52.10 Systematic Review on the Effect of Health Information Technology in Surgical Patient Care

Posted on January 18, 2016

J. Robinson1,2, H. Huth4, G. P. Jackson2,3 1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Biomedical Informatics,Nashville, TN, USA 3Vanderbilt University Medical Center,Department Of Pediatric Surgery,Nashville, TN, USA 4Vanderbilt University,Nashville, TENNESSEE, USA

Introduction: Government regulations, such as ‘meaningful use’, and consumer demand have driven widespread implementation and adoption of health information technologies. The emergence of electronic health records (EHRs), computerized order entry (CPOE), and patient portals has transformed the way health information is stored, used, and communicated to patients. The effect of such technologies on surgical practice has not been well studied. Our objective is to systematically review the available evidence regarding the impact of health information technology (HIT) on the care of surgical patients.

Methods: A systematic search of Medline, EMBASE, CINAHL, and Cochrane Library to identify data-driven, non-survey, studies on the effect of HIT, EHR, CPOE or patient portals on surgeons and their patients was performed. Experts in clinical informatics were also queried for known relevant articles to compile for review. Two authors independently reviewed abstracts to select relevant publications that met the inclusion criteria, followed by a full-text review of relevant articles, according to the PRISMA guidelines.

Results: A total of 2909 citations from 4 databases were identified, with 2879 publications remaining after duplicates were removed and the addition of expert-recommended articles. 190 articles were retrieved for full-text analysis, and 23 articles, including 21 observational studies and 2 RCTs, were found applicable. EHR and CPOE systems improved appropriate and timely antibiotic administration for surgical procedures in 6 observational studies. 5 observational studies indicated electronically generated operative notes have increased accuracy, completeness, and timely availability in the medical record compared to dictated notes. The Internet as an informative resource was inadequate for surgical procedures in 2 observational studies; however, a tailored web-based program decreased perioperative anxiety of patients in a single small-scale RCT. In observational studies, patient web portals showed high adoption and utilization, encompassing an increasing proportion of outpatient surgical encounters.

Conclusion: Overall, the quality of evidence on HIT in surgical practice found was moderate to low with only 2 RCTs identified. Currently available data suggest EHR, CPOE, and electronic notes are effective at improving the accuracy of drug administration and operative reports, but few other effects are known. While patient portals are in use, data is lacking on the quality or effect of portal encounters, and the Internet alone has not proven to be a reliable information source. With the increasing use of HIT in surgical patient care, further evidence-based research is required to optimize its utilization and efficacy.

52.09 Patient Preparation for Transitions of Surgical Care: Failing to Prepare is Preparing to Fail

Posted on January 18, 2016

L. Martin1, S. Finlayson1, B. Brooke1 1University Of Utah,Surgery,Salt Lake City, UT, USA

Introduction:

Transitions of care before and after surgery are a critical time for patients to gain essential information to ensure they understand surgical care plans, avoid adverse events and receive the best outcomes. This study was designed to evaluate how patients prepare for transitions of surgical care, and to explore the association between utilization of health information resources with readmission.

Methods:

A cross-sectional survey was conducted in March 2015 among nationwide members of Health Alliance web-based social communities who reported having direct experience with surgery as either a patient or caregiver. Respondents were asked to report on how prepared they were for the transition of care before and after their most recent surgery, what health information resources they used to get prepared, and whether they required readmission within 30-days following surgery. Survey results were analyzed using bivariate methods.

Results:

Of 1872 surveyed individuals, 93% were patients and 79% had undergone surgery within the past year. Respondents’ exposure to surgery represented a broad spectrum of ten major disciplines with Orthopedic (28%) and General Surgery (14%) being most common. The majority of respondents felt very prepared prior to undergoing surgery (64%) and before leaving the hospital after surgery (65%). As compared to patients who reported being unprepared, those who felt prepared for transitions of surgical care were most likely to be given multiple health information resources before surgery (97% vs. 79%, p=<0.001) and before leaving the hospital (91% vs. 85%, p=0.02), which included face-to-face meetings, written instructions, internet sites, videos, and smartphone applications. Feeling prepared was significantly associated with the number of resources that patients were provided by their surgical team and used before surgery (Figure 1) and before leaving the hospital. 30-Day readmission was significantly lower among patients who felt prepared either before (8% vs. 23%; p=<0.001) or after surgery (9% vs. 23%, p=<0.001). Furthermore, use of any post-operative resource was associated with a significantly lower 30-day readmission (10% vs 31%, p=<0.001) as compared to patients who reported no health information utilization.

Conclusion:

Patients who report using more health information resources before and after surgery felt more prepared for transitions of surgical care and have a lower rate of 30-day readmission. Ensuring that patients have access to multiple sources of health information and feel prepared for transitions of surgical care is critical to patient satisfaction and obtaining the best clinical outcomes.

52.07 Discrete Choice Survey App for Individualized Peripheral Arterial Disease Treatment Selection

Posted on January 18, 2016

M. A. Corriere1, R. Barnard1, S. Saldana1, R. J. Guzman3, D. Easterling1, D. Boone2, A. Hyde2, G. L. Burke1, E. Ip1 1Wake Forest University School Of Medicine,Winston-Salem, NC, USA 2Wake Forest University Schools Of Business,Winston-Salem, NC, USA 3Beth Israel Deaconess Medical Center,Vascular Surgery,Boston, MA, USA

Introduction: Multiple treatments are available for peripheral arterial disease (PAD), but an evidence-based ‘best’ choice is often unclear. Providers lack efficient methods for identifying patients’ goals and values, and treatment selection is often based on ambiguous criteria with limited patient input. We developed and pilot tested an app to help providers understand patients’ treatment preferences, facilitating shared decision making by identifying compatibile treatment choices.

Methods: Focus groups were used to explore themes, terminology, and treatment attributes patients with severe PAD (rest pain and/or tissue loss) consider important. Transcripts were analyzed using thematic content analysis. An iPad app was developed to characterize how individuals prioritize key treatment attributes, including: treatment type (i.e., medication, percutaneous procedure, or surgery), anticipated level of symptomatic improvement, odds of success versus failure, risk, and durability. These attributes were presented using 14 randomly ordered pair-wise choice tasks with varying levels for each attribute based on an orthogonal array design. Responses were used to determine part-worth utilities and generate patient-specific scores indicating the relative importance of each attribute.

