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OBJECTIVE: To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after taTME. SUMMARY BACKGROUND DATA: Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter Phase II taTME trial demonstrated the safety of taTME in patients with stage I-III tumors. METHODS: Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence (FIQL, Wexner), defecatory function (COREFO), urinary function (IPSS), and sexual function (FSFI-female, IIEF-male) were assessed preoperatively (PQ), 3-4 months post-ileostomy closure (FQ1), and 12-18 months post-taTME (FQ2). RESULTS: Among 83 patients who responded at all three time points, FIQL, Wexner, and COREFO significantly worsened post-ileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. IPSS did not change relative to preoperative scores. For females, FSFI declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, IIEF declined with no change between FQ1 and FQ2. CONCLUSIONS: Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.
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OBJECTIVE: Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients. SUMMARY OF BACKGROUND DATA: PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery. METHODS: We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion. RESULTS: After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care. CONCLUSIONS: This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.
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Cuidados Críticos , Cuidados Paliativos/normas , Assistência Perioperatória/normas , Indicadores de Qualidade em Assistência à Saúde , HumanosRESUMO
BACKGROUND AND OBJECTIVES: Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS: Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS: There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS: Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.
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Adenocarcinoma , Neoplasias Retais , Humanos , Adenocarcinoma/terapia , Adenocarcinoma/patologia , Neoplasias Retais/terapia , Neoplasias Retais/patologia , Terapia Neoadjuvante , Reto/patologia , Disparidades em Assistência à SaúdeRESUMO
BACKGROUND: Although the results of clinical trials often guide best practices, changing clinical practice based on clinical trial results can be challenging. The objective of this study was to examine provider-reported barriers to adopting best clinical practices according to clinical trial data. METHODS: A cross-sectional survey was conducted of providers from the National Accreditation Program for Breast Centers about barriers that prevent the incorporation of trial findings. Descriptive analyses and multivariable analyses were performed to determine provider characteristics that were significantly associated with reported barriers. RESULTS: Overall, 383 institutions participated (63.5% response rate), with a total of 1226 physicians responding to the survey (80% response rate). Providers identified national guidelines and meetings as the most compelling way to receive practice-changing information. They reported the following internal barriers to trial implementation: patient preference (45%), strongly held beliefs by partners/colleagues (37%), and insufficient time to discuss new practices (30%). External barriers preventing trial implementation included a lack of agreement from multidisciplinary tumor boards (32%), fear of reimbursement loss (23%), and resistance from clinical staff (20%). Reported barriers differed by provider specialty, with plastic surgeons and radiation oncologists reporting that strongly held beliefs by partners/colleagues and disagreement from multidisciplinary tumor boards were the most significant factors preventing clinical trial implementation. CONCLUSIONS: Physician beliefs and patient preferences are the most frequently reported barriers to clinical trial implementation. Tactics to better educate providers about how to explain new clinical trial data to their patients and colleagues are needed.
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Acreditação , Neoplasias da Mama/terapia , Ensaios Clínicos como Assunto/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Implementação de Plano de Saúde , Oncologistas/normas , Guias de Prática Clínica como Assunto/normas , Estudos Transversais , Feminino , Humanos , Oncologistas/psicologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients. We sought to explore clinician perspectives on the barriers and facilitators to clinician-to-clinician communication and delivery of goal-concordant patient care. METHODS: Purposive and snowball sampling were used to recruit a multidisciplinary sample of clinicians who held roles in a surgical intensive care unit at a single tertiary care facility. Semistructured interviews with clinicians were conducted between September and December 2017 to assess clinician experiences with communicating and honoring patient GOC. Two independent coders performed qualitative coding in an iterative fashion using a framework approach. Inter-rater agreement was measured by kappa coefficient. RESULTS: Thirty-three clinicians from multiple disciplines including surgery, anesthesiology, nursing, and social work, were interviewed. Analysis revealed that clinicians in all disciplines felt responsible for honoring patient GOC. Conflicts over patient GOC and how to honor them arose between clinicians with longitudinal patient relationships (preoperative and postoperative) and those with single-phase relationships (postoperative). Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations. Facilitators included recognition of a patient's unique treatment priorities and family members with a unified understanding of a patient's GOC. CONCLUSIONS: Differences in the clinician-patient relationships and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the goal concordance of patient care.
