90.19 Insurance Type Affects Short Term Outcomes After Hartmann Procedure.

Posted on January 31, 2019

M. J. Adair1, S. Markowiak1, M. Baldawi1, C. Taylor1, A. Aldhaheri1, C. Das1, W. Qu1, M. Nazzal1, S. Pannell1  1University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

INTRODUCTION
Hartmann’s procedure is traditionally performed to treat colonic obstruction or perforation. Using a national database, the aim of this study was to compare patients with different types of health insurance (different payer sources) for short-term postoperative outcomes after Hartmann's procedure. 

METHODS
From the Natioinal Inpatient Sample (NIS) database, patients who underwent elective or urgent Hartmann's procedure for the time period between 2008 and 2014 were included in this study. After adjustment for demographics and comorbidites, health insurance types were compared for in-hospital mortality, post-perative complications, length of hospital stay, and total hospital cost. Univariate analysis was performed using Chi-square test, two sample t-test and Mann-Whitney U test. Multiple logistic regression was utilized for the multivariate analysis.

RESULTS
A total of 9,836 patients were included in this study. The average age of  patients (mean ±SD) was 65.6±15.4 years old. Out of these patients, 4574 (46.5%) were males and 7667 (78%) were White. Overall in-hospital mortality rate was 11.9% (n=1169). The median hospital lenght of stay was 12 days and the median total hospital cost was US$104,635. Using multivariate analysis, we foud that Medicare and Medicaid patients had significantly higher mortality rate than private insurance patients (16.5% and 7.6% versus 5.9%, respectively. P<0.001). Medicare and Medicaid patients also had a longer hospital length of stay in comparison to Private insurance patients (13 days and 14 days versus 11 days, respectively. P<0.001).

CONCLUSION

Following Hartmann’s procedure, Medicare and Medicaid patients have a higher risk of mortality and longer total hospital length of stay in comparison to those with private insurance. A strong consideration of possible undiagnosed comorbidities, delayed presentation or inadequate prior management must be undertaken when treating these patients. We also recommend performing further research to fully analyze all the potential factors that can influence outcomes after Hartmann’s Procedure.

 

90.11 Spatial Accessibility to Colorectal Surgeons in the State of Illinois

Posted on January 31, 2019

J. Day1, W. E. Zahnd2, V. Poola1, J. Rakinic1, S. Ganai1,2  1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Population Science And Policy,Springfield, IL, USA

Introduction:   Disparities in screening, incidence, and mortality for colorectal cancer (CRC) include race/ethnicity, geography, insurance, and other socioeconomic factors. Access disparities can cause treatment delays that impact outcomes. Shortages of gastroenterologists, surgeons, and radiation oncologists have been identified in rural areas. We hypothesized that disparities in spatial access to specialty-trained colorectal surgeons exist between rural and urban Illinois.  

Methods: Data on colorectal surgeon location in Illinois and surrounding border locales were abstracted from the 2014 American Society of Colon and Rectal Surgeons directory with addresses geocoded. Data on population characteristics (age, education, median household income, and race/ethnicity) were obtained from the American Community Survey at the zip code tabulation area (ZCTA) level. Rurality was approximated using the University of Washington’s approximations of the United States Department of Agriculture’s Rural-Urban Commuting Area (RUCA) codes. Network Analyst tool in ARCGIS was used to calculate travel time. Independent t-test and ANOVA were performed to evaluate differences in travel time to the nearest colorectal surgeon by rurality. Choropleth maps were created to display travel time by ZCTA.  

Results: Over half of individuals in isolated-rural (54.1%) and small rural (51.1%) locales in Illinois live more than 60 minutes away from a colorectal surgeon. For those who live in large rural areas, a large proportion (69.4%) live >30-minutes from a colorectal surgeon. In contrast, the majority who live in urban areas (88.8%) had <30 minutes travel time. Overall, mean travel time to a colorectal surgeon was 43.6±27.9 (SD) minutes.  Mean travel time to the nearest colorectal surgeon was significantly greater from rural areas [60.30 ±24.40 minutes (SD)] compared to urban areas [29.10±22.29 minutes; p<0.001). Travel time to the nearest colorectal surgeon also differed across the 4-group RUCA rurality scale (p<0.001), with the greatest travel time for isolated (65.57±22.08 min) and small rural areas (66.88±24.97 min), and shorter travel time for large rural (47.24±19.28 min) and urban areas (29.10±22.29 min). 

Conclusion: The rural population of Illinois experiences a greater burden of travel time for access to colorectal surgeons. The results support the hypothesis that a difference exists in access to colorectal cancer care in rural Illinois via geographic proximity to a colorectal surgeon. Further analysis including correlation to incidence and mortality and the role of complementary providers will be necessary to properly assess access to CRC care needs in Illinois.

90.10 Disparities in Surgical Intervention for Colorectal Cancer: A SEER Analysis from 2000-2015

Posted on January 31, 2019

M. Liu1, M. Miller1, J. Bhattacharya1, C. Kin1, A. Morris1  1Stanford University,School Of Medicine,Palo Alto, CA, USA

Introduction:
Colorectal cancer is the 3rd leading cause of cancer mortality in the United States. Black patients with colorectal cancer have higher rates of overall and disease-specific mortality than white patients. Surgical intervention can be curative for colorectal cancer if patients have access to and receive the care. Our goal was to compare the rates of surgical intervention among black and white patients. We hypothesized that black colorectal cancer patients undergo less surgical intervention compared to white patients.

Methods:
The National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Registry was used to identify patients over age 18 years diagnosed with incident Stage I-IV from 2000-2015. We performed logistic regressions to determine surgical intervention among black and white patients stratified by stage, adjusting for sex, age, and insurance status. STATA was the statistical software used. Significance was set at a p value less than 0.05.

Results:
A total of 297,555 patients met inclusion criteria. In a logistic regression analysis, black patients had a significantly decreased odds of undergoing surgical intervention compared to white patients [unadjusted OR 0.76 (95% CI 0 .74 – 0 .78) p< 0.0001] and [adjusted OR 0.83 (95% CI 0 .79- 0.86) p<0.0001]. When stratified by stage, black patients were significantly less likely than white patients to undergo surgical intervention at Stage I [adjusted OR 0.74 (95% CI 0.66 – 0 .83) p<0.05] and Stage II [unadjusted OR 0.88 (95% CI 0.78 -0 .998) p<0.05], although not statistically significant when adjusted [OR 0.94 (95% CI 0.81-1.08) p > 0.05]. There was no significant difference in surgical intervention between white and black patients diagnosed with advanced Stages III-IV.

