37.09 ­Opioid Prescription and Consumption in Patients Undergoing Major Abdominal Surgery

Posted on January 31, 2019

S. Agarwal1, V. Gunaseelan1, J. V. Vu1, J. F. Waljee1, C. M. Brummett2, M. J. Englesbe1, J. S. Lee1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA

Introduction:  Opioid prescription and consumption have not been well characterized in patients undergoing abdominal surgery. Moreover, the impact of the indication for surgery on opioid prescription and consumption has not been well-described. The objective of this study was to compare differences in opioid prescribing and consumption for cancer and non-cancer patients undergoing abdominal surgery.

Methods:  colectomy and hysterectomy from January – December 2017. The quantity of opioid prescribed for the initial postoperative prescription and patient-reported opioid consumption were converted to the equivalent number of tablets of 5 mg oxycodone for ease of interpretation. The primary outcomes of this study were the mean quantity of opioid prescribed and consumed. Patients were stratified by type of procedure and whether or not they underwent surgery for a cancer diagnosis. The Wilcoxon signed rank sum test was used to compare the mean quantity of opioid prescribed and consumed in each group.

Results: In this study, 869 patients underwent abdominal surgery. Of these, 241 underwent elective colectomy and 628 underwent elective hysterectomy. Figure 1 compares the mean quantity of opioid prescribed and consumed with patients stratified by procedure type and cancer diagnosis. Patients who underwent colectomy were prescribed significantly more opioid than they consumed for both cancer patients (26 vs. 7 tablets of 5 mg oxycodone, P < 0.001) and non-cancer patients (29 vs. 14 tablets of 5 mg oxycodone, P < 0.001). Similarly, patients who underwent elective hysterectomy were prescribed significantly more opioid than they consumed for both cancer patients (28 vs. 11 tablets of 5 mg oxycodone, P < 0.001) and non-cancer patients (25 vs. 11 tablets of 5 mg oxycodone, P < 0.001).

Conclusion: Patients undergoing abdominal surgery were prescribed significantly more opioid than they consumed for both cancer and non-cancer operations. Future guidelines for prescribing opioids should consider indications for surgery in addition to patient demographic and procedural characteristics.

37.08 A Structured Evaluation of Preoperative Risk Assessment Tools for Visceral Oncologic Resections

Posted on January 31, 2019

L. Y. Smucker1,2, L. R. Henry2, U. W. Von Holzen1,2, A. N. Hardy2, M. J. Minarich2, R. E. Schwarz1,2  1Indiana University School Of Medicine,South Bend, IN, USA 2Goshen Center for Cancer Care,Goshen, IN, USA

Introduction: Patients requiring visceral resections for cancer therapy are at risk for complicated postoperative outcomes, dependent on disease-specific, procedure-related, constitutional and comorbidity factors. Predicting an individual's morbidity risk has been traditionally challenging, and exploration of predictive risk assessment tools is worthwhile to optimize care strategies.

Methods: Data from patients undergoing major visceral resection within a cancer center-based surgical practice were queried to generate scores or parameters of potential value for risk prediction, including clinicopathologic variables, ASA score, radiographic scan-based morphometrics, Charlson comorbidity index (CCI), modified frailty index (MFI), P-POSSUM scores and NSQIP scores. Association with untoward outcomes was tested via nonparametric and parametric group comparisons, chi-square statistics and logistic regression analyses.

Results: Two hundred forty patients who underwent visceral resection during 4 years were analyzed. There were 107 women and 133 men, with a median age of 67 (range: 17-98) and a malignancy in 90%. Procedures included 28 upper GI (12%), 62 lower GI (26%), 69 pancreatic (29%), 54 hepatobiliary (22%), and 27 other resections (11%); eight percent of resections were multivisceral, and 4% emergent. Mean POSSUM morbidity risk (63%) and death risk (10.8%) were high. Above average NSQIP scores were observed in 49% for any complication, 46% for severe complication, and 57% for risk of death. There were 125 complications (53%), of which 54 were severe (grade 3+, 23%) including 5 lethal events (2%). The median length of stay (LOS) was 8 days (IQR: 5). Discharge to home failed in 16%. Univariate score associations with any complication (in descending order of significance, with p values) were seen for POSSUM (p=0.001), NSQIP (0.001), visceral fat (0.006) CCI and MFI (both 0.03), but not for ASA, sarcopenia index or other morphometrics. Serious complications correlated with NSQIP (p=0.0008), sarcopenia visceral fat obesity index (SOVFI, 0.004), visceral fat (0.02), MFI (0.02), POSSUM and CCI (both at 0.04), but not ASA. Scores that correlated with postoperative deaths included average NSQIP risk and ASA (both at p<0.0001), POSSUM (0.003), SOVFI (0.009), visceral fat (0.02), MFI (0.02), spleen volume index (0.04), abd. depth (0.04) and girth (0.05), but not the actual calculated NSQIP death risk or CCI scores. Failure of discharge to home was linked to both NSQIP and MFI scores and to functional status (at p <0.0001), CCI (0.007), POSSUM morbidity score (0.009) and marital status (0.03). When controlled for other variables, no score retained significant association for any complication; NSQIP score remained significant for serious complications (p=0.046), and POSSUM was predictive of death (p=0.02).

Conclusion: Preoperative morbidity risk scores correlate generally well with postoperative untoward outcomes and thus serve well for risk adjustments. Their performance is limited when other clinicopathologic variables are accounted for. NSQIP and POSSUM scores emerged as superior to other score metrics, but still appear to be insufficient to be utilized for prospective treatment decisions.

 

37.07 The Impact of Obesity on the Surgical Management of Early-Stage Melanoma

Posted on January 31, 2019

C. Harrell Shreckengost1, C. R. Farley1, C. Zhang2, K. A. Delman1, R. R. Kudchadkar3, M. C. Lowe1  1Emory University School Of Medicine,Surgical Oncology,Atlanta, GA, USA 2Winship Cancer Institute,Biostatistics/Bioinformatics,Atlanta, GA, USA 3Emory University School Of Medicine,Hematology/Oncology,Atlanta, GA, USA

Introduction: Obesity is associated with adverse outcomes in multiple malignancies, but its impact in melanoma is poorly understood. Interestingly, recent data indicate protective effects of obesity on survival in systemically-treated metastatic melanoma.  To evaluate whether these effects are intrinsic to the tumor or primarily treatment-related, we sought to examine the impact of obesity on clinical outcomes in clinically non-metastatic melanoma patients. As surgery is the definitive treatment for these patients, an improved understanding of the effects of obesity in early-stage melanoma could potentially aid in surgical decision-making.

Methods:  Adults presenting to Emory University Healthcare between 2010-2017 with clinically non-metastatic cutaneous melanoma and known stage, height, and weight at the time of presentation were identified. The relationship between body-mass-index (BMI) and clinicopathologic characteristics was assessed.