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Planejamento Antecipado de Cuidados/organização & administração , Comunicação , Cuidados Críticos/organização & administração , Estado Terminal/terapia , Relações Interprofissionais , Adulto , Atitude do Pessoal de Saúde , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Equipe de Assistência ao Paciente/organização & administração , Preferência do Paciente , Relações Profissional-Paciente , Qualidade de VidaRESUMO
BACKGROUND AND OBJECTIVES: Management practices for acute appendicitis are changing. In cases of nonoperative treatment, the risk of missed or delayed diagnosis of malignancy should be considered. We aimed to identify predictors associated with appendiceal cancer diagnosis after appendectomy for acute appendicitis. MATERIALS AND METHODS: This retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) appendectomy-targeted data set from 2016 to 2017. A total of 21 069 patients with imaging-confirmed or imaging indeterminate appendicitis who underwent appendectomy were included. Logistic regression was used to identify predictors of cancer diagnosis. RESULTS: Increasing age had an increasing monotonic relationship with the odds of pathologic cancer diagnosis after appendectomy (age 50-59 odds ratio [OR], 2.08, 95% confidence interval [CI], 1.28-3.39, P = .003; age 60-69 OR, 2.89, 95% CI, 1.72-4.83, P < .001; age 70-79 OR, 3.85, 95% CI, 2.08-7.12, P < .001; age >80 OR, 5.32, 95% CI, 2.38-11.9, P < .001). Other significant predictors included obesity, morbid obesity, normal preoperative white blood cell count, and imaging indeterminate for appendicitis. CONCLUSIONS: When counseling patients regarding operative vs nonoperative treatment options for management of acute appendicitis, the rising risk of a delayed or missed cancer diagnosis with increasing age must be discussed.
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Apendicectomia/estatística & dados numéricos , Neoplasias do Apêndice/epidemiologia , Apendicite/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicite/cirurgia , Canadá/epidemiologia , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. METHODS AND FINDINGS: We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. CONCLUSIONS: National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.
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Planejamento em Saúde , Política de Saúde , Procedimentos Cirúrgicos Operatórios/legislação & jurisprudência , Humanos , Papua Nova Guiné , Formulação de Políticas , Política , Serra Leoa , Fatores Socioeconômicos , UgandaRESUMO
BACKGROUND: Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs. METHODS: We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised. FINDINGS: In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention. INTERPRETATION: Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs. FUNDING: The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.
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INTRODUCTION: Calcifications can be indicative of malignancy, but calcifications also can be a byproduct of necrotic tissue as cancer cells die. Current treatment regimens require excision of calcifications. The objective of this study was to examine the correlation between the extent of calcification on mammography and actual tumor size after neoadjuvant chemotherapy (NAC) as well as magnetic resonance imaging (MRI) for comparison. METHODS: We retrospectively reviewed all patients at the University of California, San Diego, who underwent NAC for breast cancer between 2007 and 2013. Pearson correlation coefficients were computed between breast imaging and pathological measurements. RESULTS: There were 136 patients total. Average age was 51 years. Fifty-three patients had calcifications on imaging (calc+); 83 did not (calc-). In the calc- group, extent of disease measured by mammogram (MMG) and MRI correlated moderately well with pathological tumor size (0.46 and 0.48, p = not significant). In the calc+ group, MRI was more likely to correlate with pathology than MMG (0.55 vs. -0.12, p = 0.01). Twenty-five calc+ patients had increased calcification after NAC; six of these had complete pathologic response. MRI correlated better with tumor size on pathology in patients with anti-HER2neu-based regimens than in patients with cytotoxic chemotherapy-alone regimens (0.88 vs. 0.4, p = 0.0001). MRI also is more accurate at predicting pathological tumor size in patients with triple negative disease (p = 0.002). CONCLUSIONS: Magnetic resonance imaging correlated well while MMG calcification measurements correlated poorly with tumor size on final pathology. Extent of calcifications on diagnostic mammography may not be accurate in preoperative evaluation of breast cancers after NAC.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Calcinose/diagnóstico por imagem , Mamografia , Terapia Neoadjuvante , Neoplasias da Mama/diagnóstico por imagem , Calcinose/induzido quimicamente , Calcinose/patologia , Quimioterapia Adjuvante , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Gradação de Tumores , Invasividade Neoplásica , Estadiamento de Neoplasias , Prognóstico , Estudos RetrospectivosRESUMO
CONTEXT: As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown. OBJECTIVES: To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence. METHODS: Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes. RESULTS: A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]). CONCLUSION: Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.