Results: 26 patients with severe PAD participated in focus groups, and a separate group of 34 participants completed the discrete choice survey in clinic. Mean choice task completion time was 12.8±6.0 minutes. Aggregate importance scores indicated that treatment type was most influential (41%), followed by chance of successful treatment outcome (24%), risk (18%), durability (10%), and level of symptomatic response (7%). Analysis on a per-patient level, however, demonstrated that attributes are prioritized differently between individuals (Figure), often supporting individualized choices based on the patient’s personal goals and values.

Conclusion: Patient treatment preferences are based on complex values systems that differ between individuals with similar PAD severity. Choice-based survey tools can be used to evaluate patient preferences in an objective and quantitative fashion, allowing providers to access information that is otherwise difficult and time-intensive to obtain during a standard clinic visit. Understanding patient’s goals and values has potential to facilitate individualized treatment choices based on the patient’s unique priorities, goals, and values.

52.06 Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-Analysis

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Enhanced recovery after surgery (ERAS) programs have been developed with the aim to improve patient outcomes and accelerate recovery after surgery. ERAS programs are a multimodal approach, with interventions during all stages of care: preoperative, intraoperative, and postoperative. ERAS programs have been proposed to improve patient outcomes and reduce health care costs. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery.

Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘enhanced recovery’ and ‘fast track’. Studies using at least 4 components of the ERAS program were included. Primary outcomes analyzed were length of stay (LOS), overall mortality, readmission within 30 days, and total costs. Total complications, time to first flatus, and time to first bowel movement were also analyzed.

Results: 42 RCTs involving 5,241 patients (2,595 receiving ERAS and 2,646 receiving standard of care) were analyzed. ERAS programs significantly reduced LOS by 2.35 days (MD = -2.345; 95%CI, -2.733 to -1.958; p<0.001), total complications by 38.0% (RR=0.620; 95%CI 0.545 – 0.704; p<0.001), and total costs (SMD= -0.789; 95%CI, -1.093 to -0.485; p<0.001). LOS reductions varied by type of surgery, with a 3 day reduction after orthopedic surgery (p=0.017) and no significant reduction after cardiovascular surgery (p=0.073). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus (SMD= -0.987; 95%CI, -1.389 to -0.585, p<0.001) and time to first bowel movement (SMD= -1.074; 95%CI, -1.396 to -0.752; p<0.001). Overall mortality was reduced by 29.2% (RR=0.708; 95%CI 0.377 – 1.330; p=0.283). Overall, there was no difference in readmission rates within 30 days (RR=1.151; 95%CI 0.822–1.612, p=0.412); however, readmission rates within 30 days after upper GI surgeries nearly doubled with the use of ERAS programs (RR=1.922; 95%CI 1.111 – 3.324; p=0.019).

Conclusion: ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality rates remained similar, but readmission rates varied significantly depending on the type of surgery. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery. Additional studies are required to determine the specific components of the ERAS program that are most beneficial.

52.05 The Gastrostomy Tube Consultation: An Opportunity for Palliative Care Assessment and Intervention

Posted on January 18, 2016

C. M. McGreevy1, S. Pentakota1, A. Kunac1, O. Mohamed1, K. Sigler1, A. C. Mosenthal1, A. Berlin1 1Rutgers-New Jersey Medical School,Surgery Department,Newark, NJ, USA

Introduction: General surgeons are frequently consulted for placement of a gastrostomy tube, and patients requiring feeding access are often seriously ill. Current guidelines for quality palliative care recommend that all patients with a potentially life-limiting illness receive a palliative care assessment when feeding tube placement is considered. We aimed to characterize the extent of unmet palliative care need in patients receiving gastrostomy tubes by examining palliative care processes and outcomes in this population.

Methods: This is a retrospective study of all adult non-trauma inpatients who underwent gastrostomy tube placement in the year 2013. Patients were identified based on procedure codes. We abstracted data regarding demographics, diagnosis, indications, palliative care processes, and outcomes via chart review. The primary outcome was receipt of palliative care assessment prior to tube placement. Secondary outcomes included functional status at discharge as measured by Glasgow Outcome Scale (GOS) or Modified Rankin Scale (MRS), as well as in-hospital and 6-month mortality. We used counts and proportions to describe study variables and multivariable logistic regression to identify factors associated with receipt of palliative care.

Results: One hundred twenty-eight patients met inclusion criteria. All but 3 had a serious or life-limiting illness. Of the remaining 125 patients, head and neck malignancy (37%) was the leading indication, followed by acute cerebrovascular accident (27%), prolonged respiratory failure (15%), and other neurologic disorders (14%). Only 14% of patients in whom a tube was placed had a palliative care assessment prior to the procedure. Only indication and race/ethnicity were statistically significantly associated with this care pattern. No head and neck malignancy patients received a palliative care assessment, and non-black patients were much less likely to receive palliative care assessment prior to gastrostomy placement (OR: 0.28 (0.11-0.69)). 14% of patients required tube change due to a complication within 1 year of placement. In-hospital and 6-month mortality were 6% and 16%, respectively. 62% of survivors to discharge suffered from significant functional disability defined as a GOS of ≤3 or a MRS of ≥4: unable to walk or attend to bodily needs without assistance.

Conclusion: Despite expert consensus guidelines, the majority of patients with serious or life-limiting illness did not receive palliative care assessment prior to placement of a gastrostomy tube. While considered routine procedures, patients requiring feeding access have high mortality rates and poor functional outcomes. This suggests that consultation for feeding tube placement is an appropriate trigger for palliative care assessment and intervention to ensure treatment is aligned with patient preferences. Surgeons can promote high-quality, patient-centered care by taking an active role in this process.

