71.05 Safety of Thyroid Surgery in The Elderly: A Propensity-Score Matched Cohort Study.

Posted on January 31, 2019

V. Papoian1, F. P. Marji1, J. E. Rosen1, N. M. Carroll1, E. A. Felger1  1Georgetown University Medical Center,Surgery,Washington, DC, USA

Introduction:
Thyroid surgery is becoming more common in the elderly as the proportion of the population that is elderly continues to grow. Unfortunately, there are limited studies evaluating the complication rates of thyroidectomy in elderly patients. We aim to evaluate the relative risk of morbidity from thyroidectomy in patients greater than 75 years of age.

Methods:
Medical records were used to identify all patients older than 75 years undergoing thyroidectomy between 2001 and 2018 in a multi-hospital network. A matched control group was selected with use of a propensity score based on gender, ethnicity, type of surgery, insurance status and comorbidities. The Charlson Comorbidity Index was used to quantify comorbidities. Total complications included both thyroid surgery specific complications, including recurrent laryngeal nerve injury or dysfunction, dysphagia, symptomatic hypocalcemia, hematoma, and wound complications, in addition to systemic complications. Analysis was performed with the use of chi-square analysis and two sample t-tests. A subgroup analysis was performed for patients older than 80 years of age.

Results:
We identified 313 patients over the age of 75 years with a propensity score matched group of 313 patients. There was no difference between the percent female (73% vs 73%, p=0.92), race composition (p=0.91), insurance status (p=0.99), percent undergoing total thyroidectomy (84% vs 84%, p=0.91) and Charleston Index (2.6 vs 2.69, p=0.70) of the two groups. There was no statistically significant difference between post operative emergency room visits (7% vs 6%, p=0.61), readmissions (11.5% vs 8.6%, p=0.18), cardiovascular (1.3 vs 0.6%, p=0.42), pulmonary (3.2 vs 0.9%, p=0.07), or neurologic complications (1.0 vs 0.3%, p=0.34). No re-operations were noted in either group. Elder patients did have a longer length of stay (2.64 vs 1.29 days, p<0.01). The findings for the sub-analysis for patients over the age of 80 showed comparable findings to the entire cohort.

Conclusion:
Elderly patients did have a longer length of stay when compared to a matched younger population. Although, there was a trend with higher complication rates in the elderly, those differences did not reach statistical significance. The current results indicate that thyroidectomy in the elderly is as safe as it is in younger patients when accounting for comorbidities.
 

71.04 An Institutional Experience with Primary Hyperparathyroidism in the Elderly Over Two Decades

Posted on January 31, 2019

K. L. O’Sullivan1, T. W. Yen1, K. Doffek1, S. Wagner1, I. Mazotas1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Endocrine Surgery,Milwaukee, WI, USA

Introduction: Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (pHPT) and is associated with low morbidity. An increasing number of elderly patients are undergoing elective surgery and are at greater risk for morbidity and mortality. The aim of this study was to examine the presentation and indications for surgery based on age for pHPT patients at a high-volume institution over 20 years.

Methods:  This is a retrospective review of all patients who underwent initial parathyroidectomy for sporadic pHPT from 1/1999-3/2018. Elderly patients were defined as ≥75 years. To study the progression of pHPT over time, the cohort were divided into 3 timeframes: 1999-2007, 2007-2012, and 2013-2018. Demographic and clinical data were collected.

Results: Of the 1900 patients, 1508 (79%) were female. The median age was 59.7 years (range, 18-94); 202 (11%) were ≥75 years. For the entire cohort, preoperative median serum calcium, ionized calcium, parathyroid hormone (PTH), and 24-hour urine calcium levels decreased over time, while 25-OH vitamin D levels and patient body mass index (BMI) increased (Table). There was no difference in 24-hr urine calcium levels (p=0.06). Over the 3 timeframes, the elderly had lower preoperative serum calcium (11 vs 10.7 vs 10.7;p=0.05) and PTH (150.4 vs 111.9 vs 107.9;p<0.001) levels, but higher 25-OH vitamin D (16 vs 28 vs 31;p<0.001) levels. Fewer patients had fragility fractures (27% vs 20% vs 14%;p=0.005) and more reported symptoms of gastroesophageal reflux (24% vs 41% vs 46%;p<0.001). When compared to patients <75 years, the elderly had similar preoperative serum calcium levels (10.8 vs 10.9;p=0.91), higher PTH (102 vs 121;p<0.001) and creatinine (0.8 vs 0.9;p<0.001) levels, lower 24-hr urine calcium (315 vs 196;p<0.001) levels, and lower BMI (29.4 vs. 27.4;p<0.001). The elderly were more likely to be taking vitamin D (52% vs 43%;p=0.01), have osteoporosis (58% vs 21%;p<0.001), and a history of fractures (20% vs 10%;p<0.001); younger patients had higher rates of nephrolithiasis (27% vs 16%;p=0.001). Postoperatively, by age groups, there was no difference in rates of recurrent laryngeal nerve injury (1.5% in both groups) or hypoparathyroidism (1.4% vs. 2.0%).