Results: Of 1902 patients examined, 630 were obese (33.1%; BMI≥30), 708 were overweight (37.2%, BMI≥25 & <30), and 564 were normal-weight (29.7%, BMI<25). Demographics associated with obesity included male sex (OR=2.7, 95%CI=2.1-3.4, p<0.001) and lower income (OR=1.5, 95%CI=1.2-1.9, p<0.001).  Melanomas in obese patients were thicker (2.0 mm±0.2) than in overweight (1.7 mm±0.1) or normal-weight patients (1.4 mm±0.1; p=0.002) at time of presentation.  Melanomas of obese patients were also less likely to harbor BRAF mutations (OR=0.4, 95%CI=0.1-1.0, p=0.049).  Ulceration, mitoses, and sentinel lymph node (SLN) status were not affected by obesity.  In multivariate analysis, obesity independently predicted increased odds of presenting at Stage II (vs. Stage 0 or I; OR=2.1, 95%CI=1.5-3.1, p<0.001), but not at Stage III (p>0.05). At 33 months median follow-up, obesity was not an independent predictor of stage-specific survival (p>0.05).

Conclusion: Obese patients are twice as likely as their normal-weight peers to present with thicker melanomas, but they have similar stage-specific survival and SLN positivity. Despite providing a survival advantage in the response to systemic therapy at a later stage, obesity may promote more advanced clinicopathologic characteristics in early-stage melanoma. However, nodal status in clinically non-metastatic melanoma is not impacted by obesity and SLN biopsy should continue to be performed appropriately.

 

37.06 Next Generation Sequencing Mutation Signature and Response to Immunotherapy in Melanoma

Posted on January 31, 2019

K. Loo1,2, I. Soliman2, J. D’Souza2, M. Renzetti1,2, T. Li2, H. Wu2, B. Luo2, S. Movva2, M. Lango2, A. Olszanski2, J. Farma2  1Temple University,Surgical Oncology,Philadelpha, PA, USA 2Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:  Considerable advances in melanoma therapy have been realized through immunotherapy. Unfortunately, there remains a subset of patients who fail to respond. There is a need to identify patients likely to exhibit sustained response to immunotherapy agents, versus those who would benefit from alternate therapies. It remains to be seen whether a patient’s tumor molecular gene profile could serve as a marker of response. The principle aim of this study was to utilize molecular profiling to determine the difference in gene mutation status between responders and non-responders prior to initial immunotherapy.

Methods:  Tissue samples from n=42 melanoma patients were collected. Pre-treatment tumors were profiled using a Next Generation Sequencing (NGS) panel of 50 targetable cancer-related gene mutations. Gene mutation status was analyzed. Response to immunotherapy was assessed using RECIST v1.1 criteria. Statistical analysis was conducted using Fisher’s exact test.

Results: Within the total cohort, patients received initial immunotherapy of anti-CTLA4 (n=7), anti-PD1 (n=22), ipilimumab/nivolumab combination (n=7), or clinical trial immunotherapy combinations (n=7), and were divided into responders (n=17) or non-responders (n=25). 62% were male, with a median age of 68. 65 total mutations were identified affecting 36 unique genes. No mutations were found in 10% of patients, while 52% had 1 mutation, 28% had 2 mutations, 5% had 3 mutations, and 5% had 4 or more mutations. The overall hot-spot mutation burden in the responder cohort was 1.80 versus 1.32 in the non-responder cohort. The most common mutation among responders was NRAS, detected in 70.5% of responders, vs 29.4% in non-responders. Additionally, the most common mutation among non-responders was a BRAF mutation, identified in 18.2% of responders vs. in 81.8% of non-responders.

Conclusion: Using our NGS platform, this analysis demonstrated potential associations between NRAS mutation and responders to immunotherapy, and correlations between BRAF mutation and non-responders. This unique finding should be evaluated in a larger population to confirm these results and may help predict response in the future.

 

37.05 Racial- Ethnic Disparities in Oral Cancer Screening in the US: Results from NHANES 2011 to 2016

Posted on January 31, 2019

A. Gupta1, R. Bergmark5,6,7, E. Schneider8,9, A. Villa2,3,4  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Oral Medicine And Dentisry,Boston, MA, USA 3Harvard School of Dental Medicine,Oral Medicine Infection And Immunity,Boston, MA, USA 4Dana Farber Cancer Insititute,Oral Medicine And Oncology,Boston, MA, USA 5Brigham And Women’s Hospital,Otolaryngology-Head And Neck Surgery,Boston, MA, USA 6Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 7Harvard School Of Medicine,Otolaryngology,Brookline, MA, USA 8The Johns Hopkins University School Of Medicine,Baltimore, MD, USA 9University Of Virginia,Surgery,Charlottesville, VA, Virgin Islands, U.S.

Introduction:
According to the American Cancer Society there will be an estimated 51,540 new cases of oral cavity and pharyngeal cancers in 2018 in the United States, with nearly 33,950 in the oral cavity. Racial-ethnic disparities have been reported in oral cancer stage at diagnosis, mortality, and dentist-patient communications about oral cancer. The national guidelines recommend that all adult patients should receive an extra-oral and intra-oral examination when visiting dentists to identify potentially malignant lesions or early-stage cancers. We examined the likelihood of receiving an oral cancer screening exam among different racial-ethnic groups in the US.

Methods:
National Health and Nutrition Examination Survey (NHANES), a series of ongoing cross-sectional surveys was inquired from years 2011 to 2016. NHANES uses a complex, multistage, probability sampling design, which when weighted is representative of the US non-institutionalized population. We included all individuals older than 30 years who responded to the screening question- “Have you ever had an exam for oral cancer in which the doctor or dentist pulls on your tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?”. Response to this question as ‘yes’ or ‘no’ was the primary outcome. The primary exposure variable was race-ethnicity. Weighted multivariable logistic regression models were computed to control for age, gender, poverty income ratio, education level, health insurance, tobacco smoking status, alcohol consumption and the consumption of abuse potential recreational drugs.

Results:

A total of 14,027 individuals representing 185,196,253 individuals nationally were included in this analysis. 29.7% reported receiving an oral cancer exam. 74.5% of these were performed by a dentist/oral surgeon, 10.3% by a doctor/physician, and 0.3% by a nurse/nurse practitioner. Weighted multivariable logistic regression models demonstrated that, Mexican-Americans (RR: 0.31; 95% CI: 0.22-0.44; p<0.001), Non-Hispanic Blacks (RR: 0.34; 95% CI: 0.26-0.45; p<0.001), Non-Hispanic Asians (RR: 0.33; 95% CI: 0.23-0.48; p<0.001), other Hispanics (RR: 0.27; 95% CI: 0.19-0.37; p<0.001) and other minority races (RR: 0.42; 95% CI: 0.27-0.66; p<0.001) were less likely to have received an oral cancer screening exam, as compared to Non-Hispanic Whites.

Conclusion:
Racial minorities are less likely to receive an oral cancer screening exam either during a dental or medical visit, as compared to non-Hispanic Whites, regardless of their insurance status, income, education, age group or the presence of high-risk behaviors such as smoking, alcohol or drug use. Further studies examining the underlying reasons for lower rates of screening among racial-ethnic minorities are needed in order to support the development of interventions to address the existing racial-ethnic disparities in the incidence and outcome of oral cancer. 
 