Conclusion:
We found that black patients with curable early-stage colorectal cancer had nearly 17% decreased odds of undergoing surgical intervention compared to white patients. Although our data does not permit us to identify an underlying mechanism for this disparity, further work with an enriched dataset could help to determine the relative contribution of hospital, provider, and patient-level factors.
 

90.06 Evaluating Disease Biology and Incidence of Rectal Cancer in Young People in Kentucky

Posted on January 31, 2019

M. B. Holbrook1, N. Bhutiani1, B. Huang2, Q. Chen2, T. C. Tucker3, S. Galandiuk1, R. W. Farmer1  1University of Louisville,Surgery,Louisville, KY, USA 2University of Kentucky,Biostatistics,Lexington, KY, USA 3University of Kentucky,Markey Cancer Center,Lexington, KY, USA

Introduction: Multiple studies have demonstrated an increase in rectal cancer among young people, a trend reflected in the most recent colorectal cancer screening guidelines.  Despite significant improvement in screening and education, young rectal cancer patients have emerged as a burgeoning health crisis in Kentucky.  This study sought to compare the incidence of rectal cancer and tumor biology among patients <40 years old in Kentucky and the United States. 

Methods: The Kentucky Cancer Registry (KCR) and the National Cancer Database (NCDB) were queried for patients diagnosed with cancer of the rectum or rectosigmoid junction between 2004 and 2014.  Demographics, tumor characteristics, and annual proportional incidence in patients <40 years old and those ≥ 40 years old were compared. 

Results:Patients in Kentucky and nationally had a similar distribution between rectal junctional and true rectal malignancy (p=0.13).  There was no difference in stage at diagnosis (p=0.17), gender (p=0.57), and KRAS mutational status (p=0.46).  However, a greater proportion of patients in Kentucky had undifferentiated tumors compared to the NCDB (7.5% KCR vs. 1.8% NCDB, p<.001).  Five-year overall survival was no different between groups (~70%).  Linear regression of incidence demonstrated an annual increase in Kentucky of twice the national rate (0.13% per year vs 0.05% per year) with a sharp increase in 2014 (Figure). 

Conclusion:While similar to the national cohort, young rectal cancer in Kentucky displays variation in tumor grade and incidence suggesting difference in tumor biology.  These data reinforce recent changes to screening guidelines, with potential extension to younger patients. 

 

90.04 Did the Affordable Care Act Accelerate Utilization of Minimally Invasive Colon Cancer Surgery?

Posted on January 31, 2019

T. Seykora1,2, A. Zeymo2, M. Bayasi3, T. DeLeire4, N. Shara5,6, W. Al-Refaie2,3, R. Essig3, K. Chan2  4Georgetown University,McCourt School Of Public Policy,Washington, DC, USA 5MedStar Health Research Institute,Washington, DC, USA 6Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 1Georgetown University Medical Center,Georgetown University School Of Medicine,Washington, DC, USA 2MedStar Health Research Institute,MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Georgetown University Medical Center,MedStar Georgetown University Hospital,Washington, DC, USA

Background: Despite growing evidence supporting clinical benefits of minimally invasive surgery (MIS) for colon cancer, this approach is less likely utilized for patients with lower income and Medicaid or no health insurance. It is unclear whether the Affordable Care Act (ACA) affected MIS utilization for colon cancer across various patient socio-demographic characteristics.

Methods:  Data on surgical approach and patient characteristics for 193,474 colorectal cancer cases were queried from National Cancer Database for 2011-15. Separate multivariable logistic regression models were used to determine odds of receiving MIS, controlling for patient and clinical characteristics. An interaction term was added to each model to examine the relationship between the post-ACA period and each patient variable (race, insurance, patient zipcode income, education, rurality).

Results: Laparoscopic (LS) and robotic-assisted (RAS) surgery for colon cancer increased over time (Fig. 1). Odds significantly increased (all p<0.001) post-ACA for LS (OR range=1.37-1.46) and RAS (OR range=2.77-3.03) across all models. For LS, Blacks had lower odds (0.90, 0.87-0.94) than Whites, while Asians had higher odds (1.08, 1.01-1.15). The odds of RAS did not differ by race. Uninsured and Medicaid patients had lower odds for LS (0.55, 0.51-0.59; 0.70, 0.65-0.74) and RAS (0.33, 0.25-0.42; 0.63, 0.52-0.76). Patients from higher income zipcodes had greater odds of receiving LS (OR range=1.09-1.34 for 2nd– 4th vs 1st income quartile, all p<0.001) and RAS (1.16, 1.03-1.30, 3rd vs 1st quartile). Similarly, patients from higher education zipcodes had greater odds of LS (1.17, 1.12-1.23, 4th vs 1st quartile) and RAS (3rd: 1.14, 1.02-1.29; 4th: 1.40, 1.23-1.59; vs 1st quartile). More rural areas had lower odds of LS (OR range=0.84-0.89, all p<0.001) with even smaller odds for RAS (OR range=0.47-0.71, all p<0.001). Examining the same variables with a post-ACA interaction term revealed increased odds for Hispanics (1.19, 1.10-1.30), while Blacks had lower odds post-ACA (0.83, 0.72-0.95). There was a further increase in LS odds for higher income (3rd: 1.07, 1.01-1.13; 4th quartile: 1.06, 1.00-1.13; vs 1st) although there were no significant effects for RAS. Post-ACA, non-metro areas had a further reduction in odds for LS (0.90, 0.84-0.96) while small metro increased in odds for RAS (1.13, 1.02-1.25). There were no significant post-ACA effects for insurance or education (LS and RAS).

Conclusion: Utilization of MIS increased substantially 2011-15. However, this reflects underlying trends in overall utilization rather than ACA implementation. Post-ACA, race and insurance disparities generally persisted while pre-ACA differences increased for lower income and non-metro patients.

