Arden M. Morris, MD, MPH is professor and vice chair of clinical research in the Department of Surgery, director of the Stanford-Surgery Policy, Improvement Research and Education (S-SPIRE) Center, and core faculty in the Stanford Department of Health Research and Policy. Dr. Morris joined Stanford in 2016 from the University of Michigan where she was an associate professor and division chief of colorectal surgery. In her research, she uses mixed methods to focus on improving quality and equity in surgical care. She has deployed her expertise in a number of leadership and advisory roles and policy panels such as National Quality Forum’s Consensus Standards and Approval Committee and the Medicare Coverage Advisory Committee.
- Colon and Rectal Surgery
Professor - Med Center Line, Surgery - General Surgery
Director, S-SPIRE Center, Department of Surgery, Stanford University School of Medicine (2016 - Present)
Professor, Department of Surgery, Division of General Surgery Stanford University School of Medicine (2016 - Present)
Vice Chair, Clinical Research, Department of Surgery, Stanford University School of Medicine (2016 - Present)
Honors & Awards
Top Doctor, Hour Detroit Magazine Top Doctor (2015)
Visiting Scholar, Russell Sage Foundation, New York, NY (2014-2015)
Outstanding Clinician Award, University of Michigan Medical School (2014)
Fellowship:University of Minnesota General Surgery Residency (2003) MN
Medical Education:Rush Medical College Office of the Registrar (1993) IL
Board Certification: Colon and Rectal Surgery, American Board of Colon and Rectal Surgery (2006)
Board Certification: General Surgery, American Board of Surgery (2003)
Residency:Oregon Health and Science University (2000) OR
Efficacy and Safety of LifeSeal™ Kit for Colorectal Staple Line Sealing
LifeSeal™ Kit, surgical sealant designed for staple-line reinforcement that is applied over the anastomotic line to prevent bowel content leakage until full physiological function is restored. RATIONALE : Postoperative anastomotic leakage is one of the most devastating and feared complications in colorectal surgery. The risk of postoperative anastomotic leakage varies widely depending on the level of anastomosis while the risk is higher in low anastomosis. In order to best demonstrate the benefits of LifeSeal™ in providing staple line reinforcement and helping to reduce leaks, the study includes high risk anastomoses, defined as colorectal and coloanal anastomoses performed within 10 cm from the anal verge. STUDY DESIGN: This study is designed as a prospective, multi-center, multinational randomized, single-blind, double armed study PRIMARY OBJECTIVE: The primary objective of this study is to assess the efficacy and safety of LifeSeal™ Kit as measured by the change in overall anastomotic leak rates in subjects undergoing low anterior resection with an anastomosis below 10 cm from the anal verge, over the first 17 weeks after surgery. SECONDARY OBJECTIVES: The secondary objective of this study is to assess the incidence of post-operative leaks and additional benefits that could be related to the use of LifeSeal™ Kit such as reducing the severity and improving the outcome of a leak once it has occurred. In addition, the study will allow for collection and analysis of additional safety data and usability assessment of the device, medical resource utilization, and health related quality of life measures.
Stanford is currently not accepting patients for this trial. For more information, please contact Cancer Clinical Trials Office (CCTO), 650-498-7061.
Master's Program Advisor
Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study.
Diseases of the colon and rectum
2020; 63 (2): 190–99
The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports.The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer.This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews.The study was conducted at US medical centers.Colorectal surgeons were included.After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems.Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured.Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons.The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only.Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).
View details for DOI 10.1097/DCR.0000000000001518
View details for PubMedID 31914112
Effect of a Multimodal Prehabilitation Program Prior to Colorectal Surgery on Postoperative Pain and Pain Medication Use
ELSEVIER SCIENCE INC. 2019: S58–S59
View details for Web of Science ID 000492740900092
Out-of-Pocket Spending by Surgical Patients after Implementation of the Affordable Care Act Insurance Marketplaces
ELSEVIER SCIENCE INC. 2019: S158
View details for Web of Science ID 000492740900294
Surgical Decision-Making for Rectal Prolapse: One Size Does Not Fit All.
Background: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. Methods: 91 consecutive patients ≥18 years old diagnosed with external and/or high grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgement and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. Results: Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p<0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. Conclusions: With multiple options available for treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.
View details for DOI 10.1080/00325481.2019.1669330
View details for PubMedID 31525304
A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC).
Journal of palliative medicine
2019; 22 (S1): 44–57
Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).
View details for DOI 10.1089/jpm.2019.0130
View details for PubMedID 31486730
- Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury JOURNAL OF SURGICAL RESEARCH 2019; 241: 277–84
- For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection? ANNALS OF SURGICAL ONCOLOGY 2019; 26 (8): 2497–2506
- Duration of Oxaliplatin-Containing Adjuvant Therapy for Stage III Colon Cancer: ASCO Clinical Practice Guideline JOURNAL OF CLINICAL ONCOLOGY 2019; 37 (16): 1436-+
Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.
JAMA network open
2019; 2 (5): e194330
Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS≥1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS≥1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS≥1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS≥1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS≥1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS≥1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
View details for DOI 10.1001/jamanetworkopen.2019.4330
View details for PubMedID 31125103
- Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients DISEASES OF THE COLON & RECTUM 2019; 62 (5): 586–94
- Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing ELSEVIER SCIENCE INC. 2019: 798-+
Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study.
Annals of surgery
OBJECTIVE: To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians.SUMMARY BACKGROUND DATA: STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians.METHODS: Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence.RESULTS: We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM.CONCLUSIONS: While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.
View details for PubMedID 31009390
Duration of Oxaliplatin-Containing Adjuvant Therapy for Stage III Colon Cancer: ASCO Clinical Practice Guideline.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology
PURPOSE: To develop recommendations for duration of adjuvant chemotherapy with a fluoropyrimidine and oxaliplatin for patients with completely resected stage III colon cancer based on the results of trials of 3 months compared with 6 months of treatment.METHODS: ASCO convened an Expert Panel and conducted a systematic review of relevant studies. The guideline recommendations were based on the review of evidence by the Expert Panel.RESULTS: Pooled data from the six International Duration Evaluation of Adjuvant Chemotherapy (IDEA) Collaboration randomized controlled trials comprise the evidence base for these guideline recommendations.RECOMMENDATIONS: The recommendations for therapy duration apply to patients with completely resected stage III colon cancer who are being offered adjuvant chemotherapy with oxaliplatin and a fluoropyrimidine. Recommendations are informed by the findings of a recent pooled analysis of clinical trials that compared 6 months versus 3 months of oxaliplatin-based chemotherapy. For patients at a high risk of recurrence (T4 and/or N2), adjuvant chemotherapy should be offered for a duration of 6 months. For patients at a low risk of recurrence (T1, T2, or T3 and N1), either 6 months of adjuvant chemotherapy or a shorter duration of 3 months may be offered on the basis of a potential reduction in adverse events and no significant difference in disease-free survival with the 3-month regimen. In determining duration of therapy, the Expert Panel recommends a shared decision-making approach, taking into account patient characteristics, values and preferences, and other factors and including a discussion of the potential for benefit and risks of harm associated with treatment duration. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines .
View details for PubMedID 30986117
- Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections JOURNAL OF SURGICAL RESEARCH 2019; 236: 340–44
- Epidemiology, Pathophysiology, and Treatment of Diverticulitis GASTROENTEROLOGY 2019; 156 (5): 1282-+
- Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients JAMA SURGERY 2019; 154 (2): 141–49
- Lost in translation: Informed consent in the medical mission setting MOSBY-ELSEVIER. 2019: 438–43
Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing.
Journal of the American College of Surgeons
INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.
View details for PubMedID 30660819
Epidemiology, Pathophysiology, and Treatment of Diverticulitis.
Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications, and guidelines now recommend antibiotics for only specific patients. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require more emergent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.
View details for PubMedID 30660732
Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections.
The Journal of surgical research
2019; 236: 340–44
BACKGROUND: Current procedural terminology (CPT) for colon and rectal surgery lacks procedural granularity and misclassification rates are unknown. However, they are used in performance measurement, for example, in surgical site infection (SSI). The objective of this study was to determine whether American College of Surgeons National Surgical Quality Improvement Program (NSQIP) abstraction methods accurately classify types of colorectal operations and, by extension, reported SSI rates.MATERIALS AND METHODS: This was a retrospective study conducted at a single tertiary care center. The colectomy- and proctectomy-targeted NSQIP database from January 2011 to July 2016 was used to perform a semiautomated reclassification (SAR) of all colectomy and proctectomy cases performed by colorectal surgeons. The primary outcome was the difference in perioperative SSI rates by case classification method.RESULTS: Thousand sixty-three patients underwent a colectomy or proctectomy during the study period with a mean age of 55.7 (SD=16.7) years. Use of the NSQIP classification scheme resulted in 849 colectomy and 214 proctectomy cases. Use of the SAR method resulted in 650 colectomy cases and 413 proctectomy cases (P<0.001), a 23.4% reclassification of colectomy cases. The group of cases classified as colectomy by SAR had a lower rate of deep/organ space infections than those classified as colectomy by NSQIP (4.5% versus 7.1%, P=0.034).CONCLUSIONS: These findings highlight the challenges of CPT code-based patient classification and subsequent outcomes analysis. Expanding the CPT system to more accurately represent colorectal operations would allow for more representative reported outcomes, thus enabling benchmarking and quality improvement.
View details for PubMedID 30694775
- Shared Decision Making in Appendicitis Treatment: Optimized, Standardized, or Usual Communication. JAMA network open 2019; 2 (6): e194999
THE IMPACT OF MEDICAID EXPANSION ON TRAUMA-RELATED EMERGENCY DEPARTMENT UTILIZATION: A NATIONAL EVALUATION OF POLICY IMPLICATIONS.
The journal of trauma and acute care surgery
The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption.We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%).Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p<0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p<0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p<0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p<0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p<0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p<0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p<0.001).Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems.Epidemiologic, level III.
View details for DOI 10.1097/TA.0000000000002504
View details for PubMedID 31524835
Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury.
The Journal of surgical research
2019; 241: 277–84
Monitoring longitudinal patient-reported outcomes after injury is important for comprehensive trauma care. Current methodologies are resource-intensive and struggle to engage patients.Patients ≥18 y old admitted to the trauma service were prospectively enrolled. The following inclusion criteria were used: emergency operation, ICU length of stay ≥2 midnights, or hospital length of stay ≥4 d. Validated and customized questionnaires were administered using a novel internet-based survey platform. Three-month follow-up surveys were administered. Contextual field notes regarding barriers to enrollment/completion of surveys and challenges faced by participants were recorded.Forty-seven patients were eligible; 26 of 47 (55%) enrolled and 19 of 26 (73%) completed initial surveys. The final sample included 14 (74%) men and 5 (26%) women. Primary barriers to enrollment included technological constraints and declined participation. Contextual field notes revealed three major issues: competing hospital tasks, problems with technology, and poor engagement. The average survey completion time was 43 ± 27 min-21% found this too long. Seventy-four percent reported the system "easy to use" and 95% reported they would "very likely" or "definitely" respond to future surveys. However, 10 of 26 (38%) patients completed 3-mo follow-up.Despite a well-rated internet-based survey platform, study participation remained challenging. Lack of email access and technological issues decreased enrollment and the busy hospitalization posed barriers to completion. Despite a thoughtful operational design and implementation plan, the trauma population presented a challenging group to engage. Next steps will focus on optimizing engagement, broadening access to survey reminders, and enhancing integration into clinical workflows.
View details for PubMedID 31042606
For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection?
Annals of surgical oncology
The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer.A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed.The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection.Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.
View details for PubMedID 31025228
Patient Decision-Making in Severe Inflammatory Bowel Disease: The Need for Improved Communication of Treatment Options and Preferences.
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
Patients with inflammatory bowel disease and their physicians must navigate ever-increasing options for treatment. The aim of this study was to elucidate the key drivers of treatment decision-making in inflammatory bowel disease.We conducted qualitative semi-structured in-person interviews of 20 adult patients undergoing treatment for inflammatory bowel disease at an academic medical centre who either recently initiated biologic therapy or underwent an operation or surgical evaluation. Interviews were audio-recorded, transcribed verbatim, iteratively coded, and discussed to consensus by five researchers. We used thematic analysis to explore factors influencing decision-making.Four major themes emerged as key drivers of treatment decision-making: perceived clinical state and disease severity, the patient-physician relationship, knowledge, attitudes, and beliefs about treatment options, and social isolation and stigma. Patients described experiencing a clinical turning point as the impetus for proceeding with a previously undesired treatment such as infusion medication or surgery. Patients reported delays in care or diagnosis, inadequate communication with their physicians, and lack of control over their disease management. Patients often stated that they considered surgery to be the treatment of last resort, which further compounded the complexity of making treatment decisions.Patients described multiple barriers to making informed and collaborative decisions about treatment, especially when considering surgical options. Our study reveals a need for more comprehensive communication between the patient and their physician about the range of medical and surgical treatment options. We recommend a patient-centred approach toward the decision-making process that accounts for patient decision-making preferences, causes of social stress, and clinical status. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/codi.14759
View details for PubMedID 31295766
- Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students. JAMA network open 2019; 2 (8): e199991
Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients.
