75.05 Racial disparities in Hepatocellular Carcinoma outcomes are driven by access to care.

Posted on January 31, 2019

C. Akateh1, S. M. Black1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction:
Hepatocellular carcinoma (HCC) remains a major leading cause of end-stage liver disease and cancer-related mortality in the United States. While advances in various treatment strategies have contributed to improved outcomes overall, surgical resection remains the preferred choice of therapy and in many cases the only hope of a cure. Despite improving outcomes, minority patients with HCC continue to have worse outcomes compared to non-minorities. The goal of this study is to identify underlying mechanisms for disparities in HCC outcomes.

Methods:
The Surveillance, Epidemiology and End Results (SEER) database was used to identify White and Black patients diagnosed with hepatocellular carcinoma between 2000-2014.   Age, race, marital status, stage, and receipt of surgery were evaluated as predictors of disparate outcomes and mortality in multivariate analyses.  

Results:
43,877 patients (75.6% White, 12.8% Black and 11.6% Other Races) were identified, 73% of whom were male, and 26% were female. Black patients were significantly younger at diagnosis compared to Whites (60 vs. 64 (p<0.001) and were slightly more likely to have the advanced/regional disease at presentation (18.8 vs. 21.2%, p<0.001), respectively.  Overall, blacks were significantly less likely to undergo cancer-directed surgery, including liver transplantation (OR 0.84, 95% CI= 0.76-0.92).  This decrease in odds of surgery persisted after adjusting for patient-level factors such as age, sex, marital status, and year of diagnosis (adjusted OR 0.80, 95% CI= 0.73-0.88). However, these odds of surgery were equivalent when adjusted for disease stage (adjusted OR 0.94, 95% CI= 0.82-1.10). The unadjusted hazard of mortality was 1.11 times higher in blacks compared to whites (p<0.001). However, these hazards disappeared when adjusted for disease stage (HR 0.99, p=0.908).

Conclusion:
Significant racial disparities in HCC outcomes are largely related to the advanced presentation at diagnosis and resulting underuse of cancer-directed surgery.  It is therefore imperative to address barriers to care as receipt of appropriate care eliminates these disparities.
 

75.04 Maximum Diameter is a Poor Surrogate Measure for Volume and Surface Area of Small Pancreatic Cysts

Posted on January 31, 2019

A. M. Awe1, V. Rendell3, M. Lubner2, E. Winslow3  1University Of Wisconsin,School Of Medicine & Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Determining an appropriate surveillance strategy for pancreatic cysts (PC) presents a challenge due to management guideline heterogeneity and a relatively poor ability to predict the malignant potential of PCs. Current management protocols use maximum axial diameter (MAD) to steer treatment; however, other measures may better capture the evolution of PCs. The aim of this study is to determine whether MAD is an appropriate surrogate measure for volume and surface area of PCs.

Methods: A single-institution retrospective analysis of patients with radiologically confirmed PCs was conducted. Patients with a PC >1cm and a contrast-enhanced CT or MR scan were included. Patients with pancreatic pseudocysts, underlying pancreatitis, genetic syndromes, or solid tumors were excluded. MAD, volume, and surface area data were collected using HealthMyne, a novel lesion detecting software. Pearson’s correlations were used to determine associations between volume and MAD, and surface area and MAD for total patients and size sub-groups from the Fukuoka guidelines for PC surveillance and treatment.

Results: In total, 202 patients were included in the analysis. The MADs of the cysts ranged from 1.0 cm to 7.5 cm. PC volume as a function of the MAD for all PC sizes had a strong correlation of r=0.94. When sub-grouped by size based on the Fukuoka guidelines, correlations with volume varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) PCs had correlations of 0.78, 0.53, 0.90, respectively (Fig. 1A-C). Volumes ranged for 1-2 cm cysts from 0.3- 3.8 cm3, for 2-3 cm cysts from 1.1- 10.8 cm3, and for >3 cm cysts from 6.7- 104.3 cm3. Based on volume alone, 95 cysts (47%) overlapped in Fukuoka size groupings. PC surface area as a function of the MAD for all PC sizes had a strong correlation of r=0.96. When sub-grouped by Fukuoka guideline size, correlations varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) had correlations of 0.80, 0.56, 0.92, respectively (Fig. 1D-F). Surface area ranged for 1-2 cm cysts from 0.2- 13.2 cm2, for 2-3 cm cysts from 7.3- 29.6 cm2, and for >3 cm cysts from 19.6- 126.2 cm2.  Based on surface area alone, 77 cysts (38%) overlapped between axial diameter size groupings in the Fukuoka guidelines.

Conclusion: Overall, there is strong correlation between PC volume, surface area and MAD, suggesting that unidimensional size is an appropriate surrogate measure. However, grouping PCs based on the Fukuoka guideline size criteria reveals poor volume and surface area correlation with MAD for small cysts. This suggests volume and surface area may be a useful adjunct measurements to guide surveillance and treatment decisions for smaller PCs.

 

75.03 NQO1 Expression Predicts OS and Response to Preoperative Chemotherapy in Colorectal Liver Metastasis

Posted on January 31, 2019

Y. Hirose1, J. Sakata1, T. Kobayashi1, K. Takizawa1, K. Miura1, T. Katada1, M. Nagahashi1, Y. Shimada1, H. Ichikawa1, T. Hanyu1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD (P) H: quinone oxidoreductase – 1 (NQO1) protects human cells against redox cycling and oxidative stress. We hypothesized that immunohistochemical expression of NQO1 in the resected specimen of colorectal liver metastasis (CRLM) has impact on the response to preoperative chemotherapy for CRLM and survival after liver resection in patients with CRLM.

Methods:  A retrospective analysis was conducted of 88 consecutive patients who underwent initial liver resection for CRLM from January 2005 through December 2016 in Niigata university medical and dental hospital. The median follow-up time was 65.4 months. Immunohistochemistry was conducted for the resected specimen using a monoclonal anti-NQO1 antibody. According to the NQO1 expression in tumor cells of CRLM, the patients were classified into two groups: the NQO1 positive group and the loss of NQO1 group. According to the NQO1 expression in non-neoplastic epithelial cells of the large intrahepatic bile ducts, the patients were classified into two groups: the NQO1 non-polymorphism group, which had NQO1 expression in those cells, and the NQO1 polymorphism group, which had no NQO1 expression in those cells. Overall survival (OS) after liver resection for CRLM were evaluated by univariate and multivariate analyses taking into consideration 15 other clinicopathological factors. Among 30 patients who received preoperative chemotherapy for CRLM, association between response to preoperative chemotherapy for CRLM and NQO1 status of those patients was evaluated. Response to preoperative chemotherapy was determined according to pathologic response and RECIST criteria using multidetector row CT. All tests were two-sided and P < 0.05 were considered statistically significant.