Conclusion: Over the 3 timeframes, elderly patients who underwent parathyroidectomy for sporadic pHPT had lower serum calcium and PTH levels, although the clinical significance of these findings is unclear. There was no difference in endocrine-specific complications between the age groups, suggesting that parathyroidectomy in the elderly is not associated with higher morbidity and that elderly patients with hypercalcemia should be evaluated for pHPT and considered for surgical referral.

 

71.03 Predictive Value of Surgeon Performed Ultrasound In the Diagnosis of NIFTP

Posted on January 31, 2019

M. S. Sussman1, M. B. Mulder1, O. Picado1, J. I. Lew1, J. C. Farra1  1University Of Miami,DeWitt Daughtry Department Of Surgery: Division Of Endocrine Surgery,Miami, FL, USA

Introduction:  The reclassification of noninvasive encapsulated follicular variant papillary thyroid carcinoma (FVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) has been shown to decrease the reported risk of malignancy (ROM) for all categories within the Bethesda System for Reporting Thyroid Cytology (BSRTC), with the greatest impact seen in atypia /follicular lesion of undetermined significance (AUS/FLUS) or Bethesda III thyroid nodules. There are currently no clinical factors to help predict malignancy vs. NIFTP in indeterminate thyroid nodules. This study evaluates the utility of gene expression classifier (GEC) testing and surgeon performed ultrasound (SUS) features as predictive factors for NIFTP in patients with thyroid nodules.

Methods:  A retrospective review of prospectively collected data of 847 patients who underwent thyroidectomy at a single institution from 2010 to 2016 was performed. Pathology slides with a diagnosis of FVPTC (n=146) were re-reviewed by endocrine pathologists for reclassification to NIFTP. Risk of malignancy (ROM) overall and within each BSRTC classification was determined before and after the reclassification of NIFTP. GEC testing and SUS characteristics were compared in FVPTC vs. NIFTP patients to evaluate for predictive value with significance defined as P<0.05.

Results: Of 146 patients who underwent thyroidectomy for FVPTC, 22% were reclassified as NIFTP (n=32). Of the NIFTP group, 35% (n=11) had AUS/FLUS thyroid nodules. GEC testing was performed in 25 patients, of which 22 had a suspicious result. Suspicious GEC results between FVPTC (12%) and NIFTP (12%) pathologies were identical. On multivariate regression, SUS characteristics of echogenicity and microcalcifications were independent predictors of NIFTP vs. FVPTC. Isoechogenicity was predictive of NIFTP, whereas hypoechogenicity was predictive of FVPTC (OR 3 95% CI 1.3 – 7, p<0.05). Additionally, microcalcifications was predictive of FVPTC compared to NIFTP (OR 4 95% CI .9-18, p<0.05).

Conclusion: A significant proportion of AUS/FLUS thyroid nodules are NIFTP on final pathology. Although GEC testing has limited utility, SUS features such as isoechogenicity and the absence of microcalcifications may favor a diagnosis of NIFTP in such thyroid nodules. This may help guide and determine extent of thyroidectomy in these select cases. 

 

71.02 Surveillance Strategies for Benign Non-functional Adrenal Incidentaloma:A Cost Effectiveness Study.

Posted on January 31, 2019

K. O. Memeh1, M. A. Guerrero1, F. B. Maegawa1,2  1University Of Arizona,General Surgery,Tucson, AZ, USA 2Southern Arizona VA Health Care System,Surgery,Tucson, AZ, USA

Introduction:
There is significant global variation in both society guidelines and clinical practice regarding the surveillance of an initially diagnosed non-functional, radiologically-benign adrenal incidentaloma. Given the low likelihood of these lesions becoming functional or malignant, some clinician have questioned the utility of frequent long term surveillance ( FLTS) strategy compared to no surveillance(NS) strategy.  We sought to evaluate and compare the cost effectiveness of current guidelines in the United States ( FLTS) and Europe( NS). We hypothesized that the FLTS strategy would not be a cost effective approach to managing this group of patients.

Methods:
A Markov transition- state model was created comparing the FLTS and NS strategy for a 60 year old patient diagnosed with a non-functional, non-malignant adrenal incidentaloma after adequate initial work up. Cost estimates were obtained from published Healthcare Cost and Utilization Project and Medicare reimbursement databases. Utility and outcome probabilities were estimated from published literature. Sensitivity analysis was performed to determine the uncertainty of cost, outcome probability and utility estimates on the model.  A threshold of $ 100,000/ quality adjusted life year ( QALY) was used to determine cost effectiveness. 

Results:
The FLTS strategy produced an incremental cost of $12,521 with incremental effectiveness of 0.26 QALY giving an incremental cost- effectiveness ratio ( ICER) of  $181,773/QALY which exceeds the $100,000/QALY threshold for cost effectiveness. The FLTS strategy was not cost effective and this result was confirmed on multi-way sensitivity analysis using Monte Carlo simulation. 

Conclusion:

Frequent long term surveillance ( as described in the current US adrenal incidentaloma guideline) is not a cost effective strategy for the management of non-functional, radiologically-benign adrenal incidentaloma. 