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Tomada de Decisão Compartilhada , Hospitais , Humanos , Idoso , Feminino , Masculino , Avaliação de Resultados em Cuidados de SaúdeRESUMO
CONTEXT: Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. OBJECTIVES: To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. METHODS: A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. RESULTS: There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. CONCLUSION: This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.
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Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Cuidados Paliativos , Adulto , Atenção à Saúde , Humanos , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à SaúdeRESUMO
CONTEXT: Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population. OBJECTIVES: We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year. METHODS: This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization. RESULTS: Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents. CONCLUSION: While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.
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Fragilidade , Assistência Terminal , Assistência ao Convalescente , Idoso , Idoso Fragilizado , Avaliação Geriátrica , Humanos , Medicare , Alta do Paciente , Estudos Retrospectivos , Medição de Risco , Estados UnidosRESUMO
Importance: Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. Objective: To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. Design, Setting, and Participants: This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. Exposures: Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. Main Outcomes and Measures: One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. Results: A total of 481â¯417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60â¯683 [12.6%] vs 56â¯713 [11.8%], P < .001) yet lower 1-year mortality (142â¯846 [29.7%] vs 158â¯385 [32.9%], P < .001) compared with medical patients. Among 409â¯363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). Conclusions and Relevance: In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.
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Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pneumonia/mortalidade , Pneumonia/cirurgia , Procedimentos Cirúrgicos Operatórios , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Tratamento de Emergência , Feminino , Humanos , Masculino , Medicare , Estudos Retrospectivos , Resultado do Tratamento , Estados UnidosRESUMO
CONTEXT: The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive. OBJECTIVES: To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review. METHODS: Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery. RESULTS: There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay. CONCLUSION: NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
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Cuidados Paliativos na Terminalidade da Vida , Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Idoso , Humanos , Unidades de Terapia Intensiva , Processamento de Linguagem Natural , Cuidados PaliativosRESUMO
Background: Natural language processing (NLP), a form of computer-assisted data abstraction, rapidly identifies serious illness communication domains such as code-status confirmation and goals of care (GOC) discussions within free-text notes, using a codebook of phrases. Differences in the phrases associated with palliative care for patients with different types of illness are unknown. Objective: To compare communication of code-status clarification and GOC discussions between patients with advanced pancreatic cancer undergoing palliative procedures and patients admitted with life-threatening trauma. Design: Retrospective cohort study. Setting/Subjects: Patients with in-hospital admissions within two academic medical centers. Measurements: Sensitivity and specificity of NLP-identified communication domains compared with manual review. Results: Among patients with advanced pancreatic cancer (n = 523), NLP identified code-status clarification in 54% of admissions and GOC discussions in 49% of admissions. The sensitivity and specificity for code-status clarification were 94% and 99% respectively, while the sensitivity and specificity for a GOC discussion were 93% and 100%, respectively. Using the same codebook in patients with life-threatening trauma (n = 2093), NLP identified code-status clarification in 25.9% of admissions and GOC discussions in 6.3% of admissions. While NLP identification had 100% specificity, the sensitivity for code-status clarification and GOC discussion was reduced to 86% and 50%, respectively. Adding dynamic phrases such as "ongoing discussions" and phrases related to "family meetings" increased the sensitivity of the NLP codebook for code status to 98% and for GOC discussions to 100%. Conclusions: Communication of code status and GOC differ between patients with advanced cancer and those with life-threatening trauma. Recognition of these differences can aid in identification in patterns of palliative care delivery.