 

86.20 Cartilage Oligomeric Matrix Protein Expression Correlates with Disease Stage In Colon Cancer.

Posted on January 31, 2019

N. P. Omesiete1, J. Jandova1, H. C. Jecius1, V. Nfonsam1  1University of Arizona,Surgery,Tucson, AZ, USA

Introduction:
Colon cancer (CC) is an important contributor to cancer morbidity and mortality. In our previous study we demonstrated that Cartilage Oligomeric Matrix Protein (COMP) was significantly overexpressed in Young patients with CC. The aim of this study was to establish the correlation between COMP expression levels, the stage of disease and Carcinoembryonic Antigen (CEA) Level.

Methods:
FFPE samples of CC and matching noninvolved tissues from 12 CC patients (stage I: n=3; stage II: n=4; stage III: n=4 and stage IV: n=1) were obtained from pathology archives. The samples were deparaffinized and the CC tissues were microdissected. RNA was isolated, and used for expression profiling of 770 cancer-related genes. COMP levels in serum (n=4) were measured using ELISA assay. Immunohistochemistry was performed using anti-human COMP antibody. CEA levels were checked for all the patient samples.

Results:

Gene expression profiling of 770 cancer related genes revealed increasing mRNA expression levels of COMP with increasing disease stage. Comparison between Stage I and Stage II tumors revealed higher COMP levels in Stage II tumors and TLR2, IL8, RIN1, IRAK3 and CACNA2D2 as top 5 highest correlated genes in pairwise expression association of COMP. Comparison between Stage II T4 and Stage III tumors did not show significant change in expression of COMP. However, when Stage I and Stage III tumors were compared, there was almost seven times higher COMP expression in Stage III tumors than in Stage I. VEGFC, MA3K8, SFRP1 and PRKACA, genes involved in various cellular processes such as proliferation, invasion, differentiation and angiogenesis were the highest co-expressed genes with COMP. Analysis of serum from four CC patients revealed positive correlation between COMP levels and stage of disease and CEA levels. The higher the COMP levels higher the stage of disease and CEA levels. These results were confirmed by immunohistochemistry.

Conclusion:
Increasing COMP expression and protein levels in CC tumors are associated with higher disease stage. COMP can be detected in serum of CC patients and shows strong positive correlation with stage of disease and CEA levels. COMP is a potential biomarker for aggressive CC and more studies should be done to establish this.

86.18 Enhanced Effect of Mitomycin C with HSP90 Inhibition and Hyperthermia in Colon Cancer Cell Lines

Posted on January 31, 2019

G. V. Georgakis1, N. Charisis1, F. Philanthope1, C. Preece1, M. Talamini1, J. Kim1, A. Sasson1, P. Carino-Thompson1  1Stony Brook University Medical Center,Surgical Oncology,Stony Brook, NY, USA

Introduction: Heated Intraperitoneal Chemotherapy (HIPEC) has been shown to improve outcomes in patients with several diffuse peritoneal cancer, including cancers of colorectal origin. The drugs that have been mainly used during this procedure are mitomycin C (MMC) and oxaliplatin. Since heat shock proteins (HSPs), especially HSP90, have been shown to be adundantly expressed by cancer cells, and their inhibition has been shown to induce apoptosis and cell cycle arrest in both in vitro and in vivo, we hypothesized that addition of the novel HPS90 inhibitor ganetespib, which is well tolerated and currently under clinical investigation, could increase the efficacy of chemotherapy in association with hyperthermia. 

Methods: We used two cell lines of colorectal origin (HCT116 and HT29) and we performed proliferation assays with the Cell Counting Kit-8 Cell Proliferation / Cytotoxicity Assay Kit with . Additionally, for molecular studies we perfomed western blots.

Results: HSP90 was fundamentally expressed by both HCT116 and HT29 cells. MMC and ganetespib as monotherapy were found to have an antiproliferative effect in a time and dose manner in HCT116 and HT29 cells. Additionally, hyperthermia  at 42C had a similar antiproliferative effect in a time manner. Combination of non lethal doses of MMC and ganetespib had a significant synergistic antiproliferative effect effect on both cell lines, which was more evident at 48 hours.

Conclusion: The HSP90 inhibitor ganetespib in hyperthermic conditions, potentiates the effect of chemotherapy (MMC), and may have a role in cytoreductive surgery and HIPEC.

 

69.10 The Cost of End of Life Care in Colorectal Cancer Patients

Posted on January 31, 2019

M. Delisle1, R. Helewa1, J. Park1, D. Hochman1, A. McKay1  1University of Manitoba,Surgery,Winnipeg, MB, Canada

Introduction:
End of life healthcare for oncology patients has been criticized for being inappropriate and overly aggressive resulting in low value care and inefficient use of limited resources. Strategies exist to improve patient comfort in this critical moment of life and reduce unnecessary expenditures. The objective of this study was to identify factors associated with increased end of life costs in colorectal cancer patients to guide future quality improvement.

Methods:
This is a retrospective cohort study including patients dying of colorectal cancer in a single Canadian province between 2004 to 2012 (ICD-10-CM C18-C21). Data was obtained from a single-payer, provincial administrative claims database and a comprehensive provincial cancer registry. Inpatient hospital costs were calculated using the Canadian Institute for Health Information’s (CIHI) Resource Intensity Weights multiplied by CIHI’s average Cost per Weighted Case in 2014 Canadian dollars. Outpatient costs was the total billed to the provincial government in the last 30 days of life adjusted to 2014 Canadian dollars using Statistics Canada’s Consumer Price Index. Patients with no costs over the last six months of life were excluded to account for loss to follow-up (n=21).

The primary outcome was end of life costs, defined as total inpatient and outpatient costs accrued 30-days before death. Risk adjusted 30-day end of life costs were estimated using a negative binomial regression with the log link function, robust standard errors and an offset variable to account for patients that did not survive 30 days from diagnosis. Covariates included age, sex, cancer stage, socioeconomic status, cancer location (rectal, rectosigmoid, colon), Charlson Co-Morbidity Index, year of diagnosis and death in hospital. Multivariable Logistic regression was used to assess for baseline predictors associated with in hospital death.