Results: Of the 88 patients, 61 were classified as the NQO1 positive group and 27 as the loss of NQO1 group, whereas 21 were classified as the NQO1 non-polymorphism group and 67 as the NQO1 polymorphism group. The loss of NQO1 group was associated with a lower prehepatectomy serum CEA level. The NQO1 polymorphism group was associated with higher frequency of bilobar metastases. The loss of NQO1 group had significantly better OS than the NQO1 positive group (cumulative 5-year OS rate: 90.9% vs 66.5%, P = 0.026), and loss of NQO1 expression was an independent favorable prognostic factor in multivariate analysis (relative risk: 0.139, P = 0.001). Regarding association between the response to preoperative chemotherapy for CRLM and NQO1 status, the presence of NQO1 polymorphism was significantly associated with a better response to preoperative chemotherapy in RECIST (P = 0.004). The absence or presence of NQO1 expression in CRLM was not associated with response to preoperative chemotherapy for CRLM.

Conclusion: Loss of NQO1 expression indicates favorable prognosis for patients with CRLM. The presence of NQO1 polymorphism may predict a good response to preoperative chemotherapy for CRLM.

 

75.02 Laparoscopic Distal Pancreatectomy is Associated with a Cost Savings in High Volume Centers

Posted on January 31, 2019

E. Eguia1, P. C. Kuo2, P. J. Sweigert1, M. H. Nelson1, G. V. Aranha1, G. Abood1, C. V. Godellas1, M. S. Baker1  1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA 2University Of South Florida College Of Medicine,General Surgery,Tampa, FL, USA

Introduction:
Little is known regarding the impact of minimally invasive approaches to distal pancreatectomy (DP) on the aggregate costs of care for patients undergoing DP. 

Methods:
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing laparoscopic (LDP) or open (ODP) distal pancreatectomy in FL, MD, MA, NY and WA between 2014 and 2016. Multivariable regression (MVR) was used to evaluate the association between surgical approach and rates of postoperative complication, overall lengths of stay (LOS) and aggregate costs of care including readmissions to 90 days following DP. Candidate variables were determined a priori using best variable subsets and included: age, gender, insurance, race/ethnicity, Charlson comorbidity index (CCI), pathology (benign vs. malignant), annual hospital DP volume broken into terciles (low: <6 DPs/year; moderate: 641 DPs/year) and overall LOS. 

Results:

297 (11%) patients underwent LDP; 2,436 (89%) underwent ODP. On univariate analysis, patients undergoing LDP had higher rates of malignant pathology (53% vs. 39%, p<0.001), shorter overall LOS (6 days, IQR [5-10] vs. 7 days, IQR [5-13], p< 0.001) and lower aggregated costs of care ($22,734 vs. $26,910, p<0.001) than those undergoing ODP.

On MVR adjusted for age, gender, malignant pathology, CCI and hospital volume, LDP was associated with a decreased risk of prolonged LOS (OR 0.47; 95% CI [0.30, 0.74]) relative to ODP.  Rates of perioperative morbidity and readmission for patients undergoing LDP were identical to those undergoing ODP.

On MVR adjusted for age, insurance, CCI and LOS, and volume, factors associated with being in the highest quartile for aggregate costs following DP included: male gender (OR 1.50; 95% CI [1.24,1.82]), CCI (OR 1.25; 95% CI [1.19, 1.31]), black race (OR1.40; 95% CI [1.02,1.91]), having Medicaid (OR 1.59 95% CI [1.12,1.25]), malignant pathology (OR 2.10; 95% CI [1.61, 2.74]) and readmissions (OR 5.29; 95% CI [4.35, 6.43]). Patients undergoing LDP had a lower risk of being in the highest quartile for costs (OR 0.52, 95% CI [0.37, 0.74]) than those undergoing ODP. The reduction in risk of being a high outlier for cost was independent of hospital volume but only high-volume centers realized an average lower aggregate cost of care (-$4,803; 95% CI: [-$8,341, -$1,265]) when utilizing LDP.  In low (-$3,3010; 95% CI [-$8,008, $1,988]) to moderate (+$3,606; 95% CI [-$6,629, $13,841]) volume centers, the aggregate costs of care for LDP and ODP were statistically identical. 

Conclusion:
Patients undergoing LDP have a lower risk of prolonged overall LOS relative to those undergoing ODP. This association is independent of hospital volume but translates into cost savings in high volume centers only. This finding suggests that high volume centers develop efficiencies of scale that allow them to realize aggregate cost savings when utilizing laparoscopic approaches to DP. 

75.01 Current Preoperative Ultrasound Imaging of Gallbladder Polyps is Unspecific and Risks Overtreatment

Posted on January 31, 2019

S. Z. Wennmacker1, E. De Savornin Lohman1, P. De Reuver1, N. Hasami1, M. Boermeester2, J. Verheij3, E. Spillenaar Bilgen4, J. Meijer5, K. Bosscha6, H. Van Der Linden7, I. Nagtegaal8, J. Drenth9, C. Van Laarhoven1  1Radboudumc,Surgery,Nijmegen, Netherlands 2AmsterdamUMC,Surgery,Amsterdam, Netherlands 3AmsterdamUMC,Pathology,Amsterdam, Netherlands 4Rijnstate Hospital,Surgery,Arnhem, Netherlands 5Rijnstate Hospital,Pathology,Arnhem, Netherlands 6Jeroen Bosch Hospital,Surgery,’s-Hertogenbosch, Netherlands 7Jeroen Bosch Hospital,Pathology,’s-Hertogenbosch, Netherlands 8Radboudumc,Pathology,Nijmegen, Netherlands 9Radboudumc,Gastroenterology And Hepatology,Nijmegen, Netherlands

Introduction: Cholecystectomy is only needed for neoplastic gallbladder polyps, in order to halt or prevent the development of gallbladder cancer. Current international guidelines advocate surgery for all gallbladder polyps ≥1cm, in view of the elevated risk of neoplasia of these polyps. However, the validity of this threshold may be questioned as one third of the polyps are wrongly classified. The aim of this study was to identify preoperative clinical and imaging characteristics associated with neoplastic polyps. Secondly, the concordance between imaging findings and pathological findings of gallbladder polyps was assessed.

Methods: A retrospective analysis of all histopathologically proven gallbladder polyps in four Dutch hospitals between 2003-2013 was performed. Patients were identified through PALGA, the Dutch nationwide network and registry of histo- and cytopathology. Clinical and imaging characteristics of patients with neoplastic versus nonneoplastic polyps were assessed using univariable and multivariable analysis. Concordance of polyp size, number of polyps and polyp type on ultrasound and histopathology were assessed using McNemars’ test, and subsequent sensitivities and specificities were calculated.