37.04 Rural-urban and racial/ethnic disparities in hepatocellular carcinoma incidence

Posted on January 31, 2019

S. Taylor2, W. E. Zahnd2, S. Ganai1,2  1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Population Science And Policy,Springfield, IL, USA

Introduction: Hepatocellular carcinoma (HCC) is among the fastest growing causes of cancer mortality in the United States (U.S.). Major modifiable risk factors for HCC include viral hepatitis and excess alcohol consumption, the prevalence of which may vary by region, geography, and race/ethnicity. We hypothesized that differences exist in incidence of HCC between rural and urban U.S. populations, and that these may be reflective of differences in ethnic diversity.

Methods: We analyzed data from the SEER 18 database, a population-based collection of cancer registries representative of the U.S. population, and calculated age-adjusted incidence rates, rate ratios (RR), annual percentage change (APC), and total percentage change (TPC) for HCC. Rural and urban population incidence rates were calculated by race from 2010 to 2014, with analysis of trends from 2000 to 2014.

Results: The overall incidence of HCC was 6.8 (95% CI, 6.8-6.9) per 100,000 in urban population versus 5.1 (95% CI, 6.8-6.9) in rural ones (RR 0.75, 95% CI, 0.72-0.78; p<0.05).  The lowest incidence was seen in the White non-Hispanic population (4.6 per 100,000). White Hispanics had the highest incidence of HCC (11.0 per 100,000). The greatest urban-rural difference was seen in the Black population (RR 0.58).  Both urban (APC 3.7; 95% CI, 3.1-4.3; TPC 65.6) and rural (APC 5.4, 95% CI; 4.5-6.4; TPC 108.9) populations saw an increasing trend in HCC incidence. Rural non-Hispanic Whites and Blacks had the largest annual increase in incidence at 5.6% (TPC of 106.3 and 163.5, respectively). The urban Asian population was the only group to see a decrease in incidence trend (APC -1.1, TPC -4.6).  Rural Asians (TPC 2.6) and rural American Indians (TPC 5.7) had APCs that were not significantly different from zero over the 15-year time period.

Conclusions: Although both urban and rural incidence of HCC is increasing, rural incidence is increasing at an accelerated rate compared to urban, a finding that was unexpected.  Despite the relatively high incidence of HCC in Asian-urban populations, it was the only population with a downward trend in incidence rates. Causes of this decrease should be identified and applied more broadly with the goal of decreasing the overall incidence of HCC.

37.03 The Impact of Finance-Related Distress on Gastrointestinal Cancer Patients

Posted on January 31, 2019

C. J. LaRocca1, K. Lafaro1, A. Li3, K. Clark2, M. Loscalzo2, S. G. Warner1  1City of Hope National Medical Center,Department Of Surgery,Duarte, CA, USA 2City of Hope National Medical Center,Department Of Supportive Medicine,Duarte, CA, USA 3City of Hope National Medical Center,Department Of Information Sciences,Duarte, CA, USA

Introduction:
Biopsychosocial distress in cancer patients can negatively impact treatment compliance and prognosis. Understanding sources of distress and exploring possible interventions is part of comprehensive cancer care. This study uses a biopsychosocial distress screening tool to determine the factors associated with finance-related distress and the impact of these stressors on gastrointestinal cancer patients.

Methods:
A 48-question proprietary distress screening tool was administered to patients with gastrointestinal malignancies in medical and surgical oncology clinics from 2009-2015. This validated, electronically-administered tool is given to all new patients. Responses were recorded on a five-point Likert scale from 1 (not a problem) to 5 (very severe problem). Univariate and multivariate logistic regressions analyzed factors that impacted finance-related distress.

Results:
A total of 1027 patients participated in the study. Most patients had colorectal (50%) or hepatobiliary (31%) malignancies. The median age was 63. 52% of patients were male. 61% were Caucasian. 61% of patients did not complete college. 47% of patients reported an annual income of less than $40,000. 34% of all patients expressed a high level of finance-related distress. Patients with annual income greater than $40,000 reported that pain (OR=0.40, 95% CI=0.29-0.56), swelling (0.47, 0.30-0.74), and fatigue (0.62, 0.45-0.86) were less of a problem. Additionally, higher earners reported fewer issues with anxiety (0.66, 0.46-0.93), depression (0.40, 0.23-0.70), and difficulties managing emotions (0.51, 0.35-0.74). They were also less likely to report problems managing logistical and transportation issues (0.38, 0.25-0.56) and finding a community for support (0.32, 0.20-0.50). Increasing age, college education, being partnered, and high household income were all protective against finance-related distress on univariate logistic regression (Table 1).Tobacco abuse was also significantly associated with increased distress on univariate analysis (Table 1). On multivariate regression analysis, increasing age, completing college, and high income remained significantly protective against financial concerns, whereas tobacco abuse remained associated with increasing finance-related distress (Table 1).

Conclusion:
Higher income patients with gastrointestinal malignancies have significantly less biopsychological distress, especially with regards to anxiety, depression, pain, swelling, and fatigue. Protective factors for finance-related distress include older age, college education, and high income. Further study of at-risk populations may identify patients who would benefit from pre-emptive education and counseling interventions as part of their routine cancer care.
 

37.02 Setting of Care in Colon Cancer: Which Patients Benefit the Most from Care at Academic Centers?

Posted on January 31, 2019

J. K. Ewing1, J. J. Cabo1, X. Shu2, X. O. Shu2, M. Tan1, K. Idrees1, C. E. Bailey1  1Vanderbilt University Medical Center,Department Of Surgery, Division Of Surgical Oncology And Endocrine Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Division Of Epidemiology,Nashville, TN, USA

Introduction: Some studies show that care at an academic center (AC) improves survival for patients with advanced stage colon cancer (CC). However, it remains unclear which patients have the greatest survival benefit from treatment at AC. The primary aim of this study is to determine which patients have the most improvement in overall survival (OS) from treatment at AC, relative to other treatment facilities (TF).

Methods: A retrospective cohort study of adults with histologically confirmed CC was performed using the National Cancer Database (2004-2014). TF were classified as community cancer programs (CCP; 100-500 cases/year), comprehensive community cancer programs (CCCP; >500 cases/yr), academic centers (AC; >500 cases/yr with residency training program), or integrated network cancer programs (INCP; multi-center organizations). Demographic and clinical factors were compared according to TF. Kaplan-Meier curves and log-rank tests were used for univariate survival analysis. Cox proportional hazard models were used to assess the impact of TF on OS after adjusting for patient, tumor, and treatment characteristics.  Subgroup analyses were performed stratifying by stage, age, and race.