 

71.01 Malignancy Rate of FDG-PET Avid Thyroid Nodules: Results of a US-based Single Institutional Cohort

Posted on January 31, 2019

A. G. Ramirez1, N. Nuradin1, U. Syed1, V. Grajales2, M. A. Zeiger1, J. B. Hanks1, P. W. Smith1  1University Of Virginia,Surgery,Charlottesville, VA, USA 2University Of Pittsburg,Urology,Pittsburgh, PA, USA

Introduction:
The incidence of 18F-fluorodeoxyglocose positron emission tomography (FDG-PET) avid thyroid incidentalomas is 1-2% with an associated 35% malignancy rate. Thus it is recommended that all FDG-PET avid thyroid lesions be evaluated with ultrasound (US) and fine needle biopsy. North American studies examining prevalence are mixed and difficult to interpret due to poor rates of clinical evaluation of these incidentalomas. Socio-demographic and clinical factors associated with surgical resection of incidentalomas and malignancy are also not well-defined. This study’s objective was to assess our single-institutional malignancy rate, and characterize factors associated with further evaluation of incidentalomas, and surgical resection.

Methods:
All patients undergoing FDG-PET from February 2000-March 2015 with focal thyroid uptake were identified. Those with a history of thyroid cancer or previously evaluated thyroid lesion were excluded. Patient characteristics, US and FDG-PET findings including maximum standardized uptake value (SUVmax) pathology results were reviewed. Descriptive statistics were performed using Student’s t-test and X2-squared test as appropriate. Factors were compared using parametric statistical methods and logistic regression to control for confounders.

Results:
Of 15,399 FDG-PET scans performed, 179 thyroid incidentalomas were identified (1.2%). 59/179(33%) underwent US and 49 (27.4%) had further histological evaluation. 13/49(26.5%) were resected with 10 (16.9%) confirmed malignancies.(Figure) Resection and malignancy were associated with higher SUVmax, p=0.0002 and p =0.0003, Bethesda classification 5-6, p=0.004 and p<0.0001, respectively. After adjustment for confounders, patients with a prior non-thyroidal cancer diagnosis regardless of stage (OR 0.19 p=0.004) were less likely to pursue evaluation of a thyroid incidentaloma. Patients who did not receive adjuvant therapy within 6 months of the FDG-PET (OR 3.9 p=0.012) and lesions with higher SUVmax (OR 1.13 p=0.004) were more likely to obtain US. Nodule size, TSH, and socio-demographic factors including age, race, sex, and insurance status were not significantly different for patients undergoing further evaluation of incidentaloma, receiving surgery, or malignancy.

Conclusion:
Our malignancy rate for imaged thyroid incidentalomas, evaluated and resected, was 16.9%, which is lower than previously reported (35%). These data are suggestive of epidemiological variation and differences in patient selection and preferences. Higher SUVmax and Bethesda classification were associated with malignancy. Despite this lower rate of malignancy, US and biopsy should be pursued when appropriate in the context of the patient’s overall clinical status.
 

70.10 Post-Operative Opioid Prescribing Practices: Do Pills Equal Satisfaction?

Posted on January 31, 2019

M. Flannery1, S. Stokes1, A. Jacobs1, T. Varghese1, R. Glasgow1, B. S. Brooke1, L. C. Huang1  1University Of Utah,General Surgery,Salt Lake City, UT, USA

Introduction:

In the era of patient-reported outcomes, patient satisfaction has become a key quality metric for grading providers and hospitals. A patient’s postoperative pain experience can affect these metrics. Providers may be tempted to prescribe excess pain medications to improve patient satisfaction scores. We hypothesized that satisfaction with pain control was not related to the quantity of opioids prescribed to the patient at discharge.

Methods:
We designed a prospective observational study to evaluate post-operative opioid prescribing and satisfaction among patients undergoing a broad spectrum of general, vascular, colorectal, and plastic surgery procedures at a single tertiary academic medical center. All patients received a survey to determine opioid use and satisfaction with pain control at their first post-operative follow-up visit. We extracted the quantity of opioids prescribed at discharge (normalized to hydrocodone 5 mg tablets) from the electronic medical records. Post-operative pain control satisfaction was compared with the quantity of opioids prescribed at discharge. We constructed hierarchical, mixed effects models using forward step-wise variable selection clustered by procedure to identify risk factors for patient dissatisfaction with pain control while adjusting for potential patient- and procedure-level confounders.

Results:
A total of 346 patients were contacted following surgery, and 289 patients completed the survey (response rate 84%). The distribution by specialty was 33% general, 22% vascular, 20% colorectal, 12% surgical oncology, 7% plastics, and 6% foregut. 83% of patients were satisfied with their pain control, 6% neutral, and 11% were dissatisfied. The median quantity of opioids prescribed normalized to hydrocodone 5mg tablets was 30 (IQR 15-40). After adjustment for time to follow-up, procedure, operative approach (e.g., open versus minimally invasive), and inpatient/outpatient stay, there was no statistical difference in the median number of opioids prescribed to dissatisfied patients compared to satisfied or neutral patients (41.7 ± 5.5 tabs vs. 33.1 ± 2.6 tabs, respectively; p=0.123). On univariate analysis, patient risk factors associated with dissatisfaction with pain control were past opioid use (p = 0.015), smoking history (p < 0.001), current alcohol use (p = 0.049), history of sexual abuse (p = 0.003), and history of attention deficit disorder (p = 0.015). After adjustment using multivariable regression models, we found a significant association between dissatisfaction and past opioid use (OR 3.33, 95% CI 1.12-9.94) and current alcohol use (OR 3.77, 95% CI 1.16-12.22).