Results: A total of 208 patients were included of whom 95 patients (43.7%) were diagnosed with a neoplastic polyp on histopathological evaluation. Patients’ age (OR 1.06 per year (1.03-1.08), p<0.001) and a history of gallbladder disease (OR 2.80 (1.03-7.62), p=0.04) were significantly associated with neoplastic polyps on multivariable analysis. A total of 156 patients underwent preoperative ultrasound. In 88 patients (56.4%) the polyps were preoperatively identified on ultrasound. Polyp characteristics (shape, surface, echogenicity and internal echogenic pattern) were frequently unreported in imaging reports. Polyp size and number of polyps on ultrasound were significantly associated with neoplastic polyps in univariable, but not in multivariable analysis. Polyp size as assessed on ultrasound was significantly inconsistent with size on histopathology (p=0.002). Sensitivity and specificity of ultrasound for polyp size ≥1cm were 96% and 41%, for presence of a single polyp 92% and 62%, and for identifying neoplastic polyp type 70% and 25%.

Conclusion: Patients >50 years of age and with a history of gallstone disease are more likely to have neoplastic polyps. Current standard preoperative (ultrasound) imaging has low specificity for polyp size, presence of a single polyp, and the overall diagnostic accuracy of ultrasound in establishing polyp type is poor, risking considerable surgical overtreatment of patients with nonneoplastic polyps.

74.10 Impact of Socioeconomic Status on Surgical Outcomes: Does it Matter in Rural Areas?

Posted on January 31, 2019

F. Rahim1, E. De Jager1, M. A. Chaudhary1, J. M. Havens3,4, E. Goralnick1,2, A. Haider1,4  1Center for Surgery and Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Emergency Preparedness And Access Center,Boston, MA, USA 3Harvard School Of Medicine,Brookline, MA, USA 4Brigham And Women’s Hospital,Surgery,Boston, MA, USA

Introduction:
Emergency General Surgery (EGS) conditions account for more than 2 million US hospital admissions annually. EGS patients in the highest income quartile have lower odds of mortality compared to the lowest income quartile, which may be related to a disparity in access to high quality centres. Rural areas have fewer providers and subsequently less provider choice compared with urban areas. Our objective was to examine if the high income EGS survival benefit holds true in rural areas. 

Methods:
The National Inpatient Sample (2007-2014) was queried for patients aged 18-64, with a primary diagnosis of the American Association for Surgery of Trauma’s 10 most common EGS procedures. The effect of patient income quartiles on surgical adverse events (total complications and mortality) was assessed using multivariable regression models in urban and rural cohorts adjusting for age, race/ethnicity, sex, Charlson Comorbidity Index, insurance status, hospital region and teaching status. 

Results:
1,687,828 patients underwent one of the EGS procedures performed during the study period. 16.59% (n=280,036) of patients were rural. The overall distribution of income quartiles was 21.35% (n=351,500) highest, 24.37% (n=401,292) high middle, 25.78% (n=424,409) low middle and 28.50% (n=469,152) lowest. Compared to urban settings, rural settings had higher mortality (1.16 vs 1.23% p<0.001) and complication rates (15.46 vs 16.54%, p<0.001) in our univariate analysis. In the urban cohort multivariate analysis, lower income quartiles were associated with higher odds of in hospital mortality and total complications relative to the high-income quartile. In the rural cohort, income quartiles were not associated with the odds of adverse events (Table).

Conclusion:
Patients in the highest income had a survival benefit and lower risk of postoperative complications in urban but not in rural settings. The disparity in EGS outcomes between higher and lower socioeconomic status in urban settings, but not in rural settings, could be related to limited provider choice in rural areas. 

74.09 Using the Social Vulnerability Index to Examine Local Disparities in Emergent and Elective Cholecystectomy

Posted on January 31, 2019

H. Carmichael1, A. Moore1, L. Steward1, C. G. Velopulos1  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:
The Social Vulnerability Index (SVI) is a composite scale formulated by the Centers for Disease Control to determine resource allocation for natural disasters. It includes 15 variables in four categories of socioeconomic status, household composition/disability, minority status/language, and housing/transportation, and is geocoded as a percentile ranking at the census tract level. Because many of these variables are associated with disparity in access to surgical care, SVI is potentially applicable to assess risk and target populations that are likely to present emergently for disease that could have been treated electively. Because regional variation exists in access to care, future interventions depend on understanding disparity at the discrete, local level. We applied the SVI to compare cholecystectomy patients presenting emergently versus electively.

Methods:
We identified patients who had undergone cholecystectomy at our academic medical center over a 6-month period. We excluded patients <18 yo and pregnant patients. Cases were classified as emergent or elective; cases where the patient presented electively for interval operation after a presentation in the emergent setting requiring intervention were excluded. We abstracted patient demographics, residential address, insurance status, chronic and acute symptom duration, diagnosis, and operative outcomes from the EMR. Patient addresses were geocoded to identify their census tract of residence and estimated SVI. Wilcoxon rank sum tests were used for univariable analysis, followed by multivariable logistic regression modeling.

Results:
Of 289 patients who underwent cholecystectomy, 267 met inclusion criteria. Most patients (n=196, 73.4%) had surgery in the emergent setting. Emergent patients lived in areas of greater social vulnerability compared to elective patients (median SVI 75th vs. 64th percentile, p=0.007). On multivariable analysis adjusting for patient age, sex and chronicity of symptoms, having high SVI (>80th percentile) was associated with higher odds of undergoing an emergent versus an elective procedure (OR 2.19, p=0.02). Models were then compared, with AUC of 0.819 for a model including insurance, PCP, minority, and need for interpreter versus AUC of 0.831 for the model using SVI only.

Conclusion:
The SVI has potential utility for examining health care disparities, performing comparably to a more complex model. Because it is a composite measure geocoded at the census tract level for all communities in the United States, it has potential for targeting relatively discrete geographic areas for intervention. Being a geocoded measure also offers opportunity for linking with other datasets using Geographic Information Systems.
 

74.08 Medicare Reimbursement Trends for General Surgery Procedures: 2000 to 2018

Posted on January 31, 2019

J. M. Haglin2, A. E. Eltorai1, K. R. Richter2, A. H. Daniels1  1Brown University School Of Medicine,Providence, RI, USA 2Mayo Clinic School of Medicine,Scottsdale, AZ, USA

Introduction:  A complete understanding of financial trends in general surgery is lacking, particularly regarding procedural reimbursement rates. An evaluation of such economic trends and changes in reimbursement rates in general surgery is important for the specialty’s financial health. The purpose of this study was to evaluate the monetary trends from 2000-2018 in Medicare reimbursement rates for the most common general surgery procedures. 

