index hospitalization and post-discharge care payments.

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending.

Importance: Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate. Objective: To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement. Design, Setting, and Participants: This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022. Exposures: Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey. Main Outcomes and Measures: Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics. Results: A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001). Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

Evaluation of Prices for Surgical Procedures Within and Outside Hospital Networks in the US.

This economic evaluation examines variations in prices for surgical procedures under the Hospital Price Transparency Rule at hospitals within and outside hospital networks in the US.

Treatment patterns and survival in older adults with unresected nonmetastatic biliary tract cancers.

INTRODUCTION: The optimal treatment for unresected nonmetastatic biliary tract cancer (uBTC) is not well-established. The objective of this study was to analyze the treatment patterns and compare the differences in overall survival (OS) between different treatment strategies amongst older adults with uBTC. MATERIALS AND METHODS: We identified patients aged ≥65 years with uBTC using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2004-2015). Treatments were classified into chemotherapy, chemoradiotherapy, and radiotherapy. The primary outcome was OS. The differences in OS were analyzed using Kaplan-Meier curves and multivariable Cox proportional hazard regression. RESULTS: A total of 4352 patients with uBTC were included. The median age was 80 years and median OS was 4.1 months. Most patients (67.3%, n = 2931) received no treatment, 19.1% chemotherapy (n = 833), 8.1% chemoradiotherapy (n = 354), and 5.4% radiotherapy alone (n = 234). Patients receiving no treatment were older and had more comorbidities. Chemotherapy was associated with significantly longer OS than no treatment in uBTC (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.95), but no difference was found in the subgroups of intrahepatic cholangiocarcinoma (iCCA; HR 0.87, 95% CI 0.75-1.00) and gallbladder carcinoma (GBC; HR 1.09, 95% CI 0.86-1.39). In the sensitivity analyses, capecitabine-based chemoradiotherapy showed significantly longer OS in uBTC compared to chemotherapy (adjusted HR 0.71, 95% CI 0.53-0.95). DISCUSSION: A minority of older patients with uBTC receive systemic treatments. Chemotherapy was associated with longer OS compared to no treatment in uBTC, but not in the subgroups of iCCA and GBC. The efficacy of chemoradiotherapy, especially in perihilar cholangiocarcinoma using capecitabine-based chemoradiotherapy, may be further evaluated in prospective clinical trials.

Understanding Community Health Access and Rural Transformation Reform-Implications for Rural Surgical Care.

The Viewpoint describes the Community Transformation Track of the Community Health Access and Rural Transformation Model for improving financial stability at rural hospitals and its implications for rural surgical care.

Neighborhood Deprivation, Hospital Quality, and Mortality After Cancer Surgery.

OBJECTIVE: To evaluate if receipt of complex cancer surgery at high-quality hospitals is associated with a reduction in disparities between individuals living in the most and least deprived neighborhoods. BACKGROUND: The association between social risk factors and worse surgical outcomes for patients undergoing high-risk cancer operations is well documented. To what extent neighborhood socioeconomic deprivation as an isolated social risk factor known to be associated with worse outcomes can be mitigated by hospital quality is less known. METHODS: Using 100% Medicare fee-for-service claims, we analyzed data on 212,962 Medicare beneficiaries more than age 65 undergoing liver resection, rectal resection, lung resection, esophagectomy, and pancreaticoduodenectomy for cancer between 2014 and 2018. Clinical risk-adjusted 30-day postoperative mortality rates were used to stratify hospitals into quintiles of quality. Beneficiaries were stratified into quintiles based on census tract Area Deprivation Index. The association of hospital quality and neighborhood deprivation with 30-day mortality was assessed using logistic regression. RESULTS: There were 212,962 patients in the cohort including 109,419 (51.4%) men with a mean (SD) age of 73.8 (5.9) years old. At low-quality hospitals, patients living in the most deprived areas had significantly higher risk-adjusted mortality than those from the least deprived areas for all procedures; esophagectomy: 22.3% versus 20.7%; P <0.003, liver resection 19.3% versus 16.4%; P <0.001, pancreatic resection 15.9% versus 12.9%; P <0.001, lung resection 8.3% versus 7.8%; P <0.001, rectal resection 8.8% versus 8.1%; P <0.001. Surgery at a high-quality hospitals was associated with no significant differences in mortality between individuals living in the most compared with least deprived neighborhoods for esophagectomy, rectal resection, liver resection, and pancreatectomy. For example, the adjusted odds of mortality between individuals living in the most deprived compared with least deprived neighborhoods following esophagectomy at low-quality hospitals (odds ratio=1.22, 95% CI: 1.14-1.31, P <0.001) was higher than at high-quality hospitals (odds ratio=0.98, 95% CI: 0.94-1.02, P =0.03). CONCLUSION AND RELEVANCE: Receipt of complex cancer surgery at a high-quality hospital was associated with no significant differences in mortality between individuals living in the most deprived neighborhoods compared with least deprived. Initiatives to increase access referrals to high-quality hospitals for patients from high deprivation levels may improve outcomes and contribute to mitigating disparities.