Results:
A total of 1,622 patients died of colorectal cancer between 2004 and 2012 (Table 1). The largest variations in cost existed between patients who died in hospital versus those that did not. The median length of stay for patients dying in hospital was 26 days (IQR 13-41). Significant predictors associated with in hospital death included co-morbidities (OR 1.30, 95% CI 1.16-1.45, p<0.01) and more recent diagnosis (OR 1.10, 95% CI 1.02-1.17, p=0.01).

Conclusion:
In hospital deaths are associated with significantly increased end of life costs and the odds of dying in hospital appear to be increasing in this population. This study could not assess if in hospital deaths were also associated with increased patient benefits. Future studies should aim to identify cost effective strategies to optimize end of life care.

69.09 Characterizing the Highest Cost Patients Before and After Enhanced Recovery After Surgery Programs

Posted on January 31, 2019

A. N. Khanijow1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  The overall cost-effectiveness of enhanced recovery after surgery (ERAS) programs have been demonstrated across many institutions, but it is unclear if certain patients account for disproportionate shares of ERAS costs. The purpose of this study was to characterize the cost drivers and clinical features of the highest cost patients undergoing elective colorectal surgery before and after ERAS implementation.

 

Methods:  ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, costs that vary with care decisions, were collected from the institution’s financial department for the inpatient stay of patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index and compared using Wilcoxon tests between the high cost patients (upper 10th percentile of the total variable costs) and non-high cost patients (lower 90th percentile) for both before and after ERAS. Postoperative complications were identified using National Surgical Quality Improvement Project definitions. Severity of illness (SOI) (minor, moderate, major, and extreme) was used as an indicator of burden of illness.

Results: Of 842 included patients (389 pre-ERAS and 453 ERAS), there was no significant difference in the proportion of high cost patients between the two groups (10.8% vs 9.5% patients, p=0.60). Within the pre-ERAS group, high and non-high cost patients had an average total variable cost per patient of $21,107 and $7,432, respectively ($13,675 difference, p<0.01). Within the ERAS group, high and non-high cost patients had an average total variable cost per patient of $22,737 and $6,810 ($15,926 difference, p<0.01). Over 80% of patients in the extreme SOI group were in the high cost cohort for both pre-ERAS and ERAS patients. Compared to non-high cost patients, high cost pre-ERAS patients had a longer average length of stay (LOS) (13.1 vs 5.2 days, p<0.01) with a great proportion of that time in ICU (19 vs 1%, p<0.01). High cost ERAS patients also had a longer average LOS (15.9 vs 4 days, p<0.01) and proportion of ICU time (14 vs 1%, p<0.01). High cost pre-ERAS patients experienced significantly more post-op complications (p<0.01) including myocardial infarction and pneumonia for pre-ERAS patients and pneumonia, acute renal failure, ventilator dependency, and blood transfusions for ERAS. High cost pre-ERAS patients had higher mean anesthesia costs when compared to high cost ERAS patients ($1,173 vs $841, p<0.01) but lower mean pharmacy costs ($1,453 vs $3,200, p=0.02); there were no significant differences in complications.

 

Conclusion: SOI and post-op complications were key drivers of high costs before and after ERAS implementation. High cost patients continued to experience significantly longer LOS and ICU stays. The need for quality improvement in surgical care remains even in the era of ERAS.

 

69.07 Cumulative Narcotic Dose Associated With Ultimate Risk of Long Term Opioid Use in Colorectal Surgery Patients

Posted on January 31, 2019

P. Cavallaro1, A. Fields2, R. Bleday2, H. Kaafarani1, Y. Yao1, K. F. Ahmed1, T. Sequist1, M. Rubin1, L. Bordeianou1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:  Nearly 42,000 people died from opioid overdose and an estimated 40% of overdose deaths involved a prescription opioid in 2016 alone. However, the relationship between postoperative inpatient opioid use and the subsequent risk of long-term opioid abuse remains unknown, with studies focusing primarily on opioid prescriptions at time of discharge. We therefore aimed to evaluate the relationship between inpatient opioid use and ultimate prolonged opioid use (POU) in patients undergoing colorectal surgery.

Methods:  We merged pharmacy records and the prospectively maintained ACS-NSQIP data on surgical outcomes of patients undergoing colectomy from June 2015 to October 2017 across 5 institutions (2 academic, 3 community) participating in a regional Colorectal Surgery Collaborative. Narcotic administration was converted into Morphine Milligram Equivalents (MMEs). Patients using patient-controlled analgesia were excluded.  POU was the primary outcome and was defined as any new opioid prescriptions between 90 and 180 days post-operatively. We compared patient demographics, surgical indications, comorbidities, and postoperative complications, daily MME administration and total inpatient MMEs.

Results: 940 colectomy patients were included in the study (52% female, 43.3% opioid naive, mean age 62.2 years old). 99 patients (10.4%) had POU. On univariate analysis, POU patients had higher ASA (ASA > 3 in 61% vs 44%, p=0.002) and were less opioid naive (23% vs 46%, p<0.001). These patients had longer lengths of stay, more readmissions, and more post-operative complications (P<0.05). POU patients also had higher rates of stomas (p<0.05). POU patients had increased rates of cumulative MMEs administered throughout their more complex hospitalization, even though their daily dosages were similar to non PRU patients (50+/-44 vs 73+/-704, p=0.7). In multivariable analysis, only cumulative use of narcotics —not overall complications or length of stay — was predictive of POU (Top quartile OR 2.0, 95% CI 1.2-3.2; p=0.005). Previous opioid use within the last year was also and independent predictor of POU (OR 2.6, 95% CI 1.6-4.3; p<0.001).

Conclusion: Prolonged narcotic use appears to be associated with previous narcotic exposure and the cumulative does of narcotics administered during the post-operative inpatient hospitalization, and not by the complexity of the surgical procedure or by surgical complications. This underscores the importance of minimizing opioid use through the entire peri-operative course, especially in patients with prior opioid use, post-operative complications, and protracted hospital courses. It also suggests the need for development of longer-lasting postoperative narcotic-sparing strategies, beyond the current ERAS efforts, that are mostly focused on the first 24-48 hours after surgery.  