Diseases of the colon and rectum
Sex-based treatment disparities occur in many diseases. Women undergo fewer procedural interventions, and their care is less consistent with guideline-based therapy. There is limited research exploring sex-based differences in ulcerative colitis treatment. We hypothesized that women are less likely to be treated with strategies consistent with long-term disease remission, including surgery and maintenance medications.The aim of this study was to determine if patient sex is associated with choice of treatment strategy for ulcerative colitis.This is a retrospective cohort analysis.Data were gathered from a large commercial insurance claims database (Truven MarketScan) from 2007 to 2015.We identified a cohort of 38,851 patients newly diagnosed with ulcerative colitis, aged 12 to 64 years with at least 1 year of follow-up.The primary outcomes measured were the differences between male and female patients in 1) rates and types of index ulcerative colitis operations, 2) rates and types of ulcerative colitis medication prescriptions, and 3) rates of opioid prescriptions.Men were more likely to undergo surgical treatment for ulcerative colitis (2.94% vs 1.97%, p < 0.001, OR 1.51, p < 0.001). The type of index operation performed did not vary by sex. Men were more likely to undergo treatment with maintenance medications, including biologic (12.4% vs 10.2%, p < 0.001, OR 1.22, p < 0.001), immunomodulatory (16.3% vs 14.9%, p < 0.001, OR 1.08, p = 0.006), and 5-aminosalicylate medications (67.0% vs 63.2%, p < 0.001, OR 1.18, p < 0.001). Women were more likely to undergo treatment with rescue therapies and symptomatic control with corticosteroids (55.5% vs 54.0%, p = 0.002, OR 1.07, p = 0.002) and opioids (50.2% vs 45.9%, p < 0.001, OR 1.17, p < 0.001).Claims data lack clinical characteristics acting as confounders.Men with ulcerative colitis were more likely to undergo treatment consistent with long-term remission or cure, including maintenance medications and definitive surgery. Women were more likely to undergo treatment consistent with short-term symptom management. Further studies to explore underlying mechanisms of sex-related differences in ulcerative colitis treatment strategies and disease trajectories are warranted. See Video Abstract at http://links.lww.com/DCR/Axxx.
View details for PubMedID 30762599
- Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development'' ANNALS OF SURGERY 2018; 268 (6): E52–E53
- The Challenges of Providing Feedback to Referring Physicians After Discovering Their Medical Errors JOURNAL OF SURGICAL RESEARCH 2018; 232: 209–16
- Surgeon Perspectives Regarding Death and Dying JOURNAL OF PALLIATIVE MEDICINE 2019; 22 (2): 132–37
Surgeon Perspectives Regarding Death and Dying.
Journal of palliative medicine
BACKGROUND: Surgical patients most commonly receive palliative care services within 24-48 hours of death, and reasons for this delay are poorly understood. Research with nonsurgeons suggests that physician characteristics and beliefs about death and dying may contribute to late referral.OBJECTIVE: To describe surgeon perspectives related to death and dying, and their relationship with delayed referrals to palliative care.DESIGN: Using a previously validated survey instrument supplemented by open-ended questions, deductive content analysis was used to describe surgeon preferences for end-of-life care.SETTINGS: Participants were all current nonretired members of the American Society of Colon and Rectal Surgeons.MAIN OUTCOME MEASURES: Surgeon descriptions of a "good death" and how personal experiences influence care provided.RESULTS: Among 131 survey respondents (response rate 16.5%), 117 (89.3%) completed all or part of the qualitative portion of the survey. Respondents consistently reported their personal preferences for end-of-life care, and four central themes emerged: (1) pain and symptom management, (2) clear decision making, (3) avoidance of medical care, and (4) completion. Surgeons also reflected on both good and bad experiences with patients and family members dying, and how these experiences impact practice.LIMITATIONS: The small sample size inherent to Internet surveys may limit generalizability and contribute to selection bias.CONCLUSION: This study reveals surgeon preferences for end-of-life care, which may inform initiatives aimed at surgeons who may underuse or delay palliative care services. Future studies are needed to better understand how surgeon preferences may directly impact treatment recommendations for their patients.
View details for PubMedID 30457430
Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients.
Importance: Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.Objective: To compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, Setting, and Participants: This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.Exposures: Appendectomy (control arm) or nonoperative management (treatment arm).Main Outcomes and Measures: Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.Results: Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P<.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P<.001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P<.001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and Relevance: According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
View details for PubMedID 30427983
- Common Issues in the Unique Environment of Global Surgical Health Services Research JAMA SURGERY 2018; 153 (11): 979–80
Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach?
ANNALS OF SURGICAL ONCOLOGY
2018; 25 (12): 3587–95
Compared with open surgery, minimally invasive surgery for colon cancer has been shown to improve short-term outcomes and yield equivalent long-term oncologic results. It remains to be seen if oncologic outcomes for the minimally invasive approach for rectal cancer are equivalent to traditional open rectal resection.We conducted a systematic review of Medline, SCOPUS, and Cochrane databases. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five key questions comparing minimally invasive and open oncologic outcomes for rectal cancer were specifically analyzed. A meta-analysis was not done due to heterogeneity of studies.Forty-five studies met inclusion criteria, including six randomized controlled trials. The laparoscopic approach to rectal resection was not more likely than the traditional open approach to have clear circumferential and distal margins, a complete total mesorectal excision grade, ≥ 12 lymph nodes in the resected specimen, reduced local recurrence rates, or reduced overall survival rates. Two randomized trials revealed that successful laparoscopic resection was not noninferior to open.Caution should be exercised when choosing surgical options for rectal cancer. Results of randomized trials could not prove that short-term oncologic outcomes of laparoscopic surgery were equivalent to those after open surgery even when performed by surgeons with laparoscopic expertise. However, reported long-term data have not shown a difference in outcomes between laparoscopic and open surgery. Future advances in minimally invasive technology may improve oncologic margins but these will require careful study and scrutiny.
View details for PubMedID 30187281
Life After Surgery: Surgeon Assessments of Quality of Life Among Patients With Familial Adenomatous Polyposis
DISEASES OF THE COLON & RECTUM
2018; 61 (10): 1217–22
Without prophylactic surgery, patients with familial adenomatous polyposis are at high risk for colorectal cancer development. Various surgical options for prophylaxis are available. Patient decision-making for preventative treatments is often influenced by the preferences of healthcare providers.We determined surgeon preferences for the surgical options available to patients with familial adenomatous polyposis.We obtained preference estimates for postoperative health states from colorectal surgeons who had treated ≥10 patients with familial adenomatous polyposis.Assessments were made at an annual meeting of the American Society of Colon and Rectal Surgeons.Utilities were measured through the time trade-off method. We determined utilities for 3 procedures used for prophylaxis, including total proctocolectomy with permanent ileostomy, colectomy with ileorectal anastomosis, and total proctocolectomy with IPAA. We also assessed utilities for 2 short-term health states: 90 days with a temporary ileostomy and 2 years with a poorly functioning ileoanal pouch.Twenty-seven surgeons who had cared for >1700 patients with familial adenomatous polyposis participated in this study. The highest utility scores were provided for colectomy with ileorectal anastomosis (0.98). Lower utility scores were provided for total proctocolectomy with permanent ileostomy (0.87) and IPAA (0.89). The number of patients with familial adenomatous polyposis who were treated by participating surgeons did not influence these estimates; however, more-experienced surgeons gave lower utility scores for a poorly functioning ileoanal pouch than less-experienced surgeons (0.15, 0.50, and 0.25 for high-, medium-, and low-volume surgeons; p = 0.02).This study was limited by the sample size.For patients with familial adenomatous polyposis and relative rectal sparing, surgeon preferences are greatest for colectomy with ileorectal anastomosis. Utility estimates provided by this study are important for understanding surgical decision-making and suggest a role for ileorectal anastomosis in appropriately selected patients. See Video Abstract at http://links.lww.com/DCR/A656.
View details for PubMedID 30192330
- Interaction of Frailty and Postoperative Complications on Unplanned Readmission after Elective Outpatient Surgery ELSEVIER SCIENCE INC. 2018: E25
- Coordination of Care in Colorectal Cancer Patients: A Population-Based Study ELSEVIER SCIENCE INC. 2018: S141–S142
- Should Surgery Feel Like the Last Resort? Drivers of Decision Making in Inflammatory Bowel Disease ELSEVIER SCIENCE INC. 2018: S163–S164
- Nonoperative Management of Appendicitis in Privately Insured Patients ELSEVIER SCIENCE INC. 2018: S156–S157
- Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing ELSEVIER SCIENCE INC. 2018: S228–S229
- Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2018; 227 (2): 172–80
Lost in translation: Informed consent in the medical mission setting.
BACKGROUND: Informed consent is a fundamental tenet of ethical care, but even under favorable conditions, patient comprehension of consent conversations may be limited. Little is known about providing informed consent in more uncertain situations such as medical missions. We sought to examine the informed consent process in the medical mission setting.METHODS: We studied informed consent for adult patients undergoing inguinal herniorrhaphy during a medical mission to Guatemala using a convergent mixed-methods design. We audiotaped informed consents during preoperative visits and immediately conducted separate surveys to elicit comprehension of risks. Informed consent conversations and survey responses were translated and transcribed. We used descriptive statistics to examine informed consent content, including information provided by surgeon, the translation of information, and patient comprehension, and used thematic analysis to examine the consent process.RESULTS: Thirteen adult patients (median age 53 years, 69% male) participated. Surgeons conveyed 4 standard risks in 10 out of 13 encounters (77%); all 4 risks were translated to patients in 10 out of 13 encounters (77%). No patient could recall all 4 risks. Qualitative themes regarding the informed consent process included limited physician language skills, verbal domination by physicians and interpreters, and mistranslation of risks. Patients relied on faith and prior or vicarious experiences to qualify surgical risks instead of consent conversations. Many patients restated surgical instructions when asked about risks.CONCLUSION: Despite physicians' attempts to provide informed consent, medical mission patients did not comprehend surgical risks. Our data reveal a critical need to develop more effective methods for communicating surgical risks during medical missions.
View details for PubMedID 30061041
Common Issues in the Unique Environment of Global Surgical Health Services Research.
View details for PubMedID 30046811
The Effect of Peer Support on Colorectal Cancer Patients' Adherence to Guideline-Concordant Multidisciplinary Care
DISEASES OF THE COLON & RECTUM
2018; 61 (7): 817–23
Multidisciplinary care is critical for the successful treatment of stage III colorectal cancer, yet receipt of adjuvant chemotherapy remains unacceptably low. Peer support, or exposure to others treated for colorectal cancer, has been proposed as a means to improve patient acceptance of cancer care.The purpose of our study was to evaluate the effect of peer support on the attitudes of patients with colorectal cancer toward chemotherapy and their adherence to it.We conducted a population-based survey of patients with sage III colorectal cancer and compared demographics and adjuvant chemotherapy adherence after patient-reported exposure to peer support.Patients were identified by using Surveillance, Epidemiology, and End Results Program cancer registries and were recruited 3 to 12 months after cancer resection.All patients with stage III colorectal cancer who underwent colorectal resection between 2011 and 2013 and were located in the Detroit and Georgia regions were included.The main outcome measure was adjuvant chemotherapy adherence. Exposure to peer support was an intermediate outcome.Among 1301 patient respondents (68% response rate), 48% reported exposure to peer support. Exposure to peer support was associated with younger age, higher income, and having a spouse or domestic partner. Exposure to peer support was significantly associated with receipt of adjuvant chemotherapy (OR, 2.94; 95% CI, 1.89-4.55). Those exposed to peer support reported positive effects on attitudes toward chemotherapy.This study has limitations inherent to survey research including the potential lack of generalizability and responses that are subject to recall bias. Additionally, the survey results do not allow for determination of the temporal relationship between peer support exposure and receipt of chemotherapy.Our study demonstrates that exposure to peer support is associated with higher adjuvant chemotherapy adherence. These data suggest that facilitated peer support programs could positively influence patient expectations and coping with diagnosis and treatment, thereby affecting the uptake of postoperative chemotherapy. See Video Abstract at http://links.lww.com/DCR/A587.
View details for PubMedID 29771795
View details for PubMedCentralID PMC5992023
Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors
ANNALS OF SURGERY
2018; 267 (6): 1077–83
Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors.Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral.We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure.Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships.Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.
View details for DOI 10.1097/SLA.0000000000002427
View details for Web of Science ID 000434301200021
View details for PubMedID 28742712
Precision Medicine Versus Population Medicine in Colon Cancer: From Prospects of Prevention, Adjuvant Chemotherapy, and Surveillance.
