Operating room use for emergency general surgery cases: analysis of the Patterns of Complex Emergency General Surgery in Canada study.

BACKGROUND: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. METHODS: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. RESULTS: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. CONCLUSION: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

Failure to rescue in emergency general surgery in Canada.

BACKGROUND: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. METHODS: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). RESULTS: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. CONCLUSION: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

Impact of interhospital transfer on patient outcomes in emergency general surgery.

BACKGROUND: Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers. METHODS: We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority. RESULTS: A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis. CONCLUSION: Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

Patterns of complex emergency general surgery in Canada.

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 46­73 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.

Drivers of Inpatient Costs After Colorectal Surgery Within a Publicly Funded Healthcare System.

BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN: This was a population-based, retrospective administrative analysis. SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682-$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583-$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548-$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739-$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study. LIMITATIONS: Inherent biases associated with administrative databases limited this study. CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at http://links.lww.com/DCR/A839.

The value of surgical experience: excess costs associated with the Roux-en-Y gastric bypass learning curve.

BACKGROUND: Gastric bypass has a steep learning curve that is associated with increased adverse outcomes and these adverse outcomes are associated with increases in cost. This study sought to quantify the effect of cumulative procedure volume on inpatient cost and characterize the excess cost associated with a surgeon's learning curve. METHODS: This was a retrospective study of 29 high-volume surgeons during the first 6 years of performing gastric bypass in a regionalized center of excellence system. Cumulative volume was determined using the procedure date and analyzed in blocks of 25 cases. The main outcomes of interest were inpatient cost for the initial hospital stay in 2014 Canadian dollars as well as prolonged length of stay (≥ 3 days). RESULTS: Overall, 11,684 cases were identified from April 2009 to March 2015. After a surgeon's 50th case, the adjusted inpatient cost decreased by $2775 (95% CI $- 4352 to $- 1204 p = 0.001) compared to the first 25 cases. Cost savings were maintained through a surgeon's 400th case. The average cost savings after the 50th case was $2082 (95% CI $- 3194 to $- 962 p < 0.001) and the excess cost attributable to the first 50 cases was $104,077 (95% CI 48,104 to 159,682) per surgeon. Surgeon experience was also associated with a decrease odds of prolonged length of stay. CONCLUSIONS: This study demonstrated the influence of surgeon experience on improved cost efficiencies. We also characterized that the average excess cost per surgeon of implementing gastric bypass was approximately $104,000. This is relevant to future health system planning as well as providing an economic incentive for impactful training interventions.

The effect of distance on short-term outcomes in a regionalized, publicly funded bariatric surgery model.

BACKGROUND: While high-volume Centers of Excellence (COE) for bariatric surgery may have improved clinical outcomes, their disparate distribution results in longer travel distances for patients. The purpose of this study was to investigate effect of distance from COE on outcomes and readmission. METHODS: This was a retrospective study of all adults, aged 18 years or older, receiving bariatric surgery from April 2009 to March 2012 in the province of Ontario. Main outcomes included 30-day complication rates and readmission. Multivariable logistic regression was used to examine the impact of distance from patients' primary residence to their bariatric COE on patient outcomes and readmissions. RESULTS: Five thousand and seven patients were identified, two-thirds residing within 100 km of a COE with a mean distance of 117.2 km. The majority of patients did not reside within a Local Integrated Health Network (LHIN) that contained a COE, while 18.3% of patients lived in rural areas. Using multivariable adjustment, for every 10 km increase from the COE where surgery was performed, the Odds Ratio (OR) for complications was 1.00 [95% Confidence Interval (CI) 0.99-1.01; P = 0.747]. Additionally, both residing in a LHIN without a COE, OR 1.10 (95% CI 0.87-1.40; P = 0.434), and rural status, OR 0.97 (95% CI 0.77-1.23; P = 0.821) showed no increase in risk of complication. Similarly, further distances did not influence rate of readmission, OR 0.99 (95% CI 0.98-1.00; P = 0.077) nor did rural status OR 1.31 (95% CI 0.97-1.76; P = 0.076). CONCLUSION: The COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients that live further away receive appropriate short-term care.