52.04 Barriers to Translational Research: Specimen Attrition in a Prospective Cancer Tissue and Databank

Posted on January 18, 2016

A. Gangi1, W. Sun1, S. Yoder3, M. Fournier2, M. C. Lee1 1Moffitt Cancer Center,Comprehensive Breast Program,Tampa, FL, USA 2Moffitt Cancer Center,Tissue Core Facility,Tampa, FL, USA 3Moffitt Cancer Center,Molecular Genomics Core Facility,Tampa, FL, USA

Introduction: Translational cancer research is increasingly reliant on existing tissue and data banks for retrospective tissue and data studies with potential clinical impact. Despite significant infrastructure and funding, these investigations are hindered by a multitude of unanticipated hurdles.

Methods: This is a funded, prospective/retrospective, IRB-approved, tissue and data study incorporating SNP analysis of breast cancer patients treated at an NCI designated, comprehensive cancer center. All cases and controls had archival tissue and were at least 5 years from their incident breast cancer diagnosis. Large-scale prospective institutional and programmatic databanks, tissue banks, and medical record chart review were leveraged. Tissue specimens were reviewed by a research pathologist for verification and adequacy. Sequencing of 10 selected genes at 30x coverage was targeted. Causes of attrition in the 1:1 matched case-control population were evaluated. Matched pairs were not matched by tissue type.

Results: 2927 stage I-III breast cancer patients were reviewed to identify 130 matched case-control pairs (260 total subjects) with specimens and data. Because of paired matching, elimination of one specimen resulted in the elimination of a pair if a replacement could not be identified. Of 260 specimens (130 pairs), 192 tissue samples (96 matched pairs) were identified (73.8%) over an 18-month time frame. 156 were archived FFPE (slides or blocks) and 36 were frozen (solid tissue, blood, extracted DNA). Thirty-four of the 130 data-matched pairs were unusable (26.1%): in 28 pairs, tissue could not be identified for one of the paired subjects. This was due to: missing blocks/slides, compromised tissue cases, or specimens that did not represent normal tissue due to inflammation or necrosis. In 2 other pairs, adequate tissue for macrodissection could not be identified. Four additional pairs were excluded due to insufficient DNA yields at extraction for one of the paired specimens. Of 192 specimens, 150 (75 pairs) passed the quantifiable DNA quality control studies (Qubit). Of 75 pairs sent for DNA sequencing, 47 pairs (36.2%) had evaluable data. The remaining 28 had insufficient hybridization for 30x coverage.

Conclusion: Despite significant infrastructure and resources, retrospective tissue studies are fraught with evaluable specimen loss at each step of the process. When assessing feasibility of retrospective tissue studies, investigators should consider a significant dropout rate within populations of archival tissue specimens.

52.02 Post-Operative Outcomes Following Elective Colorectal Surgery in the Obese Population

Posted on January 18, 2016

F. C. Patel1, A. Gullick1, A. DeRussy1, D. I. Chu1, J. Grams1, M. Morris1 1University Of Alabama Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Obesity remains a growing epidemic in the United States. Studies have suggested that obesity may worsen post-operative outcomes such as surgical site infection (SSI), but many of these studies categorized patients only as obese or non-obese. By further stratifying the obese population, we aim to investigate the role of obesity classes in determining post-operative outcomes for patients undergoing elective colorectal surgery.

Methods: Patients who underwent elective colorectal surgery were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 2011-2013 cohort and stratified by body mass index category into underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and class I (30-34.9 kg/m2), II (35-39.9 kg/m2), and III (>40 kg/m2) obesity. Univariate and bivariate comparisons were made with Chi-square and Wilcoxon Rank Sums tests to determine differences among categorical and continuous variables, respectively. Logistic regression analyses identified risk factors for 30-day mortality, 30-day readmission, and SSI (defined as superficial/deep SSI or wound disruption but excluding organ space infection).

Results: Of 74,891 patients who underwent elective colorectal surgery, 3,265 (4.4%) were underweight, 21,685 (29%) normal weight, 24,705 (33%) overweight, 14,797 (19.8%) class I obesity, 6,324 (8.4%) class II obesity, and 4,115 (5.5%) class III obesity. Comorbidities included non-insulin-dependent diabetes (10%), smoking (17.5%), and hypertension (49.2%). SSI rates in the overall cohort were 8.7% and ranged from the highest in class III obesity to the lowest in normal weight patients (15% vs. 6.5%, p<0.001). Fully adjusted modelling showed an increased risk of post-operative SSI with increased obesity class: Overweight (OR 1.34, CI 1.24-1.44), Class I (OR 1.68, CI 1.55-1.82), Class II (OR 2.32 CI 2.10-2.55), and Class III (OR 2.56 CI 2.20-2.74). Underweight patients were at increased risk of 30-day mortality (OR 1.34 CI 1.01-1.79), but obesity did not predict mortality. No weight categories were associated with an increased risk of readmission.

Conclusion: Obesity has a dose dependent association with SSI following elective colorectal surgery, but is not associated with readmission or 30-day mortality. BMI may account for some of the variation in post-operative outcomes such as SSI. In order to improve post-operative outcomes, pre-habilitation including supervised weight loss may play an important role prior to elective surgery.

52.03 Big Data In Surgery: Modeling How Post-Surgical Complications Increase Risk For Further Complications

Posted on January 18, 2016

S. I. Feld1, S. E. Tevis1, A. G. Cobian2, M. W. Craven2, G. D. Kennedy1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Department Of Biostatistics And Medical Informatics,Madison, WI, USA

Introduction:

Patients who suffer from post-operative complications have longer hospital stays, higher rates of readmission and mortality, and higher cost of care. Many studies have evaluated predictors of complication development. The goal of this study was to assess the temporal relationships among post-operative complications. Knowledge of these relationships will improve our ability to select targeted interventions to prevent cascades of these complications.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database includes preoperative risk factors, intraoperative variables and 30-day postoperative outcomes for patients who underwent major inpatient and outpatient surgical procedures. This study includes cases from this database from 2005 – 2013. Data included all ACS NSQIP-defined complications within 30 days post operation. Machine learning methods were used to model the temporal dependencies between complications. A Markov chain model was developed to model the development of subsequent complications given knowledge of the complications a patient has experienced.

