Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study.

OBJECTIVE: To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). BACKGROUND: EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. METHODS: Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. RESULTS: Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. CONCLUSIONS: We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.

Automated Generation of Individual and Population Clinical Pathways with the OMOP Common Data Model.

INTRODUCTION: Clinical pathways represents the sequence of interventions from which the patients benefit during their encounters with health care structures. There are several complex issues which make it difficult to represent these pathways (e.g. high numbers of patients, heterogeneity of variables). METHODS: We developed a tool to automate the representation of clinical pathways, from an individual and population points of view, and based on the OMOP CDM. The tool implemented the Sankey diagram in three stages: (i) data extraction, (ii) generation of individual sequence of steps and (iii) aggregation of sequence to obtain the population-level diagram. We tested the tool with three surgery procedures: the total hip replacement, the coronary bypass and the transcatheter aortic valve implantation. RESULTS: The tool provided different ways of visualizing pathways depending on the question asked: a pathway before a surgery, the pathway of deceased patients or the complete pathway with different steps of interest. DISCUSSION: We proposed a tool automating the representation of the clinical pathways, and reducing complexity of visualization. Representations are detailed from an individual and population points of view. It has been tested with three surgical procedures. The tool functionalities will be extended to cover a greater number of use cases.