Methods:  The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each of the top 10 procedures in general surgery, and comprehensive reimbursement data was extracted from this database. The total raw percent change in Medicare reimbursement rate for each procedure from 2000 to 2018 was calculated and averaged. This was statistically compared to the total percent change in consumer price index (CPI) over the same time, where CPI is a measure of inflation. Based on CPI from each year, all data was corrected for inflation. All trend analysis was then performed using this adjusted data. Both average annual and total percentage change were calculated based on these adjusted trends, as well as R-squared for all procedures. Compound annual growth rate was calculated using the adjusted data.

Results: After adjusting all data for inflation, the reimbursement rate for all included procedures decreased by an average of 26.9% throughout the study period. During this time, the adjusted reimbursement rate decreased by an average of 1.6% each year with an average compound annual growth rate of -1.8%, indicating a steady decline in reimbursement rate in general surgery.

Conclusion: This is the first study to evaluate trends in Medicare reimbursement rates in general surgery. After adjusting for inflation, Medicare reimbursement rates in general surgery have steadily decreased from 2000 to 2018. It is important that these trends are understood and considered by surgeons, healthcare administrators, and policy-makers in order to develop and implement agreeable models of reimbursement while ensuring access to quality general surgery care in the United States. 

 

74.07 Gender Bias in Surgical Publication: Improvement but Still Progress to be Made

Posted on January 31, 2019

L. T. Boitano1,2, K. L. Hart3, A. Tanious1,2, M. J. Eagleton1,2, K. D. Lillemoe2, R. H. Perlis3, S. D. Srivastava1,2  1Massachusetts General Hospital,Vascular And Endovascular Surgery, Surgery,Boston, MA, USA 2Massachusetts General Hospital,Surgery,Boston, MA, USA 3Massachusetts General Hospital,Center For Quantitative Health And Department Of Psychiatry,Boston, MA, USA

Introduction:  Despite an increase in the female graduates entering surgical residency, there remains a gender disparity in academic surgical leadership. Scholarly activity, as measured by scientific publications in high impact journals, is the foundation for academic promotion. Thus, this study seeks evaluate the distribution of authorship by gender over the last 10 years among the top 25 surgical journals.    

Methods:  Original research articles published in the 25 highest-impact general surgery and general surgery subspecialty journals between January 2008 and March 2018 were considered for inclusion. Excluded were journals for which at least 70% of author gender could not be identified. Articles were categorized by gender of first, last and overall authorship using the established genderize.io application programming interface (API) for R, which predicts gender and provides the probability of the associated gender. We examined changes in proportions of female first, last, and overall authorship over time, and analyzed the correlation between these measurements and journal impact factor.

Results: There were a total of 71,867 articles from 19 journals included for analysis. The general surgery and sub-specialty journals included in this analysis represent the following subspecialties: general surgery, cardiothoracic surgery, vascular surgery, transplantation, bariatric surgery, surgical oncology, colorectal surgery, plastic surgery, surgical pathology and trauma and acute care surgery. Gender was successfully predicted for 87.3% of authors (range: 79.1%-92.5%). There were significant increases in the overall percentage of female authors (β = 0.55, p = 1.01e-6), in the percentage of female first authors (β = 0.97, p = 1.69e-8), and in the percentage of female last authors (β = 0.53, p = 3.09e-5) over the 10-year study period. In regards to last author, one journal, Eur J Cardiothorac Surg (β= -0.5), had a significant decrease in the proportion of female last authors. Furthermore, all journals representing the cardiothoracic subspecialty failed to show a significant increase in the proportion of female last authors over the study period. There were, however, no significant correlations between the impact factor of the journal and the overall percentage of female authors (rs = 0.39, p = 0.09), percentage of female first authors (rs = 0.29, p = 0.22), or percentage of female last authors (rs = 0.35, p = 0.13).

Conclusion: The current study identifies continued but slow improvement in female authorship of high impact surgical journals during the contemporary era. However, the improvement was more apparent in the first author compared to senior author positions.

 

74.06 Do EGS Outcomes Differ Among Homeless Patients in Medicaid Expansion vs Non-Expansion States?

Posted on January 31, 2019

R. Manzano-Nunez1, J. P. Herrera-Escobar1, C. K. Zogg2, N. Bhulani1, T. Andriotti1, J. C. McCarty1, T. Uribe-Leitz1, M. Jarman1, A. Salim1, A. H. Haider1, G. Ortega1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Yale University School Of Medicine,New Haven, CT, USA

Introduction:  State decisions not to implement Medicaid expansion under the Affordable Care Act have the potential to leave many homeless individuals without an affordable insurance coverage option, which in turn could be associated with worse outcomes and higher costs. We hypothesize that by placing additional obstacles in the flow of care of homeless patients requiring emergency general surgery (EGS) operations, non-expansion states impact patient outcomes and their health-related decision-making process. 

Methods:  We used 2014 State Inpatient Database claims to identify homeless individuals admitted with a primary EGS diagnosis, as defined by the American Association for the Surgery of Trauma, who underwent a surgical procedure. Data related to homeless status was available for nine states (AZ, CO, FL, GA, MA, MD, NY, WA, and WI). States within this group were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression (MQR) models at the 50th, 75th and 90th quantiles accounting for variations in age, gender, race/ethnicity, insurance status and Charlson Comorbidity Index were used to examine associations between non-Medicaid expansion states and (1) LOS and (2) total index hospital charges within the homeless population. Multivariable logistic regression (MLR) models, adjusted for the same variables, were fitted to examine the associations between non-Medicaid expansion and discharge against medical advice, surgical complications, and mortality.

Results: A total of 6,930 homeless patients were identified. Of these, 435 (6.2%) were admitted in non-expansion states. Seventy-four percent (n=5,162) were insured through Medicaid (77.4% in Medicaid expansion states; 30.3% in non-expansion states). Homeless individuals living in non-expansion states had significantly higher total hospital charges and longer hospital stays (Table). After adjusting for confounders, MQR showed that non-Medicaid expansion was associated with longer LOS and higher charges (Table). The effect was observed in all quantiles examined.  MLR showed no differences in mortality (OR=1.4, 95% CI, 0.8-2.6; p=0.1) or surgical complications (OR=1.1, 95% CI 0.7-1.8; p=0.4). However, homeless individuals living in non-expansion states did have higher risk-adjusted odds of being discharged against medical advice (OR= 2.1, 95% CI, 1.08-4.05 p=0.02). 