Results:

The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned re-intubation, longer than 2 days on a ventilator and bleeding transfusion (greater than 75% sensitivity at the 75% specificity threshold). The risk for later complications depends on the complications a patient has experienced. We found some complications to be more likely to occur in insolation while others are likely to be associated with a second. Figure 1 shows the risk for complications given a prior complication (normalized by the overall likelihood of diagnosing that complication), with red indicating greater risk and blue less risk than baseline. Complications such as cardiac arrest or MI, renal insufficiency or failure, stroke, intubation, septic shock and coma contributed to complication cascades to a much greater extent than other complications. For example, a patient who has a coma has on odds ratio of >2 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of pneumonia is <0.5.

Conclusions:

A Markov Chain Model combining information about prior complications and time to occurrence after surgery can inform the likelihood of future complications. The present study utilized a novel method to determine several associations among post-operative complications which will contribute to our ability to better target interventions for high-risk post-operative patients.

52.01 Decision Making and Outcomes of Breast Reconstruction after Mastectomy: A Prospective, Longitudinal Study

Posted on January 18, 2016

C. Lee1,4, A. Deal4, P. A. Ubel2, R. Hugh1, L. Blizard3, K. R. Sepucha3, Y. Liu1, D. Ollila1,4, M. P. Pignone1,4 1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2Duke University,Fuqua School Of Business,Durham, NC, USA 3Harvard School Of Medicine,Brookline, MA, USA 4Lineberger Comprehensive Cancer Center,Chapel Hill, NC, USA

Introduction: Breast reconstruction after mastectomy has the potential to improve patient reported outcomes. Prior studies have been limited by retrospective, cross-sectional designs and lack of controls, and most have not assessed patient decision making. We evaluated outcomes of reconstruction in a prospective, longitudinal, controlled study and examined whether informed choice was associated with outcomes.

Methods: Adult women undergoing mastectomy for stage 0-III breast cancer or prophylaxis were enrolled at a single site and surveyed before surgery and at 12 months. Decision making was assessed with the Decision Quality Instrument, rating and ranking scales, and conjoint analysis. Making an ‘informed choice’ was defined as having at least 50% knowledge and treatment concordant with preferences. Satisfaction w/ breasts, psychosocial well-being (WB), sexual WB, and physical WB of the chest were measured with the BreastQ (range 0-100). Decisional outcomes were measured with the Satisfaction with Decisions and Decision Regret scales. Baseline scores were compared using t-tests. Preference concordance was assessed with a kappa score. Multivariable linear regression was used to examine differences (by treatment and by informed choice) in patient-reported outcomes at 12 months, adjusting for baseline values, demographics, and clinical characteristics.

Results: 126 patients enrolled (83% participation); 111 completed baseline and 12 mo surveys. The immediate reconstruction rate was 44% (15 delayed reconstruction cases were excluded to simplify analysis). Patients having reconstruction were more likely to be white (88 vs. 69%, p=0.05), partnered (81 vs. 49%, p=0.002), or college educated (95 vs. 76%, p=0.01), and less likely to have adjuvant therapy (17 vs. 65%, p<0.01). Mean age was 54 and did not differ by treatment. Mean knowledge was 57%. 63% of patients had treatment that was concordant with preferences. 43% of patients made an informed choice. Satisfaction with breasts, sexual WB, psychosocial WB, and physical WB-chest declined from baseline to 12 mos, regardless of reconstruction. On multivariable analysis and adjusting for baseline values, reconstruction was associated with higher satisfaction w/ breasts (beta 13.1, p=0.008) at 12 mos; it was not associated with change in sexual WB (p=0.07), psychosocial WB (p=0.16) or physical WB (p=0.61). Informed choice was not associated with higher psychosocial WB (p=0.20), decision satisfaction (p=0.57), or decision regret (p=0.77).

Conclusion: Patients having mastectomy-only are different at baseline from patients having reconstruction. Both groups experienced decline in all well-being scores after surgery. Reconstruction was associated with higher satisfaction with breasts at 12-mos, but not with higher sexual, psychosocial, or physical WB. Informed choice was not associated with better outcomes, and most patients did not make an informed choice.

34.10 Does Distance Matter? Patient Travel and Pancreaticoduodenectomy Costs

Posted on January 18, 2016

L. H. Nicholas1, C. Wolfgang1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Whether to concentrate risky surgical procedures in high-volume hospitals is a long-standing question among surgeons, policy-makers and payers. Despite decades of interest in this question, little is known about the potential costs of increased patient travel.

Methods: We studied all radical pancreaticoduodenectomy inpatient admissions to hospitals that exceeded low-volume thresholds (more than 6 operations per year) among Maryland residents from 2004 – 2012 (N = 1,277). We used general linear regression models to assess the relationship between the total cost of hospitalization and distance patients traveled controlling for patient demographics, complexity and severity.

Results: Maryland residents traveled an average of 34.6 miles (median 19.5) for surgery. Admissions costs averaged $46,597 (median $36,803). Total costs were higher from patients living further from their hospitals. Compared to patients in the lowest quartile of hospital distance (who lived fewer than 8 miles from their hospital), patients in the second distance quartile (8 – 20 miles) incurred an additional $5,205 in admissions costs (p = 0.001), while those in the highest quartile (47 – 300 miles) had an additional $4,616 in total costs (p = 0.055).

Conclusion: Greater patient travel distance was associated with increased costs for pancreaticoduodenectomy. Patients traveling to high-volume centers may require duplicative testing if they initiated care elsewhere and longer stays before they can return home. These costs should be accounted for in payer and policy-maker decisions about regionalizing surgical procedures.

34.09 High Safety Net Hospitals and Pancreatic Surgery: Should it Be Abandoned?

Posted on January 18, 2016

D. E. Go1, D. E. Abbott1, K. Wima1, D. J. Hanseman1, A. Ertle1, A. Chang1, J. J. Sussman1, S. A. Shah1, R. S. Hoehn1 1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA

Introduction: Previous work has demonstrated significant outcome and cost disparities between hospitals with different safety-net burdens, though the implications of policy changes to limit operative interventions at specific hospital types are unclear. We aimed to understand how performance of pancreaticoduodectomy (PD) at different safety-net burden hospitals affects cost and outcomes, and how redistribution of patients from low performing hospitals to high performing hospitals could improve cost-effectiveness.

