Care fragmentation in hepatopancreatic surgery and postoperative outcomes.

BACKGROUND: Practice fragmentation in surgery may be associated with poor quality of care. We sought to define the association between fragmented practice and outcomes in hepatopancreatic surgery relative to surgeon volume and sex. METHODS: Medicare beneficiaries who underwent hepatopancreatic surgery between 2016 and 2021 were identified. Multivariable analysis was performed to determine provider sex-based differences in the rate of fragmented practice relative to the achievement of a textbook outcome and health care expenditures after adjusting for procedure-specific case volume. RESULTS: Among 37,416 patients, almost one-half were female (n = 18,333, 49.0%) with the majority treated by male surgeons (n = 33,697, 90.8%). Female surgeons were more likely to have a greater rate of fragmented practice (females: n = 242, 84.9% vs males: n = 1,487, 78.4%, P = .003; odds ratio 2.66, 95% confidence interval 2.33-3.03, P < .001). Patients treated by high rate of fragmented practice surgeons had increased odds of postoperative complications (odds ratio 1.40, 95% confidence interval 1.28-1.54), extended length-of-stay (odds ratio 1.52, 95% confidence interval 1.38-1.68), 90-day-mortality (odds ratio 1.49, 95% confidence interval 1.28-1.72), and lower odds of achieving a textbook outcome (odds ratio 0.76, 95% confidence interval 0.71-0.83). This association persisted independent of surgeon-specific volume (textbook outcome, high vs low rate of fragmented practice: high-volume surgeon, odds ratio 0.53, 95% confidence interval 0.31-0.91, P = .021 vs. low-volume surgeon, odds ratio 0.76, 95% confidence interval 0.69-0.82, P < .001). Among patients treated by male surgeons, a high rate of fragmented practice was associated with reduced odds of achieving a textbook outcome (male surgeons: odds ratio 0.76, 95% confidence interval 0.70-0.82, P < .001; female surgeons: odds ratio 0.81, 95% confidence interval 0.63-1.05, P = .110). Treatment by surgeons with higher fragmented practice was associated with higher expenditures (index expenditure: percentage difference 9.87, 95% confidence interval, 7.42-12.36; P < .05). CONCLUSION: A high rate of fragmented practice adversely affected postoperative outcomes and healthcare expenditures even among high-volume surgeons with the impact varying based on surgeon sex.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

BACKGROUND: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Prognostic value of nodal staging classification and number of examined lymph nodes among patients with ampullary cancer.

BACKGROUND: Metastatic disease in the regional lymph nodes (LNs) is a strong indicator of worse outcomes among patients after curative-intent resection of ampullary cancer (AC). This study aimed to ascertain the threshold number of examined LNs (ELNs) for AC to compare the prognosis accuracy of various nodal classification schemes relative to long-term prognosis. METHODS: Patients who underwent pancreatoduodenectomy (PD) for AC (2004-2019) were identified using the National Cancer Database. Locally weighted regression scatter plot smoothing (LOWESS) curves were used to ascertain the optimal cut point for ELNs. The accuracy of the American Joint Committee on Cancer N classification, LN ratio, and log odds transformation (LODDS) ratio to stratify patients relative to survival was examined. RESULTS: Among 8127 patients with AC, 67% were male with a median age of 67 years (IQR, 59-74). Tumors were most frequently classified as T3 (34.9%), followed by T2 (30.6%); T1 (12.9%) and T4 (17.6%) were less common. LN metastasis was identified in 4606 patients (56.7%). Among patients with nodal disease, 37.0% and 19.7% had N1 and N2 disease, respectively. The LOWESS curves identified an inflection cutoff point in the hazard of survival at 20 ELNs. The survival benefit of 20 ELNs was more pronounced among patients without LN metastasis vs patients with N1 disease (median overall survival [OS]: 54.1 months [IQR, 45.9-62.1] in ≥20 ELNs vs 39.0 months [IQR, 35.8-42.2] in <20 ELNs; P < .001) or N2 disease (median OS: 22.5 months [IQR, 18.9-26.2] in ≥20 ELNs vs 25.4 months [IQR, 23.3-27.6] in <20 ELNs; P < .001). When comparing the 4 different N classification schemes, the LODDS classification scheme yielded the highest predictive ability. CONCLUSIONS: Evaluation of a minimum of 20 LNs was needed to stratify patients with AC relative to the prognosis and to minimize stage migration. The LODDS nodal classification scheme had the highest prognostic accuracy to differentiate survival among patients after PD for AC.

Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer.

BACKGROUND AND OBJECTIVES: Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS: Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS: Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS: Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.

Association of Textbook Outcome and Hospital Volume with Long-Term Survival Following Resection for Hepatocellular Carcinoma: What Matters More?

BACKGROUND: Both textbook outcome (TO) and hospital volume have been identified as quality metrics following cancer surgery. We sought to examine whether TO or hospital volume is more important relative to long-term survival following surgical resection of hepatocellular carcinoma (HCC). METHODS: Patients who underwent surgery for HCC between 2004 and 2018 were identified using the National Cancer Database. TO was defined as R0 margin resection, no extended length of stay, no 30-day readmissions, and no 90-day mortality. The impact of TO and hospital case volume on long-term survival was determined using multivariable Cox regression. RESULTS: Among 24,895 patients who underwent HCC resection, 9.0% (n = 2,252), 79.5% (n = 19,787), and 11.5% (n = 2,856) of patients were operated on at low-, medium-, and high-volume hospitals, respectively. Treatment at high-volume hospitals and achievement of a post-operative TO were independently associated with improved 5-year overall survival (OS). Pairwise comparison demonstrated that patients treated at high-volume hospitals who did not achieve a TO still had a better 5-year OS versus individuals treated at low-volume hospitals who did achieve a TO (5-year OS, no TO vs. TO: low-volume hospitals, 26.5% vs. 48.6%; high volume hospitals: 62.6% vs. 74.9%, respectively; p < 0.001). Overall, resection of HCC at a high-volume hospital was independently associated with a 54% reduction in mortality. CONCLUSION: Long-term survival following HCC resection was largely associated with hospital case volume rather than TO. The effect of TO on long-term outcomes was largely mediated by hospital case volume highlighting the importance of centralization of care for patients with HCC.

Attitudes and practice of surgeons in reporting medical errors at a tertiary care hospital.

Medical error reporting is essential in creating a culture of accountability in our healthcare system. The aim of this study was to evaluate the frequency of reporting errors by surgeons in our setup and to analyse the factors resulting in under-reporting of medical errors. A total of 96 practicing surgeons at Mayo Hospital, Lahore were surveyed between the months of February, 2018 to June 2018 on their beliefs regarding the reporting of medical errors by means of a specifically designed questionnaire. This study revealed that 71 (74%) respondents had committed a medical error but only 16 (16.6%) of them reported those errors. Major factors in under-reporting of errors included work stress and fear of medico-legal consequences due to disclosure of error. Eighty-four (87.5%) believed that increase in reporting medical errors would contribute to a better system. Most surgeons had a positive view towards the process but believed that the reporting system was ineffective.

Root cause analysis of pre-microscopic errors in anatomical pathology using Eindhoven classification.

OBJECTIVE: To evaluate pre-microscopic errors in anatomical pathology. METHODS: The cross-sectional descriptive study was conducted at the Department of Pathology of a tertiary care hospital in Lahore, Pakistan, from September, 2016, to January, 2017, and comprised surgical pathology specimens. Errors were noted across the pre-microscopic process. Defects per million opportunities were calculated to determine sigma metric value in every step, from requisition to slide preparation. Root cause analysis was applied to the process of histology preparation to identify the root cause of each previously identified problem using Eindhoven classification. All errors were recorded on a pre-designed proforma. RESULTS: There were 2420 specimens. While errors were encountered in all phases of the pre-microscopic process, but the (G6: n=1085, 44.83%), followed by requisition (R3: n=893, 36.9%) and cover slipping (C1: n=776, 32.06%). CONCLUSIONS: Development of standard procedures and protocols with staff training is likely to help in controlling the errors.