Conclusion: Homeless patients living in Medicaid expansion states had reduced LOS, lower odds of being discharged against medical advice, and overall lower total index hospital charges. Not expanding Medicaid appears to result in the persistence of worse modifiable outcomes and increased hospital charges for an often-overlooked segment of the EGS population least equipped to handle them.
 

74.05 Incidence of Appendicitis in Washington State and the Tri-County Puget Sound: A Spatial Analysis

Posted on January 31, 2019

F. T. Drake1, R. Golz3, C. Donovan3, X. Liu3, D. R. Flum2, S. E. Sanchez1  3San Francisco State University,Geography And Environment,San Francisco, CA, USA 1Boston Medical Center,Boston, MA, USA 2University Of Washington,Seattle, WA, USA

Introduction: Acute appendicitis (AA) has long been considered an ideal model for studying surgical disparities because AA is thought to be random in onset and to inevitably progress towards perforated appendicitis (PA) without treatment. However, these assumptions may be inaccurate. Most studies of risk factors for perforation rely on proportions of PA among cases of AA, but this depends on an equivalent baseline risk of AA across groups being compared. We studied geographic patterns in population-based incidences of AA and PA and evaluated these patterns for associations with socioeconomic status (SES).

Methods: We queried a statewide administrative database for adults with appendicitis treated between 2008-2012. Population estimates were based on the 2010 US Census. We generated age/sex-standardized incidences for AA and PA at the census tract level. The Tri-county Puget Sound was our analytic area (>50% WA population). Geographic correlation of incidence rates (“clustering”) was examined using Moran’s Index for spatial dependency.

Results: Overall annual incidence of AA and PA was 106/100,000 and 29/100,000. Incidence was strongly associated with male sex and peaked at 10-19 years. Age/sex-standardized incidence of AA showed strong geographic clustering (Moran’s Index 0.30, p<0.001), meaning it is not randomly distributed across the region. PA was also clustered (0.16, p<0.001), but the geographic association was only half as strong. Areas of low-incidence (“cold spots”) and high-incidence (“hot spots”) were identified using the Getis-Ord GI* statistic [Figure]. One low-incidence region, the Seattle area, had an AA incidence of 88/100,000/year. A comparable hot spot, the Tacoma area, had an AA incidence of 120/100,000/year. However, the rate ratio of PA to AA was similar: 0.29 for low-incidence regions and 0.26 for high incidence regions. SES markers such as college education and income were dramatically higher in low incidence regions compared to high incidence regions. Other SES markers were similar, including high school education, employment, public assistance, and race.

Conclusion: Incidence of appendicitis is not randomly distributed across geographic space, and AA is twice as clustered as PA. These findings challenge the conventional view that AA occurs randomly and has no predisposing characteristics or circumstances. Rate-ratios are similar between high incidence and low incidence regions. Interestingly, major markers of advantaged-SES are strongly associated with low-incidence regions of PA and AA. Relationships between SES and both AA/PA are more complex than previously understood, and proportion of PA is an inadequate measure of surgical disparities.

 

74.04 Healthcare utilization in older adults after emergency general surgery versus acute medical illness

Posted on January 31, 2019

K. C. Lee1,2, D. Sturgeon1, S. Mitchell4,5, A. Salim1,3, Z. Cooper1,3,4  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2University of California, San Diego,Department Of Surgery,La Jolla, CA, USA 3Brigham And Women’s Hospital,Division Trauma, Burns, And Critical Care,Boston, MA, USA 4Hebrew Senior Life Institute for Aging Research,Boston, MASSACHUSETTS, USA 5Beth Israel Deaconess Medical Center,Department Of Medicine,Boston, MA, USA

Introduction: Although 40% of emergency general surgery (EGS) procedures are performed in older adults, long-term outcomes remain understudied in this population. Furthermore, few studies have contextualized outcomes after EGS with acute hospitalizations for other common, high-risk medical conditions that have been targets for national quality improvement, such as pneumonia (PNA), acute myocardial infarction (AMI), or congestive heart failure (CHF). We hypothesized that older EGS patients have similar one-year survival and healthcare utilization compared to matched patients with an acute medical admission.

Methods:  Patients 65 years or older were identified from 100% fee-for-service Medicare claims data from January 1, 2008 to December 31, 2014. EGS patients received one of the five highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, laparotomy). Medical patients were emergently admitted for PNA, AMI, or CHF. Patients were propensity-score matched based on age, gender, race/ethnicity, Medicare region, Charlson score, frailty index, hospital bed size, teaching hospital status, year of admission, and intensive care unit (ICU) stay. Bivariate analysis and a Cox regression model accounting for competing risk of death, hospital-level clustering, and follow-up time were performed to compare one-year mortality and healthcare utilization (rehospitalization, emergency department [ED] visit, and ICU stay) between the two groups. 

Results: Propensity matches were obtained for 471,429 pairs. EGS patients and medical patients had an in-hospital mortality of 9.5% and 5.5% respectively, and experienced similar one-year mortality (adjusted hazard ratio [95% CI]: 0.96 [0.95-0.97]). In bivariate analysis, EGS patients had lower rates of ED visit (56.4% vs 64.6%, p<0.0001), re-hospitalization (26.1% v. 30.3%, p<0.0001), and ICU stay (21.7% vs 31.0%, p<0.0001) in the year after discharge compared to medical patients. After Cox regression, EGS patients had a lower hazard of healthcare utilization in the year after discharge compared to medical patients (Table).

Conclusion: Older EGS patients experience comparable one-year mortality to patients with acute medical admissions. Although hospital use after discharge is less likely when compared to medical patients, over 50% of EGS patients experience an ED visit and over 25% are re-hospitalized in the year after discharge. As such, EGS quality improvement programs are also needed to reduce healthcare utilization, identify targets for resource allocation, and improve outcomes among older patients.

 

74.03 Impact of Hospital-Level Resources on Timing of and Outcomes for Appendectomy and Cholecystectomy

Posted on January 31, 2019

A. Ingraham1, A. Z. Paredes2, A. Diaz2, A. P. Rushing2, K. B. Ricci2, V. T. Daniel3, D. Ayturk3, H. E. Baselice2, S. A. Strassels2, H. Santry2  3University Of Massachusetts Medical School,Worcester, MA, USA 1University Of Wisconsin,Surgery,Madison, WI, USA 2Ohio State University,Columbus, OH, USA

Introduction: The timing of appendectomy and cholecystectomy, the two most frequent procedures performed non-electively by general surgeons, can be influenced by hospital-level operative resources. We measured the impact of hospital-level structures and processes related to operating room (OR) access on the timing of as well as the outcomes following appendectomy and cholecystectomy.