 

69.08 Economic Analysis of ERAS Programs: Lack of Adherence to Standards for Cost Effectiveness Reporting

Posted on January 31, 2019

M. A. Eid1, N. Dragnev1, C. Lamb1, S. Wong1  1Dartmouth Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:

Enhanced Recovery After Surgery (ERAS) is an evidence-based, multimodal pre and post-operative care pathway which results in significant improvements in patient outcomes after major surgery.  Along with the decreased complication rates and recovery times, economic benefit of implementing ERAS has been widely heralded. However, it is unclear how rigorous the associated economic analyses are.  We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines to assess the quality of these studies.

Methods:
Using PubMed and OVID, we performed a systematic literature search to identify economic analyses evaluating the cost effectiveness of ERAS on colorectal, hepatobiliary, and gynecologic surgery in English language journals. The MESH terms  included colorectal surgery, cost analysis, and ERAS. We retrieved 45 articles, of which 17 were found to be directly relevant to the topic.  Each paper was evaluated against the items in the CHEERS guidelines to abstract data which formally included 7 categories with 27 specified criteria, mainly focusing on a study’s methodology (n=16) and how results are reported (n=5).

Results:
Of the 17 publications, including 14 colorectal, 2 hepatobiliary and 1 gynecologic studies, all but one paper described ERAS as being cost-effective; one study made no definitive statement regarding the cost effectiveness. However, none of the studies fully adhered to the CHEERS guidelines. Only 47% of the studies fulfilled at least 14 (50%) checklist items. All of the papers included “an explicit statement regarding the broader context of the study” and most titles identified the studies as economic evaluations. Papers generally performed poorly with regard to checklist items for methods and results. For example, none of the papers reported on choice of discount rates used for costs and outcomes. Overall, of the 16 analytic methods items, there was only an average concordance of 40%. Other key components of economic evaluations such as measurement and valuation of outcomes and assumptions underlying the decision-analytic model were not well reported. 

Conclusion:
Based on our evaluation of economic analyses of ERAS protocols, the quality of these studies is generally quite poor. Less than half of the studies adhered to 50% of the CHEERS reporting guidelines though nearly all of them posited cost savings with ERAS. Although most studies claimed to be cost effective evaluations, the vast majority lacked methodologic quality and appear to be merely cost reports. Cost effective and economic analysis plays a pivotal role in evidence-based medicine, but the current literature may be limited in terms of actually evaluating costs and outcomes of interventions. 

69.06 Association of Enhanced Recovery Pathways with Postoperative Renal Complications: Fact or Fiction?

Posted on January 31, 2019

Q. L. Hu1,2, J. Y. Liu1,3, C. Y. Ko1,2, M. E. Cohen1, K. Y. Bilimoria4, D. B. Hoyt1, R. P. Merkow1,4  1American College Of Surgeons,Chicago, IL, USA 2University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Enhanced Recovery Pathways (ERPs) have been shown to dramatically improve perioperative outcomes in colorectal surgery. However, one important factor limiting its widespread adoption is concern regarding postoperative renal complications. Our objective was to evaluate the association of the overall use of an ERP protocol and adherence to its potentially renal-compromising components (e.g., epidural use [hypotension], multimodal pain management [NSAID use], fluid restriction [hypovolemia]) with postoperative renal complications.

Methods:
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Enhanced Recovery data between 2014 and 2017 were used to identify patients who were managed under an ERP (ERP group). A 1:1 propensity-score match was used to identify control patients during the same time period who were managed without an ERP (non-ERP group). Hierarchical multivariable logistic regression models were used to evaluate the overall association of an ERP (vs. non-ERP) as well as adherence to individual ERP components with postoperative renal complications (either renal insufficiency or dialysis requirement). 

Results:
We identified 36,452 patients who received at least one ERP component, including 16.1% who received epidural analgesia, 87.6% who received multi-modal pain management, and 53.0% who received fluid restrictive care. Compared to non-ERP, ERP management was not associated with postoperative renal complications (1.0% vs. 1.0%; OR 0.96, 95% CI 0.83-1.11). Independent predictors of renal complications included male sex, African American race, higher ASA class, severe obesity, and preoperative co-morbidities, including hypertension, heart failure, diabetes, ascites, and disseminated cancer. Among patients managed under ERPs, adherence with individual potentially renal-compromising components was not associated with renal complications: epidural use (1.0% vs. 1.0%; OR 0.77, 95% CI 0.54-1.11), multi-modal pain management (0.9% vs. 1.3%; OR 0.78, 95% CI 0.59-1.05), and fluid restriction (0.9% vs. 1.0%; OR 1.05, 95% CI 0.79-1.39). Finally, adherence with all three components versus none was also not associated with renal complications (1.2% vs. 1.0%; OR 0.92, 95% CI 0.52-1.65). 

Conclusion:
Management under ERPs and adherence with individual potentially renal-compromising components were not associated with postoperative renal complications. Postoperative renal complication is a serious adverse event, however, clinicians should focus on other modifiable factors precipitating its occurrence other than the use of an ERP.  

69.05 Survival Outcome of RNF43 Mutant-type Differs between Right-sided and Left-sided Colorectal Cancer

Posted on January 31, 2019

Y. Shimada1, Y. Tajima1, M. Nagahashi1, H. Ichikawa1, K. Yuza1, Y. Hirose1, T. Katada1, M. Nakano1, J. Sakata1, H. Kameyama1, Y. Takii2, S. Okuda3, K. Takabe4, T. Wakai1  1Niigata University,Digestive And General Surgery,Niigata, NIIGATA, Japan 2Niigata Cancer Center Hospital,Surgery,Niigata, NIIGATA, Japan 3Niigata University,Bioinformatics,Niigata, NIIGATA, Japan 4Roswell Park Cancer Institute,Breast Surgery,Buffalo, NY, USA

Introduction: Right-sided colorectal cancer (CRC) demonstrates worse survival outcome compared with left-sided CRC, and clinicopathological characteristics of right-sided CRC differ from left-sided CRC. Recently, the importance of RNF43 mutation has been reported along with BRAF mutation in serrated neoplasia pathway. We hypothesized that clinical significance of RNF43 mutation differs between right-sided and left-sided CRCs, and RNF43 mutation associates with tumor biology of right-sided CRC. To test this hypothesis, we investigated the clinicopahotlogical characteristics and survival outcome of patients with RNF43 mutation in right-sided and left-sided CRCs.