Conclusion:
Prescribing more opioids in this study was not associated with greater patient satisfaction after surgery. Patients with past opioid or alcohol use are more likely to be dissatisfied with their pain control. Further research is needed on how to improve pain control and satisfaction in this challenging patient population.

70.09 Sunshine in my Pocket: Industry’s Payments to Surgeons

Posted on January 31, 2019

R. Ahmed1,2, D. Segev2, S. Bloom1, A. Massie2, S. Eubanks1  1Florida Hospital,General Surgery,Orlando, FL, USA 2Johns Hopkins University School Of Medicine,General Surgery,Baltimore, MD, USA

Introduction: Collaboration between industry and surgeons is essential in developing new approaches to treat surgical patients. The Physician Payment Sunshine Act (PPSA) was implemented to publicly disclose financial transactions between industry and physicians, thus informing patients of potential conflicts-of-interest. The objective of this study is to characterize industry payments to surgeons.

Methods: We used the most recent PPSA data (January 2017-December 2017) to assess industry payments made to physicians listed as surgeons or surgical specialists in the CMS Open Payments website.

Results: Surgeons (N=61,2014) received a total of $660,474,480 during the 2017 fiscal year. The median (IQR) was $80 ($22-269). Among surgeons 25% received <$100; 41% received $100-$999; 26% received $1K-$10K; 7% received >$10K-$100K; and 1.6% received >$100K. The top 3 payment categories were royalties or licensing fees ($393,097,177); Consulting fees ($98,089,885); and speaker fees ($53,849,118). A total of 1,004 companies made payment to surgeons ($7 to $69,256,633), of which 10 comprised 66.5% of all payments. The highest to lowest median(IQR) payments by surgical specialty were: orthopedic surgeons $146 (37-782); pediatric orthopedic surgeons $114 (34-477); thoracic surgeons $104 (27-338); transplant surgeons $102 (26-432); neurosurgeons $98 (27-330); hand surgeons $90 (22-209); plastic surgeons $87 (24-203); vascular surgeons $77 (21-239); surgical oncologists $63 (20-198); general surgeons $56 (19-187); colorectal surgeons $55 (19-157); and critical care surgeons $55 (19-147).

Conclusion: The 2017 PPSA data demonstrate that 60% of total amount were made for royalties and licensing fees tp 3.5% of surgeons; 66 % of surgeons received <$1,000. Orthopedic surgeons were the highest paid specialists. Awareness of the PPSA data is critical for surgeons, as it provides a means to prevent potential public misconceptions about industry payments within surgeons that may affect patient trust.

 

70.08 Accurately Predicting 30-day Unplanned Postoperative Readmission Using Eight Predictor Variables

Posted on January 31, 2019

A. B. Singh1, D. R. Gibula3, M. R. Bronsert1, W. G. Henderson1, K. E. Hammermeister1, N. O. Glebova4, R. A. Meguid1  1University Of Colorado Denver,Aurora, CO, USA 3University Of Utah,Salt Lake City, UT, USA 4Mid-Atlantic Permanente Medical Group,Vascular Department,Rockville, MD, USA

Introduction: Unplanned postoperative readmissions may indicate inferior healthcare quality which adversely impact patient recovery and quality of life. Patients desire to know their risk of unplanned readmissions and the surgeons need to know the risk to adequately counsel their patients.  The existing Surgical Risk Preoperative Assessment System (SURPAS) shared decision making tool is a parsimonious model including eight predictor variables: Current Procedural Terminology-related risk, operative complexity, age, functional health status, American Society of Anesthesiologists physical status classification, in- or outpatient status, surgeon specialty, and emergency or elective operation.  Developed from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) dataset, SURPAS applies to >3000 operations in nine surgical specialties and predicts mortality, overall morbidity and eight clusters of common complications, and is incorporated into our health system’s electronic health record (EHR). We aim to develop an accurate preoperative prediction model for identifying the risk of unplanned postoperative readmission related to the primary procedure for integration into the EHR using all ACS NSQIP preoperative non-laboratory predictor variables and compare it to a model limited to the eight SURPAS predictor variables.

Methods: The full model was developed using logistic regression from all twenty-eight non-laboratory variables from the ACS NSQIP 2012-2016 dataset. It was compared to the model of the eight SURPAS predictor variables using the c-index as a measure of discrimination, the Hosmer-Lemeshow observed-to-expected plots testing calibration, and the Brier score, a  combined metric of discrimination and calibration

Results: Of 3,715,921 patients,149,648 (4.03%) experienced an unplanned readmission related to the initial operation.  The SURPAS model’s c-index, 0.727, was of 99.2% of that of the full model, 0.733, and Brier score of 0.0375 equal to the full model. Hosmer-Lemeshow analyses indicated similar calibration between the two models (see Figure).