American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting
With the advances of technologic revolution that provides new insights into human biology, genetics and cancer, as well as advantages of big data which amasses large amounts of information for us to approach cancer treatment and prevention, we are facing challenges of organically combining data from studies based on general population and information from individual testing and setting out precisional recommendations in cancer diagnosis, prevention, and treatment. We are obligated to accelerate the adaptation of new scientific discoveries into effective treatments and prevention for cancer. In this review, we introduce our opinions on bringing knowledge of precision and population medicine together to guide our clinical practice from the prospects of colorectal cancer prevention, stage III colon cancer adjuvant therapy, and postsurgery surveillance.
View details for PubMedID 30231337
Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals.
Journal of the American College of Surgeons
BACKGROUND: Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability.STUDY DESIGN: We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin.RESULTS: California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n= 4) and nonprofit-owned SNHs (64%, n= 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p<0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively.CONCLUSIONS: The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.
View details for PubMedID 29680414
Characterizing the Role of US Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis
JOURNAL OF PAIN AND SYMPTOM MANAGEMENT
2018; 55 (4): 1196-+
The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear.We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients.We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings.A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers.Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
View details for PubMedID 29221845
Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society
JOURNAL OF PALLIATIVE MEDICINE
Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care.To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs.This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions.Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons.Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified.Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources.Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias.Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
View details for PubMedID 29649396
Employment benefits and job retention: evidence among patients with colorectal cancer
2018; 7 (3): 736–45
A "health shock," that is, a large, unanticipated adverse health event, can have long-term financial implications for patients and their families. Colorectal cancer is the third most commonly diagnosed cancer among men and women and is an example of a specific health shock. We examined whether specific benefits (employer-based health insurance, paid sick leave, extended sick leave, unpaid time off, disability benefits) are associated with job retention after diagnosis and treatment of colorectal cancer. In 2011-14, we surveyed patients with Stage III colorectal cancer from two representative SEER registries. The final sample was 1301 patients (68% survey response rate). For this study, we excluded 735 respondents who were not employed and 20 with unknown employment status. The final analytic sample included 546 respondents. Job retention in the year following diagnosis was assessed, and multivariable logistic regression was used to evaluate associations between job retention and access to specific employment benefits. Employer-based health insurance (OR = 2.97; 95% CI = 1.56-6.01; P = 0.003) and paid sick leave (OR = 2.93; 95% CI = 1.23-6.98; P = 0.015) were significantly associated with job retention, after adjusting for sociodemographic, clinical, geographic, and job characteristics.
View details for PubMedID 29473344
Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development".
Annals of surgery
View details for PubMedID 29064907
- Financial Stability of Level I Trauma Centers within Safety Net Hospitals ELSEVIER SCIENCE INC. 2017: S117–S118
- The Primary Care Provider (PCP)-Cancer Specialist Relationship: A Systematic Review and Mixed-Methods Meta-Synthesis CA-A CANCER JOURNAL FOR CLINICIANS 2017; 67 (2): 156-169
Surgery for diverticulitis in the 21st century: recent evidence.
Minerva gastroenterologica e dietologica
Sigmoid diverticulitis is an increasingly common disease in Western countries. As technology has led to increased knowledge about the disease and options for treatment, management strategies have become less certain. In previous years, the rationale for early elective surgery was largely preventive, due to concern that diverticulitis recurrence would result in increased risk of sepsis or the need for a colostomy. New technology has enabled diagnosis, through computed tomography scans, predictive information through clinical and administrative databases, and less invasive treatment options, through laparoscopic techniques. While the new data have mitigated outdated beliefs regarding recurrence prevention strategies, there is little to replace previous guidelines for care. For example, we lack clear guidelines for whether and when to use percutaneous drainage, intra-peritoneal lavage, minimally invasive techniques, and fecal diversion via ostomy. Fortunately, several newly published high impact studies attempt to address these more nuanced questions. In this paper, we review available findings and potential for use of the data from recent surgical randomized controlled trials. It is important to note that controlling sepsis when present remains the most important goal of treatment.
View details for DOI 10.23736/S1121-421X.17.02389-3
View details for PubMedID 28240005
- Cultural challenges to engaging patients in shared decision making PATIENT EDUCATION AND COUNSELING 2017; 100 (1): 18-24
The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis.
CA: a cancer journal for clinicians
Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.
View details for DOI 10.3322/caac.21385
View details for PubMedID 27727446
Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians
2016; 25 (9): 1050-1056
American Indian/Alaska Native (AI/AN) patients are significantly less likely than non-Hispanic whites to receive guideline-concordant cancer care. Our objective was to examine cancer treatment decision making among AI/AN patients and their providers.From 2011 to 2014, AI/AN cancer patients and their surgeons were identified through a hospital registry in Washington State. Patients were invited to participate in a mailed survey that queried socio-demographics, cultural affiliation, everyday perceived discrimination, and trust in providers. Both patients and surgeons were queried about decision-making quality (collaboration and satisfaction). The primary outcome was association between patient and provider assessments of decision-making quality. The secondary outcome was non-adherence to treatment.Forty-nine patients (62% response rate) and 14 surgeons (37% response rate) returned surveys. Half of patients had not completed high school; 41% were living in poverty. Half of patients reported a strong tribal affiliation and most reported experiencing some form of discrimination. Patients endorsed high trust in surgeons and a high quality decision-making process; and surgeons' rated decision-making quality even more highly than patients did in every domain. Non-adherence to treatment recommendations was common (26%) and was significantly associated with lower patient-reported collaboration and satisfaction with decision making.Given the importance of adherence to cancer treatment for survival, the many non-clinical reasons for non-adherence, and the currently demonstrated association between decision-making quality and adherence, it would be worthwhile to investigate how to increase AI/AN patient satisfaction with decision making and whether improving satisfaction yields improved adherence to the cancer treatment plan. Copyright © 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.
View details for DOI 10.1002/pon.4191
View details for Web of Science ID 000385722700006
View details for PubMedID 27279001
Cancer Journey for American Indians and Alaska Natives in the Pacific Northwest
ONCOLOGY NURSING FORUM
2016; 43 (5): 625-635
To describe the experiences of American Indian and Alaska Native cancer survivors to improve understanding of the trajectory of cancer treatment. .Qualitative focus group research..Rural and geographically isolated American Indian and Alaska Native communities in the Pacific Northwest..30 American Indian and Alaska Native cancer survivors or caregivers. .The authors analyzed data from two focus groups with cancer survivors by using thematic analysis informed by indigenous methodologies..Based on focus group findings, the authors developed a conceptual model of the cancer experience called Rough Waters. Participants described their cancer experience as a collective journey involving family and friends and requiring resources to offset challenges along the way. Dominant themes were delays, isolation, communication, money, advocacy, spirituality, and family involvement..American Indians and Alaska Natives in the Pacific Northwest have special cultural needs during cancer care. The current study provides examples that can guide patient-provider interactions..Using the metaphor of cancer as a journey, clinicians can begin a dialogue to identify what will impede or assist the cancer journey for their American Indian and Alaska Native patients.
View details for DOI 10.1188/16.ONF.625-635
View details for Web of Science ID 000382298000015
View details for PubMedID 27541555
Cultural challenges to engaging patients in shared decision making.
Patient education and counseling
Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.
View details for DOI 10.1016/j.pec.2016.07.008
View details for PubMedID 27461943
Development of The American Society of Colon and Rectal Surgeons' Rectal Cancer Surgery Checklist
DISEASES OF THE COLON & RECTUM
2016; 59 (7): 601-606
There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality.The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer.A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed.The study was conducted through meetings and discussion to consensus.Patient data were extracted from an initial literature review.The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases.The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery.The study was limited by its lack of prospective validation.The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.
View details for DOI 10.1097/DCR.0000000000000606
View details for PubMedID 27270511
Assessing Cultural Competence Among Oncology Surgeons.
Journal of oncology practice
2016; 12 (1): 61-?
Racial and ethnic minority groups in the United States have the highest mortality rates for the most common cancers. Various factors, including a perceived lack of culturally congruent care and culturally competent providers, might lead minority patients to decline or delay care. As part of a large multimethod study to understand barriers to care among American Indian and Alaskan native patients with cancer, we examined surgical provider attributes associated with culturally congruent care.Surgical providers from six hospitals in the Puget Sound region of Washington State were invited to participate. Participants completed a 50-item survey that assessed demographic data and incorporated the Cultural Competence Assessment (CCA) and the Marlowe-Crowne Social Desirability Scale.Survey response rate was 51.1% (N = 253). Participants reported treating diverse patient populations; 71% encountered patients from six or more racial and ethnic groups. More than one half of participants (58%) reported completing cultural diversity training, with employer-sponsored training being the most common type reported (48%; 71 of 147). CCA scores ranged from 5.99 to 13.75 of a possible 14 (mean, 10.3; standard deviation, ±1.3), and receipt of diversity training was associated with higher scores than nonreceipt of diversity training (10.56 v 9.82, respectively; P<.001). After controlling for Marlowe-Crowne Social Desirability Scale score and hospital system,participation in diversity training was the variable most significantly associated with CCA score (P<.001).Culturally competent care is an essential but often overlooked component of high-quality health care. Future work should compare training offered by various hospital systems.
View details for DOI 10.1200/JOP.2015.006932
View details for PubMedID 26759469
- Association of Paid Sick Leave With Job Retention and Financial Burden Among Working Patients With Colorectal Cancer JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2015; 314 (24): 2688-2690
A Composite Measure of Personal Financial Burden Among Patients With Stage III Colorectal Cancer
2014; 52 (11): 957-962
Despite improved survival with chemotherapy for stage III colorectal cancer (CRC), patients may suffer substantial economic hardship during treatment. Methods for quantifying financial burden in CRC patients are lacking.To derive and validate a novel patient-reported measure of personal financial burden during CRC treatment.Within a population-based survey of patients in the Detroit and Georgia Surveillance, Epidemiology and End Results regions diagnosed with stage III CRC between 2011 and 2013, we asked 7 binary questions assessing effects of disease and treatment on personal finances.We used factor analysis to compute a composite measure of financial burden. We used χ tests to evaluate relationships between individual components of financial burden and chemotherapy use with χ analyses. We used Mantel-Haenszel χ trend tests to examine relationships between the composite financial burden metric and chemotherapy use.Among 956 patient surveys (66% response rate), factor analysis of 7 burden items yielded a single-factor solution. Factor loadings of 6 items were >0.4; these were included in the composite score. Internal consistency was high (Cronbach α=0.79). The mean financial burden score among all respondents was 1.72 (range, 0-6). The 812 (85%) who reported chemotherapy use had significantly higher financial burden scores than those who did not (mean burden score 1.88 vs. 0.88, P<0.001).Financial burden is high among CRC patients, particularly those who use adjuvant chemotherapy. We encourage use of our instrument to validate our measure in the identification of patients in need of additional financial support during treatment.
View details for Web of Science ID 000343930300004
View details for PubMedID 25304021
The Personal Financial Burden of Complications After Colorectal Cancer Surgery
2014; 120 (19): 3074-3081
Patients with colorectal cancer (CRC) may suffer significant economic hardship during treatment. Complications are common after surgery for CRC and may exacerbate the financial burden of CRC even further.Within a population-based survey of patients with stage III CRC, the authors investigated the effects of disease and treatment on personal finances and computed a composite measure of financial burden. Correlations were examined between components of financial burden and patient-reported postoperative complications using chi-square analyses, and Mantel-Haenszel chi-square tend tests were used to evaluate correlations between composite financial burden scores and surgical complications, controlling for patient characteristics and other factors by using multivariable Poisson regression.Among 937 respondents, 224 (24%) reported complications after surgery. Those with complications had significantly higher composite financial burden (P < .001 for trend): they were more likely to spend savings (40% vs 31%; P = .01), borrow or take loans (18% vs 11%; P = .007), fail to make credit card payments (18% vs 11%; P = .005), reduce spending for food or clothes (38% vs 27%; P = .001), and decrease recreational activities (41% vs 33%; P = .03). They took significantly longer to return to work (P = .009) and were more likely to experience significant worry about finances (61% vs 52%; P = .01).Complications after surgery for CRC result in significant personal financial consequences as well as morbidity. Financial stress impairs quality of life and may prevent adherence to recommended treatments. Therefore, patients who suffer complications may require not just additional clinical care but also economic support and services.
View details for DOI 10.1002/cncr.28812
View details for Web of Science ID 000342630000021
View details for PubMedID 24889014
Expanding the NCCN guidelines for distress management: a model of barriers to the use of coping resources.
The Journal of community and supportive oncology
2014; 12 (8): 271-277
Cancer-related distress impacts quality of care, resource use, and patient outcomes. Patients are increasingly screened for distress, yet many do not receive coping resources and psychosocial support services that may help to reduce their distress. Distress screening must be paired with attention to the different phases of the distress and coping process, with emphasis on barriers and facilitators of cancer patients' use of coping resources. This paper offers a conceptual model illustrating key pathways and modifying factors of distress and use of coping resources among cancer patients, and potential roles for cancer care providers and institutions in facilitating effective coping and distress reduction. Building on a review of relevant empirical and theoretical literature, we developed a conceptual model that integrates concepts from Stress and Coping Theory into the National Comprehensive Cancer Network's guidelines for Distress Management. We found that barriers and facilitating factors that may inhibit receipt of coping resources and services to reduce cancer-related distress include health and cancer beliefs, accessibility and acceptability, the role of caregivers in cancer treatment, coordination of care, and the quality of patient-provider relationships. Herein, we highlight largely modifable factors that can infuence the successful uptake of coping resources and services to reduce distress among cancer patients. We conclude with recommendations for how cancer care providers and systems can better identify and address barriers to the use of distress reduction resources and support services.