Methods: One-hundred-nine microsatellite stable Stage IV CRC patients were analyzed. Thirty-three and 76 patients were right-sided CRC and left-sided CRC, respectively. We investigated genetic alterations using a 415-gene panel, which includes RNF43 and the other genes associated with tumor biology. We analyzed clinicopathological characteristics between RNF43 wild-type and RNF43 mutant-type using Fisher’s exact test. Moreover, we classified RNF43 mutant-type according to primary tumor sidedness, i.e., right-sided RNF43 mutant-type or left-sided RNF43 mutant-type, and compared clinicopathological characteristics between the two groups. Overall survival rates of RNF43 wild-type, right-sided RNF43 mutant-type, and left-sided RNF43 mutant-type were analyzed using log-rank test.

Results:CGS revealed that 8 of 109 patients (7%) had RNF43 mutation. RNF43 mutation was significantly associated with high age (65 or more) (P = 0.020), presence of BRAF mutation (P = 0.005), absence of KRAS and PTEN mutations (P = 0.049 and P = 0.026, respectively). RNF43 mutation was observed in 3 of 33 right-sided CRC (9%) and 5 of 76 left-sided CRC (7%), respectively. Interestingly, RNF43 mutations in right-sided CRC were nonsense mutation (R145X) or frameshift mutation (P192fs, S262fs), while those in left-sided CRC were missense mutations (T58S, W200C, R221W, R519Q, R519Q). All the three right-sided RNF43 mutant-type were high age (65 or more), female, BRAF V600E mutant-type. Right-sided RNF43 mutant-type showed significantly worse OS than RNF43 wild-type and left-sided RNF43 mutant-type (P = 0.007 and P = 0.046, respectively).

Conclusion:Clinicopathological characteristics and survival outcome of patients with RNF43 mutation might differ between right-sided and left-sided CRC. In right-sided CRC, RNF43 mutation is a small, but distinct molecular subtype which is associated with aggressive tumor biology along with BRAF V600E mutation. Future preclinical and clinical studies might have to focus on RNF43 mutation for improving survival outcome in right-sided CRC.

 

69.04 What Drives Surgeon Workload in Colorectal Surgery?

Posted on January 31, 2019

K. E. Law1,2, B. R. Lowndes1,2,3, S. R. Kelley4, R. C. Blocker1,2, D. W. Larson4, M. Hallbeck1,2,4, H. Nelson4  1Mayo Clinic,Health Sciences Research,Rochester, MN, USA 2Mayo Clinic,Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA 3Nebraska Medical Center,Neurological Sciences,Omaha, NE, USA 4Mayo Clinic,Surgery,Rochester, MN, USA

Introduction: Surgical techniques and technology are continually advancing, making it crucial to understand potential contributors to surgeon workload. Our goal was to measure surgeon workload in abdominopelvic colon and rectal procedures and attribute possible contributors.

Methods: Between February and April 2018, following each surgical case surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) which included questions on distractions, fatigue, procedural difficulty, and expectation in addition to the validated NASA-TLX questions. All but the expectation question were rated on a 20-point scale (0=low, 20=high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Patient and procedural data were analyzed for procedures with completed surveys. Surgical approach was categorized as open, laparoscopic, or robotic.

Results: Seven surgeons (3 female) rated 122 procedures over the research period using the modified NASA-TLX survey. Across the subscales, mean surgeon-reported workload was highest for effort (M=10.83, SD=5.66) followed by mental demand (M=10.18, SD=5.17), and physical demand (M=9.19, SD=5.60). Procedures were rated moderately difficult (M=10.74, SD=5.58). There was no significant difference in procedural difficulty or fatigue by surgical approach.
Fifty-four percent (n=66) of cases were rated as meeting expected difficulty, with 35% (n=43) considered more difficult than expected. Mean surgeon-reported procedural difficulty aligned with expectation with a mean procedural difficulty level of 9.29 (SD=5.11) for as expected, 14.39 (SD=4.49) for more difficult than expected, and 5.92 (SD=4.15) for less difficult than expected (F(2,118)=21.89, p<0.001). Surgeons also reported significantly more fatigue for procedures considered more difficult than expected (F(2,118)=8.13, p<0.001) compared to procedures less difficult than expected.
Self-reported mental demand (r=0.88, p<0.001), physical demand (r=0.87, p<0.001), effort (r=0.90, p<0.001), and surgeon fatigue (r=.71, p<0.001) were strongly correlated with procedural difficulty. Furthermore, fatigue was strongly correlated with overall workload and the NASA-TLX subscales (r>0.7, p<0.001). Surgeons most frequently reported patient anatomy and body habitus, unexpected adhesions, and unfamiliar team members as contributors to ease or difficulty of cases.

Conclusion: Self-reported mental demand, physical demand, and effort were strongly correlated with procedural difficulty and surgeon fatigue. Surgeons attributed case ease or difficulty levels to patient and intraoperative factors; however, procedural difficulty did not differ across surgical approach. Understanding contributors to surgical workload, especially unexpectedly difficult cases, can help define ways to decrease workload.

 

69.03 Population-based Analysis of Adherence to Extended VTE Prophylaxis after Colorectal Resection

Posted on January 31, 2019

A. Mukkamala1, J. R. Montgomery1, A. De Roo1, S. E. Regenbogen1  1University Of Michigan,Surgery, Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  Since 2012, the American College of Chest Physicians (ACCP) has recommended 4 weeks of pharmacologic prophylaxis against venous thromboembolism (VTE) after abdominopelvic cancer surgery. Additionally, there is growing expert consensus favoring extended prophylaxis after surgery for inflammatory bowel disease (IBD). National studies have revealed very low uptake of prophylaxis before adoption of the ACCP guideline, but it remains unclear to what extent it has been adopted in standard practice in recent years. We sought to understand responsiveness to guidelines versus expert opinion by evaluating adherence to extended VTE prophylaxis after colectomy in a statewide registry. 

Methods:  We identified all patients in the Michigan Surgical Quality Collaborative (MSQC) registry who underwent elective colon or rectal resection between October 2015 (when MSQC first began recording post-discharge VTE prophylaxis) and February 2018. MSQC is an audited and validated, statewide population-based surgical registry including all major acute care hospitals in the state. We used descriptive statistics and chi-square tests to compare annual statewide utilization trends for extended VTE prophylaxis with low molecular weight heparin by operative year and by diagnosis among all patients without documented exclusions.