Methods: In 2015, we surveyed 2,811 US hospitals on emergency general surgery (EGS) practices, including how OR access is assured (e.g., block time, OR staffing, etc.). 1,690 hospitals (60%) responded. We linked survey data to 2015 Statewide Inpatient Database data from 17 states using American Hospital Association identifiers. We identified patients ≥18yrs who underwent an appendectomy or cholecystectomy urgently/emergently for appendicitis or cholecystitis (without choledocholithiasis) respectively. Patients transferred from another acute care facility were excluded. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to measure the association between OR resource variables and the timing of operation (early [date of admission] vs late [any other date]). Similar models measured the association between the timing of operation and major operative complications, systemic complications, and length of stay (LOS).

Results: Of 510 hospitals representing 17 states, 327 (64%) had no block time for EGS cases. Daytime surgeons covering EGS were free from other clinical duties at 59 (12%) hospitals; 234 (46%) hospitals lacked in-house overnight surgeon coverage. A total of 24,195 appendectomy or cholecystectomy patients were identified at these hospitals. 8,536 (97%) patients with appendicitis and 10,299 (67%) patients with cholecystitis underwent early surgery, respectively. Limited block time as well as the absence of dedicated daytime coverage and in-house overnight coverage were associated with decreased odds of an early operation (Table). Overall, late operation was associated with decreased odds of major operative complication (OR 0.75, 95% CI 0.68-0.84), increased odds of systemic complication (OR 1.41, 95% CI 1.29-1.54), and increased LOS (Coef 2.23, 95% CI 2.14-2.32).

Conclusions: While the majority of appendicitis and cholecystitis patients undergo early operation, our findings suggest that efforts to ensure timely access to surgery may reduce time to surgery and possibly result in fewer complications and shorter LOS. Given the large numbers of patients with these diseases seen annually, these results have implications for hospital-level processes to identify and reduce barriers to OR access.

 

74.02 Operating Room Personnel Response to Surgeon Behavior: Predictors of Sex-Based Bias

Posted on January 31, 2019

E. M. Corsini1, J. G. Luc2, K. G. Mitchell1, N. S. Turner1, A. A. Vaporciyan1, M. B. Antonoff1  1University Of Texas MD Anderson Cancer Center,Thoracic And Cardiovascular Surgery,Houston, TX, USA 2University Of British Columbia,Cardiovascular Surgery,Vancouver, BRITISH COLUMBIA, Canada

Introduction:
While recent attention has been directed toward exploring differential treatment of male versus female health care professionals in the hospital setting, detailed understanding is lacking regarding those circumstances which may contribute to display of bias. The operating room (OR) provides a unique setting in which to examine these biases, which are of particular interest given the changing face of surgery in recent years. We sought to evaluate the presence of sex-based biases of OR staff in response to surgeon behaviors, as well as explore predictors of such bias.

Methods:
We performed a prospective, randomized study in which OR personnel, including registered nurses (RN), surgical technologists (ST), and surgical assistants (SA), were asked to assess questionable surgeon behaviors across a standardized set of 5 scenarios via online survey. Respondents were randomized to surveys that either described a female or male surgeon, with all other aspects of the survey identical. For each scenario, respondents were asked to identify the behavior as Acceptable; Unacceptable but would ignore; Unacceptable and would confront surgeon directly; or Unacceptable and would report to OR management. Detailed demographic information was also collected. Analyses compared respondents’ assessments of surgeon behaviors with the sex of the surgeon and respondent characteristics; χ2 was used to identify associations among these variables.

Results:
3,186 respondents completed the survey (response rate=4.5%), among whom 81% were female, 54% were RN, 21% were SA, and 15% were ST. Assessed across all scenarios, likelihood to write up the surgeon was predicted by job role: ST, RN, and SA reported surgeons with frequencies of 65.5%, 53.2%, and 48.8%, respectively (p=0.008). Moreover, ST were also more likely to specifically report female surgeons (p=0.006) than other OR staff, (Table). When scenarios were evaluated individually, there were participants who reported female surgeons more frequently than males, including staff at academic hospitals (p=0.031), staff with more than 15 years’ experience (p=0.005), and male RN (p=0.034). Similarly, certain groups found particular behaviors more appropriate when they were exhibited by a male, rather than female, surgeon, including millennial respondents (p=0.011).

Conclusion:
Role appears to be predictive of sex bias in the OR, with ST evaluating behaviors of female surgeons more critically than males.  More subtle implicit sex biases may exist between other OR staff and surgeons, yet such attitudes are complex and may not be uniformly present. Additional investigations are needed to determine the interpersonal and task-related circumstances which may accentuate these biases.
 

74.01 Nationwide Post-Discharge Outcomes in Adults Undergoing Non-Operative Treatment of Acute Appendicitis

Posted on January 31, 2019

A. J. Rios Diaz1, D. Metcalfe2, C. L. Devin1, A. C. Berger1, F. Palazzo1  1Thomas Jefferson University Hospital,Department Of Surgery,Philadelphia, PA, USA 2University of Oxford, John Radcliffe Hospital,,Nuffield Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences (NDORMS),Oxford, OX3 9BU, United Kingdom

Introduction: A number of randomized controlled trials have suggested that non-operative treatment of acute appendicitis is an acceptable alternative to appendectomy. However, it is not yet clear what implications this has for patients or the healthcare system in the United States. We hypothesized that those treated non-operatively would have higher inpatient healthcare utilization after discharge.

Methods:  All adult patients (≥ 18 years old) admitted with a ICD-9-CM diagnosis of acute appendicitis (with or without peritonitis, or with abscess) between 2010 and 2015 were identified from the Nationwide Readmission Database (NRD). Transfers between hospitals and incomplete follow up were excluded. The NRD is a nationally-representative database that permits longitudinal tracking of patients between hospital admissions. The outcomes were 30- and 180-day readmission, mortality, complications, and prolonged hospital length of stay (>75th percentile). Multivariable logistic regression models were used to adjust outcomes for differences in and hospital characteristics.

Results: Records from 406,478 with acute appendicitis were extracted, of which 96.3% were treated operatively and 3.7% non-operatively. The patients treated non-operatively were more likely to be older (49 vs. 43 years, p<0.01), be admitted to a teaching hospital (63.5% vs. 45%, p<0.01), have public insurance (Medicare/Medicaid; 38.2% vs. 28.5%, p<0.01), have comorbidities (Charlson Comorbidity Index >=2, 12.5% vs. 5.9%, p<0.01), present with peritonitis (29.6% vs. 18.8%) or abscess (36.6% vs. 13%, p<0.01). The non-operatively treated patients were less likely to be discharged home (87.2% vs. 94.9% p<0.01). Readmission rates between the two groups were 10.6% vs. 5.2% at 30 days and 24.2% vs. 9.5% at 180 days (all p<0.01). This trend persisted within multivariable regression models (30-day adjusted odds ratio [aOR] 1.55, 95% confidence interval [95% CI] 1.41-1.71; and 90-day aOR 2.24, 95% CI 2.09-2.41; see Table). Of those readmitted within 180 days, 20.3% were readmitted to a different hospital, and of those initially treated non-operatively, 14.5% underwent an interval procedure.