View details for PubMedID 25372363
The quality of surgical dare in safety net hospitals: A systematic review
2014; 155 (5): 826-838
The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs.We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article.Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent.Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States.
View details for DOI 10.1016/j.surg.2013.12.006
View details for Web of Science ID 000335291100013
View details for PubMedID 24787109
The effect of complications on the patient-surgeon relationship after colorectal cancer surgery
2014; 155 (5): 841-850
Trust in physicians is an essential part of therapeutic relationships. Complications are common after colorectal cancer procedures, but little is known of their effect on patient-surgeon relationships. We hypothesized that unexpected complications impair trust and communication between patients and surgeons.We performed a population-based survey of surgically diagnosed stage III colorectal cancer patients in the Surveillance Epidemiology and End Results registries for Georgia and Metropolitan Detroit between August 2011 and October 2012. Using published survey instruments, we queried subjects about trust in and communication with their surgeon. The primary predictor was the occurrence of an operative complication. We examined patient factors associated with trust and communication then compared the relationship between operative complications and patient-reported trust and communication with their surgeons.Among 622 preliminary respondents (54% response rate), 25% experienced postoperative complications. Those with complications were less likely to report high trust (73% vs 81%, P = .04) and high-quality communication (80% vs 95%, P < .001). Complications reduced trust among only 4% of patient-surgeon dyads with high-quality communication, whereas complications diminished patients' trust in 50% with poorer communication (P < .001). After controlling for communication ratings, we found there was no residual effect of complications on trust (P = .96).Most respondents described trust in and communication with their surgeons as high. Complications were common and were associated with lower trust and poorer communication. However, the relationship between complications and trust was modified by communication. Trust remained high, even in the presence of complications, among respondents who reported high levels of patient-centered communication with their surgeons.
View details for DOI 10.1016/j.surg.2013.12.011
View details for Web of Science ID 000335291100015
View details for PubMedID 24787111
View details for PubMedCentralID PMC4254758
Implementation of a hospital-based quality assessment program for rectal cancer.
Journal of oncology practice
2014; 10 (3): e120-9
Quality improvement programs in Europe have had a markedly beneficial effect on the processes and outcomes of rectal cancer care. The quality of rectal cancer care in the United States is not as well understood, and scalable quality improvement programs have not been developed. The purpose of this article is to describe the implementation of a hospital-based quality assessment program for rectal cancer, targeting both community and academic hospitals.We recruited 10 hospitals from a surgical quality improvement organization. Nurse reviewers were trained to abstract rectal cancer data from hospital medical records, and abstracts were assessed for accuracy. We conducted two surveys to assess the training program and limitations of the data abstraction. We validated data completeness and accuracy by comparing hospital medical record and tumor registry data.Nine of 10 hospitals successfully performed abstractions with ≥ 90% accuracy. Experienced nurse reviewers were challenged by the technical details in operative and pathology reports. Although most variables had less than 10% missing data, outpatient testing information was lacking from some hospitals' inpatient records. This implementation project yielded a final quality assessment program consisting of 20 medical records variables and 11 tumor registry variables.An innovative program linking tumor registry data to quality-improvement data for rectal cancer quality assessment was successfully implemented in 10 hospitals. This data platform and training program can serve as a template for other organizations that are interested in assessing and improving the quality of rectal cancer care.
View details for DOI 10.1200/JOP.2014.001387
View details for PubMedID 24839288
View details for PubMedCentralID PMC4018456
Surgery for Diverticulitis in the 21st Century A Systematic Review
2014; 149 (3): 292-302
Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years.To review and classify the primary data published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis.We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines.We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms.The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.
View details for DOI 10.1001/jamasurg.2013.5477
View details for Web of Science ID 000334609400014
View details for PubMedID 24430164
Sigmoid Diverticulitis A Systematic Review
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2014; 311 (3): 287-297
Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms.To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines.We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics: pathophysiology, natural history, medical management, and indications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines.Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted.Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.
View details for DOI 10.1001/jama.2013.282025
View details for Web of Science ID 000329566400021
View details for PubMedID 24430321
Shared Decision-Making for Cancer Care Among Racial and Ethnic Minorities: A Systematic Review
AMERICAN JOURNAL OF PUBLIC HEALTH
2013; 103 (12): E15-E29
To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of "shared decision-making," "cancer," and "minority groups," using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals' preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient-physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders.
View details for DOI 10.2105/AJPH.2013.301631
View details for Web of Science ID 000331043200009
View details for PubMedID 24134353
View details for PubMedCentralID PMC3828995
Palliative Care and End-of-Life Outcomes Following High-Risk Surgery.
Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.Exposures: Palliative-care consultation within 30 days before or 90 days after surgery.Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P=.007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P=.004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P=.05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
View details for DOI 10.1001/jamasurg.2019.5083
View details for PubMedID 31895424
- Checklist Compliance and Long-term Outcomes. Diseases of the colon and rectum 2020; 63 (1): 1–2
Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study.
Diseases of the colon and rectum
BACKGROUND: Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes.OBJECTIVE: The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection.DESIGN: This is a multicenter, quasiexperimental cohort study using propensity score weighting.SETTINGS: Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.PATIENTS: Adult patients who underwent rectal cancer resection in 2016 were included.MAIN OUTCOME MEASURES: The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated.RESULTS: Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002).LIMITATIONS: This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings.CONCLUSIONS: Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70.
View details for DOI 10.1097/DCR.0000000000001534
View details for PubMedID 31764247
Surgery, Stomas, and Anxiety and Depression in Inflammatory Bowel Disease: A Retrospective Cohort Analysis of Privately Insured Patients.
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
AIM: Inflammatory bowel disease (IBD) patients are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and temporal association with abdominal surgery and stoma formation.METHODS: We conducted a retrospective cohort study in adult IBD patients using difference-in-differences methodology using a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.RESULTS: We identified 10,481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41,924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (p<0.001). Surgical patients had higher odds of anxiety (one surgery: adjusted odds ratio 6.90, 95% confidence interval [6.11-7.79], p<0.001; 2+ surgeries: 7.53 [5.99-9.46], p<0.001) and depression (one surgery: 6.15, [5.57-6.80], p<0.001; 2+ surgeries: 6.88 [5.66-8.36], p<0.001) than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from pre- to post-time periods (1.43, [1.18-1.73, p<0.001). Amongst surgical patients, stoma formation was independently associated with anxiety (1.40, [1.17-1.68], p<0.001) and depression (1.23, [1.05-1.45], p=0.01). New ostomates experienced a greater increase in postoperative anxiety (1.24, [1.05-1.47], p=0.01) and depression (1.19, [1.03-1.45], p=0.01) than other surgical patients.CONCLUSIONS: IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.
View details for DOI 10.1111/codi.14905
View details for PubMedID 31713994
- Surgery for diverticulitis in the 21(st) century: recent evidence MINERVA GASTROENTEROLOGICA E DIETOLOGICA 2017; 63 (2): 158–62
Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation.
Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m(2), tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 10(9)/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.
View details for DOI 10.1016/j.surg.2016.12.033
View details for PubMedID 28238345
Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.
Diseases of the colon & rectum
2016; 59 (12): 1117-1133
View details for PubMedID 27824697
- Shared Decision Making for Rectal Cancer Care: A Long Way Forward. Diseases of the colon & rectum 2016; 59 (10): 905-906
Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure
JOURNAL OF SURGICAL RESEARCH
2016; 205 (1): 108-114
Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates.We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions.A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications.Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.
View details for DOI 10.1016/j.jss.2016.05.017
View details for Web of Science ID 000383360300015
View details for PubMedID 27621006
Evaluating disparities in inpatient surgical cancer care among American Indian/Alaska Native patients
AMERICAN JOURNAL OF SURGERY
2016; 212 (2): 297-304
American Indian/Alaska Native (AI/AN) patients with cancer have the lowest survival rates of all racial and ethnic groups, possibly because they are less likely to receive "best practice" surgical care than patients of other races.Prospective cohort study comparing adherence with generic and cancer-specific guidelines on processes of surgical care between AI/AN and non-Hispanic white (NHW) patients in Washington State (2010 to 2014) was conducted.A total of 156 AI/AN and 6,030 NHW patients underwent operations for 10 different cancers, and had similar mean adherence to generic surgical guidelines (91.5% vs 91.9%, P = .57). AI/AN patients with breast cancer less frequently received preoperative diagnostic core needle biopsy (81% vs 94%, P = .004). AI/AN patients also less frequently received care adherent to prostate cancer-specific guidelines (74% vs 92%, P = .001).Although AI/ANs undergoing cancer operations in Washington receive similar overall best practice surgical cancer care to NHW patients, there remain important, modifiable disparities that may contribute to their lower survival.
View details for DOI 10.1016/j.amjsurg.2015.10.030
View details for Web of Science ID 000382234300016
View details for PubMedID 26846176
View details for PubMedCentralID PMC4939142
Rational vs. Intuitive Judgment in Surgical Decision Making.
Annals of surgery
2016; 264 (6): 887–88
View details for PubMedID 27828817
Potential Biases Introduced by Conflating Screening and Diagnostic Testing in Colorectal Cancer Screening Surveillance
CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION
2015; 24 (12): 1850-1854
Screening and postsymptomatic diagnostic testing are often conflated in cancer screening surveillance research. We examined the error in estimated colorectal cancer screening prevalence due to the conflation of screening and diagnostic testing.Using data from the 2008 National Health Interview Survey, we compared weighted prevalence estimates of the use of all testing (screening and diagnostic) and screening in at-risk adults and calculated the overestimation of screening prevalence across sociodemographic groups.The population screening prevalence was overestimated by 23.3%, and the level of overestimation varied widely across sociodemographic groups (median, 22.6%; mean, 24.8%). The highest levels of overestimation were in non-Hispanic white females (27.4%), adults ages 50-54 years (32.0%), and those with the highest socioeconomic vulnerability [low educational attainment (31.3%), low poverty ratio (32.5%), no usual source of health care (54.4%), and not insured (51.6%); all P < 0.001].When the impetus for testing was not included, colorectal cancer screening prevalence was overestimated, and patterns of overestimation often aligned with social and economic vulnerability. These results are of concern to researchers who use survey data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess cancer screening behaviors, as it is currently not designed to distinguish diagnostic testing from screening.Surveillance research in cancer screening that does not consider the impetus for testing risks measurement error of screening prevalence, impeding progress toward improving population health. Ultimately, to craft relevant screening benchmarks and interventions, we must look beyond "what" and "when" and include "why."
View details for DOI 10.1158/1055-9965.EPI-15-0359
View details for Web of Science ID 000366129100006
View details for PubMedID 26491056
View details for PubMedCentralID PMC4670579
- Laparoscopic peritoneal lavage for perforated diverticulitis: in search of evidence LANCET 2015; 386 (10000): 1219-1221
- Putting the Integration Into Integrated Health Care Systems JOURNAL OF CLINICAL ONCOLOGY 2015; 33 (8): 821-?
MLH1 promotor hypermethylation does not rule out a diagnosis of Lynch syndrome: a case report
2015; 14 (1): 77-80
There are approximately 136,830 new colorectal cancer (CRC) cases diagnosed annually in the United States. In an effort to identify those at highest risk for Lynch Syndrome, an inherited CRC predisposition syndrome, several professional guidelines advocate for routine screening of all colorectal adenocarcinomas for features of DNA mismatch repair, microsatellite instability (MSI) and/or absent immunohistochemistry staining. Approximately 12-17 % of CRCs demonstrate MSI with germline mutations in genes involved in DNA mismatch repair, MLH1, MSH2, MSH6, PMS2 and TACSTD1/EPCAM and somatic MLH1 promotor hypermethylation being alternative pathways for the development of microsatellite unstable CRC. It is important to distinguish between these two events as the underlying cause of cancer development as management and implications for the patient and family members vary significantly. We describe a patient with multiple primary cancers, a deleterious germline MSH6 mutation and somatic MLH1 promotor hypermethylation highlighting the importance of incorporating the clinical history with the genetic evaluation.
View details for DOI 10.1007/s10689-014-9753-0
View details for Web of Science ID 000351171000010
View details for PubMedID 25213678
The Effect of Care Setting in the Delivery of High-Value Colon Cancer Care
2014; 120 (20): 3237-3244
The effect of care setting on value of colon cancer care is unknown.A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File.Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001).Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.