Results: Of 5722 eligible patients, 373 (6.5%) received extended VTE prophylaxis after discharge. Use of extended prophylaxis was similar between patients with cancer (282/1945, 14.5%) and IBD (31/242, 12.8%), but was significantly increased when compared with patients with other indications (60/3051, 1.97%, p<0.001). Overall use during the study period significantly increased among cancer patients from 8.2% in 2015 to 9.0% in 2016 to 18.6% in 2017-18 (p=0.001). Use among IBD patients also significantly increased from 0% to 6.6% to 17.1% (p=0.03). Use among patients with other diagnoses was rare and did not vary over the study period (1.5 to 2.4%, p=0.50). Annual trends are shown in Figure 1.

Conclusion: Use of extended VTE prophylaxis after discharge is increasing, but remains uncommon in spite of guidelines recommending its use for colorectal cancer surgery and expert consensus supporting its use in IBD. Efforts to improve dissemination of guidelines and recommendations may require quality implementation initiatives accompanied by payment incentives to improve adherence.

 

69.02 Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy

Posted on January 31, 2019

A. C. De Roo1,2, J. V. Vu1,2, S. E. Regenbogen1,2,3  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA 3University Of Michigan,Division Of Colorectal Surgery,Ann Arbor, MI, USA

Introduction:
Multimodal analgesia is a critical component of both enhanced recovery protocols (ERP) and efforts to reduce opioid misuse after surgery. Postoperative multimodal pain therapy, using more than one class of pain medication: opioids, acetaminophen, non-steroidal anti-inflammatories (NSAIDs), gabapentinoids, and regional and epidural anesthesia, has been associated with lower pain scores, decreased opioid use, and avoidance of opioid inhibition of gut motility. Whether multimodal analgesia is widely used in practice remains unknown, and its effect on hospital length of stay has not been evaluated outside of controlled trials.

Methods:
Within the population-based, statewide Michigan Surgical Quality Collaborative (MSQC), we evaluated all adult patients undergoing elective colorectal resection between 2012 and 2015. Colectomy has been a targeted procedure for ERP implementation and MSQC collects ERP-specific data elements for colectomy, including details of perioperative analgesia. The primary outcome was mean postoperative hospital length of stay (LOS). To reduce bias from rare, extremely prolonged hospitalizations, we winsorized LOS at 30 days which excluded 27 patients. T-tests were used to evaluate associations between LOS and opioid-only vs multimodal therapy, defined as two or more classes of pain medication used.

Results:
Among the 7249 patients who underwent elective colectomy, 6746 received opioids (93.1%), and 2391 patients (33.0%) received no other analgesia besides opioids. Acetaminophen was used by 2701 (37.2%) patients, NSAIDs in 2551 (35.2%), and epidural, spinal, or regional anesthesia in 1400 (19.3%) patients. Average LOS for patients receiving multimodal analgesia (5.4 days, 95% CI 5.3-5.5) was significantly shorter than for patients receiving opioids alone (6.0 days, 95% CI 5.8-6.2; p<0.001).

Conclusion:
One third of patients undergoing colectomy in the state of Michigan received solely opioid analgesia. Ongoing improvement efforts will aim for near-universal use of opioid sparing pain regimens, in order to reduce opioid-related adverse effects and opioid exposure. Use of opioid-sparing multimodal analgesia, compared with opioids alone, is associated with a small reduction in hospital LOS, perhaps from improved pain control and lower rates of ileus, and could therefore accrue cost savings at a population level.  Multimodal analgesia is also an essential component of efforts to combat opioid use disorders related to surgical encounters and Michigan hospitals have room for improvement.
 

69.01 Achieving the High-Value Colectomy: Preventing Complications or Improving Efficiency

Posted on January 31, 2019

J. V. Vu1, J. LI3, D. S. LIKOSKY2, E. C. NORTON4,5, D. A. CAMPBELL1, S. E. REGENBOGEN1  1University Of Michigan,SURGERY,Ann Arbor, MI, USA 2University Of Michigan,CARDIAC SURGERY,Ann Arbor, MI, USA 3University Of Michigan,SCHOOL OF PUBLIC HEALTH,Ann Arbor, MI, USA 4University Of Michigan,ECONOMICS,Ann Arbor, MI, USA 5University Of Michigan,HEALTH MANAGEMENT AND POLICY,Ann Arbor, MI, USA

Introduction:  As payers increasingly tie reimbursement to value, there is increased focus on both outcomes and expenditures for surgical care. One way of measuring hospital value is by comparing episode payments to adverse outcomes. While postoperative complications increase spending and decrease value, it is unknown whether hospitals that achieve highest value in major surgery also deliver efficient care beyond the prevention of complications. We aimed to identify the contributions of clinical quality and efficiency of perioperative care to high-value strategies for success in episode-based reimbursement for colectomy.

Methods:  This was a retrospective observational cohort study of elective colectomy patients from 2012 to 2016, from 56 hospitals in the Michigan Surgical Quality Collaborative and Michigan Value Collaborative. Hospitals were assigned a value score (proportion of cases without adverse outcome divided by mean episode payment). Adverse outcomes included postoperative complications, reoperation, or death within 30 days of surgery. Risk-adjusted payments for total 30-day episode and components of care were compared using ANOVA between hospitals by value tertile.

Results: We matched 2,947 patients enrolled in both registries, 646 (22%) of which experienced adverse outcomes. Mean adjusted complication rate was 31% (+10.7%) at low-value hospitals and 14% (+4.6%) at high-value hospitals (p<0.001). Mean episode payments for all cases were $3,807 (17%) higher in low-value than high-value hospitals, ($22,271 vs. $18,464 p<0.001). Among cases without adverse outcomes only, payments were still $2,257 (11%) higher in low-value hospitals ($19,424 vs. $17,167, p=0.04).

Conclusion: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases both with and without complications, indicating mechanisms for increasing value beyond reducing complications alone. High-value hospitals had two-fold lower complication rates, but also achieved 11% savings in uncomplicated cases. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care.