Conclusions: The eight variable SURPAS model detects patients at risk for postoperative unplanned, related readmission as accurately as the full model developed from all available non-laboratory preoperative variables in the ACSNSQIP dataset.  Therefore, unplanned readmission can be integrated into the existing SURPAS tool providing accurate prediction of postoperative readmission without necessitating the collection of additional predictor variables.

We aim to develop an accurate preoperative prediction model for identifying the risk of unplanned postoperative readmission related to the primary procedure for integration into the EHR using all ACS NSQIP preoperative non-laboratory predictor variables and compare it to a model limited to the eight SURPAS predictor variables.

 

70.07 Does the Day of the Week Predict a Cesarean Section?: A Statewide Analysis

Posted on January 31, 2019

G. A. Del Carmen1, S. Stapleton1, M. Qadan1, D. Chang1, Y. Bababekov1, B. Zhang1, Y. Hung1, Z. Fong1, M. G. Del Carmen1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA

Introduction:  While guidelines for clinical indications of Cesarean sections (CS) exist, non-clinical factors may affect CS practices. We hypothesize that CS rates vary by day of the week.

Methods:  An analysis of the Office of Statewide Health Planning and Development database for California from 2006-2010 was performed. All female patients admitted to a hospital for attempted vaginal deliveries were included. Patients who died within 24 hours of admission were also excluded. Weekend days were defined as Saturday and Sunday; weekdays were defined as Monday through Friday. The primary outcome was rates of CS relative to vaginal delivery. Multivariate regression was performed, adjusting for patient demographic, clinical, and system factors.

Results: 1,855,675 women were analyzed. Overall CS rates were 9.02%. On unadjusted analysis, CS rates were significantly lower on weekends than on weekdays (6.65% vs. 9.58%, p<0.001). On adjusted analysis, women were 27% less likely to have a CS on weekends than on weekdays (OR: 0.73, 95% CI 0.71-0.75, p<0.001). In addition, Hispanic ethnicity and delivery in a teaching hospital were also associated with a decreased likelihood of CS (OR 0.91, 95% CI 0.86-0.96, p=0.01; OR 0.80, 95% CI 0.69-0.93, p <0.001, respectively).

Conclusion: CS rates are significantly decreased on weekends relative to weekdays, even when controlling patient, hospital, and system factors. Further exploration of this novel finding is warranted and will lead to improved quality of care for patients.
 

70.06 In pursuit of person-centered care: Do patients value competence over compassion?

Posted on January 31, 2019

K. Heinze3, P. A. Suwanabol2,6, K. Gibson1, B. Lansing1, C. A. Vitous6, P. Abrahamse5, L. Mody1,4  1University of Michigan,Internal Medicine,Ann Arbor, MI, USA 2University Of Michigan,Surgery,Ann Arbor, MI, USA 3St. Joseph’s Mercy Hospital,Ann Arbor, MI, USA 4Veterans Affairs Ann Arbor Healthcare System,Ann Arbor, MI, USA 5University of Michigan,Biostatistics,Ann Arbor, MI, USA 6University of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Focus has turned to the importance and often lack of compassion in providing high-quality healthcare. Patients routinely rank intrinsic physician characteristics higher than technical skills when caring for patients with cancer and in end-of-life care.  However, the preferences of patients in other scenarios such as during surgical interventions, chronic disease management, and pediatric conditions are not well studied. To address this, we sought to identify whether clinical or demographic characteristics influence patient preferences for a compassionate or a competent surgeon or physician.

Methods:  We sent 800 surveys to patients identified through the University of Michigan (U-M) Geriatrics Center and the U-M Research volunteer registries in July 2017. Surveys comprised 7 clinical vignettes followed by a 5-point Likert scale assessing the relative importance of surgeon or physician compassion or competence, and an open-ended question to elaborate on their choice. Multivariable logistic regression was performed on quantitative data and thematic analysis on qualitative responses.

Results: Of the mailed surveys, 36 were returned due to address changes, and we received 651 completed surveys (85% response rate). Older age (p < 0.001), male sex (p = 0.016), and higher income levels (p = 0.039) were associated with a preference of competence over compassion in surgical vignettes. Competence was more often preferred in surgical and pediatric scenarios, and less often in chronic care and end-of-life care scenarios where female sex (p = 0.008) and increasing number of physician visits per year (p = 0.01) were associated with a preference of compassion.

Thematic analysis demonstrated that patient preferences were influenced by: 1) explicit beliefs regarding their value of competence versus compassion; 2) perceived role of the surgeon or physician in various clinical scenarios; 3) impact of emotional and mental health on medical experiences; and 4) type and frequency of healthcare exposure. Furthermore, although patients desired a competent approach from surgeons overall, a complex interplay of preferences exists suggesting that compassion is a priority once competence is established and vice-versa (Table 1).