View details for DOI 10.1002/cncr.28874
View details for Web of Science ID 000342908800020
View details for PubMedID 24954628
View details for PubMedCentralID PMC4325980
Guideline-Concordant Cancer Care and Survival Among American Indian/Alaskan Native Patients
2014; 120 (14): 2183-2190
American Indians/Alaskan Natives (AI/ANs) have the worst 5-year cancer survival of all racial/ethnic groups in the United States. Causes for this disparity are unknown. The authors of this report examined the receipt of cancer treatment among AI/AN patients compared with white patients.This was a retrospective cohort study of 338,204 patients who were diagnosed at age ≥65 years with breast, colon, lung, or prostate cancer between 1996 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare database. Nationally accepted guidelines for surgical and adjuvant therapy and surveillance were selected as metrics of optimal, guideline-concordant care. Treatment analyses compared AI/ANs with matched whites.Across cancer types, AI/ANs were less likely to receive optimal cancer treatment and were less likely to undergo surgery (P ≤ .025 for all cancers). Adjuvant therapy rates were significantly lower for AI/AN patients with breast cancer (P < .001) and colon cancer (P = .001). Rates of post-treatment surveillance also were lower among AI/ANs and were statistically significantly lower for AI/AN patients with breast cancer (P = .002) and prostate cancer (P < .001). Nonreceipt of optimal cancer treatment was associated with significantly worse survival across cancer types. Disease-specific survival for those who did not undergo surgery was significantly lower for patients with breast cancer (hazard ratio [HR], 0.62), colon cancer (HR, 0.74), prostate cancer (HR, 0.52), and lung cancer (HR, 0.36). Survival rates also were significantly lower for those patients who did not receive adjuvant therapy for breast cancer (HR, 0.56), colon cancer (HR, 0.59), or prostate cancer (HR, 0.81; all 95% confidence intervals were <1.0).Fewer AI/AN patients than white patients received guideline-concordant cancer treatment across the 4 most common cancers. Efforts to explain these differences are critical to improving cancer care and survival for AI/AN patients.
View details for DOI 10.1002/cncr.28683
View details for Web of Science ID 000339010800018
View details for PubMedID 24711210
View details for PubMedCentralID PMC4219619
Complication Rates of Ostomy Surgery Are High and Vary Significantly Between Hospitals
DISEASES OF THE COLON & RECTUM
2014; 57 (5): 632-637
Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement.The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement.This was a retrospective cohort study.The study took place within the 34-hospital Michigan Surgical Quality Collaborative.Patients included were those undergoing ostomy creation surgery between 2006 and 2011.We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type).A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals.This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes.Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.
View details for Web of Science ID 000334475100496
View details for PubMedID 24819104
View details for PubMedCentralID PMC4197143
- Funding Sources in Faculty Development: Strategies for Success in Submitting Proposals CLINICS IN COLON AND RECTAL SURGERY 2013; 26 (4): 224-227
Analytic morphometric assessment of patients undergoing colectomy for colon cancer
JOURNAL OF SURGICAL ONCOLOGY
2013; 108 (3): 169-175
Analytic morphometrics provides objective data that may better stratify risk. We investigated morphometrics and outcome among colon cancer patients.An IRB-approved review identified 302 patients undergoing colectomy who had CT scans. These were processed to measure psoas area (PA), density (PD), subcutaneous fat (SFD), visceral fat (VF), and total body fat (TBF). Correlation with complications, recurrence, and survival were obtained by t-tests and linear regression models after adjusting for age and Charlson index.The best predictor of surgical complications was PD. PMH, Charlson, BMI, and age were not significant when PD was considered. SF area was the single best predictor of a wound infection. While all measures of obesity correlated with outcome, TBF was most predictive. Final multivariate Cox models for survival included age, Charlson score, nodal positivity, and TBF.Analytic morphometric analysis provided objective data that stratified complications and outcome better than age, BMI, or co-morbidities.
View details for DOI 10.1002/jso.23366
View details for Web of Science ID 000322318500008
View details for PubMedID 23846976
Racial Disparities in Esophageal Cancer Outcomes
ANNALS OF SURGICAL ONCOLOGY
2013; 20 (4): 1136-1141
Racial disparities in outcomes have been documented among patients with esophageal cancer. The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality.Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer (squamous cell carcinoma or adenocarcinoma) from 2003-2008. Age, marital status, stage, histology and location were examined as predictors of receipt of surgery and mortality in multivariate analyses.A total of 6,737 patient files (84 % white, 10 % black, 6 % Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26 %, respectively; p < 0.001) and lesions in the midesophagus (58 vs. 38 vs. 26 %, respectively; p < 0.001). Blacks and Hispanics were less likely to undergo esophagectomy (adjusted odds ratio 0.48, 95 % confidence interval (CI) 0.39-0.60 and 0.71, 95 % CI 0.56-0.90]. We noted significant variations in esophagectomy rates among patients with midesophageal cancers; 15 % of blacks underwent esophagectomy compared to 22 % of Hispanics and 29 % of whites (p < 0.001). Black and Hispanic patients had a higher unadjusted risk of mortality (hazard ratio 1.38, 95 % CI 1.25-1.52 and 1.20, 95 % CI 1.05-1.37). However, differences in mortality were no longer significant after adjusting for receipt of surgery.Disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery. To decrease disparities in mortality it will be necessary to understand and target underlying causes of lower surgery rates in nonwhite patients and develop interventions, especially for midesophageal cancers.
View details for DOI 10.1245/s10434-012-2807-3
View details for Web of Science ID 000316392600014
View details for PubMedID 23263780
View details for PubMedCentralID PMC4547835
Preoperative risk factors for postoperative Clostridium difficile infection in colectomy patients
AMERICAN JOURNAL OF SURGERY
2013; 205 (3): 343-347
Wide variation among hospitals in the rate of Clostridium difficile infection (CDI) after surgery was hypothesized to be related to different prophylactic antibiotic practices.Between March 2008 and March 2010, 30-day confirmed postoperative CDI rates were prospectively collected for patients undergoing colectomy surgery at 23 hospitals participating in a collaborative quality improvement program. Preoperative variables significantly associated with CDI (P ≤ .10) in a bivariate analysis were incorporated into a logistic regression model to test for independent associations.Among 4,936 patients, the overall rate of CDI was 1.6% (range by hospital, 0%-9%). After adjusting for patient comorbidities and hospital site, type of preoperative antibiotics used for prophylaxis was not significantly associated with CDI. Emergency surgery, low albumin, and neurologic and renal comorbidities emerged as independent preoperative predictors of CDI.Perioperative antibiotic practices did not prove to be independently associated with CDI after colectomy surgery.
View details for DOI 10.1016/j.amjsurg.2012.10.028
View details for Web of Science ID 000315948900043
View details for PubMedID 23375705
Evaluating Patients Undergoing Colorectal Surgery to Estimate and Minimize Morbidity and Mortality
SURGICAL CLINICS OF NORTH AMERICA
2013; 93 (1): 1-?
This review discusses the preoperative evaluation of patients preparing for elective colorectal resection, touching on several specific categories of morbidity, including cardiac, pulmonary, hepatic, renal, and surgical site complications. For each of these, the evidence for practices that optimize patient function and minimize risk is reviewed. Finally, authors discuss how to counsel high-risk surgical patients, including those for whom elective surgery is not recommended.
View details for DOI 10.1016/j.suc.2012.09.005
View details for Web of Science ID 000313145800003
View details for PubMedID 23177062
Surgeon-Level Variation in Patients' Appraisals of Their Breast Cancer Treatment Experiences
ANNALS OF SURGICAL ONCOLOGY
2013; 20 (1): 7-14
While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.
View details for DOI 10.1245/s10434-012-2582-1
View details for Web of Science ID 000312709400004
View details for PubMedID 23054105
Routine Leak Testing in Colorectal Surgery in the Surgical Care and Outcomes Assessment Program
ARCHIVES OF SURGERY
2012; 147 (4): 345-351
To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined.Observational, prospectively designed cohort study.Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP).Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009.Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter.Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals.Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99).Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.
View details for Web of Science ID 000302904600012
View details for PubMedID 22508778
Identification of Consensus-Based Quality End Points for Colorectal Surgery
DISEASES OF THE COLON & RECTUM
2012; 55 (3): 294-301
Process and outcome measures for quality assessment of colorectal surgical care are poorly defined.The aim of this study was to develop candidate end points for use in surgeon-specific registries designed for case reporting and quality improvement program development.The study design was based on modified Delphi-based development of consensus quality end points.This study was undertaken by the American Society of Colon and Rectal Surgeons Executive Council, Quality Committee, and by the ColoRectal Education System Template Committee, American Board of Colon and Rectal Surgery.No patients were included in this study.Six areas of colorectal surgery were defined by members of the American Society of Colon and Rectal Surgeons' Executive Council and the American Board of Colon and Rectal Surgery to cover areas of importance for colorectal surgeons. These included colectomy, rectal cancer, hemorrhoidectomy, anal fistula and abscess, colonoscopy, and rectal prolapse. Relevant American Society of Colon and Rectal Surgeons' committee members through a series of 4 panel discussions identified important demographic, process, and outcome measures in each of these 6 areas that might be suitable for the American College of Surgeons case log. Panel size was sequentially expanded from 8 members to 28 members to include all active committee members. Panelists contributed additional process and outcome measures for inclusion during each discussion. Modified Delphi methodology was used to generate consensus, and, after each panel discussion, members rated the relative importance of each end point from 1 (least important) to 4 (most important).The mean rating for each process and outcome measure after each round was recorded with the use of standardized definitions for relevant variables.Eighty-nine process and outcome measures were compiled and rated. Mean scores following the final round ranged from a low of 1.3 (anal fistula/abscess, preoperative imaging) to a high of 4.0 (colectomy-anastomotic leak).The limitations of this study involved the use of consensus, small study size, and the fact that no end points were excluded.With the use of modified Delphi methodology, a consensus-derived ranked list of 89 process and outcome measures was developed in 6 key areas of colorectal surgery. These data provide a framework for development of guideline standards for case-reporting program development initiatives for colon and rectal surgery.
View details for DOI 10.1097/DCR.0b013e318241b11f
View details for Web of Science ID 000300636200012
View details for PubMedID 22469796
Features Associated with Successful Recruitment of Diverse Patients onto Cancer Clinical Trials: Report from the American College of Surgeons Oncology Group
ANNALS OF SURGICAL ONCOLOGY
2011; 18 (13): 3544-3550
The clinical trials mechanism of standardized treatment and follow-up for cancer patients with similar stages and patterns of disease is the most powerful approach available for evaluating the efficacy of novel therapies, and clinical trial participation should protect against delivery of care variations associated with racial/ethnic identity and/or socioeconomic status. Unfortunately, disparities in clinical trial accrual persist, with African Americans (AA) and Hispanic/Latino Americans (HA) underrepresented in most studies.We evaluated the accrual patterns for 10 clinical trials conducted by the American College of Surgeons Oncology Group (ACOSOG) 1999-2009, and analyzed results by race/ethnicity as well as by study design.Eight of 10 protocols were successful in recruiting AA and/or HA participants; three of four randomized trials were successful. Features that were present among all of the successfully recruiting protocols were: (1) studies designed to recruit patients with regional or advanced-stage disease (2 of 2 protocols); and (2) studies that involved some investigational systemic therapy (3 of 3 protocols).AA and HA cancer patients can be successfully accrued onto randomized clinical trials, but study design affects recruitment patterns. Increased socioeconomic disadvantages observed within minority-ethnicity communities results in barriers to screening and more advanced cancer stage distribution. Improving cancer early detection is critical in the effort to eliminate outcome disparities but existing differences in disease burden results in diminished eligibility for early-stage cancer clinical trials among minority-ethnicity patients.
View details for DOI 10.1245/s10434-011-1818-9
View details for Web of Science ID 000297358900005
View details for PubMedID 21681382
Proximity to Disease and Perception of Utility: Physicians' vs Patients' Assessment of Treatment Options for Ulcerative Colitis
DISEASES OF THE COLON & RECTUM
2011; 54 (12): 1529-1536
Physician values regarding the benefit of continued medical therapy vs colectomy for moderate ulcerative colitis have not been defined. If physicians perceive these states differently than patients, their therapeutic recommendations may not align with patient values.This study aimed to compare physician and patient willingness to trade life years with moderately active ulcerative colitis vs undergoing colectomy.This survey of physicians' and patients' utility values used standardized scenarios for moderately active ulcerative colitis and colectomy.The investigation was conducted at a tertiary academic medical center.Gastroenterologists, colorectal surgeons, and patients with ulcerative colitis who were either living with moderate disease or were postcolectomy completed the survey.Utility values were measured by the use of the time trade-off method.We surveyed 17 physicians, 150 postcolectomy patients, and 69 patients with moderate ulcerative colitis. Utility values for ulcerative colitis and colectomy states were (0.87, 0.95), (0.86, 0.92), and (0.91, 0.91). On average, physicians and postcolectomy patients assessed the utility of life with ulcerative colitis more poorly than the postcolectomy state. Patients with moderately active ulcerative colitis who had not undergone colectomy viewed both health states equally.This study was limited by the physician subject sample size.Patients living with moderate ulcerative colitis value the pre- and postcolectomy states differently than physicians and postcolectomy patients. Recognizing the differences between their own and patients' values may help physicians to better counsel patients preoperatively. In addition, exposure to postcolectomy patients may help those with moderate disease who are weighing the comparative benefits of colectomy.