Conclusion: Non-operative treatment of acute appendicitis is utilized in only a small proportion of patients. This strategy may have substantial resource implications as these patients may experience significantly higher utilization of the healthcare system, as demonstrated by increased readmissions as long as 6-months post-discharge.

 

73.10 Clinic-Based Education and Retrieval Program Related to Lower Use and Greater Disposal of Opioids

Posted on January 31, 2019

R. Khorfan1, J. Coughlin1,2, M. Shallcross1, B. Yu3, N. Sanchez3, S. Parilla1, K. Bilimoria1,3,4, J. Stulberg1,3,4  1Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Rush University Medical Center,Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 4Northwestern Memorial Hospital,Chicago, IL, USA

Introduction:
Opioid overdose continues to be a major cause of mortality in the U.S., with 42,249 deaths reported by the CDC in 2016. Between 50-70% of nonmedical users obtain prescription opioids through friends or relatives. With 70-90% of opioids prescribed after surgery going unused, disposal of these medications is a critical element for preventing opioid misuse, abuse, and death. We developed a multi-component opioid reduction program dedicated to supporting appropriate opioid drug disposal. Our objectives were to assess patient exposure to the interventions and associations with opioid use and disposal rates.

Methods:
We piloted a multicomponent opioid reduction intervention and implemented it in our Digestive Health Center (DHC) at Northwestern Memorial Hospital (NMH). Intervention components included; 1) patient education, 2) expectation setting, 3) provider education, and 4) an in-clinic disposal box. Patients were surveyed by phone 30-60 days after surgery regarding their experience with post-surgical pain management. Surveys were conducted from April – June 2018. Data were analyzed with descriptive statistics and are reported here. Data collection will continue with planned analyses including bivariate and multivariate regression analyses.

Results:
Fifty-five of 204 eligible patients agreed to participate in the telephone survey (27% response rate). Patients receiving both pre- and post-operative counseling on pain management were more likely to feel prepared to manage their pain (89%) than those who only received it pre- or postoperatively (72%). Patients who reported feeling prepared to manage their pain used fewer opioids on average than those who did not (7 vs 10 pills, respectively). Twenty-eight patients (78%) who filled their prescription had excess pills, and 21% disposed of their excess pills. Forty percent of patients who reported that they received opioid safety information disposed of their excess opioids, compared with 0% of those who did not.

Conclusion:
Exposure to clinic-based interventions can potentially decrease quantity of opioids used and increase disposal of excess opioids. Reinforcing patient education across phases of care may be key to achieving this effect. Nevertheless, additional strategies are needed to increase appropriate opioid disposal to prevent nonmedical opioid use and diversion.
 

73.09 Long-term Outcomes of Prehabilitation in Ventral Hernia Patients: A Randomized Controlled Trial

Posted on January 31, 2019

K. Bernardi1, O. A. Olavarria1, J. L. Holihan1, D. V. Cherla1, D. H. Berger2, T. C. Ko1, L. S. Kao1, M. K. Liang1  1McGovern Medical School at UT Health,General Surgery,Houston, TX, USA 2Baylor College Of Medicine,General Surgery,Houston, TX, USA

Introduction:  Obesity and poor fitness are associated with complications following ventral hernia repair (VHR). We previously presented the early outcomes of a randomized controlled trial (RCT) comparing prehabilitation and standard care among obese patients seeking VHR. Prehabilitation, or preoperative nutritional counseling and exercise, was associated with higher percentage of patients who lost weight, achieved preoperative weight loss goals, and underwent VHR. Also, patients in the prehabilitation group had a lower percentage of wound complications and were more likely to be hernia-free and complication-free up to 7 months post randomization.  We hypothesized that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2 years post randomization.?

Methods:  This was a blinded RCT at a safety-net academic institution. Obese patients (BMI 30-40) seeking VHR were randomized to prehabilitation versus standard counseling.  Prehabilitation included a multi-disciplinary approach with nutritional counseling, physical therapy sessions, and weekly meetings. Standard counseling consisted of a standardized script discussed during preoperative appointments. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years post randomization. Complications included recurrence, need for re-operation, and mesh complications (such as mesh infection). ?

Results: A total of 118 patients were randomized, 110 (93.2%) completed a median (range) follow-up of 26.6 (19.1- 35.6) months. Baseline BMI (mean±SD) was similar between the two groups (36.8±2.6 in prehabilitation and 37.0±2.6 in standard counseling). At late follow-up, there was no difference in the percentage of patients who were hernia-free and complication-free (75.0% versus 68.5%, p=0.527) (Table). Almost half of all patients, 44.2% in prehabilitation and 43.2% in standard counseling, gained weight over their baseline and 14.5% of patients (5 with prehabilitation, 10 with standard counseling) sought hernia repair elsewhere. ?

Conclusion: While prehabilitation compared to standard care resulted in a higher percentage of patients who were hernia- and complication-free in the short-term, there is no difference in long-term results. This may be because patients often regain the weight they lost or seek VHR elsewhere if they fail to meet preoperative requirements.  Continuing diet and exercise programs even after VHR along with establishing national guidelines and changes in compensation may be important components of tackling VHR in obese patients. ?

73.08 Transfer Status is Associated with Increased Mortality in Necrotizing Soft Tissue Infections

Posted on January 31, 2019

M. K. Khoury1,2, M. L. Pickett1, T. Hranjec1, S. A. Hennessy1, M. W. Cripps1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
A necrotizing soft tissue infection (NSTI) is a life-threatening surgical emergency associated with significant morbidity and mortality. These patients often require multiple debridements, intensive care, and complex wound management. Therefore, it is thought that NSTIs are best treated in large tertiary centers. While regionalization of care for emergency general surgery patients has been a topic of debate, there is evidence that shows it can improve outcomes. In this study, we used NSTIs as a surrogate for patients in need of higher level of care and examined whether transfer status affected outcomes.

Methods:
We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with necrotizing fasciitis from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (Transfer-NSTI) were compared to those who were primarily treated at a tertiary center (Primary-NSTI). These patients were compared on demographics, comorbidities, surgical debridement, and outcomes. The primary endpoint was in-hospital mortality. Early transfer was defined ≤1 hospital day at the OSH, while late transfer was defined as >1 hospital day at the OSH. Patients were compared by univariate analysis using Wilcoxon rank sum, Chi-square, and Fisher’s exact tests where appropriate.