Results:The cohort included 433,997 patients with median age of 69(Interquartile range: 59-78). Most were white(83.8%), had Medicare(55.4%) or private insurance(34.8%), and were treated at CCCP(49.1%) or AC(26.5%). Median OS was greatest for patients treated at AC(107.1 months), compared to INCP(98.5 mo), CCCP(95.9 mo), and CCP(90.2 mo) (P<0.001). On multivariate analysis, there was no significant difference in OS between patients with stage IV CC treated at CCCP or INCP relative to those treated at CCP. However, an improvement in OS was observed for patients with stage IV CC treated at AC(Hazard ratio [HR] 0.85, 95% Confidence Interval [CI] 0.83-0.87, P<0.001) (Figure 1A). Similarly, among patients younger than 70, patients treated at CCCP or INCP had similar OS relative to those treated at CCP, whereas those treated at AC had improved OS relative to those treated at CCP(HR 0.86, 95% CI 0.84-0.88, P<0.001) (Fig. 1B). Finally, for African American (AA) patients, treatment at CCCP and INCP had similar OS compared to treatment at CCP, whereas improved OS was observed for AA patients treated at AC(HR 0.88, 95% CI 0.84-.91, P<0.001). A similar pattern was observed for non-white, non-AA patients (Fig. 1C).

Conclusion:Treatment at AC is especially beneficial for patients with stage IV CC, patients younger than 70, and non-white patients. For these patients, treatment at AC was independently associated with 12-15% reduced mortality relative to treatment at CCP. Further work is needed to examine why certain groups benefit more from care at AC.

37.01 Expansion Coverage and Preferential Utilization of Cancer Surgery Among Minorities and Low-Income Groups

Posted on January 31, 2019

A. B. Crocker1, A. Zeymo1,2, J. McDermott1, D. Xiao1, T. Watson4, T. DeLeire5, N. Shara2,3, K. S. Chan1,2, W. B. Al-Refaie1,4  1MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 4Department of Surgery, MedStar-Georgetown University Hospital,,Washington, DC, USA 5Georgetown McCourt School of Public Policy,Washington, DC, USA

Introduction:
Pre-Affordable Care Act (ACA) Medicaid expansions have demonstrated inconsistent effects on cancer surgery utilization rates among racial minorities and low-income Americans. Currently, it remains unknown how Medicaid expansion coverage under the ACA will impact these vulnerable populations with long standing disparities in access and outcomes of surgical cancer care. Using a quasi-experimental design, this study seeks to examine whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid program relative to states that did not.

Methods:
A cohort of over 95,000 patients aged 18-64 years who underwent cancer surgery were examined in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion states (Florida and North Carolina). This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File from the Health Resources and Services Administration for the years 2012-2015. Poisson interrupted time series analysis (ITS) were performed to examine the impact of ACA Medicaid expansion on the utilization of surgical cancer care for the uninsured overall, low-income persons, and racial and ethnic minorities after adjusting for age, sex, Elixhauser comorbidity score, population- and provider-level characteristics.

Results:
Following Medicaid expansion, the share of Medicaid patients receiving surgical cancer care in expansion states increased by 56%, compared to an 11% decrease in non-expansion states (p <0.001). Simultaneously, the percentage of uninsured patients declined by 63.4% in expansion states relative to a 10% reduction in non-expansion states (p < 0.001).  For persons from low-income zip codes, Medicaid expansion was associated with an immediate 24% increase in utilization (p = 0.002), relative to no significant change in non-expansion states. However, there were no significant trends observed post ACA expansion for racial and ethnic minorities in expansion vs. non-expansion states (Figure). 

Conclusion:
In this quasi-experimental evaluation, Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans, but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these early findings highlight the need for additional investigation to uncover other factors that contribute to racial disparities in surgical cancer care.
 

36.10 Treatment of Appendicitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

Posted on January 31, 2019

A. Fazzalari1,2, N. Pozzi2, D. Alfego1, N. Erskine1, S. Qiming1, J. Mathew1, G. Tourony1, D. Litwin1, M. Cahan1  1University Of Massachusetts Medical School,Surgery,Worcester, MA, USA 2Saint Mary’s Hospital,Surgery,Waterbury, CT, USA

Introduction:
Previous studies using national datasets have suggested that insurance type drives a disparity in care delivered to emergency surgery patients. These large databases lack the granularity that smaller single institution series may provide.  The goal of this study is to identify socioeconomic and geographic factors that may account for disparities in care between Medicaid and Non-Medicaid enrollees with acute appendicitis in Central Massachusetts.

Methods:
This retrospective cohort study included all adult patients with acute appendicitis at two campuses of an academic medical center in Central Massachusetts between 2010-2017. Baseline sociodemographic and clinical characteristics were compared according to Medicaid enrollment status and univariate and multivariate analyses were performed to assess differences in the frequency of surgery performed, time to surgery (TTS), length of stay (LOS), and rates of readmission between those with and without Medicaid.

Results:
The sample consisted of 1,257 patients, with a mean age of 39.4 years old, 46.4% were female and 135 (10.7%) were enrolled in Medicaid. Medicaid enrollees were significantly younger (33.5 vs 40.1 years, p<0.0001), and more likely to be unmarried (73% vs 48.1%, p<0.0001) or Non-White (54.1% vs 24.4%, p<0.0001) when compared to Non-Medicaid enrollees. Medicaid enrollees were more likely to live in a neighborhood that was closer to the hospital (4.0 miles vs 8.3 miles, p<0.0009), had a lower median annual income ($40,400.00 vs $67,700.00, p<0.0001), had a lower level of formal education (82.9% vs 91.6% with high school diploma, p<0.0001) and were more likely to belong to a racial/ethnic minority (31.0% vs 17.1%, p<0.0001). Medicaid enrollees were also less likely to have diabetes mellitus, hyperlipidemia, or hypertension. There were no significant differences between the number of Medicaid and Non-Medicaid enrollees who presented with perforated appendicitis (28.9% vs 31.2%, p=0.857) or who underwent laparoscopic appendectomy (96.3% vs 90.7%, p=0.081). While LOS (20h:30m vs 22h:38m, p=0.109) and 30-day readmission rates (17.8% vs 14.5%, p=0.683) were similar between the two groups, there was a significant difference in the median TTS, with Medicaid patients waiting longer, even after adjusting for social and clinical characteristics (6h:47m vs 4h:49m, p<0.001).

Conclusion:
This study underscores the importance of local data in understanding delivery of care at the individual level.  Despite anticipated population differences between patients with and without Medicaid, locally the treatment of appendicitis did not differ substantially.  While Medicaid enrollees did experience longer TTS, the explanation for this is unclear. Further studies are needed to investigate factors that may account for insurance-based discrimination, racial or unconscious bias, or other unanticipated factors which may account for delays to surgery among Medicaid enrollees.
 

36.09 Refugee Access to Surgical Care in Lebanon: A Post Hoc Analysis of the SCAR Study

Posted on January 31, 2019

M. W. El Hechi1, J. M. Khalifeh2, E. P. Ramly3,4, J. Abed Elahad1, A. I. Eid1, A. Bonde1, G. Velmahos1, J. Hoballah5, H. Kaafarani1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Washington University,School Of Medicine,St. Louis, MO, USA 3New York University School Of Medicine,Hansjörg Wyss Department Of Plastic Surgery,New York, NY, USA 4Oregon Health And Science University,Department Of Surgery,Portland, OR, USA 5American University of Beirut Medical Center,Department Of General Surgery,Beirut, Lebanon

Introduction:

Lebanon, a country of 6 million people, hosts approximately one million Syrian refugees registered with the United Nations High Commissioner for Refugees (UNHCR). The UNHCR contracts with select hospitals throughout the country to facilitate the provision of affordable and accessible basic primary health and emergency care to refugees. We aimed to assess the surgical capabilities of UNHCR-covered hospitals in Lebanon.