Methods: Hospitals performing PD were queried from the University HealthSystem Consortium database (UHC; 2009-2013) and grouped according to safety-net burden (proportion of Medicaid and uninsured patient charges, as previously described). A decision analytic model was then constructed, populated with UHC clinical and DRG-based cost data. Primary endpoints were perioperative mortality, readmission, and cost (index hospitalization plus readmission, when applicable). Sensitivity analyses were conducted to determine how primary endpoints were affected by alternative distribution of patients between hospital types and clinical outcomes.

Results: 15,090 patients populated the final dataset. Low (LBH), medium (MBH) and high (HBH) burden hospitals were comprised of 4,220 (28%), 9,505 (63%) and 1,365 (9%) patients, respectively. Perioperative mortality was twice as high at HBH (3.7%) than at LBH (1.6%) and MBH (1.7%) (p<0.001). In the base case, when all clinical and cost data were considered, PD at HBH hospitals cost $35,628/patient, 35% and 55% higher than MBH ($26,357) and LBH ($22988) hospitals, respectively. This increased cost at HBH hospitals was associated with a significantly higher readmission rate (23%) than at MBH (18%) and LBH (15%) hospitals (p<0.001. Patients at HBH hospitals were more likely to have extreme severity of illness (SOI) (18.8%) than at MBH (12.8%) and LBH (11.4%) but less likely to have moderate SOI (74.2% vs. 78% and 79.4%, respectively) (p<0.001). After patient SOI-adjusted equal redistribution of all HBH to LBH and MBH hospitals, per patient cost remained significantly lower at LBH ($25,594; 39.2% less) and MBH ($27,860; 27.9% less), with a readmission rate of 18% (vs. 23% at HBH in the base case).

Conclusion: HBH perform a minority of PDs, but have higher readmission and perioperative mortality rates at significantly higher costs. Redistribution of patients from HBH to LBH/MBH—adjusted for patient-specific risk—demonstrates significant improvement in clinical outcomes, with a potential for over $2M in annual cost savings. While patient-specific factors partially contribute to sub-optimal clinical outcomes, these data show that inherent hospital characteristics are important in optimizing cost-effective PD care, and that certain hospital types may not be optimally equipped for complex pancreatic surgery.

34.08 Extended LOS in Patients Undergoing Orthognathic Surgery: Does Surgeon Volume Matter?

Posted on January 18, 2016

A. Gupta1, R. Chaudhary1,2,3, A. W. Davis1, A. Krasnova1,2,3, S. Haring1,3,4, C. K. Zogg1,2,3, M. A. Morris1,3, A. H. Haider1,2,3, E. B. Schneider1,3,4,5 5Johns Hopkins University School Of Medicine,Baltimore, MD, USA 1Brigham And Women’s Hospital,Center For Surgery And Public Health,,Boston, MA, USA 2Harvard School Of Public Health,Boston, MA, USA 3Harvard School Of Medicine,Brookline, MA, USA 4Johns Hopkins Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA

Introduction:
Surgeon-specific annual procedure volume has been associated with improved outcomes in a variety of complex surgical procedures. The relationship between surgeon volume and outcomes for patients undergoing orthognathic surgery has not been reported. We examined the relationship between surgeon volume and hospital length of stay (LOS), and total hospital charges for patients undergoing the two most common orthognathic procedures, namely segmental osteoplasty/osteotomy of maxilla or open osteoplasty/osteotomy of mandibular ramus.

Methods:
All patients undergoing the aforementioned procedures as in-patients were selected from the 2002 to 2009 Nationwide Inpatient Sample. Year-specific annual procedure volumes were calculated for each surgeon and dichotomized into low- and high volume groups (<10 vs. ≥ 10 procedures/year respectively). The relationship between year-specific annual volume and the likelihood of extended patient LOS (defined as LOS ≥ 75th percentile) was examined using multivariable logistic regression, adjusting for patient and hospital-level factors. Possible provider-volume related differences in total charges were examined using a generalized linear model, with a log-link and gamma distribution also adjusting for patient and hospital-level factors.

Results:
Among the 3,705 patient admissions eligible for inclusion, age ranged between 4 days to 80 years, with 68.7% of patients being between 15-30 years of age. Annual surgeon volume ranged from 1 to 36 with a mean of 6 (SD=7) procedures/year. Overall, 81.2% of procedures were performed by low-volume surgeons and 46.8% of surgeons performed 3 or fewer procedures annually. In univariable analyses, patient demographics did not differ between high and low volume providers. Also, no surgeon-volume-related differences were observed between teaching and non-teaching hospitals. Patients treated by high volume surgeons demonstrated 34% lower odds of experiencing extended LOS (OR 0.66 95% CI: 0.46-0.95) after adjusting for patient demographic factors, insurance status, comorbidities, and hospital characteristics (rural vs. urban, teaching status and bed-size). There was no association between surgeon volume and total hospital charges after adjusting for potential confounders.

Conclusion:
Regionalization of patients to high volume surgeons/centers for surgical treatment has been recommended for specific subsets of surgical patients, including those with major trauma and requiring certain cardiac, cancer or gastric bypass procedures. Our findings suggest the possibility that similar regionalization strategies might reduce the likelihood of extended LOS for patients undergoing orthognathic procedures.

34.07 The Time Required to Review Research Protocols at 10 IRBs in the Veterans Health Administration.

Posted on January 18, 2016

D. E. Hall1,2, U. Feske1, S. Gao1, R. Stone1,2, S. Zhang1, R. Arnold2 1VA Pittsburgh Healthcare System,Pittsburgh, PA, USA 2University Of Pittsburg,Pittsburgh, PA, USA

Introduction: Although data demonstrate that VA investigators perceive the need to reduce the time required to secure IRB approval, little is known about the actual time required to secure IRB approval. Therefore, we measured IRB review times across the research portfolios of 10 large VHA IRBs.