Conclusion: Overall, patients ranked competency higher than compassion particularly in surgical scenarios where technical skill was critical to the patient’s perception of a good outcome. However, qualitative analyses suggest that competence is a priority as long as compassion is established. These novel findings can inform surgeons and surgical training programs on how best to elicit, navigate and prioritize patient communication and informational needs in diverse clinical settings.
 

70.05 Comparison of the Accuracy of SURPAS vs ACS NSQIP Surgical Risk Calculators

Posted on January 31, 2019

S. Khaneki1,2, M. R. Bronsert1, W. G. Henderson1, M. Yazdanfar1, A. Lambert-Kerzner1, K. E. Hammermeister1, R. A. Meguid1  1University Of Colorado Denver,Surgery,Aurora, CO, USA 2Hurley Medical Center,Internal Medicine,Flint, MI, USA

Introduction:

The Surgical Risk Preoperative Assessment System (SURPAS) is a parsimonious surgical risk assessment tool integrated into our electronic health record (EHR) for the preoperative prediction of postoperative adverse events.  SURPAS applies to >3000 operations in 9 surgical specialties, requires entry of 7 readily available predictor variables, and predicts outcomes of mortality, overall morbidity, unplanned readmission and 8 clusters of common complications.  It was developed from the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) dataset. The objective of this study was to compare the accuracy of predictions of postoperative mortality and morbidity using SURPAS vs. the ACS NSQIP risk calculator.

 

Methods:

We calculated predicted preoperative risk of postoperative mortality and morbidity using both SURPAS and the ACS NSQIP risk calculator for 1,006 patients randomly selected from the ACS NSQIP database across 9 different surgical subspecialties.  We calculated the relative and absolute mean and median of the risk differences and plotted histograms and Bland-Altman graphs to analyze these differences.  We also compared the goodness of fit statistics for expected and observed adverse postoperative outcomes between SURPAS and the ACS NSQIP risk calculator using the c-index, Hosmer-Lemeshow analysis, and Brier scores.

 

Results:

The SURPAS risk estimates for mortality were slightly higher (Mean=0.64%) than the ACS NSQIP estimates (0.59%) and considerably higher for overall morbidity (10.65% vs 7.73%).  The ACS NSQIP risk estimates for morbidity tended to underestimate risk compared to observed adverse postoperative outcomes, particularly for the highest risk patients.  Goodness of fit statistics were similar for SURPAS and the ACS NSQIP risk calculator, except for the c-index for mortality (SURPAS c=0.853 vs ACS NSQIP c=0.937), although this finding is probably tentative because there were only 6 deaths. Hosmer-Lemeshow graphs and fit statistics for ACS NSQIP and SURPAS risk estimates vs observed adverse postoperative outcomes are shown for mortality and overall morbidity (Figure).

 

Conclusions:

The SURPAS risk predictions for mortality and overall morbidity are as good as those of the ACS NSQIP risk calculator.  SURPAS has the advantages that it requires only one-third of the number of predictor variables as the ACS NSQIP tool, provides patient risk estimates compared to national averages for patients undergoing the same operation, is integrated into the EHR, and automatically provides a preoperative note in the patient’s medical record and a graphical handout of risks for the patients to take home.

70.04 Does a Surgery Specific Rapid Response Team Decrease the Time to Intervention in Surgical Patients?

Posted on January 31, 2019

M. Chang1, P. Sinha2, P. Ayoung-Chee2  1St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 2New York University School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction:
Rapid response teams (RRT) have been shown to decrease cardiac arrests and unexpected deaths while increasing the number of admissions to the intensive care unit (ICU). They are alerted when patients display clinical signs of deterioration, bringing a team comprised of critical care nurses and a medical intensivist. At our institution, surgical patients with post-operative complications were not benefiting from RRT activations. Therefore, we implemented a surgical rapid response team (SRRT) with the goal of improving surgical patient outcomes. The SRRT alerted a surgical intensivist and the in-house surgical resident team in addition to the usual RRT members. The goal of this study was to evaluate the impact of the SRRT implementation.

Methods:
We completed a retrospective study of 87 total RRTs involving surgical patients in the six months prior to the implementation of the SRRT (period 1) and in the eight months after (period 2). For each RRT, we measured the time elapsed from the initiation of the RRT to the time of intervention. An intervention was defined as prescribing medication, infusing intravenous fluids, intubating the patient or beginning cardiopulmonary resuscitation. Additional outcomes included the time that elapsed from the initiation of the RRT to the admission of the patient to the ICU and the time that elapsed from the initiation of the RRT to the patient’s return to the OR.

Results:
There were 26 total RRTs in period 1 and 61 SRRTs in period 2. This represented a 75.9% increase in RRTs in surgical patients after the implementation of the SRRT. In our analysis, 8 RRTs from period 1 and 18 SRRTs from period 2 were excluded due to missing time to intervention. The average time to intervention decreased significantly from 12.2 mins in period 1 to 7.4 mins in period 2, a decrease of 4.8 mins (CI 1.37 – 8.21, P=0.0068). For patients who required ICU admission, the average time to ICU admission decreased from 40.9 mins in period 1 to 27.0 mins in period 2, a difference of 13.9 mins (CI 10.22 – 37.97, P=0.2458). For patients who required a return to the OR, the average time decreased from 66.5 mins in period 1 to 26.0 mins in period 2, a decrease of 40.5 mins (CI -61.70 – 142.70, P=0.2303).