Mastery in Bariatric Surgery: The Long-term Surgeon Learning Curve of Roux-en-Y Gastric Bypass.

OBJECTIVE: To determine the effect of cumulative volume on all-cause morbidity and operative time. BACKGROUND: Gastric bypass is an important public health procedure, but it is difficult to master with little data about how surgeon cumulative volume affects outcomes longitudinally. METHODS: This was a longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high-volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. Cumulative volume was analyzed in blocks of 75 cases. The main outcome of interest was all-cause morbidity during the index admission and the secondary outcome was operative time. RESULTS: Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The overall morbidity rate was 10.1% and short-term outcomes were related significantly to cumulative volume. Perioperative risk plateaued after approximately 500 cases and was lowest for surgeons who had completed more than 600 cases (odds ratio 0.53 95% confidence interval 0.26-0.96 P = 0.04) compared to the first 75 cases. Operative time also stabilized after approximately 500 cases, with an operative time 44.7 minutes faster than surgeons in their first 75 cases (95% confidence interval 37.0-52.4 min P < 0.001). CONCLUSIONS: The present study demonstrated the clear, substantial influence of surgeon cumulative volume on improved perioperative outcomes and operative time. This finding emphasizes role of the individual surgeon in perioperative outcomes and that the true learning curve needed to master a complex surgical procedure such as gastric bypass is longer than previously thought, in this case requiring approximately 500 cases to plateau.

A Longitudinal Analysis of Short-Term Costs and Outcomes in a Regionalized Center of Excellence Bariatric Care System.

BACKGROUND: Evaluating how morbidity and costs evolve for new bariatric centers is vital to understanding the expected length of time required to reach optimal outcomes and cost efficiencies. Accordingly, the objective of this study was to evaluate how morbidity and costs changed longitudinally during the first 5 years of a regionalized center of excellence system. METHODS: This was a longitudinal analysis of the first 5 years of a bariatric center of excellence system. The main outcomes of interest were all-cause morbidity and cost for the index admission. Predictors of interest included patient demographics, comorbidities, annual hospital and surgeon volume, fellowship teaching center status, and year of procedure. Hierarchical regression models were used to determine predictors of morbidity and costs. RESULTS: Procedures done in 2012 (OR 0.65, 95%CI 0.52-0.79; p < 0.001), 2013 (OR 0.63, 95%CI 0.51-0.78; p < 0.001), and 2014 (OR 0.53, 95%CI 0.43-0.65; p < 0.001) all conferred a significantly lower odds of morbidity when compared to the initial 2009/2010 years. Surgeon volume was associated with a decreased odds of morbidity as for each increase in 25 bariatric cases per year the odds of all-cause morbidity was 0.94 lower (95%CI 0.88-1.00; p = 0.04). There was no significant variation at the hospital or surgeon level in perioperative outcomes. CONCLUSION: This study determined that volume was important even for high resource, fellowship-trained surgeons. It also found a decrease in morbidity over time for new centers. Lastly, there was little variation in outcomes across hospitals and surgeons suggesting that strict accreditation standards can help to ensure high quality across hospital sites.

The effect of health system factors on outcomes and costs after bariatric surgery in a universal healthcare system: a national cohort study of bariatric surgery in Canada.

INTRODUCTION: Previous data demonstrate that patients who receive bariatric surgery at a Center of Excellence are different than those who receive care at non-accredited centers. Canada provides a unique opportunity to naturally exclude confounders such as insurance status, hospital ownership, and lack of access on comparisons between hospitals and surgeons in bariatric surgery outcomes. The objective of this study was to determine the effect of hospital accreditation and other health system factors on all-cause morbidity after bariatric surgery in Canada. METHODS: This was a population-based study of all patients aged ≥18 who received a bariatric procedure in Canada (excluding Quebec) from April 2008 until March 2015. The main outcomes for this study were all-cause morbidity and costs during the index admission. All-cause morbidity included any documented complication which extended length of stay by 24 h or required reoperation. Risk-adjusted hierarchical regression models were used to determine predictors of morbidity and cost. RESULTS: Overall, 18,398 patients were identified and the all-cause morbidity rate was 10.1%. Surgeon volume and teaching hospitals were both found to significantly decrease the odds of all-cause morbidity. Specifically, for each increase in 25 bariatric cases per year, the odds of all-cause morbidity was 0.94 times lower (95% CI 0.87-1.00, p = 0.03). Teaching hospitals conferred a 0.75 lower odds of all-cause morbidity (95% CI 0.58-0.95, p < 0.001). Importantly, formal accreditation was not associated with a decrease in all-cause morbidity within a universal healthcare system. No health system factors were associated with significant cost differences. CONCLUSION: This national cohort study found that surgeon volume and teaching hospitals predicted lower all-cause morbidity after surgery while hospital accreditation was not a significant factor.