Methods:

Cross-sectional data from the Surgical Capacity in Areas with Refugees (SCAR) study were combined with hospital affiliation data directly obtained from the UNHCR. The SCAR study evaluated surgical capacity in Lebanon by mapping all acute care hospitals in the country and administering the validated five domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool to each hospital. Surgical capacity, specifically overall and domain-specific PIPES indices and mean numbers of surgeons, anesthesiologists, and hospital beds, were compared between UNHCR affiliated and non-affiliated hospitals. In an effort to understand regional disparities, the geographic distribution of UNHCR-affiliated hospitals was cross-referenced with refugee population distributions across the country.

Results:

A total of 129 hospitals were included and the PIPES tool was successfully administered in all hospitals (100%) between 2014 and 2017. Out of the 35 hospitals affiliated with the UNHCR, 43% were public, while 57% were operated privately. The mean overall and domain-specific PIPES indices and the mean number of hospital beds were similar between the UNHCR affiliated and non-affiliated hospitals (Figure 1). The mean numbers of general surgeons and anesthesiologists per hospital were also similar between the two groups (7.94 vs. 7.52, p=0.64; 3.86 vs. 4.05, p=0.68, respectively). Upon geographical mapping of hospital coordinates and refugee populations across Lebanon, the greatest disparity was found in the Northeastern region of the country (Baalbeck-Hermel): that region had the highest number of refugees but lacked any UNHCR-coverage.

Conclusion:

Hospitals covered by the UNHCR performed similarly to non-affiliated hospitals with respect to all aspects of the PIPES surgical capacity tool. However, there is a concerning geographic mismatch between UNHCR hospital coverage and refugee density, specifically in the underserved Northeastern region of Lebanon.
 

36.08 Helmet Usage in New Delhi: Revision of the Exemption

Posted on January 31, 2019

C. Pathak1, S. Siddiqui2, S. Sagar3, M. Swaroop1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA 3The All India Institute Of Medical Sciences,New Delhi, India, India

Introduction:  Helmet usage laws have been a cornerstone in preventing and minimizing injuries in motorized two-wheeled (MTW) vehicle accidents. In 1988, India passed the Motor Vehicle Act nationally, making it mandatory for MTW riders to wear helmets. In 1999, the Act was challenged as undermining religious expression in the New Delhi High Court and an exemption was passed, allowing women and Sikhs to ride pillion without wearing helmets. These exemptions made the law difficult to enforce. In a study conducted of MTW pillions in New Delhi in 2011, 58.7% were helmeted and 41.3% were unhelmeted. In 2014, the New Delhi government revised the exemption requiring all MTW riders to wear helmets, with fewer exemptions. The purpose of this study was to determine the prevalence of helmet usage in MTW vehicle riders in New Delhi, India following the revision of the exemption.

Methods:  An observational video study was conducted to determine the prevalence of helmet usage in MTW riders in New Delhi, India. At least twenty-five minutes of traffic video was recorded in the morning rush hour, mid-day and evening rush hour from June 15 to June 25, 2016 at four representative intersections in the city: Rajiv Chawk Circle and Barakhambha road, AIIMS Trauma Center and Mahatma Ghandi road, India Gate C Hexagon, and Safdarjung Hospital and Mahatma Gandhi road intersections. The video recordings were analyzed for the number of MTW riders, gender, approximate age (adult or child), and helmet usage by two reviewers who are versed in Indian culture.

Results: A total of 12,625 MTW riders were observed on video. Of those, 88% (11,121) were male, 10% (1198) were female and 2% (237) were children. Compared to the 2011 study, the percentage of MTWs who used helmets increased from 88.4% to 93% for males, p<0.001 and from 0.6% to 45% for females, p<0.001. While the percentage of women who were helmeted increased from the 2011 study, there remained a significant difference, p<0.0001, in the percentage of males and females that were helmeted. Of the children observed, only 6% were helmeted. However, there are no data points for comparison from the 2011 study for children.

Conclusion: Since the revision of the exemption, there has been an increase in male and female MTWs using helmets. While males already demonstrated a high rate of helmet usage, the rate of increase in helmet usage by women has been dramatic. Overall, however, the rate of helmet usage for women remains low, at 45%. Additionally, helmet usage in children remains exceptionally low at 6%. While the change in mandatory helmet laws is a significant factor in influencing an increase in overall helmet usage, additional factors including improved media and public educational campaigns, law enforcement, and shifting cultural norms may affect usage as well. Barriers to helmet usage by women and children need to be studied further to improve the rate of helmet usage in these populations.

36.07 The Efficacy of Trauma Transfers in a Resource Poor Setting

Posted on January 31, 2019

L. N. Purcell1, T. N. Reid1, C. Mabedi2, A. N. Charles1, R. N. Maine1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Lilongwe, LILONGWE, Malawi

Introduction: Trauma is a leading cause of morbidity and mortality worldwide with the burden borne by low- and middle-income countries (LMICs). Important trauma principles are early triage, expedited care, and transfer of patients to appropriate higher levels of care. Inappropriate transfers (IT), or overtriage, tax overburdened hospitals in LMICs. Little data exists on efficacy of trauma transfers in LIMCs. We sought to determine the rate and characteristics of inappropriate trauma transfer patients in Malawi.

Methods: A retrospective analysis of prospectively collected data was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. IT were defined as patients discharged alive from the emergency department or patients admitted for less than one day without undergoing surgery. Variables included were demographics, injury severity and characteristics. Bivariate analysis, Kruskal-Wallis, t-Test, and logistic regression were utilized when appropriate.

Results: From February 2008 – July 2017, 120,573 trauma patients presented. Transferred patients constituted 17.0% (n=20,460), of these 57.3% (n=11,725) were IT. Inappropriately transferred patients were younger (mean 21.9±17.2 yrs, CI: 21.6 – 22.2) than appropriately transferred (mean 26.3±19.8 yrs, CI: 25.8 – 26.7), p<0.001. IT occurred more in women than men, 60.5% versus 56.0%, respectively (p<0.001). Primary extremity injury were more often IT (n=6,975, 61.7%) compared to primary torso (n=1,764, 48.5%) or head injuries (n=2,862, 54.0%), p<0.001. IT (median 1 hr, IQR 1-1 hr) arrived at KCH faster than appropriate transfers (median 1 hr, IQR 1-2), p=0.002. Fewer IT occurred at night (n=2554, 46.6%, p,0.001) vs day (n=9141, 61.4%) and on weekends (n=2653,55.8%, p=0.02) vs weekdays (n=2563, 55.8%). The injury mechanisms with the highest rate of IT were lacerations (n=320, 69.3%), animal bites (n=295, 70.7%), and falls (n=4199, 64.1%). IT rates were lowest in motor vehicle collisions (n=3098, 50.0%) and burns (n=429, 31.3%) injury mechanisms. In the logistic regression model, lacerations (OR 2.26, CI 1.63 – 3.13), animal bites (OR 1.97, CI 1.48 – 2.63), assault (OR 1.76, CI 1.54 – 2.00), falls (OR 1.25, CI 1.12 – 1.40), and female sex (OR 1.21, CI 1.10 – 1.32) had increased odds of IT, p<0.001. Night admits (OR 0.54, CI 0.49 – 0.59) and burn injuries (OR 0.44, CI 0.37–0.54) were protective for IT, p<0.001. Primary head (OR 1.34, CI 1.17 – 1.52) and extremity injuries (OR 1.86, CI 1.65 – 2.10) had increased odds of IT compared to torso injuries, p<0.001.