Conclusion:
Creating a surgery-specific RRT decreased the time to intervention by nearly 40% for surgical patients. The time to ICU admission and time to return to the OR were also decreased, although not statistically significant. Additionally, there was a disproportionate increase in RRTs called on surgical patients after the implementation of the SRRT. We were unable to evaluate why there was an increase in RRTs but having a surgery-specific RRT may represent a resource staff feel comfortable using when their patients show clinical signs of deterioration. This study shows promising results for improved outcomes with a surgery-specific RRT.

70.03 Modifiable Risk Factors Associated with Poor Wellness and Suicidal Ideation in Surgical Residents

Posted on January 31, 2019

R. J. Ellis1,2, D. Hewitt3, Y. Hu1, A. D. Yang1, J. T. Moskowitz4, E. O. Cheung4, D. B. Hoyt2, J. Buyske5, T. J. Nasca6, J. R. Potts6, K. Y. Bilimoria1,2  1Northwestern University,Department Of Surgery, Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2American College of Surgeons,Chicago, IL, USA 3Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA 4Northwestern University,Department Of Medical Social Sciences,Chicago, IL, USA 5American Board of Surgery,Philadelphia, PA, USA 6Accreditation Council for Graduate Medical Education,Chicago, IL, USA

Introduction:  Poor physician wellness often manifests as burnout and may lead to thoughts of attrition and suicidal ideation, with suicide a leading cause of physician mortality. Surgical residents may be particularly at risk for these issues. Objectives of this study were (1) to examine the frequency of burnout, thoughts of attrition, and suicidal ideation in general surgery residents and (2) to characterize individual and environmental factors associated with poor wellness outcomes.

Methods: Cross-sectional national study of clinically active general surgery residents administered in conjunction with the 2018 American Board of Surgery In-Training Examination. Outcomes of interest were burnout, thoughts of attrition, and suicidal ideation. Individual resident and environmental factors associated with resident wellness included resident grit, stress, duty hour violations, discrimination, abuse, and sexual harassment. Associations between exposures and outcomes were assessed using multivariable logistic regression models.

Results: Among 7,413 residents (99.3% response rate) from 262 general surgery programs, 12.9% of residents reported at least weekly symptoms on both burnout subscales (emotional exhaustion and depersonalization). Burnout was more likely in residents with low grit scores (OR 2.27 [95%CI 1.95-2.63]), frequent duty hour violations (OR 1.46 [95%CI 1.22-1.74]), and in those reporting discrimination (OR 1.23 [95%CI 1.02-1.49]), verbal/physical abuse (OR 1.78 [95%CI 1.47-2.15]), or sexual harassment (OR 1.28 [95%CI 1.00-1.63]). Thoughts of attrition were reported by 12.6% of residents and were more likely in female residents (OR 1.32 [95%CI 1.09-1.60]), those with lower grit scores (OR 1.26 [95%CI 1.06-1.50]), frequent duty hour violations (OR 1.68 [95%CI 1.38-2.04]), or in those reporting severe stress (OR 2.47 [95%CI 2.04-2.99]), frequent burnout symptoms (OR 2.35 [95%CI 1.92-2.87]), discrimination (OR 1.27 [95%CI 1.06-1.51]), or verbal/physical abuse (OR 2.16 [95%CI 1.81-2.57]). Suicidal ideation was reported by 4.5% of residents and was more likely in those with lower grit scores (OR 1.43 [95%CI 1.10-1.84]), or in those who reported severe stress (OR 2.61 [95%CI 1.99-3.42]), frequent burnout symptoms (OR 1.94 [95%CI 1.43-2.63]), verbal/physical abuse (OR 1.80 [95%CI 1.39-2.33]), or sexual harassment (OR 1.58 [95%CI 1.13-2.21]).

Conclusion: Burnout symptoms, thoughts of attrition, and suicidal ideation were reported at lower rates in this comprehensive national survey than in previous studies, but remain an important problem among general surgery residents. Resident grit and environmental factors such as duty hour violations, discrimination, abuse, and harassment are associated with burnout. Burnout and negative environmental factors are further associated with thoughts of attrition and suicidal ideation. Targeted interventions aimed at minimizing inappropriate behaviors and improving the learning environment may improve trainee wellness.

70.02 CGCAHPS Scores are Influenced by Social Determinants of Health

Posted on January 31, 2019

M. Emerson1, S. Markowiak1,2, S. Pannell1,2, M. Nazzal1,2, F. C. Brunicardi1,2  1University Of Toledo Medical Center,College Of Medicine,Toledo, OH, USA 2University Of Toledo Medical Center,Department Of Surgery,Toledo, OH, USA

Introduction:  The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), a standardized tool used in office settings to measure patient perceptions of care, was implemented for Physician Quality Reporting Systems (PQRS) beginning in 2012. By 2015, these publicly reported survey scores were tied to Medicare reimbursement for medical groups with over 100 eligible professionals. Understanding the impact of health disparities in social determinants of health is evolving. The purpose of our study was to determine whether CGCAHPS scores were influenced by social determinants of health (SDOH). 