A comparison of endoscopic localization error rate between operating surgeons and referring endoscopists in colorectal cancer.

BACKGROUND: Colonoscopy for colorectal cancer (CRC) has a localization error rate as high as 21 %. Such errors can have substantial clinical consequences, particularly in laparoscopic surgery. The primary objective of this study was to compare accuracy of tumor localization at initial endoscopy performed by either the operating surgeon or non-operating referring endoscopist. METHODS: All patients who underwent surgical resection for CRC at a large tertiary academic hospital between January 2006 and August 2014 were identified. The exposure of interest was the initial endoscopist: (1) surgeon who also performed the definitive operation (operating surgeon group); and (2) referring gastroenterologist or general surgeon (referring endoscopist group). The outcome measure was localization error, defined as a difference in at least one anatomic segment between initial endoscopy and final operative location. Multivariate logistic regression was used to explore the association between localization error rate and the initial endoscopist. RESULTS: A total of 557 patients were included in the study; 81 patients in the operating surgeon cohort and 476 patients in the referring endoscopist cohort. Initial diagnostic colonoscopy performed by the operating surgeon compared to referring endoscopist demonstrated statistically significant lower intraoperative localization error rate (1.2 vs. 9.0 %, P = 0.016); shorter mean time from endoscopy to surgery (52.3 vs. 76.4 days, P = 0.015); higher tattoo localization rate (32.1 vs. 21.0 %, P = 0.027); and lower preoperative repeat endoscopy rate (8.6 vs. 40.8 %, P < 0.001). Initial endoscopy performed by the operating surgeon was protective against localization error on both univariate analysis, OR 7.94 (95 % CI 1.08-58.52; P = 0.016), and multivariate analysis, OR 7.97 (95 % CI 1.07-59.38; P = 0.043). CONCLUSIONS: This study demonstrates that diagnostic colonoscopies performed by an operating surgeon are independently associated with a lower localization error rate. Further research exploring the factors influencing localization accuracy and why operating surgeons have lower error rates relative to non-operating endoscopists is necessary to understand differences in care.

Outcomes the Ontario Bariatric Network: a cohort study.

BACKGROUND: Bariatric surgery centres of excellence are relatively new in Canada and were first started in Ontario in 2009. This study presents short-term outcomes of Canada's largest bariatric collaborative, from Ontario, during its first 3 years. METHODS: We performed a population-based cohort study that included all patients (age ≥ 18) who received a Roux-en-Y gastric bypass or sleeve gastrectomy for the purpose of weight loss from March 2009 to April 2012 within Ontario. Data were derived from the Canadian Institute for Health Information Discharge Abstract and Hospital Morbidity Databases. Primary outcomes included short-term overall complication rate, reoperation rate, anastomotic leak rate and death. Hierarchical logistic regression was used to identify risk factors for overall complications. A median odds ratio (OR) was used to compare risk-adjusted complication rates across centres of excellence. RESULTS: A total of 5007 procedures (91.7% Roux-en-Y gastric bypass, 8.3% sleeve gastrectomy) were performed during the 3-year study period, with an overall complication rate of 11.7% (95% confidence interval [CI] 10.8%-12.6%). The leak rate was 0.84% (95% CI 0.61%-1.13%), the reoperation rate was 4.6% (95% CI 4.0%-5.2%) and mortality was 0.16% (95% CI 0.07%-0.31%). Male sex, chronic kidney disease and osteoarthritis were identified as risk factors for overall complications (p value < 0.05). The median ORs across centres of excellence, calculated for both overall complications and reoperation rate, were 1.76 and 1.49, respectively. INTERPRETATION: Bariatric surgery within Ontario has similar short-term outcomes to those of other major world centres. The variability of outcomes within centres of excellence highlights areas for program quality improvement.