Methods: We collected the IRB records pertaining to a random sample of research protocols from the research portfolio of 10 VA IRBs, stratified by review type (i.e., exempt, expedited, full board). We included IRBs operated by the VA, and based on the number of actively managed protocols, we sequentially approached the 26 largest IRBs to achieve our target sample of 10 participating IRBs, including the VA Central IRB. Using detailed maps of each site’s review process, two independent analysts abstracted time data from the IRB records from which we calculated the overall and incremental review times. Multivariable models assessed differences between site, review type and and increments of the IRB review process.

Results:We obtained documentation for 278 protocols: 48 exempt, 106 expedited and 124 full board. Raters agreed on 3038 of 3090 time points (98.3%) abstracted from a sub-sample of 72 (22.4%) protocols. Total review time ranged from 24 to 310 days, with means of 93±51, 107±54, and 131±63 days for expedited, exempt and full board protocols respectively. Multivariable models using robust variance estimation controlling for site and review level demonstrate that, on average, expedited reviews were 45 days faster than full board reviews ( 95% CI = 31-59 days). There was no significant difference between full board and exempt reviews. However, after subtracting the time required for Research and Development (R&D) Committee review, both exempt and expedited reviews were 21 (95% CI = 1-41) and 39 (95% CI = 23-55) days faster than full board reviews, respectively, in the subgroup of protocols for which we could determine the time for R&D Committee Review (N = 178). Finally, when compared to Site 1, full board reviews at Sites 3, 8 9 and 10 were 27 (6-48), 38 (12-63), 45 (20-69) and 24 (1-46) days faster, and Site 6 was 56 (28-84) days slower (ranges show 95% CI).

Conclusion:IRB review times differ significantly between sites and review types. Some sites approach a consensus panel goal of 60 days for IRB review, but other sites need improvement to reach this goal. Review times for exempt protocols are unexpectedly long due to delay with the R&D Committee review. These data could inform site-specific initiatives for reducing the time required for IRB review.

34.05 Variations in Hospitals Costs for Surgical Procedures among Patients and Providers

Posted on January 18, 2016

F. Gani1, M. Daniel1, J. Hundt1, J. E. Efron1, M. A. Makary1, T. M. Pawlik1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Reducing unwanted variations in healthcare has been identified as an opportunity for cost containment. We sought to characterize variations in hospital costs for several surgical procedures and quantitate the variability attributable to the patient, procedure, and provider.

Methods: Patients who underwent coronary artery bypass grafting (CABG), open abdominal aortic aneurysm repair (AAA), laparoscopic cholecystectomy (LC), pancreatectomy or colectomy between 2009 and 2013 were identified at a large tertiary care hospital. Inter- and intra-provider variations in costs were compared using coefficient-of-variation (CV). Multivariable hierarchical linear modeling was utilized to quantitate variation in total hospital costs attributable to the patient, procedure and provider.

Results: Among the 4,802 patients that underwent surgery, the average cost of surgery was $34,697 (SD=25,844) ranging from $11,177 (SD=$4,955) for LC to $63,654 (SD=54,046) for AAA repair. While perioperative complications resulted in increased cost (no complication: $25,864, SD=16,838 vs. complication: $47,171, SD=72,692, p<0.001), total hospital costs remained variable even among patients without complications (p<0.001, Figure). Substantial variation in total costs was observed among surgeons performing the same surgery (CV: CABG, 103%; AAA, 104%, LC, 69%, pancreatectomy, 82%; colectomy, 122%). Further, marked variations in costs were also observed within the same surgeon performing the same surgery (CV: CABG, 21%-116%; AAA, 26%-111%, LC, 19%-107%, pancreatectomy, 31%-101%; colectomy, 17%-155%). After accounting for patient comorbidity, postoperative complications and length of stay, 90% of total variability was explained by patient- and procedure-related factors, while 10% was attributed to variations in surgeon practices.

Conclusion: Hospital procedure costs varied markedly among and even within providers. While patient level factors explained most of the variation in cost, up to 10% of the variation was due to provider-level differences, which can be a potential target for cost containment.

34.06 Value-Based Purchasing: An Analysis of Current Utilization of In-Patient Care for GI Malignancies

Posted on January 18, 2016

J. Tong1, K. T. Collier1, S. Dasani1, R. Hoffman1, G. C. Karakousis1, R. R. Kelz1 1University Of Pennsylvania,Department Of Surgery,Phiadelphia, PA, USA

Background: A shift from the fee-for-service system to a value-based-purchasing model(VBP) is underway. In a GI cancer model, the study aimed to examine treatment patterns and observed costs in the in-patient setting to understand the impact that VBP may have on patients.

Methods: A retrospective cohort study was performed using inpatient claims from California and New York (2008-2011) for all patients admitted with a new diagnosis of colon, rectal, stomach, or pancreatic cancer regardless of the intended treatment plan. Patterns of treatment, surgical and non-surgical, and associated costs during the index admission for cancer were examined. Patient characteristics were compared by treatment pattern using the Chi square test. Univariate costs were compared using the Kruskal Wallis test. Log-transformed wage-adjusted total costs were compared using multivariate linear regression.

Results: Of 75,177 patients, there were 39,207(52.2%) colon cancer, 14,020(18.7%) rectal cancer, 12,341(16.4%) pancreatic cancer, and 9,609(12.8%) stomach cancer admissions. Patients admitted with a new diagnosis of colon cancer were most likely to be treated with surgery during the index admission(81.8%) compared to 61.3% of rectal cancer patients, 23.5% of pancreas cancer patients and 43.1% of stomach cancer patients(p<0.001). 34% of surgical patients underwent an operation within 24 hours of admission. The median cost per admission was $20,819(IQR 12,448-34,928). Cost was greatest for patients with stomach cancer($24,168; IQR 12,861-43,978) and least expensive for pancreas cancer patients($19,474; IQR 10,506-36,708) (p<0.001). Cost for patients who had surgery during the index admission($24,177; IQR 15,311-38,714) differed from that those who did not($15,351; IQR 8,767-27,673)( p<0.001). Among patients who underwent an operation during the index admission, the cost was significantly less for those who underwent surgery within 24 hours of admission($21,606; IQR 13,990-34,396) when compared to those that were admitted for >24 hours before surgery($27,360; IQR 17,251-43,801) (p<0.001). The direction of the relationship between cost and treatment type and timing of surgery remained the same after adjustment for potential confounders.