View details for DOI 10.1097/DCR.0b013e31823436a8
View details for Web of Science ID 000296854300010
View details for PubMedID 22067181
Early Discharge and Hospital Readmission After Colectomy for Cancer
DISEASES OF THE COLON & RECTUM
2011; 54 (11): 1362-1367
Early discharge after colectomy has been shown to be feasible in studies from specialty centers, but we hypothesized that benefits of early discharge might be offset by higher risk of readmission in the surgical community as a whole. Minimizing readmissions is a national health policy priority.This study aimed to determine whether hospitals discharging patients early had increased readmission rates.Patients undergoing colectomy surgery for cancer were studied using national Medicare data (MEDPAR database). Multiple logistic regression was performed to determine whether hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) had increased readmission rates. Results were adjusted for patient comorbidity, emergency operation, laparoscopic surgery, demographic factors, and complications. A separate analysis at the patient level was conducted to determine risk factors for readmission.Early discharge rates at US acute care hospitals were investigated.Patients 65 and older undergoing colectomy surgery for cancer (2003-2008, n = 477,461) were included.The main outcome measure was 30-day, all hospital readmission rates.Hospitals with a pattern of early discharge (median length of stay ≤ 5 d) were not found to have a higher risk-adjusted readmission rate than hospitals with the usual median length of stay (16.3% vs 15.7%, P = .077). However, changing the cutoff for "early discharge" to ≤ 4 days revealed an increased risk for readmission among "very early discharge" hospitals (risk-adjusted readmission rate 21.3% vs 15.7%, P < .001). At the patient level, independent risk factors for readmission included older age, male sex, black race, lower socioeconomic status, urgent/emergent surgery, comorbidities, complications, open (vs laparoscopic) surgery, and longer length of stay for the index hospitalization.Limitations of this study included the limitations of the administrative data and elderly population.Hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) do not have a higher risk-adjusted readmission rate than other hospitals. These results support the safety of early discharge programs in the Medicare population.
View details for DOI 10.1097/DCR.0b013e31822b72d3
View details for Web of Science ID 000295878800005
View details for PubMedID 21979179
- Measuring quality in colorectal surgery BRITISH MEDICAL JOURNAL 2011; 343
Bowel Preparation for Colectomy and Risk of Clostridium difficile Infection
DISEASES OF THE COLON & RECTUM
2011; 54 (7): 810-817
Mechanical bowel preparation before colectomy is controversial for several reasons, including a theoretically increased risk of Clostridium difficile infection.The primary aim of this study was to compare the incidence of C difficile infection among patients who underwent mechanical bowel preparation and those who did not. A secondary objective was to assess the association between C difficile infection and the use of oral antibiotics.This was an observational cohort study.The Michigan Surgical Quality Collaborative Colectomy Project (n = 24 hospitals) participates in the American College of Surgeons-National Surgical Quality Improvement Program with additional targeted data specific to patients undergoing colectomies.Included were adult patients (21 years and older) admitted to participating hospitals for elective colectomy between August 2007 and June 2009.The main outcome measure was laboratory detection of a positive C difficile toxin assay or stool culture.Two thousand two hundred sixty-three patients underwent colectomy and fulfilled inclusion criteria. Fifty-four patients developed a C difficile infection, for a hospital median rate of 2.8% (range, 0-14.7%). Use of mechanical bowel preparation was not associated with an increased incidence of C difficile infection (P = .95). Among 1685 patients that received mechanical bowel preparation, 684 (41%) received oral antibiotics. The proportion of patients in whom C difficile infection was diagnosed after the use of preoperative oral antibiotics was smaller than the proportion of patients with C difficile infection who did not receive oral antibiotics (1.6% vs 2.9%, P = .09).The potential exists for underestimation of C difficile infection because of the study's strict data collection criteria and risk of undetected infection after postoperative day 30.In contrast to previous single-center data, this multicenter study showed that the preoperative use of mechanical bowel preparation was not associated with increased risk of C difficile infection after colectomy. Moreover, the addition of oral antibiotics with mechanical bowel preparation did not confer any additional risk of infection.
View details for DOI 10.1007/DCR.0b013e3182125b55
View details for Web of Science ID 000291382600008
View details for PubMedID 21654247
Individual Health Discount Rate in Patients with Ulcerative Colitis
INFLAMMATORY BOWEL DISEASES
2011; 17 (6): 1328-1332
In cost-effectiveness analysis, discount rates are used in calculating the value of future costs and benefits. However, standard discount rates may not accurately describe the decision-making of patients with ulcerative colitis (UC). These patients often choose the long-term risks of immunosuppressive therapy over the short-term risks of colectomy, demonstrating very high discount rates for future health. In this study we aimed to measure the discount rate in UC patients and identify variables associated with the discount rate.We surveyed patients with UC and patients who were postcolectomy for UC to measure their valuations of UC and colectomy health states. We used Standard Gamble (SG) and Time-Trade-Off (TTO) methods to assess current and future health state valuations and calculated the discount rate.Participants included 150 subjects with UC and 150 subjects who were postcolectomy for UC. Adjusted discount rates varied widely (0%-100%), with an overall median rate of 55.0% (interquartile range [IQR] 20.6-100), which was significantly higher than the standard rate of 5%. Within the normal range of discount rates, patients' expected discount rate increased by 0.80% for each additional year of age, and female patients had discount rates that averaged ≈ 8% less than their age-matched counterparts and approached statistical significance.The accepted discount rate of 5% grossly underestimates UC patients' preference for long-term over short-term risk. This might explain UC patients' frequent choice of the long-term risks of immunosuppressive medical therapy over the short-term risks of colectomy.
View details for DOI 10.1002/ibd.21515
View details for Web of Science ID 000290442400031
View details for PubMedID 21560195
Perceived and Actual Quality of Life With Ulcerative Colitis: A Comparison of Medically and Surgically Treated Patients
AMERICAN JOURNAL OF GASTROENTEROLOGY
2011; 106 (4): 794-799
Patients with chronic ulcerative colitis (UC) often refuse colectomy, despite data indicating that it might improve quality of life. We hypothesized that perceived utility values are different for patients living with UC compared with UC patients after total proctocolectomy. Our aims were to compare the perceived utility assigned by UC patients with and without a colectomy to standardized chronic UC and post-colectomy scenarios, and to compare the utility of actual health states among groups.We surveyed patients in a tertiary referral center from three groups, including non-UC, UC patients without colectomy, and UC patients who were post-colectomy. We measured the Time-Trade-Off (TTO) utilities of subjects for standardized scenarios, describing moderate UC and a post-colectomy state. Among all UC patients (with and without colectomy), we measured TTO utility for their own health state.Responses were obtained from 150 patients per group (n=450). The non-UC patients considered UC and colectomy scenarios equally (0.92), which was similar to UC patients without colectomy (0.90 and 0.91). Post-colectomy patients strongly preferred the colectomy scenario to the UC scenario (0.86 vs. 0.92, P<0.001). The median utility of UC patients without colectomy for their actual health state was higher than that of post-colectomy patients (0.96 and 0.92, P<0.05). Patients with more social support were more likely to have undergone colectomy compared with patients with little social support (odds ratio=1.20 per dependent/supporter).Patients living with UC prefer their actual health state to a perceived UC scenario or a post-colectomy scenario. Patients who have undergone colectomy equate the quality of life in their actual state with that in a post-colectomy scenario, and prefer each to a perceived chronic UC state. Given the variety of preferences and the importance of social support, opportunities to interact with UC patients who have previously undergone colectomy could help patients living with UC and their physicians to navigate these complex choices.
View details for DOI 10.1038/ajg.2011.39
View details for Web of Science ID 000289232900024
View details for PubMedID 21364547
Surgical Complications Are Associated With Omission of Chemotherapy for Stage III Colorectal Cancer
DISEASES OF THE COLON & RECTUM
2010; 53 (12): 1587-1593
Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer.We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied.We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001).Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.
View details for DOI 10.1007/DCR.0b013e3181f2f202
View details for Web of Science ID 000284146500001
View details for PubMedID 21178851
- Understanding Racial Disparities in Cancer Treatment and Outcomes JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2010; 211 (1): 105-113
- Canadian Association of General Surgeons and the American College of Surgeons DISEASES OF THE COLON & RECTUM 2010; 53 (6): 953-955
- Health Care Reform and Comparative Effectiveness Implications for Surgeons ARCHIVES OF SURGERY 2010; 145 (2): 120-122
Hospital Factors and Racial Disparities in Mortality After Surgery for Breast and Colon Cancer
JOURNAL OF CLINICAL ONCOLOGY
2009; 27 (24): 3945-3950
Black patients have worse prognoses than whites with breast or colorectal cancer. Mechanisms underlying such disparities have not been fully explored. We examined the role of hospital factors in racial differences in late mortality after surgery for breast or colon cancer.Patients undergoing surgery after new diagnosis of breast or colon cancer were identified using the Surveillance Epidemiology and End Results-Medicare linked database (1995 to 2005). The main outcome measure was mortality at 5 years. Proportional hazards models were used to assess relationships between race and late mortality, accounting for patient factors, socioeconomic measures, and hospital factors. Fixed and random effects models were used to account for quality differences across hospitals.Black patients, compared with white patients, had lower 5-year overall survival rates after surgery for breast (62.1% v 70.4%, respectively; P < .001) and colon cancer (41.3% v 45.4%, respectively; P < .001). After controlling for age, comorbidity, and stage, black race remained an independent predictor of mortality for breast (adjusted hazard ratio [HR] = 1.25; 95% CI, 1.16 to 1.34) and colon cancer (adjusted HR = 1.13; 95% CI, 1.07 to 1.19). After risk adjustment, hospital factors explained 36% and 54% of the excess mortality for black patients with breast cancer and colon cancer, respectively. Hospitals with large minority populations had higher late mortality rates independent of race.Hospital factors, including quality, are important mediators of the association between race and mortality for breast and colon cancer. Hospital-level quality improvement should be a major component of efforts to reduce disparities in cancer outcomes.
View details for DOI 10.1200/JCO.2008.20.8546
View details for Web of Science ID 000269064300013
View details for PubMedID 19470926
Racial Clustering and Access to Colorectal Surgeons, Gastroenterologists, and Radiation Oncologists by African Americans and Asian Americans in the United States A County-Level Data Analysis
ARCHIVES OF SURGERY
2009; 144 (6): 532-535
Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level.A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists.All counties in the United States.Prevalence rate of African Americans and Asian Americans within a county.Rate of colorectal surgeons, gastroenterologists, and radiation oncologists.Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13).Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.
View details for Web of Science ID 000267011300009
View details for PubMedID 19528386
Socioeconomic status and surgical mortality in the elderly
2008; 46 (9): 893-899
Although racial disparities in the quality of surgical care are well described, the impact of socioeconomic status on operative mortality is relatively unexplored.We used Medicare data to identify all patients undergoing 1 of 6 common, high risk surgical procedures between 1999 and 2003. We constructed a summary measure of socioeconomic status for each US ZIP code using data from the 2000 US Census linked to the patient's ZIP code of residence. We assessed the effects of socioeconomic status on operative mortality rates while controlling for other patient characteristics and then examined the extent to which disparities in operative mortality could be attributed to differences in hospital factors.Socioeconomic status was a significant predictor of operative mortality for all 6 procedures in crude analyses and in those adjusted for patient characteristics. Comparing the lowest quintile of socioeconomic status to the highest, the adjusted odds ratios (OR) and 95% confidence intervals (CI) ranged from OR = 1.17; 95% CI: 1.10-1.25 for colectomy to OR = 1.39; 95% CI: 1.18-1.65 for gastrectomy. After further adjustment for hospital factors, the odds ratio associated with socioeconomic status for coronary artery bypass (OR = 1.14; 95% CI: 1.09-1.19), aortic valve replacement (OR = 1.13; 95% CI: 1.04-1.23), and mitral valve replacement (OR = 1.11; 95% CI: 1.00-1.23) were diminished, and those for lung resection (OR = 0.93; 95% CI: 0.81-1.07), colectomy (OR = 1.04; 95% CI: 0.98-1.12), and gastrectomy (OR = 1.11; 95% CI: 0.90-1.38) were reduced and also were no longer statistically significant. Within hospitals, there were only small differences in adjusted operative mortality by patient socioeconomic status.Patients with lower socioeconomic status have higher rates of adjusted operative mortality than patients with higher socioeconomic status across a wide range of surgical procedures. These disparities in surgical outcomes are largely attributable to differences between the hospitals where patients of higher and lower socioeconomic status tend to receive surgical treatment.
View details for Web of Science ID 000258945400002
View details for PubMedID 18725842
Does surgeon case volume influence nonfatal adverse outcomes after rectal cancer resection?