Neighborhood Variation in the Utilization of Laparoscopy for the Treatment of Colon Cancer.

BACKGROUND: The rates of laparoscopic colectomy for colon cancer have steadily increased since its inception. Laparoscopic colectomy currently accounts for a third of colectomy procedures in the United States, but little is known regarding the spatial pattern of the utilization of laparoscopy for colon cancer. OBJECTIVE: This study evaluated the utilization of laparoscopy for colon cancer at the neighborhood level in Ontario. DESIGN: Retrospective analysis of prospectively collected data was performed. SETTING: This study was conducted at all hospitals in the province of Ontario. PATIENTS: This population-based study included all patients aged ≥18 who received an elective colectomy for colon cancer from April 2008 until March 2012 in the province of Ontario. MAIN OUTCOME MEASURES: The primary outcome measure was the neighborhood rates of laparoscopy. RESULTS: Overall, 9,969 patients underwent surgery, and the cluster analysis identified 74 cold-spot neighborhoods, representing 1.8 million people, or 14% of the population. In the multivariate analysis, patients from rural neighborhoods were less than half as likely to receive laparoscopy, OR 0.44 (95% CI, 0.24-0.84; p = 0.012). Additionally, having a minimally invasive surgery fellowship training facility within the same administrative health region as the neighborhood made it more than 23 times as likely to be a hot spot, OR 25.88 (95% CI, 12.15-55.11; p < 0.001). Neighborhood socioeconomic status was not associated with variation in the utilization of laparoscopy. LIMITATIONS: Patient case mix could affect laparoscopy use. CONCLUSION AND RELEVANCE: This study identified an unequal utilization of laparoscopy for colon cancer within Ontario with rural neighborhoods experiencing low rates of laparoscopic colectomy, whereas neighborhoods in the same administrative region as minimally invasive surgery training centers experienced increased utilization. Further study into the causes of this variation in resource allocation is needed to identify ways to improve more efficient spread of knowledge and technical skills advancement.

A population-based comparison of 30-day readmission after surgery for colon and rectal cancer: How are they different?

BACKGROUND: An implicit assumption in the analysis of colorectal readmission is that colon and rectal cancer patients are similar enough to analyze together. However, no studies have examined this assumption and whether substantial differences exist between colon and rectal cancer patients. METHODS: This was a retrospective analysis of the differences in predictors, diagnoses, and costs of readmission between colon and rectal cancer cohorts for 30-day readmission. This study included all patients aged >18 who received an elective colectomy or low anterior resection for colorectal cancer from April 2008 until March 2012 in the province of Ontario. RESULTS: Overall, 13,571 patients were identified and the readmission rates significantly differed between rectal and colon cancer patients (7.1% colon and 10.7% rectal P = 0.001). Diabetes, age, and discharge to long term care were significantly different among colon and rectal patients in the prediction of readmission. Readmission for renal and stoma causes was more prominent in the rectal cohort. The adjusted cost difference for readmission did not significantly differ between rectal and colon cancer $178 ($1,924-1,568 P = 0.84) CONCLUSION: Several important differences in predictors and diagnoses exist between the two cohorts. Conversely, the costs associated with readmission were homogenous between rectal and colon cancer patients. J. Surg. Oncol. 2016;114:354-360. © 2016 Wiley Periodicals, Inc.

A population-based analysis of the drivers of short-term costs after bariatric surgery within a publicly funded regionalized center of excellence system.