Methods:  Data was drawn from the publicly reported Physician Compare datasets provided by the Centers for Medicare and Medicaid Services (CMS). We created a database linking medical practices with over 100 eligible medical professionals data to the corresponding census measures at the county level. Multivariate analysis and Pearson’s Correlation Coefficient (Pearson r) were used to test 133 SDOH against CGCAHPS score.

Results: All medical practices with over 100 medical professionals in 1,468 counties were analyzed. Of the 133 SDOH analyzed, 56 had statistically significant negative correlation with CGCAHS scores. 67 had a statistically significant positive correlation with CGCAHPS score. 10 measures were not statistically significant. Statstically higher CGCAHPS scores were associated with higher proportion of males (r=0.025, p<0.001), elderly patients (r=0.026, p<0.001), higher proportion of Caucasian patients (r=0.029, p<0.001), and greater proportion of persons employed in professional careers (r=0.024, p<0.001).  Statstically lower CGCAHPS scores were associated with higher proportion of African American patients (r= -0.050, p<0.001), higher proportion of recent immigrants (r= -0.024, p<0.001), and communities with higher unemployment rates (r= -0.031, p<0.001).  

Conclusion: Of the SDOH analyzed, 92.5% had a statistically significant correlation with CGCAHPS scores. 42.1% of SDOH analyzed showed negative correlations and 50.4% of SDOH showed positive correlations. CGCAHPS scores are directly tied to medical practices’ CMS reimbursement by federal law. Because of disparities in SDOH, the CGCAHPS survey will shift CMS reimbursement from medical practices in poor and diverse communities to medical practices in wealthier ones.

 

70.01 Blue Spectrum Filtering Cataract Lenses Are Associated With Reduced Survival

Posted on January 31, 2019

J. Griepentrog1, X. Zhang1, O. Marroquin3, J. Chang3, N. Loewen2, M. Rosengart1  1University Of Pittsburgh,Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Ophthalmology,Pittsburgh, PA, USA 3University Of Pittsburgh,Medicine,Pittsburgh, PA, USA

Introduction: During the process of aging, the lens undergoes progressive changes that perturb the transmission of light, particularly the short-wavelength (400-500nm) blue spectrum. It is this shorter wavelength that maximally entrains our circadian rhythms, which orchestrate adaptive alterations in physiology, metabolism, and immunity. Several recent studies highlight that cataract surgery is associated with a reduced risk of all-cause mortality. Intraocular lenses (IOL) differ in transmission properties: conventional (Natural-IOL) and blue-light filtering (Blue-IOL). We hypothesized that in patients undergoing bilateral cataract surgery, the restoration of exposure to blue light with the implantation of Natural-IOL compared to continued blockage with Blue-IOL is associated with a reduced risk of death.

Methods: We conducted a retrospective cohort analysis of all subjects undergoing bilateral cataract surgery within a single healthcare system. We abstracted data for each subject regarding age, sex, race, zip code and state of residence, health insurance status, smoking status, alcohol use, and body mass index. Systemic comorbidities were classified using the Charlson Comorbidity Index. The primary outcome was all-cause mortality. We conducted a multivariate Cox Proportional Hazards model, stratified by and clustered on surgeon, to compare the adjusted risk of death in subjects undergoing bilateral implantation of Blue-IOL with those receiving Natural-IOL. A p<0.05 was considered significant. Sensitivity analyses for mortality were performed 1) using a more restrictive definition of ‘concomitant’ bilateral cataract surgery (<90-day interval), 2) excluding any surgeon implanting predominantly (>90%) Blue-IOL, and 3) restricting the analysis to Pennsylvania (PA) residents.

Results: A total of 1482 subjects underwent bilateral cataract surgery during the period of analysis, of which 512 (34.6%) received a Blue-IOL. Natural-IOL were associated with a reduced risk of all-cause mortality: aHR, 0.60 [95% CI, 0.38 to 0.94]; p=0.03. There was a significant difference by age category (p=0.02 for interaction with age >65): for the subgroup >65, Natural-IOL were associated with reduced mortality: aHR 0.52 [95% CI, 0.35 to 0.78]; p=0.001. Restricting bilateral surgery to a 90-day interval (n=1163), eliminating the surgeon implanting predominantly Blue-IOL (n=1133), and restricting the analysis to PA residents (n=1463), each showed that Natural-IOL are associated with prolonged survival.

Conclusion: Among patients undergoing cataract surgery, restoring the transmission of the entire visible spectrum compared to blocking the shorter wavelength blue spectrum, is associated with a reduced risk of death. These data suggest that a progressive blockage of blue light by cataracts may perturb circadian biology, and that cataract surgery that restores the shorter wavelength of visible blue light may restore these homeostatic mechanisms.

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

Posted on January 31, 2019

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

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

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

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

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

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

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

Posted on January 31, 2019

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

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

 

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

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

 

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

Introduction:

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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