Conclusion: The majority of patients transferring to KCH for injury care are inappropriately transferred. The lack of clear transfer triage criteria and protocols contribute to this overtriage. Implementation of transfer criteria, trauma protocols, and inter-hospital clinician communication can mitigate the strain of IT in the resource limited setting.

36.06 What Outcomes are Important to Patients with Acute Cholecystitis at a Safety-Net Hospital?

Posted on January 31, 2019

G. E. Hatton1, K. M. Mueck1, I. M. Leal2, S. Wei1, T. C. Ko1, L. S. Kao1  1McGovern Medical School at UTHealth,Houston, TX, USA 2University Of Houston,Houston, TX, USA

Introduction:  The patient-centeredness of surgical care in safety-net hospitals is under-evaluated.  Surgical care for acute cholecystitis is often delayed among patients presenting to a safety-net hospital due to lack of access to medical care and limited hospital resources.  Multiple strategies exist to improve the timeliness and efficiency of surgical management of gallstone disease, such as acute care models and nighttime surgery.  However, the patient-centeredness of such strategies is unknown.  Our objective was to identify patient perceptions of their surgical care and the outcomes most important to them.  We hypothesized that efforts to improve timeliness of surgical care are also patient-centered.

Methods: Adult patients with acute cholecystitis were interviewed upon admission to a safety-net hospital.  Interviews were semi-structured and designed to obtain both exploratory qualitative data and ratings of patient-centered outcomes, ranked by importance to the patient.  Outcomes included for rating were previously identified by the Patient-Centered Outcomes Research Institute: general health, symptom status, quality of life, and return to prior functional status. Purposive sampling was utilized until data saturation was reached. Latent content analysis applying inductive coding methods were used to code and condense raw qualitative data from interview transcripts. Triangulation methods were used to increase the validity and credibility of the results.

Results: Interviews were conducted until thematic saturation was reached with a sample size of 15 patients.  The majority of participants were female (87%), Hispanic (87%), and had prior non-operative management of biliary colic (60%).  Patients identified symptom resolution as the highest-ranked outcome in their treatment (Figure).  Themes commonly expressed by patients during the exploratory segments of the interview included:  desire for pain alleviation, frustration with delays to both symptom resolution and surgical intervention, lack of perceived control over their current health, and reticence in discussing preferences with physicians.  All patients preferred to have surgical treatment for their gallstone disease as soon as possible, even if that meant having nighttime surgery.

Conclusions: Effective and timely resolution of symptoms is of utmost importance to patients with acute cholecystitis at a safety-net hospital.  Efforts to improve timeliness and patient-centeredness of surgical care are concordant.  Evaluation of the relationship between improvement in timeliness and other quality domains, such as safety, is needed.

36.05 Water-Soluble Contrast in Adhesive Small Bowel Obstruction Management: a Canadian Center’s Experience

Posted on January 31, 2019

B. Elsolh1, D. Naidu1, A. Nadler1  1University of Toronto,Division Of General Surgery,Toronto, Ontario, Canada

INTRODUCTION

Adhesions following abdominal surgery are the most common cause of small bowel obstruction (SBO). Surgical intervention for SBO is sometimes necessary, and delays in treatment can lead to morbidity and mortality. Determining which SBOs will resolve non-operatively is not standardized and relies on clinical acumen. Orally-administered water-soluble radiographic contrast (WSC) can be used diagnostically and therapeutically by tracking transit time to the cecum using X-rays in stable SBO patients. This more rapidly ascertains need for surgery and reduces length of stay (LOS). We review the outcomes of SBO patients following the implementation of a standardized SBO pathway at a Canadian tertiary care academic center.

METHODS

A WSC pathway for adhesive SBO management was created after a literature review. This was implemented by the General Surgery service at a large tertiary care academic center. The pathway (attached) was introduced gradually in 2018. Data prior to pathway implementation was gathered from 2016 (PRE group), and after implementation from the first half of 2018 (POST group). The primary outcome was LOS. Secondary outcomes included rates of failure of conservative management and subsequent need for surgery, in-hospital complications, mortality, and readmission rates for recurrent SBO. The hospital’s research ethics committee approved this study.

 

RESULTS

A total of 234 patients were admitted with SBO in the studied timeframe (102 PRE vs. 132 POST). Of these, 131 had adhesive SBO (66 vs. 65). 1 patient (2%) in the PRE group received WSC, compared to 26 (40%) in the POST group. The groups were matched in age, gender, and comorbidities. NG use was similar (77.3% vs. 80.0%, P=0.828). More POST patients required immediate surgery (6.1% vs. 24.6%, P<0.01) for either concerning CT findings (75%), clinical exam concerning for ischemia (12.5%), or other reasons (12.5%). There was no significant difference in failure of conservative therapy (3.1% vs. 6.2%, P=0.39). Median LOS (3 days vs. 4 days, P=0.259) was not significantly different. There was a higher rate of readmission in the PRE group (34.8% vs. 10.8%, P=0.001). There was 1 severe complication (Clavien-Dindo grade 3 or higher) in the PRE group, and 2 in the POST group. Mortality did not differ between groups (4.5% vs. 9.2%, P=0.29). 

 

CONCLUSION

While LOS did not change following WSC pathway implementation, the number of patients undergoing immediate surgery increased and readmissions decreased. This may be a result of early operative decision making as a result of the pathway or may represent a change in management practices over time. Further evaluation is required to increase pathway compliance and ensure that outcomes are improved by the pathway. 

36.04 Financial Risk Protection in Cesarean Section Patients at a Rural District Hospital in Rwanda

Posted on January 31, 2019

R. Koch1, T. Nkurunziza2, H. L. Irasubiza2, M. Shrime1, B. Hedt-Gauthier2,3, F. Kateera2  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 2Partners in Health/Inshuti Mu Buzima,Kigali, Rwanda 3Harvard School Of Medicine,Global Health And Social Medicine,Boston, MA, USA

Introduction:  To ensure universal health coverage (UHC), essential surgical care must be affordable. In Rwanda, more than 90% of citizens have community-based health insurance (Mutuelle de Sante). For all but the poorest citizens who are fully covered, insured members are responsible for a 10% co-pay as out of pocket (OOP) payment at time of service. However, 59.5% of the population is already below the international poverty line meaning that even this amount along with associated care-seeking costs have a significant impact on a family’s financial health. The aim of this study was to describe OOP payments for cesarean sections in the context of Mutuelle de Sante and determine if having insurance reduces catastrophic health expenditure in rural Rwanda.