Association of Elective Surgical Volume With State Executive Order Curtailing Elective Surgery in Michigan During the COVID-19 Pandemic.

OBJECTIVE: Our objective was to evaluate changes in elective surgical volume in Michigan while an executive order (EO) was in place curtailing elective surgery during the COVID-19 pandemic. SUMMARY BACKGROUND DATA: Many state governors enacted EOs curtailing elective surgery to protect scare resources and generate hospital capacity for patients with COVID-19. Little is known of the effectiveness of an EO on achieving a sustained reduction in elective surgery. METHODS: This retrospective cohort study of data from a statewide claims-based registry in Michigan includes claims from the largest private payer in the state for a representative set of elective operations on adult patients from February 2 through August 1, 2020. We reported trends in surgical volume over the period the EO was in place. Estimated backlogs in elective surgery were calculated using case counts from the same period in 2019. RESULTS: Hospitals achieved a 91.7% reduction in case volume before the EO was introduced. By the time the order was rescinded, hospitals were already performing elective surgery at 60.1% of pre-pandemic case rates. We estimate that a backlog of 6419 operations was created while the EO was in effect. Had hospitals ceased elective surgery during this period, an additional 18% of patients would have experienced a delay in surgical care. CONCLUSIONS: Both the introduction and removal of Michigan's EO lagged behind the observed ramp-down and ramp-up in elective surgical volume. These data suggest that EOs may not effectively modulate surgical care and could also contribute to unnecessary delays in surgical care.

Postacute Care Utilization and Episode of Care Payments Following Common Elective Operations.

OBJECTIVE: To describe PAC utilization and associated payments for patients undergoing common elective procedures. SUMMARY OF BACKGROUND DATA: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures. METHODS: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization. RESULTS: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039). CONCLUSIONS: We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Surgical Leadership Competencies for Navigating Hospital Network Expansion.

INTRODUCTION: Today, many hospitals are part of a multihospital network, which changes the context in which surgeons are asked to lead. This study explores key leadership competencies that surgical leaders use to navigate this hospital network expansion. METHODS: In this qualitative study, 30 surgical leaders were interviewed. Interviews were coded and analyzed via thematic analysis. RESULTS: We identified three key competencies that leaders felt were important leadership skills to successfully navigate expanding hospital networks. First, leaders must steer the departmental vision within the evolving hospital network landscape. Second, leaders must align the visions of the department and of the hospital network. Third, leaders must build a network-oriented culture within their department. CONCLUSIONS: As networks expand, leaders are tasked with unifying vision in their department. Leaders identified a unique opportunity to leverage their growing influence across the hospital network and invested in the people and culture of their department.

MHC Class II Expression Influences the Composition and Distribution of Immune Cells in the Metastatic Colorectal Cancer Microenvironment.

Despite advances in therapy over the past decades, metastatic colorectal cancer (mCRC) remains a highly morbid disease. While the impact of MHC-I on immune infiltration in mCRC has been well studied, data on the consequences of MHC-II loss are lacking. Multiplex fluorescent immunohistochemistry (mfIHC) was performed on 149 patients undergoing curative intent resection for mCRC and stratified into high and low human leukocyte antigen isotype DR (HLA-DR) expressing tumors. Intratumoral HLA-DR expression was found in stromal bands, and its expression level was associated with different infiltrating immune cell makeup and distribution. Low HLA-DR expression was associated with increased intercellular distances and decreased population mixing of T helper cells and antigen-presenting cells (APC), suggestive of decreased interactions. This was associated with less co-localization of tumor cells and cytotoxic T lymphocytes (CTLs), which tended to be in a less activated state as determined by Ki67 and granzyme B expression. These findings suggest that low HLA-DR in the tumor microenvironment of mCRC may reflect a state of poor helper T-cell interactions with APCs and CTL-mediated anti-tumor activity. Efforts to restore/enhance MHC-II presentation may be a useful strategy to enhance checkpoint inhibition therapy in the future.