BACKGROUND: The most significant driver of healthcare utilization for bariatric surgery is the index admission and readmissions within the first 30 days after a procedure. Identifying areas to create efficiencies during this period is essential to decreasing overall healthcare costs. OBJECTIVE: The objective of the study was to characterize the short-term costs of bariatric surgery within a regionalized center of excellence bariatric care system. SETTING: The Ontario Bariatric Network is a regionalized bariatric care system with 4 high-volume Bariatric Centers of Excellence. METHODS: We performed a population-based retrospective analysis including all adult patients who received a bariatric surgical procedure in Ontario from April 2009 until March 2012. Total hospital cost and number of days in hospital was calculated for all index admissions and all readmissions within 30 days of a bariatric surgical procedure. An inverse Gaussian generalized linear model was utilized to model the effect of covariates on costs. A Poisson regression was used to determine the effect on covariates on total days in hospital. RESULTS: After multivariable adjustment, the sleeve gastrectomy procedure decreased costs by $1447 over gastric bypass (95% confidence interval [CI] $1578 to-$1315]); P<.001). This effect increased when adjusting only for preoperative factors with a cost savings of nearly $2000 ($1953) (95% CI-$3250 to-$533; P = .003). Conversely, complications were the major drivers of increased cost as anastomotic leaks added $24,397 (95% CI $20,688-$28,106; P<.001) to healthcare costs. In addition, medical complications, such as respiratory failure/infection ($19,465) (95% CI $11,007-$27,924; P<.001), were also significant cost drivers. CONCLUSION: Major drivers of increased resource utilization included major surgical and medical complications, such as anastomotic leaks and respiratory failure/infection. Days in hospital were affected more by medical complications than surgical complications. Sleeve gastrectomy resulted in a clear short-term cost advantage over Roux-en-Y gastric bypass (RYGB), and this was likely related to the procedure itself as opposed to differences across procedures in co-morbidity and complication rates.

Regional Variations in the Public Delivery of Bariatric Surgery: An Evaluation of the Center of Excellence Model.

OBJECTIVE: We evaluated regional access to bariatric surgery within the high-volume, center of excellence (COE) model of Ontario, Canada. BACKGROUND: In 2009, Ontario implemented Canada's first regionalized bariatric surgical care system based on a COE. Because of this, a small number of COEs service a large population and geographic area. METHODS: This study identified all patients older than 18 years, who received bariatric surgery from April 2009 to March 2012. Morbid obesity-adjusted rates of surgery were then calculated for each neighborhood, and a cluster analysis was performed to determine aggregation of neighborhoods with significantly higher (hot spots) or lower (cold spots) rates of surgery. Ordinal logistic regression was used to identify independent predictors of neighborhood access. RESULTS: The cluster analysis identified 49 cold spot neighborhoods, representing 1.7 million people. Forty of these neighborhoods lie within a relatively small area that contains 3 of the 4 COEs. In the multivariate analysis, for every 100 km from the nearest COE, neighborhoods were 0.88 times as likely to live in a hot spot [95% CI (confidence interval): 0.80-0.97; P = 0.012]. In addition, having a bariatric facility within the same administrative health region as the neighborhood made it almost twice as likely to be a hot spot, odds ratio = 1.75 (95% CI: 1.10-2.79; P = 0.018). Low neighborhood socioeconomic status was not associated with decreased delivery of care. CONCLUSIONS: This study identified an unequal delivery of bariatric surgery within Ontario. Both longer distances and not having a bariatric facility within the same health region had significant negative effects. Further research into patient attitudes and referral patterns is required to better characterize these disparities.

30-Day readmission after bariatric surgery in a publicly funded regionalized center of excellence system.