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2008; 206 (6): 1167-1177
The aim of this study was to assess the relationship between surgeon and hospital volume and major postoperative complications after rectal cancer surgery, and to define other surgeon and hospital characteristics that may explain observed volume-complication relationships.This was a retrospective cohort design using data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry program for individuals with stage I to III rectal cancer diagnosed between 1992 and 1999 and treated with resection. The patients' Surveillance, Epidemiology, and End Results data were linked with Medicare claims data from 1991 to 2000. The primary outcomes were 30-day postoperative procedural interventions (PPI) to treat surgical complications, such as reoperation. The association between surgeon volume and PPI was examined using logistic regression modeling with adjustment for covariates.The odds of a rectal cancer patient requiring a PPI is notably less if the operation is performed by one of a small subset of very high volume surgeons (unadjusted odds ratio 0.53; 95% CI 0.31 to 0.92). Board certification in colorectal surgery did not alter the relationship between surgeon volume and PPI, although surgeon age did, with mid-career surgeons having the lowest rates of PPI, regardless of practice volume. When adjusted for surgeon age, surgeon volume is no longer a marked predictor of complications (adjusted odds ratio 0.57; 95% CI 0.30 to 1.09).Overall, rectal cancer operations are safe, with a low frequency of severe complications. A subset of very high volume rectal surgeons performs these operations with fewer complications that require procedural intervention or reoperation. Surgeon age, as an indicator of experience, also contributes modestly to outcomes. These data do not justify regionalizing rectal cancer care based on safety concerns.
View details for DOI 10.1016/j.jamcollsurg.2007.12.042
View details for PubMedID 18501815
Residual treatment disparities after oncology referral for rectal cancer
JOURNAL OF THE NATIONAL CANCER INSTITUTE
2008; 100 (10): 738-744
Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.
View details for DOI 10.1093/jnci/djn145
View details for Web of Science ID 000256172400011
View details for PubMedID 18477800
Hospital lymph node examination rates and survival after resection for colon cancer
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2007; 298 (18): 2149-2154
Several studies suggest improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer. The National Quality Forum and other organizations recently endorsed a 12-node minimum as a measure of hospital quality.To assess whether hospitals that examine more lymph nodes after resection for colon cancer have superior late survival rates.Retrospective cohort study, using the national Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1995-2005), of US patients undergoing colectomy for nonmetastatic colon cancer (n = 30 625). Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into 4 evenly sized groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.Hospitals' lymph node examination rates in association with cancer staging, use of adjuvant chemotherapy (indicated for patients with node-positive disease), and 5-year survival rate.Hospitals with the highest proportions of patients with examination of 12 or more lymph nodes tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery (adjusted hazard ratio, highest vs lowest hospital quartile, 0.95; 95% confidence interval, 0.88-1.03). Although the 4 hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors and had very similar overall unadjusted rates of adjuvant chemotherapy (26% vs 25%, highest vs lowest hospital quartile).The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.
View details for Web of Science ID 000250869800020
View details for PubMedID 18000198
Racial variation in colorectal polyp and tumor location
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
2007; 99 (7): 723-728
The incidence and mortality from colorectal cancer among whites have decreased, but they have remained unchanged among African Americans. To explain this disparity, we used the multicenter endoscopy database of the Clinical Outcomes Research Initiative to compare the prevalence of proximal polyps and tumors among asymptomatic African Americans and whites undergoing routine screening colonoscopy.African Americans and whites undergoing colonoscopy between January 1, 2002 and September 30, 2003 were considered for analysis.There were 145,175 index colonoscopy reports on unique patients. After applying exclusion criteria, 46,726 patients remained for analysis. Adjusting for age, gender, American Society of Anesthesiologists level, bowel preparation and endoscopic setting, African Americans were less likely to have polyps [adjusted odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.70-0.84]. However, the odds of having proximal polyps was higher in African Americans (OR = 1.30; 95% CI: 1.11-1.52) compared to whites. In regards to tumors, African Americans were more likely to have tumors (OR = 1.78; 95% CI: 1.14-2.77) and more likely to have proximal tumors than whites (OR = 4.37; 95% CI: 1.16-16.42).After adjusting for confounders, African Americans undergoing screening colonoscopy in multiple practice settings had higher odds of proximal polyps and tumors than whites, suggesting current colorectal cancer screening recommendations in African Americans should be expanded.
View details for Web of Science ID 000248108300003
View details for PubMedID 17668638
Reoperation as a quality indicator in colorectal surgery - A population-based analysis
ANNALS OF SURGERY
2007; 245 (1): 73-79
To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay.Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored.Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database.sociodemographics, tumor characteristics, comorbidity, and acuity.postoperative procedural intervention.Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures.A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5-3.6), obstruction (RR = 1.6; 95% CI = 1.4-1.8), and emergent admission (RR = 1.3; 95% CI = 1.1-1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1-2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1-2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3-3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4-1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1-2.3).Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.
View details for DOI 10.1097/01.sla.0000231797.37743.9f
View details for Web of Science ID 000243314300012
View details for PubMedID 17197968
Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery - Understanding the volume-outcome relationship
ARCHIVES OF SURGERY
2007; 142 (1): 23-31
Although numerous studies have demonstrated an association between surgical volume and improved outcome in cancer surgery, the specific structures and mechanisms of care that are associated with volume and lead to improved outcomes remain poorly defined. We hypothesize that there are modifiable surgeon and hospital characteristics that explain observed volume-outcome relationships.Retrospective cohort study.Surveillance, Epidemiology, and End Results cancer registry areas.Patients aged 66 years and older, diagnosed and surgically treated for stage I, II, or III colon cancer between 1992 and 1996 (n = 22 672).Thirty-day postoperative mortality and 30-day postoperative procedural interventions, including reoperation and image-guided percutaneous procedures.Surgeon volume, but not hospital volume, is a significant predictor of postoperative procedural intervention (adjusted odds ratio for very high-volume surgeons vs low-volume surgeons, 0.79; 95% confidence interval, 0.64-0.98). In the unadjusted analyses, high hospital volume (odds ratio, 0.67; 95% confidence interval, 0.56-0.81) and very high hospital volume (odds ratio, 0.65; 95% confidence interval, 0.54-0.79) is associated with lower postoperative mortality. Postoperative procedural intervention is not a significant mediator of the relationship between hospital volume and mortality. A single variable-the presence of sophisticated clinical services-was the most important explanatory variable underlying the relationship between hospital volume and mortality.Very high surgeon volume is associated with a reduction in surgical complications. However, the association between increasing hospital volume and postoperative mortality appears to derive mainly from a full spectrum of clinical services that may facilitate the prompt recognition and treatment of complications.
View details for PubMedID 17224497
- Medicare policy and colorectal cancer screening - Will changing access change outcomes? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2006; 296 (23): 2855-2856
Racial disparities in late survival after rectal cancer surgery
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2006; 203 (6): 787-794
African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear.Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality.African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20).Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients.
View details for DOI 10.1016/j.jamcollsurg.2006.08.005
View details for Web of Science ID 000242567300001
View details for PubMedID 17116545
Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis
2006; 55 (11): 1575-1580
Increased infertility in women has been reported after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis but reported infertility rates vary substantially.(1) To perform a systematic review and meta-analysis of the relative risk of infertility post-IPAA compared with medical management; (2) to estimate the rate of infertility post-IPAA; and (3) to identify modifiable risk factors which contribute to infertility.Medline, EMBASE, Current Contents, meeting abstracts, and bibliographies were searched independently by two investigators. The titles and abstracts of 189 potentially relevant studies were reviewed; eight met the criteria and all data were extracted independently. Consensus was achieved on each data point, and fixed effects meta-analyses, a funnel plot, and sensitivity analyses were performed.The initial meta-analysis of eight studies had significant heterogeneity (p = 0.004) due to one study with very high preoperative infertility (38%). When this study was omitted, the relative risk of infertility after IPAA was 3.17 (2.41-4.18), with non-significant heterogeneity. The weighted average infertility rate in medically treated ulcerative colitis was 15% for all seven studies, and the weighted average infertility rate was 48% after IPAA (50% if all eight studies are included). We were unable to identify any procedural factors that consistently affected the risk of infertility.IPAA increases the risk of infertility in women with ulcerative colitis by approximately threefold. Infertility, defined as achieving pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis. This provides a basis for counselling patients considering colectomy with IPAA. Further studies of modifiable risk factors are needed.
View details for DOI 10.1136/gut.2005.090316
View details for Web of Science ID 000241363600013
View details for PubMedID 16772310
Race and surgical mortality in the United States
ANNALS OF SURGERY
2006; 243 (2): 281-286
This study describes racial differences in postoperative mortality following 8 cardiovascular and cancer procedures and assesses possible explanations for these differences.Although racial disparities in the use of surgical procedures are well established, relationships between race and operative mortality have not been assessed systematically.We used national Medicare data to identify all patients undergoing one of 8 cardiovascular and cancer procedures between 1994 and 1999. We used multiple logistic regression to assess differences in operative mortality (death within 30 days or before discharge) between black patients and white patients, controlling for patient characteristics. Adding hospital indicators to these models, we then assessed the extent to which racial differences in operative mortality could be accounted for by the hospital in which patients were cared for.Black patients had higher crude mortality rates than white patients for 7 of the 8 operations, including coronary artery bypass, aortic valve replacement, abdominal aortic aneurysm repair, carotid endarterectomy, radical cystectomy, pancreatic resection, and esophagectomy. Among these 7 procedures, odds ratios of mortality (black versus white) ranged from 1.23 (95% confidence interval, 1.18-1.29) for CABG to 1.61 (95% confidence interval, 1.28-2.03) for esophagectomy. Adjusting for patient characteristics had modest or no effect on odds ratios of mortality by race. However, there remained few clinically or statistically significant differences in mortality by race after we accounted for hospital. Hospitals that treated a large proportion of black patients had higher mortality rates for all 8 procedures, for white as well as black patients.Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.
View details for DOI 10.1097/01.sla.0000197560.92456.32
View details for Web of Science ID 000234912700019
View details for PubMedID 16432363
Patient-centered outcomes after therapy for colorectal cancer
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA
2006; 15 (1): 195-?
In practical terms, clinicians can use the results of patient-centered outcome instruments to track patients' functional status and quality-of-life changes through treatment. Noting formalized results might help clinicians better communicate with patients at critical times during treatment, especially with regard to patient expectations.Although numerous clinical variables of uncertain value are regularly followed, validated functional and quality-of-life results have been put to use only rarely in the clinical setting. Clinicians' ability to interpret and apply quality-of-life results will surely improve with practice, and likely would be well worth the contribution to our patients' well-being.
View details for DOI 10.1016/j.soc.2005.09.005
View details for Web of Science ID 000241757800014
View details for PubMedID 16389158
Misdiagnosis of appendicitis and the use of diagnostic imaging
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2005; 201 (6): 933-939
CT and ultrasound (US) are increasingly recommended to establish the diagnosis of appendicitis, but population-based rates of misdiagnosis (negative appendectomy [NA]) have not improved over time. The objective of this study was to determine the relationship between CT/US and NA in common practice.Using data from the Group Health Cooperative on all patients undergoing appendectomy between 1980 and 1999, a longitudinal study was conducted to determine the frequency of NA over time and a case-control, medical record-based study of a subset of patients from the 1990s was conducted to determine the accuracy of CT/US.Of 4,058 patients undergoing appendectomy (mean age 31 +/- 18.6 [SD] years, 49.6% women), 631 (15.5%) had an NA. The overall incidence of NA remained stable over time at 1.5/10,000 patient-years, as did the age and gender adjusted rate (incident rate ratio 0.95, 95% CI 0.97, 1.01). In 1999, nearly 40% of patients had either CT or US. The aggregate sensitivity of these tests was only 74.2% (95% CI 65.7, 83.7), with a positive predictive value of 95.1% (95% CI 91.5, 96.8). CT scans were 88.3% sensitive, with 97.2% positive predictive value (95% CI 92.9, 100). Ultrasounds were 69.5% sensitive, with a positive predictive value of 94.1% (95% CI 89.6, 96.4). More than one in five tests obtained in patients with NA were positive for appendicitis (21.7% for CT and 20.8% for US).The rate of NA was unchanged over time despite the introduction and use of CT/US, and this appeared to be related to the inconsistent performance characteristics of the tests. This study cautions against overreliance on CT/US in diagnosing appendicitis and emphasizes the need for test benchmarking in routine practice before establishing protocols for presumed appendicitis.
View details for DOI 10.1016/j.jamcollsurg.2005.04.039
View details for Web of Science ID 000233737300015
View details for PubMedID 16310698
Lymph node evaluation in colorectal cancer patients: A population-based study
JNCI-JOURNAL OF THE NATIONAL CANCER INSTITUTE
2005; 97 (3): 219-225
Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation.For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided.Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location.In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.
View details for DOI 10.1093/jnci/dji020
View details for Web of Science ID 000226748200013
View details for PubMedID 15687365
Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: A population-based analysis
INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS
2005; 61 (2): 426-431
To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown.The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection.In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS.Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.