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Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Cuidados Paliativos , Comunicação , Humanos , Planejamento de Assistência ao Paciente , Estudos RetrospectivosRESUMO
CONTEXT: Clinicians lack reliable methods to predict which patients with congestive heart failure (CHF) will benefit from cardiac resynchronization therapy (CRT). Symptom burden may help to predict response, but this information is buried in free-text clinical notes. Natural language processing (NLP) may identify symptoms recorded in the electronic health record and thereby enable this information to inform clinical decisions about the appropriateness of CRT. OBJECTIVES: To develop, train, and test a deep NLP model that identifies documented symptoms in patients with CHF receiving CRT. METHODS: We identified a random sample of clinical notes from a cohort of patients with CHF who later received CRT. Investigators labeled documented symptoms as present, absent, and context dependent (pathologic depending on the clinical situation). The algorithm was trained on 80% and fine-tuned parameters on 10% of the notes. We tested the model on the remaining 10%. We compared the model's performance to investigators' annotations using accuracy, precision (positive predictive value), recall (sensitivity), and F1 score (a combined measure of precision and recall). RESULTS: Investigators annotated 154 notes (352,157 words) and identified 1340 present, 1300 absent, and 221 context-dependent symptoms. In the test set of 15 notes (35,467 words), the model's accuracy was 99.4% and recall was 66.8%. Precision was 77.6%, and overall F1 score was 71.8. F1 scores for present (70.8) and absent (74.7) symptoms were higher than that for context-dependent symptoms (48.3). CONCLUSION: A deep NLP algorithm can be trained to capture symptoms in patients with CHF who received CRT with promising precision and recall.
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Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca , Documentação , Registros Eletrônicos de Saúde , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Humanos , Processamento de Linguagem NaturalRESUMO
OBJECTIVES: Few studies examine the impact of frailty on long-term patient-oriented outcomes after emergency general surgery (EGS). We measured the prevalence of frailty among older EGS patients and examined the impact of frailty on 1-year outcomes. DESIGN: Retrospective cohort study using 2008 to 2014 Medicare claims. SETTING: Acute care hospitals. PARTICIPANTS: Patients 65 years or older who received one of the five EGS procedures with the highest mortality burden (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy). MEASUREMENTS: A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < .15), pre-frail (.15 ≤ CFI < .25), mildly frail (.25 ≤ CFI < .35), and moderately to severely frail (CFI ≥ .35). Multivariable Cox regression compared 1-year mortality. Multivariable Poisson regression compared rates of post-discharge hospital encounters (hospitalizations, intensive care unit stay, emergency department visit) and home time over 1 year after discharge. All regression models adjusted for age, sex, race, admission from facility, procedure, sepsis, inpatient palliative care delivery, trauma center designation, hospital bed size, and teaching status, and they were clustered by patient and hospital referral region. RESULTS: Among 468 459 older EGS adults, 37.4% were pre-frail, 12.4% were mildly frail, and 3.6% were moderately to severely frail. Patients with mild frailty experienced a higher risk of 1-year mortality compared with non-frail patients (hazard ratio = 1.97; confidence interval [CI] = 1.94-2.01). In the year after discharge, patients with mild and moderate to severe frailty had more hospital encounters compared with non-frail patients (7.8 and 11.5 vs 2.0 per person-year; incidence rate ratio [IRR] = 4.01; CI = 3.93-4.08 vs IRR = 5.89; CI = 5.70-6.09, respectively). Patients with mild and moderate to severe frailty also had fewer days at home in the year after discharge compared with non-frail patients (256 and 203 vs 302 mean days; IRR = .97; CI = .96-.97 vs IRR = .95; CI = .94-.95, respectively). CONCLUSION: Older EGS patients with frailty are at increased risk for poor 1-year outcomes and decreased home time. Targeted interventions for older EGS patients with frailty during the index EGS hospitalization are urgently needed to improve long-term outcomes. J Am Geriatr Soc 68:1037-1043, 2020.
Assuntos
Fragilidade/epidemiologia , Mortalidade Hospitalar , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fragilidade/classificação , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Análise de Sobrevida , Estados UnidosRESUMO
CONTEXT: Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context. OBJECTIVES: The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts. METHODS: We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement. RESULTS: All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V. CONCLUSION: We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.