BACKGROUND: Avoidable readmission after surgery is a major burden on healthcare resources and is common after major surgery. Bariatric surgery is one of the most common surgical procedures in North America, and there is a paucity of strategies to prevent readmission. Strategies for prevention must first identify actual risk factors before interventions can be designed. METHODS: Our objective was to evaluate the readmission rate, characteristics of readmitted patients, and factors associated with readmission. We performed a population-based cohort study that included all patients who received a Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) procedure in Ontario from April 2009 until March 2012 for the purposes of weight loss. Data were derived from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. RESULTS: Over 3 years, 5007 procedures (91.7 % RYGB, 8.1 % SG) were performed with an overall 30-day readmission rate of 6.1 %. Readmission stays of 72 h or less accounted for 83 % of the cohort. The most common reasons for readmission were: infectious complications (24.6 %), pain (16.4 %) nausea/vomiting (11.5 %), bleeding complications (11.5 %), obstruction (5.6 %). A complication during initial admission OR 2.07 (95 % CI 1.44-2.97; P value < 0.001) and a length of stay greater than 2 days OR 1.40 (95 % CI 1.07-1.84; P value = 0.013) were independent predictors of readmission within 30 days. CONCLUSION: The readmission rate after bariatric surgery in Ontario is similar to other major population-based bariatric surgery programs. Complications on initial admission and prolonged length of stay were independent predictors of readmission. Considering a large proportion of the readmissions were short term, future research into potential measures to prevent these readmissions is essential.

Perception and Awareness of Bariatric Surgery in Canada: a National Survey of General Surgeons.

BACKGROUND: The objective of this study was to assess Canadian general surgeons' knowledge of bariatric surgery and perceived availability of resources to manage bariatric surgery patients. METHODS: A self-administered questionnaire was developed using a focus group of general surgeons. The questionnaire was distributed at two large general surgery conferences in September and November 2012. The survey was also disseminated via membership association electronic newsletters in November and December 2012. RESULTS: One hundred sixty-seven questionnaires were completed (104 practicing surgeons, 63 general surgery trainees). Twenty respondents were bariatric surgeons. Among 84 non-bariatric surgeons, 68.3 % referred a patient in the last year for bariatric surgery, 79 % agreed that bariatric surgery resulted in sustained weight loss, and 81.7 % would consider referring a family member. Knowledge gaps were identified in estimates of mortality and morbidity associated with bariatric procedures. The majority of surgeons surveyed have encountered patients with complications from bariatric surgery in the last year. Over 50 % of surgeons who do not perform bariatric procedures reported not feeling confident to manage complications, 35.4 % reported having adequate resources and equipment to manage morbidly obese patients, and few are able to transfer patients to a bariatric center. Of the respondents, 73.3 % reported residency training provided inadequate exposure to bariatric surgery, and 85.3 % felt that additional continuing medical education resources would be useful. CONCLUSIONS: There appears to be support for bariatric surgery among Canadian general surgeons participating in this survey. Knowledge gaps identified indicate the need for more education and resources to support general surgeons managing bariatric surgical patients.

Bariatric surgery in patients with reduced kidney function: an analysis of short-term outcomes.

BACKGROUND: With rates of obesity among patients with chronic kidney disease (CKD) mirroring that of the general population, there is growing interest in offering bariatric surgery to these patients. We sought to determine the safety of bariatric surgery in this patient population. METHODS: Patients who underwent selected laparoscopic bariatric procedures between 2005 and 2011. Estimated glomerular filtration rate (eGFR) was calculated and divided into stages of CKD. Procedures included Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), and laparoscopic sleeve gastrectomy (SG). Univariable analysis and multivariable adjustment was used to compare complication rates across stages of eGFR. RESULTS: A total of 64,589 patients were included: 64.5% underwent RYGB, 29.8% LAGB, and 5.7% SG. A total of 61.7% of patients had normal eGFR (Stage 1), 32.0% were stage 2, 5.3% were stage 3, and 1.0% were stage 4/5. After adjusting for relevant patient characteristics, there was a trend toward increasing complications from stage 1 to stage 4/5 CKD among RYGB, LAGB, and SG groups, but none were statistically significant. Similarly, major complications generally increased across stages of CKD for each procedure, but was only significant for RYGB comparing stage 3 to stage 1 (OR 1.22; 95% CI: 1.01-1.47; P = .042) and risk difference .96% (95% CI: .03-1.96). Considering only stage 4/5 CKD, overall (P = .114) and major complications (P = .032) were highest in the RYGB group, followed by SG and LAGB. CONCLUSION: More advanced stages of CKD do not appear to be statistically associated with an increased risk of 30-day postoperative complications.