View details for DOI 10.1016/j.ijrobp.2004.06.259
View details for Web of Science ID 000226700200016
View details for PubMedID 15667963
Adjuvant radiation for rectal cancer: Do we measure up to the standard of care? An epidemiologic analysis of trends over 25 years in the United States
DISEASES OF THE COLON & RECTUM
2005; 48 (1): 9-15
In the United States, adjuvant radiation therapy is currently recommended for most patients with rectal cancer. We conducted this population-based study to evaluate the rate of radiation therapy and the factors affecting its delivery.We used the Surveillance Epidemiology and End Results database to assess treatment of patients with nonmetastatic rectal cancer diagnosed over a 25-year period (1976 through 2000). We evaluated the rate of radiation therapy use and its timing (preoperative vs. postoperative) and the influence of factors such as tumor stage and grade; patient gender and race; and geographic location.In this 25-year period, 45,627 patients met our selection criteria. The rate of radiation therapy use increased dramatically over time: from 17 percent of advanced-stage patients in 1976 to 65 percent in 2000 (P < 0.0001). Until 1996, the increase was due almost entirely to postoperative radiation therapy. Since 1996, the rate of preoperative radiation therapy use has increased (P < 0.0001) and the rate of postoperative radiation therapy use has begun to decline. We found, after controlling for the year of diagnosis, that female patients, African Americans, older patients, and patients with low-grade lesions were less likely to undergo radiation therapy (P < 0.0001). Geographic location was also an important predictor of radiation therapy use.The use of radiation therapy for patients with rectal cancer has dramatically increased over the 25-year period studied, with a recent shift to the use of preoperative radiation therapy; however, in 2000, over 30 percent of patients with advanced-stage nonmetastatic rectal cancer did not undergo radiation therapy. Given the variation in radiation therapy use that we found to be due to demographic factors, access to adjuvant radiation therapy can be improved.
View details for DOI 10.1007/s10350-004-0792-8
View details for Web of Science ID 000226058500002
View details for PubMedID 15690651
- Complications of chronic pelvic radiation injury JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2004; 198 (6): 1022-1023
Racial disparities in rectal cancer treatment - A population-based analysis
ARCHIVES OF SURGERY
2004; 139 (2): 151-155
We hypothesized that there are significant racial disparities in delivery of care to rectal cancer patients. We examined differential surgical and radiation treatment for these patients and determined whether blacks were less likely than whites to undergo sphincter-sparing procedures, which are associated with a higher quality of life than sphincter-ablating procedures.Cross-sectional cohort study.The Surveillance Epidemiology and End Results database provided population-based data for rectal cancer patients who were diagnosed between 1988 and 1999, were older than 35 years, and had no prior colorectal or other pelvic cancer.Using logistic regression, we compared receipt and type of surgical therapy and radiation therapy, controlling for age, sex, year, geography, stage, and anatomic location.Among 52 864 patients, 3851 were black and 44 010 were white. Blacks were younger than whites and had more advanced disease (P<.001). Among patients who underwent operation, rates of sphincter-ablating procedure were 37% for whites and 43% for blacks (adjusted odds ratio [AOR], 1.42; 95% confidence interval [CI], 1.23-1.65). Moreover, 53% of whites and 56% of blacks received no radiation therapy for stage II to III disease (AOR, 1.30; 95% CI, 1.15-1.47).Blacks with rectal cancer were diagnosed at a younger age and more advanced disease stage than whites, implying a need for more aggressive screening. After adjusting for stage and other covariates, surgical and radiation treatment also differed along racial lines. Our data suggest that treatment disparities may contribute to differences in outcome among racial/ethnic groups with rectal cancer, and they highlight the need for improving access to state-of-the-art surgical care for minority patients with rectal cancer.
View details for Web of Science ID 000188791000007
View details for PubMedID 14769572
Acute transanal evisceration of the small bowel - Report of a case and review of the literature
DISEASES OF THE COLON & RECTUM
2003; 46 (9): 1280-1283
We report a patient who presented with rectal rupture and transanal evisceration, a rare entity with only 52 cases previously described in the world literature. Our case is the first to implicate sheer stress on the anterior rectum caused by postoperative adhesions as the major etiologic contributing feature. Moreover, this case is the third reported with chronic constipation without rectal prolapse as an additional preexisting contributory condition. A summary of the medical literature including etiology, treatment, and outcomes is presented.
View details for DOI 10.1097/01.DCR.0000084368.32164.88
View details for Web of Science ID 000185384700018
View details for PubMedID 12972975
Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses
2003; 41 (8): 962-971
Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy.To compare cost-effectiveness of TTS and traditional methods.The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions.In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost.The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model.
View details for Web of Science ID 000184477700009
View details for PubMedID 12886175
Clostridium difficile colitis - An increasingly aggressive iatrogenic disease?
ARCHIVES OF SURGERY
2002; 137 (10): 1096-1100
The diagnosis of Clostridium difficile colitis is increasing in frequency, with worsening patient outcomes.Retrospective cohort study.University hospital.One hundred fifty-seven patients diagnosed with C difficile colitis between 1994-2000.Resolution of disease, operative intervention, and death.Compared with our previous 10-year experience, overall cases of C difficile colitis have risen by more than 30%, and immunocompromised patients comprise a larger proportion of those affected. One third of patients were receiving posttransplantation medication, chemotherapy, or had human immunodeficiency virus. Of these, 2 (4%) of 51 required surgical intervention and 10 (20%) of 51 died. An additional 18.5% of patients had diabetes, renal failure, or both. Of these, 2 (7%) of 30 required surgery and 4 (13%) of 30 died. Only 9.5% of patients had prophylactic perioperative antibiotics as a sole risk factor; 2 (13%) of 15 required surgery and 3 (20%) of 15 died. The overall mortality rate was 15.3%, increased from 3.5% in our previous series. Neither need for surgery nor mortality differed among these patient groups.The frequency of C difficile colitis remains high and seems to be associated with increasing mortality. Among patients with positive C difficile toxin assay results, immunocompromise and delayed diagnosis no longer seem to be associated with higher risk for death. All patients taking antibiotics are at risk and require early recognition and aggressive medical intervention.
View details for Web of Science ID 000178493300002
View details for PubMedID 12361411
Has misdiagnosis of appendicitis decreased over time? A population-based analysis
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2001; 286 (14): 1748-1753
Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery.To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy.Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998.Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix.Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P =.005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P =.17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001).Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.
View details for Web of Science ID 000171466800025
View details for PubMedID 11594900
Usefulness of the triple test score for palpable breast masses
ARCHIVES OF SURGERY
2001; 136 (9): 1008-1012
The triple test score (TTS) is useful and accurate for evaluating palpable breast masses.Diagnostic test study.University hospital multidisciplinary breast clinic.Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000.Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up.The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255).All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign.The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.
View details for Web of Science ID 000170895600008
View details for PubMedID 11529822
Induction of anti-mammary cancer immunity by engaging the OX-40 receptor in vivo
BREAST CANCER RESEARCH AND TREATMENT
2001; 67 (1): 71-80
The OX-40 receptor (OX-40R) is a member of the tumor necrosis factor receptor (TNF-R) superfamily that is expressed on activated CD4+ T cells. The OX-40R is a costimulatory molecule that induces CD4+ T cell activation when engaged by its ligand (OX-40 L; found on antigen presenting cells). In human and murine tumors, we have shown upregulation of the OX-40R on CD4+ T cells from tumor-infiltrating lymphocytes (TIL) and tumor-draining lymph node cells (TDLNC) but not on systemic CD4+ T cells, such as peripheral blood lymphocytes (PBL) or splenocytes. In order to examine potentially heightened anti-tumor immunity through enhanced costimulation when engaging OX-40R in vivo, we inoculated mice with a murine mammary cancer cell line (SM1) and then treated with a soluble form of the OX-40 L. Mice injected with a lethal inoculum of SM1 cells were given two intraperitoneal injections (days 3 and 7 post-inoculation) of 100 microg soluble OX-40 L. Seven of 28 treated mice survived the lethal tumor inoculum, as compared to one of 28 control mice, demonstrating a significant survival benefit with treatment (p = 0.0136, log rank analysis). Mice that did not develop tumor by day 90 were rechallenged; all remained tumor-free. Mice were also injected with a second mammary tumor line (4T1) and treated with OX-40L:Ig with similar therapeutic results. Activation of OX-40R+ CD4+ T cells during mammary cancer priming stimulated an antitumor immune response resulting in enhanced survival and protective anti-tumor immunity. These results should have practical applications for treatment modalities for patients with breast cancer.
View details for PubMedID 11518468
Engagement of the OX-40 receptor in vivo enhances antitumor immunity
JOURNAL OF IMMUNOLOGY
2000; 164 (4): 2160-2169
The OX-40 receptor (OX-40R), a member of the TNFR family, is primarily expressed on activated CD4+ T lymphocytes. Engagement of the OX-40R, with either OX-40 ligand (OX-40L) or an Ab agonist, delivers a strong costimulatory signal to effector T cells. OX-40R+ T cells isolated from inflammatory lesions in the CNS of animals with experimental autoimmune encephalomyelitis are the cells that respond to autoantigen (myelin basic protein) in vivo. We identified OX-40R+ T cells within primary tumors and tumor-invaded lymph nodes of patients with cancer and hypothesized that they are the tumor-Ag-specific T cells. Therefore, we investigated whether engagement of the OX-40R in vivo during tumor priming would enhance a tumor-specific T cell response. Injection of OX-40L:Ig or anti-OX-40R in vivo during tumor priming resulted in a significant improvement in the percentage of tumor-free survivors (20-55%) in four different murine tumors derived from four separate tissues. This anti-OX-40R effect was dose dependent and accentuated tumor-specific T cell memory. The data suggest that engagement of the OX-40R in vivo augments tumor-specific priming by stimulating/expanding the natural repertoire of the host's tumor-specific CD4+ T cells. The identification of OX-40R+ T cells clustered around human tumor cells in vivo suggests that engagement of the OX-40R may be a practical approach for expanding tumor-reactive T cells and thereby a method to improve tumor immunotherapy in patients with cancer.
View details for Web of Science ID 000085296600067
View details for PubMedID 10657670
Accurate evaluation of palpable breast masses by the triple test score
ARCHIVES OF SURGERY
1998; 133 (9): 930-933
We previously reported that the triple test (physical examination, mammography, and fine needle aspiration) for palpable breast masses yields 100% diagnostic accuracy when all 3 components are concordant (all benign or all malignant). However, 40% of cases are nonconcordant and require open biopsy.To evaluate our experience with the triple test to develop a method to further limit the need for surgical biopsy.Diagnostic test study.University hospital multidisciplinary breast clinic.Two hundred fifty-nine patients with 261 palpable breast masses studied between 1991 and 1997.The triple test was prospectively applied to each breast mass. Each component of the triple test was assigned 1, 2, or 3 points for a benign, suspicious, or malignant result, respectively, yielding a total triple test score (TTS).The TTS was correlated with subsequent histopathologic examination results.Eighty-eight masses had a TTS of more than 6 points; all had malignant histopathologic characteristics. One hundred fifty-two masses had a TTS of 4 points or lower; all were benign. In both groups, diagnostic accuracy and predictive value were 100%, with P<.001. Twenty-one masses had a TTS of 5 points; of these, 13 (62%) were benign and 8 (38%) were malignant.The TTS reliably guides evaluation and treatment of palpable breast masses. Masses that score 6 points or higher are malignant and should undergo definitive therapy; masses that score 4 points or lower are benign and may be clinically followed up. Only those masses that score 5 points (8% of our database) require open biopsy.
View details for PubMedID 9749842
Presence of the T-cell activation marker OX-40 on tumor infiltrating lymphocytes and draining lymph node cells from patients with melanoma and head and neck cancers
AMERICAN JOURNAL OF SURGERY
1997; 174 (3): 258-265
The OX-40 antigen is a cell surface glycoprotein in the tumor necrosis factor receptor family that is expressed primarily on activated CD4+ T cells. Selective target organ expression of the OX-40 receptor on autoantigen specific T cells has been found in autoimmune disease. In order to evaluate whether OX-40 is expressed on T cells from patients with nodal-draining carcinomas, OX-40 expression was assessed in tumor infiltrating lymphocytes (TILs), draining lymph node cells (DLNCs), and/or peripheral blood lymphocytes (PBLs) of 13 patients with head and neck squamous cell carcinomas and 9 patients with melanomas.Cell phenotype was determined by fluorescence cell analysis using a monoclonal antibody to human OX-40, and CD4+ T cell lymphokine production was determined by reverse transcriptase-polymerase chain reaction (RT-PCR).Expression of the OX-40 receptor was found in as many as 31% of the TILs and as many as 28% of the DLNCs tested. Conversely, no OX-40 expression was found in PBLs. In addition, CD4+ T cells isolated from DLNCs (but not from TILs or PBLs) secreted a Th1 pattern of cytokines (IL-2, gamma interferon). Co-culture of autologous CD4+ TILs with an MHC class II+ melanoma cell line transfected with OX-40 ligand cDNA resulted in T cell proliferation and in vitro tumor regression.These findings suggest that OX-40+ CD4+ T cells isolated from tumors and their adjacent draining nodes may represent a tumor-specific population of activated T cells capable of mediating tumor reactivity. These cells may play an exploitable role in future trials of immunotherapy.
View details for PubMedID 9324133