 

63.03 Feasibility of Using Resident-Specific Outcomes to Measure Individual Performance

Posted on January 31, 2019

A. N. Kothari1, T. Qu1, C. P. Fischer1, M. J. Anstadt2, P. P. Patel1, M. Singer1, G. J. Abood1  1Loyola University Medical Center,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA

Introduction:  The development and use of novel measures of resident performance have gained the attention of national regulatory and accrediting bodies. With improvements in the availability of surgical quality improvement data and improved risk adjustment, a potential opportunity is to leverage resident-specific patient outcome data to evaluate resident performance. The objective of this study was to determine the feasibility of using surgical outcomes data to measure individual resident performance.

Methods: Institutional NSQIP data were obtained for all patients that underwent colectomy on a single surgical service from January, 2016 – December, 2017. A composite outcome of the following postoperative occurrences was used to develop risk-adjusted models: surgical site infection, wound disruption, unplanned intubation, pulmonary embolism, renal insufficiency, urinary tract infection, c. diff infection, readmission, death. These were chosen using a nominal group technique to identify occurrences potentially modified by resident involvement by program faculty. Resident-level outcomes were estimated from 2-level, random effects models.

Results: A total of 280 cases for 12 chief residents were analyzed. Resident case volume ranged from 15 to 32 with unadjusted composite occurrence rates ranging from 11.1% to 53.3%. No residents were classified as low outliers with better than expected outcomes, while one resident was classified as a high outlier with worse than expected outcomes (risk-adjusted rate: 41.8%). The proportion of variation in outcomes attributable to the resident was 0.03 (model intra-class correlation). Reliability of estimates was a median of 0.02 (0.01 – 0.06).

Conclusion: Resident-specific surgical outcomes cannot be reliably used to determine individual resident performance on an institutional level. Variation in measured outcomes can only minimally be attributed to the operating resident. Efforts to use resident-specific patient outcomes to measure performance should be avoided.

 

56.18 Robot-assisted Versus Laparoscopic Colonic Resection for Colon Cancer: Are We Getting Better?

Posted on January 31, 2019

K. Memeh1, V. Pandit1, P. N. Omesiete1, V. N. Nfonsam1  1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction:
Robotic assisted surgery has continued to gain popularity amonsgt surgeons in the past decade. Over the last decade, robotic surgey has also started to emarge as probable porcedure of choice in sometimes difficult minimal invasive cases like colon resection. The aim of our study is to compare the outcomes of robotic colon resection (RCR) vs laparoscopic colon resection (LCR) for colon cancer.

Methods:
2-year review (2015-2016) of the ACS-NSQIP Colectomy database and included all patients with colon cancer who underwent RCR or LCR with primary anastomosis. Patients were stratified into two groups: RCR and LCR. Outcomes were conversion rates to open, 30-d complications and 30-d mortality. Regression analysis was performed.

Results:
14824 patients were analyzed of which 5726 who underwent colonic resection with primary anastomosis and were included. Mean age was 65±12 years, 52% were males, and median ASA class was 3[2-4]. Overall 16% patients underwent RCR and mortality rate was 1.6%. There was no difference in age (p=0.25), gender (p=0.35), ASA class (p=0.77), comorbidities, and pre-operative labs between the two groups. Median operative time for RCR was (218 vs. 160 minutes, p=0.01) and conversion to open rate was lower (4.7% vs. 7.7%, p=0.03) compared to LCR. There was no difference in 30-day complications and 30-day mortality (Table-1). On regression analysis, patients who underwent LCR had higher odds of converting to open (OR: 2.6[1.2-11.8], p=0.03) compared to RCR

Conclusion:
Patients who underwent robotic colonic resection for colon cancer though had longer operative times, is more likely stay minimal invasive compared to LCR. There was no difference in 30-day outcomes between robotic and laparoscopic approach for colon resection.
 

56.15 Patients, Tell Us What You Think: Qualitative Evaluation of an Enhanced Recovery Pathway

Posted on January 31, 2019

L. J. Kreutzer1, M. W. Meyers3, M. McGee1,3, S. Ahmad3, K. Gonzalez3, S. Oberoi3, K. Engelhardt1, K. Y. Bilimoria1,2,3, J. K. Johnson1,2  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: Enhanced Recovery Pathways (ERPs) improve post-surgical recovery and patient outcomes by reducing complications, decreasing length of stay, and improving patient satisfaction; however, hospitals underestimate the complexity of implementing a multifaceted intervention that requires high levels of patient participation pre- and post-operatively. Our goal was to evaluate patient perspectives during early ERP implementation and to address challenges patients face when preparing for, and recovering from, surgery.

Methods: As part of an in-depth, formative evaluation of an ERP for patients recovering from elective colorectal resections at a large urban tertiary care teaching hospital, we conducted semi-structured interviews with patients (n=9) from September 2016 to August 2017. At least two patients for each colorectal surgeon (n=4) participated in the interviews. Patients were asked if they knew they were participating in an ERP and about their pre-operative experience, level of preparedness, and expectations for surgery and post-operative recovery.  Detailed notes were taken during each interview in lieu of audio recording to maintain patient confidentiality. We conducted thematic analysis using the constant comparative method to identify common themes.

Results: All patients approached for an interview agreed to participate.  Patients interviewed were not able to identify specific benefits of ERP related to clinical outcomes but focused their comments on the patient-facing components of ERP. While all patients shared positive feedback regarding their care and post-operative pain control, their comments about ERP were inconsistent. Themes identified included expectations, preparation for surgery, the ERP patient education booklet, and inpatient experience (specifically diet, pain, and education). Patient views about the ERP patient education booklet provided prior to surgery ranged from useful – one patient strongly agreed and said she used the booklet to identify which activities to undertake each postoperative day to enhance her recovery – to inadequate or forgettable with some patients unable to remember receiving the book or not feeling that it fully answered their questions. Another common theme during the interviews involved patient confusion about the early feeding component of the protocol that allowed patients to eat on postoperative day 0.

Conclusion: Conducting patient interviews during the post-operative inpatient stay enabled us to explore patient understanding of an ERP. Patient activation is an important component of a successful ERP and careful attention is needed to engage patients in preoperative expectation setting and postoperative recovery. Multiple modes of education and augmented patient education materials may be more effective than a one-size-fits-all approach to facilitate engagement.
 

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