Results: 

A total of 138 NSTI patients were identified with an overall mortality rate of 20.3%. Of these, 99 (71.8%) were Primary-NSTI patients and 38 (28.2%) were Transfer-NSTI patients. The mortality rate was significantly higher for Transfer-NSTI patients compared to Primary-NSTI patients (33.3% versus 15.2%, p=0.032). Transfer-NSTI patients had significantly higher rates of mechanical ventilation (68.4% versus 46.4%, p=0.019). There was no difference in mortality in Transfer-NSTI patients that were debrided prior to transfer than those who were not debrided (36.0% versus 25.0%, p=0.71.). There was also no difference in mortality for patients who were transferred early (30%) versus those who were transferred late (38.1%).

Conclusion: 

Regionalization of care has shown significant improvement in survival for injured patients and many believe the same will be true for emergency general surgery. Using NSTI as a surrogate for patients in need of higher level of care, we identified that primary treatment of NSTI at a large tertiary has significantly better outcomes than those who were transferred. However, large multi-institutional studies are needed to identify risk factors for morbidity and mortality in transfer patients to improve outcomes.

73.07 Impact of ERAS Implementation on Racial Disparities at the VA

Posted on January 31, 2019

C. M. Rentas1, L. Goss1, S. Baker1, J. Richman1, S. Knight1, M. Morris1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Racial disparities in post-operative length of stay (pLOS) exist. Enhanced Recovery After Surgery (ERAS) has been shown to reduce racial disparities following surgery at large Academic Medical Centers. We hypothesized that racial disparities in pLOS exist among veterans at a Veterans Affairs Hospital and implementation of an ERAS protocol would mitigate these disparities.

Methods: A cohort study was conducted at the Birmingham VA Medical Center between January 2012 and March 2018 for patients undergoing elective general surgery. All patients that underwent an operation using the ERAS protocol between January 2016- March 2018 were identified as ERAS patients. CPT Codes identified pre-ERAS patients that underwent similar operations from January 2012- January 2016. Demographic and procedural information was collected through Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients undergoing emergent surgery or who had an in-hospital mortality were excluded. The primary outcome assessed was the pLOS between the two racial groups (Black vs. White). Patient demographics, surgery characteristics, and complication rates were compared across groups using student’s t-test. Wilcoxon-ranked test was used to determine median LOS.

Results: Of 584 patients included (445 pre-ERAS vs. 139 ERAS), 36.1% were black. The average age of the cohort was 61.4 (SD 10.4) and 96% were male. Black and white patients were similar in age, body mass index, sex, and American Society of Anesthesiology class. Overall, ERAS patients had a significantly shorter pLOS (4 vs. 6 days) when compared with pre-ERAS patients (p<0.0001). Within the pre-ERAS group, median pLOS for black patients was 7 days and 6 days for white patients (p<0.44). Both groups experienced a decrease in length of stay from ERAS implementation. When compared to the pre-ERAS pathway, patients treated under the ERAS pathway had significantly shorter lengths of stay: black patients median pLOS of 4 days (IQR: 3-13) vs. 7 days, p<0.0237 and white patients median pLOS of 5 days (IQR: 3-7) vs. 6 days, p<0.0001. After implementation of the ERAS pathway, black and white patients had a similar pLOS (4 vs. 5 days, p<0.17).

Conclusion: Contrary to data published in non-VA settings, racial disparities did not exist in patients undergoing colorectal surgery.  Implementation of an ERAS pathway significantly reduced pLOS for both black and white patients in the VA hospital system.

 

73.06 Characterization of Wound Misclassification in Common Surgical Procedures

Posted on January 31, 2019

A. P. Worden1, P. Kandagatla1, I. Rubinfeld1, A. Stefanou1  1Henry Ford Health System/Wayne State University,Surgery,Detroit, MICHIGAN, USA

Introduction:  Wound class helps predict wound related complications and is useful for stratifying surgical site infection (SSI) reporting.  Misclassification could be significant as report cards increasingly affect reimbursement and publicly reported data. We sought to evaluate misclassification among commonly performed surgeries that are defined to be clean-contaminated or higher. We hypothesized that rates of misclassification are increasing, and this increasing trend may be correlated with laparoscopic approaches.
 

Methods:  The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005-2016 by CPT codes identifying common surgeries that are by definition not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Misclassification was defined as a procedure classified as clean.  Obtained information included year of surgery, pre-operative patient characteristics, intra-operative characteristics, laparoscopic vs open approach, wound complications, readmission, and mortality. Variables were compared between correctly and incorrectly classified patients. Multivariate logistic regression was performed to derive independent predictors of misclassification.

Results: We reviewed 789,221 cases, of which 17,696 (2.29%) were misclassified as clean. There were 75,684 colectomies (16,749 laparoscopic and 58,935 open), 374,564 cholecystectomies (347,894 laparoscopic and 26,670 open), 65,3940 hysterectomies (15,089 laparoscopic and 63,8851 open) and 25,6905 appendectomies (24,8491 laparoscopic and 8,414 open). Misclassification was associated with the type of procedure (p<0.01). Hysterectomy was the most commonly misclassified procedure (4.8%), and colectomy the most accurately classified (0.8%). Misclassification was lower in laparoscopic cases (2.1% vs 2.7%, p<0.01).

Misclassified cases increased from 2005 to 2016 (0.2% vs 3.7%, p<0.01). Misclassified patients were younger (46.7 vs 47.7 years, p<0.01) and had lower rates of HTN (27.7% vs 30.4%, p<0.01), COPD (2.0% vs 2.7%, p<0.01), smoking history (17.1% vs 18.8%, p<0.01), and steroid use (1.7% vs 3.0%, p<0.01).  Post-operatively, misclassified patients had lower rates of Clavien 4 complications (1.0% vs 2.7%, p<0.01), shorter length of stay (2.2 vs 3.2 days, p<0.01), and 30-day readmission (3.7% vs 5.0%, p<0.01). The rate of any SSI is decreased in misclassified patients (1.7% vs 3.4%, p<0.01). Open hysterectomy was the most significant positive predictor for misclassification (OR 3.34, p<0.01), while open appendectomy was the most significant negative predictor (OR 0.20, p<0.01).

 

Conclusion: Despite guidelines, there is an increasing trend of wound misclassification. Given that misclassified patients have better outcomes, misclassification may be affected by patient characteristics, operative approach, and type of procedure, rather than reflecting the true infectious burden. Further research is warranted to explore this phenomenon.
 
 

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