Methods:  This study is nested in a larger study of women undergoing cesarean section at a rural district hospital in the Eastern Province of Rwanda. All eligible women between March and June 2018 were surveyed at time of discharge. Data included demographics, household income and routine monthly expenditures and direct and indirect spending related to the cesarean delivery hospitalization. Catastrophic health expenditure (CHE) can be defined as >10% estimated total yearly expenses or >40% annual non-food expenses.

Results: Of 346 women, 339 (98.0%) met the World Bank definition of extreme poverty (income <$1.90/person/day). 339 (98.0%) reported having health insurance; the majority (93.2%, n=316) have Mutelle de Sante. The median OOP expenditure for a direct medical costs related to a cesarean section was $26.29 (IQR 21.20-29.48). 30 (8.7%) patients had unpaid balances at time of discharge. The average cost including transportation to the hospital was $34.35 (IQR 26.99-40.93). 168 patients (48.6%) had to borrow money and 43 (12.4%) had to sell possessions to pay for the hospitalization. The direct medical costs alone were a CHE, defined as >10% estimated total yearly expenses, for 22 patients (6.3%). However, this increased to 33 (9.5%) when including direct non-medical costs such as transportation and food and 94 (27.0%) when including indirect expenses such as lost wages. Using 40% of non-food expenses to define CHE, up to 51.5% of patients experienced CHE when including other direct and indirect costs.

Conclusion: Despite universal health insurance, essential surgery still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although insurance offers some protection against catastrophic expenditure from the cost of healthcare alone, when adding in the cost of non-medical expenses, cesarean section is still too often a catastrophic financial event. Further innovation in financial risk protection is needed in order to provide equitable UHC.

 

36.03 Burden, Outcomes, and Economic Benefit of Neonatal Surgery in Uganda: Results of a Five-Year Follow-up Study

Posted on January 31, 2019

S. Ullrich1, N. Kakembo2, P. Kisa3, A. Muzira4, M. Nabukenya8, J. Tumukunde3, T. Fitzgerald5, M. Langer6, M. Situma7, J. Sekabira2, O. Doruk1  1Yale University School Of Medicine,Pediatric Surgery,New Haven, CT, USA 2Mulago Hospital,Surgery,Kampala, Uganda 3Makerere University,College Of Health Sciences,Kampala, Uganda 4University of British Columbia,Surgery,Vancouver, BC, Canada 5Duke University,Department Of Surgery,Durham, NC, USA 6Ann & Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 7Mbarara Regional Referral Hospital,Surgery,Mbarara, Uganda 8Mulago Hospital,Anesthesia,Kampala, Uganda

Introduction: Ninety-four percent of congenital anomalies occur in low and middle-income countries (LMICs). In Uganda, only four pediatric surgeons and three pediatric anesthesiologists serve over 20 million children. This study estimates burden, outcomes, and coverage of neonatal surgical conditions in Uganda and compares them with our prior estimates. We also estimate economic benefit of neonatal surgery.

 

Methods: A prospectively collected database was reviewed for neonatal (age < 30 days) general surgical admissions from January 1 2012, to May 31, 2017 at the only two sites with specialist pediatric surgical coverage, one that started providing services in mid-2014. Outcomes were compared with high-income countries, and met and unmet need were estimated using disability-adjusted life years (DALYs). We estimated economic benefit using a value of a statistical life-year approach.

 

Results: A total of 1,177 neonatal admissions were identified, representing 25% of all pediatric surgery admissions. Mean age of presentation was 7 days and overall mortality was 36%. Mean distance travelled was 92 km. The most common conditions were anorectal malformations (18%), gastroschisis (17%), omphalocele (15%), and intestinal atresia (10%). Almost half of presenting neonates (49%) underwent surgical intervention. Post-operative mortality was 24%.  Mortality for neonates was significantly associated with surgical intervention (p<0.001) and age (p<0.001). Highest mortality conditions were gastroschisis (85%) and biliary atresia (80%). Gastroschisis (42%) and anorectal malformations (42%) had the greatest reduction in mortality with surgical intervention. Met need was 3,531 DALYs/ year and 140,220 DALYS were potentially avertable (unmet need). The current met need corresponds to a $2.9 million net economic benefit to Uganda, with a potential additional benefit of $116 million if unmet need were fully addressed. Approximately 2.3% of the total need was met by the healthcare system.   

 

Conclusions: Neonatal surgery improves survival for most conditions despite resource limitations such as lack of neonatal intensive care. Despite slight increases in workforce and infrastructure, a negligible proportion of the need for neonatal surgery is currently being met in Uganda, similar to estimates five years ago (3%). This is likely multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial. More advocacy is needed to increase capacity for pediatric surgical care in Uganda and similarly resourced LMICs.

36.02 Preparing for Increased Surgical Need in an Era of Improved Infant and Child Mortality

Posted on January 31, 2019

C. Ewbank1,4, A. L. Kushner2,3, C. Newton1, W. Stehr1,5  1UCSF Benioff Children’s Hospital Oakland,Surgery,Oakland, CA, USA 2Johns Hopkins Bloomberg School of Public Health,Center For Humanitarian Health,Baltimore, MD, USA 3Surgeons OverSeas,New York, NY, USA 4University Of California – San Francisco East Bay,Surgery,Oakland, CA, USA 5Presbyterian Hospital,Surgery,Albuquerque, NM, USA

Introduction:

Successful interventions by the global health community have reduced the total number of under-five deaths from 12.6 million to 5.6 million (55.6%) since 1990. Over the same time period, neonatal mortality fell from 37 deaths per 1,000 to 19 (49%). With more babies surviving childbirth and into early childhood, the incidence of life-threatening pediatric surgical diseases will likely increase. We sought to characterize this increased surgical need for children under five years old based upon the improvement in child mortality worldwide.

Methods:

The incidence of ten common emergent pediatric surgical conditions, excluding those resulting from trauma, was compared to country level data from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) and the 2017 United Nations World Population Prospects probabilistic projections to estimate and characterize global surgical need among children under five by 2030.

Results:

Children under five are projected to require a mean net total of 83,557 additional essential procedures/year by 2030. The majority of additional surgical need is projected to be from incarcerated inguinal hernias (48,224 mean additional procedures, 57.7% of the total increase). Hypertrophic pyloric stenosis and intussusception represent other major contributors to overall surgical need (18,543 (22.2% of total) and 7,467 (8.9% of total), respectively). The countries with the greatest projected need due to increase in under-five population were Nigeria (117,814 additional needed procedures/year (28.7% increase)), the Democratic Republic of the Congo (68,430 additional needed procedures/year (36.8%)), and the United Republic of Tanzania (45,158 additional needed procedures/year (36.3% increase)). Although the overall global surgical need was net positive, many countries are projected to have significant decreases in under-five surgical need by 2030, the largest of which were China (236,067 fewer needed procedures (20.8% decrease)), India (50,999 fewer needed procedures (3.2% decrease)), and Iran (31,841 fewer needed procedures (35.0% decrease)).