Conclusions: Surgical care remains the definitive therapy for solid GI cancers with variable cost depending on tumor type. Not all patients are receiving surgical treatment at the time of admission. Patients that are ready for surgery at the time of admission incur less costly care. The goal of bundled cancer care should be timely diagnosis and referral for definitive surgical care. Optimizing outpatient health status prior to admission may result in substantial cost savings. While VBP offers sensible features for cost containment for insurers and employers, the current inefficiencies in utilization of in-patient services will ultimately lead to greater costs incurred by the patient.

34.04 Where the Sun-Shines: Industry Payments to Surgeons

Posted on January 18, 2016

R. Ahmed1, S. Bae2, E. Chow2, A. B. Massie2, J. Lopez2, C. Atallah2, D. L. Segev2 1Duke University Medical Center,Plastic & Reconstructive Surgery,Durham, NC, USA 2Johns Hopkins University School Of Medicine,General Surgery,Baltimore, MD, USA

Introduction: Under the Physician Payment Sunshine Act (PPSA), data were released publicly disclosing biomedical industry non-reasearch payments to physicians; enabling patients to be aware of potential financial conflicts-of-interests (COI). The objective of this study is to provide general surgeons a better understanding of the PPSA data.

Methods: Using the first wave of PPSA data (Aug-Dec, 2013), published December 2014, we describe the distribution of payments to all general surgeons (GS) and general surgical subspecialists (GSS), and compared it to gastroenterologists.

Results: There were total of 17,331 GSS (4.8% of all providers) who collectively received $27,015,046 (3.9% of all payments). GS received median (IQR) $100 (32-319) mean $1,199; compared to $94 ($29-$255) mean $1,900 among other providers. The largest payment to a surgeon was $253,468. The three major payment categories were speaker fees (18%), consulting (17%) and royalties (16%). Among GSS, 44.5% received payments <$100, 38.5% between ($100-<$1K), 14% between ($1K-<$10K), and 2.9% >= $10K. A total of 497 companies made payments to GSS ($9.33-$3,580,066) of which 10 comprised 54% of all payments. On average, cardiac surgeons were the highest paid GSS (ranksum, p<0.001). Gastroenterologists received higher payments than GS (ranksum, p<0.001).

Conclusion: This description of the PPSA showed that majority amount paid to GS and GSS comprised of consulting and speaker fees; 50% of GS received payments <$100. Payments to GS were lower than gastroenterologists. Although the PPSA data provides transparency to potential COI, its value is yet to be determined. Awareness of the PPSA, its data and implications are critical for all physicians.

34.03 The Cost of Surgical Care: How Much Are We Really Charging?

Posted on January 18, 2016

F. Gani1, M. A. Makary1, T. M. Pawlik1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Hospital markups (ratios of charges-to-Medicare-allowable costs) are not subject to regulation in most states, yet contribute to increasing insurance premiums as well as rising health-care spending. We sought to characterize national variations in hospital markup for major cardio-thoracic (CT) and hepato-pancreatico-biliary-gastrointestinal (HPB-GI) surgical procedures, as well as examine perioperative outcomes at hospitals with extreme markup.

Methods: All hospitals in which a patient underwent a CT (n=577,275) or HPB-GI (n=618,700) procedure were identified using the Nationwide Inpatient Sample (NIS) for 2012. Charge-to-cost ratios(CCR) were compared across hospitals. In-hospital outcomes were examined relative to ‘extreme markup'(≥75th percentile).

Results: Among the 17,490 hospitals identified, median CCR was 2.8 (IQR 2.7-3.9). 4,373 hospitals that treated 411,540 patients were in the highest CCR quartile (range, 3.9-12.2) (Figure). While patient age, gender and insurance status were not associated with extreme markup hospitals (all p>0.05), minority patients were more likely to be treated at high CCR hospitals (non-extreme CCR: 20.3% vs. extreme CCR: 30.4%, p<0.001). Extreme markup hospitals were more often large (non-extreme CCR: 33.7% vs. extreme CCR: 46.3%), non-teaching (non-extreme CCR: 37.9% vs. extreme CCR: 56.7%), and located in the South (non-extreme CCR: 32.8% vs. extreme CCR: 45.8%, all P<0.001). Extreme mark up hospitals had higher perioperative morbidity (non-extreme CCR: 26.4% vs. extreme CCR: 32.7%), failure-to-rescue (non-extreme: 10.2% vs. extreme CCR: 12.2%) and mortality (non-extreme CCR: 3.2% vs. extreme CCR: 4.4%, all P<0.001).

Conclusions: Many patients undergo surgery at hospitals charging over 4-times Medicare-allowable cost. Extreme markup hospitals had worse perioperative outcomes than non-extreme markup hospitals. Federal regulations should consider price disclosure to regulate hospital markups.

34.02 Catastrophic health expenditure risk among uninsured trauma patients in the United States

Posted on January 18, 2016

J. W. Scott1,2, N. Raykar2,3, C. K. Zogg1, A. H. Haider1, J. G. Meara2,4, M. G. Shrime2,5 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery,Boston, MA, USA 2Program For Global Surgery And Social Change,Harvard Medical School,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 4Children’s Hospital Boston,Department Of Plastic And Oral Surgery,Boston, MA, USA 5Massachusetts Eye And Ear Infirmary,Department Of Otolaryngology And Office Of Global Surgery,Boston, MA, USA

Introduction:
The Affordable Care Act attempts to decrease the uninsured population in the US by extension of coverage for young adults, creation of insurance exchanges, and expansion of Medicaid eligibility. However, implementation of these programs—most notably Medicaid expansion—remains incomplete. Approximately 1/5th of US trauma patients ages 18-64y are uninsured, and lack of insurance may increase the risk of potentially impoverishing catastrophic health expenditure–previously defined as any expense exceeding 10% of annual household income. We aimed to use a nationally-representative patient sample to determine the proportion of uninsured trauma patients admitted to a hospital who incurred catastrophic medical bills.