Conclusion:

Children under five will require nearly 100,000 additional life-saving procedures each year by 2030, with many developing nations and remote areas within developed nations already unable to treat the current essential pediatric surgical need. This need is overwhelmingly projected to affect the least developed nations, and particularly those in Sub-Saharan Africa, where neonatal and early childhood disease treatable by surgical intervention represent a tremendous opportunity to improve morbidity and mortality. As population growth slows in many parts of the world, continued research and clinical efforts should be directed toward children in those places where the need is the greatest.
 

36.01 Pediatric Surgical Outreach Camps in Uganda: Results and Use of Guidelines for Quality Improvement

Posted on January 31, 2019

D. F. Grabski1, N. Kakembo2, M. Cheung3, I. Okello2, A. Shikanda5, M. Langer7, M. Nabukenya4, M. Ajiko8, G. Villalona6, T. Fitzgerald9, G. Kateregga10, J. Tumukunde4, A. Muzira2, P. Kisa2, M. Situma5, J. Sekabira2, D. Ozgediz3  1University of Virginia School of Medicine,Department Of Surgery,CHARLOTTESVILLE, VIRGINIA, USA 2Makerere University, Mulago Hospital,Department Of Surgery,Kampala, KAMPALA, Uganda 3Yale University School of Medicine,Department Of Surgery,New Haven, CT, USA 4Makerere University, Mulago Hospital,Department Of Anesthesia,Kampala, KAMPALA, Uganda 5Mbarara University of Science and Technology, Mbarara Hospital,Department Of Surgery,Mbarara, MBARARA, Uganda 6Saint Louis University School of Medicine,Department Of Surgery,Saint Louis, MO, USA 7Northwestern University School of Medicine,Department Of Surgery,Chicago, IL, USA 8Soroti Regional Referral Hospital,Department Of Surgery,Soroti, SOROTI, Uganda 9Duke University School of Medicine,Department Of Surgery,Durham, NC, USA 10Mbarara University of Science and Technology,Department Of Anesthesia,Mbarara, MBARARA, Uganda

Introduction:
Pediatric surgical resources are significantly limited in Uganda, especially in rural areas.  The result is a back-log of elective cases and emergency procedures performed by general surgeons or medical officers in rural hospitals.  Surgical camps run by local and international partners have historically assisted with rural service delivery.  We describe the effectiveness of locally led rural pediatric surgical outreach on service delivery and training.

Methods:
We performed a retrospective review of data from rural outreach camps completed by the pediatric surgery and anesthesia teams at Mulago Hospital in collaboration with international partners from 2012-2017. Primary outcomes included surgical volume and immediate surgical outcomes.  Secondary outcomes included the share of elective cases and the trainee involvement in the camps.  The 2017 joint “Guidelines for Short Term Missions” (STMs) from the American Pediatric Surgery Association (APSA) were used to assess possible areas of quality improvement.

Results:
From 2012-2017, 7 surgical outreach camps ranging from 3-5 days occurred in Soroti (5/2012, 1/2013), Masaka (8/2013, 02/2015) and Mbarara (01/2016, 11/2016, 04/2017) (Table 1).  394 cases were completed, with 383 (97.2%) elective procedures.  There were 4 re-operations and 2 post-operative deaths.  48 Trainees (6 from USA) in general surgery and anesthesia were involved in the camps.  6 general surgeons and 11 anesthesia officers were additionally involved in pediatric surgical and anesthesia skill transfer.  Reduction of elective case backlog and clinical skill transfer in pediatric surgery and anesthesia were successes highlighted by the local team.  Perceived challenges included a lack of reliable intensive care, radiology and pathology.  Qualitative review by the pediatric surgery and anesthesia teams of the Day-of Surgery Checklist from published guidelines revealed several areas of potential improvement including: allergy history (specifically where language barriers exist), evaluation for clinical changes after screening, pre-operative image review, and more formal intra-operative debriefing. Participants also emphasized possible burden on local hospitals.

Conclusion:
Pediatric surgical outreach camps led by local pediatric surgeons in Uganda are safe and help to address the back-log of elective cases.  Outreach camps can be closely linked with surgical training and skill transfer.  Challenges vary by site and camps can stress the local system and must be well-coordinated with local teams. Lastly, the 2017 joint guidelines for STMs, adapted to the local context, may be a helpful tool for quality improvement and prospective evaluation is warranted. 
 

35.10 Reducing Opioid Utilization After Appendectomy: An Institutional Quality Improvement Project

Posted on January 31, 2019

K. K. Somers1, R. Amin2, K. M. Leack1, D. M. Gourlay1, M. J. Arca1  1Medical College Of Wisconsin,Children’s Hospital Of Wisconsin And Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA

Introduction: Postoperative care after appendectomy may be first exposure to opioids for many children. We implemented quality improvement (QI) project to decrease inpatient and outpatient opioid utilization after laparoscopic appendectomy for acute appendicitis, hypothesizing that a significant impact can be achieved with simple, targeted steps.

Methods: We organized our QI project using Excellence in Quality Improvement Principles (EQUIP).  We compared the following variables between pre-implementation (2013-2016) to post-implementation (9/2017 through 7/2018) periods:  demographic data, pain scores, inpatient post-operative intravenous (IV) and enteral narcotics use, number of opioid doses prescribed at discharge, length of stay (LOS), returns to system for pain or constipation.  We queried a state-based enhanced prescription drug monitoring program (ePDMP) to determine if narcotic prescriptions were filled. A multidisciplinary team reviewed current state using driver diagrams, fishbone diagrams, impact assessment models, and rank ordering creating “Plan –Do-Study-Act” (PDSA) program. Interventions to optimize pain management included: 1) ice packs on incisions in the recovery unit; 2) pain scores within thirty minutes of arrival to the ward; 3) standardized order set with scheduled non-opioid analgesics; and 4) instructing surgery team on pre- and post-op communication with parents. Post implementation, data were discussed weekly to enable rapid and contemporaneous cycle changes.

Results: There were 815 patients pre-implementation and 193 post-implementation, with no statistically significant differences in age, gender, and median pain scores. Post-implementation, 73.5% had local ice packs in recovery unit, 98.8% had appropriately documented pain scores on arrival to ward, and the order set was utilized in over 94% of patients. There were statistically significant decreases in the use of IV and enteral opioids while in hospital, and number of opioid doses prescribed at discharge, and mean length of stay (hours). 59.4% of patients filled narcotic prescriptions. Though not statistically significant, we found overall reduction in return to the health care system for pain or constipation.

Conclusion: By  using a multidisciplinary assessment of current state, culture and management of parental, patient, and nursing expectations, organizations may be able reduce overall opioid consumption in postoperative patients.

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