Methods:
Uninsured patients ages 18-64y who were admitted for traumatic injury (ICD-9-CM 800-959) were abstracted from the 2007-2011 National Inpatient Sample (NIS). To provide a more detailed estimate of median household income, patients were matched to data obtained from the US census bureau, wherein zip codes were ranked by median income into quartiles and linked to states. State and median zip code household income quartiles were matched to the corresponding NIS variables to provide an estimated household income for each patient. Charges were determined by the NIS total hospital charges billed to each patient. Proportions and estimations were calculated using nationally-representative discharge scaling weights provided in the NIS.

Results:
A total of 117,497 patients (weighted to represent 579,656 patients nationwide) were included. Median estimated household income was $44,287 (IQR: $35,456-$56,646). Median total hospital charges were $26,339 (IQR: $14,575-$47,941). The proportion of uninsured trauma patients with total charges exceeding 10% of estimated household income was 95.8% (95% CI: 94.7-96.9%). The proportion of uninsured trauma patients with total charges exceeding 40% of estimated post-subsistence income was 71.6% (95%CI: 69.4-73.8%). When scaled to the total US population, these proportions imply an estimated total of 555,385 (95%CI: 496,728-614,041) uninsured trauma patients ages 18-64y incurred catastrophic medical bills between 2007-2011–equivalent to 110,077 patients per year (95%CI: 99,346-122,808) patients per year.

Conclusion:
Applying an established definition of catastrophic heath spending, estimates from a nationally representative sample suggest that over 95% of uninsured patients ages 18-64y incur catastrophic medical bills if hospitalized for a traumatic injury in the US. Surgeons should take note, especially in states in which Medicaid has not been expanded, that nearly all of their uninsured trauma patients are at risk of financial catastrophe. Whether through enhanced insurance coverage or other means of improving access to affordable care, providers and policy makers should take note and promote efforts that favor financial risk protection for patients.

34.01 The Impact of SUS Membership on the Scholarship of American Surgery

Posted on January 18, 2016

N. Valsangkar1, J. Kays1, P. Martin1, J. Parett1, M. M. Joshi1, T. A. Zimmers1, L. Koniaris1 1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction: A core objective of the Society of University Surgeons (SUS) is research focused: to ‘advance the art and science of surgery through original investigation.’ Herein, we sought to determine the current impact of the SUS on surgical academic productivity.

Methods: Individual faculty data for numbers of publications, citations, and NIH funding history were collected for 4,015 surgical faculty at the top 55-NIH funded departments of surgery using SCOPUS, and NIH RePORTer. SUS membership was determined from membership registry data.

Results: Overall, 502 surgical faculty (12.5%) were SUS members and 92.7% were associate or full professors (versus 59% of non-members). Median publications (P) and citations (C) among SUS members were P:112, C:2460 versus P:29, C:467 (p < 0.001). Academic productivity was considerably higher by rank for SUS-members: associate (P:61 vs. 36, C:1199 vs. 591, p < 0.001) and full professors (P:141 vs. 81, C:3537 vs. 1856, p < 0.001). Among full professors, SUS members had much higher rates of any NIH funding (52.6% vs. 26%, p < 0.05) and specifically for R01, P01, and U01 awards (37% vs. 17.7%, p<0.01). SUS members were two times as likely to be serving in divisional leadership or chair positions (23.5% vs. 10.2%, p < 0.05).

Conclusion: SUS society members are academically a highly productive group. These data support the premise that the SUS is meeting its research mission and identify its members as extremely academically productive contributors to research and scholarship in American surgery and medicine.

21.12 Lymphovascular Invasion is Associated with Compromised Survival for Papillary Thyroid Cancer

Posted on January 18, 2016

L. N. Pontius1, L. M. Youngwirth1, S. M. Thomas1, R. P. Scheri1, S. A. Roman1, J. A. Sosa1 1Duke University Medical Center,Durham, NC, USA

Introduction: Data regarding the association between lymphovascular invasion for survival for papillary thyroid cancer (PTC) are limited. This study sought to examine lymphovascular invasion as an independent prognostic factor for patients with PTC undergoing total thyroidectomy.

Methods: The National Cancer Data Base (2010-2011) was queried for all patients with a diagnosis of PTC undergoing total thyroidectomy. Patients were classified into two groups based on the presence/absence of lymphovascular invasion. Demographic, clinical, and pathologic features at the time of diagnosis were evaluated for all patients. A Cox proportional hazards model was developed to identify factors associated with survival.

Results: In total, 40,324 patients met inclusion criteria; 12.5% had lymphovascular invasion. Patients with lymphovascular invasion were more likely to have larger tumors (2.8 cm vs 1.6 cm, p<0.01), metastatic lymph nodes (75.1% vs 34.1%, p<0.01), and distant metastases (3.1% vs 0.5%, p<0.01). They also were more likely to receive radioactive iodine when compared to patients without lymphovascular invasion (70.2% vs 48.7%, p<0.01). Unadjusted overall survival was reduced for patients with lymphovascular invasion compared to patients without it (log-rank p<0.01), with 5-year survival rates of 86.1% and 94.2%, respectively. After adjustment, increasing patient age (HR=1.06, p<0.01), male gender (HR=1.63, p<0.01), presence of metastatic lymph nodes (HR=1.73, p<0.01), presence of distant metastases (HR=4.90, p<0.01), and presence of lymphovascular invasion (HR=1.99, p<0.01) all were associated with compromised survival. Treatment with radioactive iodine was protective in both patients with lymphovascular invasion (HR=0.42, p<0.01) and patients without lymphovascular invasion (HR=0.48, p<0.01).

Conclusion: The presence of lymphovascular invasion among patients undergoing total thyroidectomy for PTC is independently associated with compromised survival. Patients with PTC and lymphovascular invasion should be considered higher risk, and providers should consider aggressive surgical and adjuvant treatment measures to maximize patient outcomes.

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