74.03 Substantial Uncompensated Medical Care Delivered By Surgeons Through Patient Portals

Posted on January 26, 2017

J. Robinson1,2, A. Valentine2, C. Carney2, D. Fabbri1, G. P. Jackson1,2  1Vanderbilt University Medical Center,Department Of Biomedical Informatics,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Pediatric Surgery,Nashville, TN, USA

Introduction:  Patient portals are online applications that allow patients and their caregivers to interact with healthcare organizations and view health information. Surgeons conduct growing numbers of online encounters by exchanging messages with patients through such portals. We analyzed a random sample of patient portal communications between patients and surgical providers to determine the types of care provided and complexity of medical decision making associated with patient portal messaging. 

Methods:  We obtained all message threads (i.e., sets of messages exchanged between patients and providers) initiated by patients and sent to surgical providers through the Vanderbilt University Medical Center patient portal from June 1 to December 31, 2014. Of these, 500 were randomly selected for detailed analysis. Message content was analyzed by two research team members and classified using a validated consumer health taxonomy, including categories for medical, logistical, informational, and social communications. Within each thread, we determined the complexity of medical decision making, one of the three defined elements of outpatient billing, according to the Center for Medicare and Medicaid Services (CMS) Evaluation and Management (E/M) guidelines. Discrepancies in category assignments were discussed to reach consensus. 

Results: 9,408 message threads were sent to 567 surgical providers during the analyzed period. Of the 500 randomly selected message threads, 1281 distinct issues were communicated, with an average of 2.6 issues per thread. Medical care was delivered in 453 message threads (90.6%) as described in Table 1. Logistical needs, such as contact information or insurance questions, were addressed in 150 threads (30.0 %); health information needs in 77 threads (15.4 %); and social communications (e.g., complaints or emotional needs) in 62 threads (12.4 %). 339 (67.8 %) of message threads contained medical decision making, low risk in 171 (50%) and moderate risk in 132 (39%), with the remaining straightforward or high risk. The overall complexity of medical decision making was straightforward in 62% (210 messages), low in 30% (102 messages), and moderate in 8% (27 messages). No highly complex decisions were made over portal messaging.

Conclusion: Through patient portal messages, surgeons deliver substantial medical care with varied levels of medical complexity. Implementation of patient portals by healthcare systems will continue to increase in response to consumer demand and regulatory pressures such as the Affordable Care Act. Models for compensation of online care must be developed as consumer and surgeon adoption of these technologies increases.
 

74.02 A perioperative care map improves outcomes in morbidly obese patients

Posted on January 26, 2017

B. D. Boodaie1, A. H. Bui1, D. L. Feldman1,2, M. Brodman1, P. Shamamian3, R. Kaleya4, M. Rosenblatt1, D. Somerville2, P. Kischak2, I. M. Leitman1  1Icahn School Of Medicine At Mount Sinai,Surgery,New York, NY, USA 2Hospitals Insurance Company,New York, NY, USA 3Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA 4Maimonides Medical Center,Brooklyn, NY, USA

Introduction:  

The surgical management of obese patients is very complex and plagued with relatively high rates of postoperative complications. In 2012, a perioperative care map for obese patients was developed with the goal of eliminating these disparities in outcomes. The care map expanded best practices and precautions already used for bariatric patients to obese patients undergoing all types of surgery. The care map calls for a supplemental consent form, various perioperative medical assessments including nutritional and mobility assessments, more stringent guidelines for anesthetic care, the availability of bariatric medical equipment, and evaluation for anticoagulation among other items. In 2013, the care map was implemented at four major urban teaching hospitals, which required its use for morbidly obese patients undergoing all types of surgery. By 2015, surgeons and anesthesiologists reported a significant change in their management to match best practices while random audits showed 98% care map compliance. Here, the impact of these behavioral changes on patient outcomes was evaluated.

Methods:

National Surgical Quality Improvement Program (NSQIP) data was collected for 2013 and 2015 from four urban teaching hospitals that implemented the care map. Morbidly obese patients that met hospital criteria for care map implementation were identified; this criteria is defined as BMI>=40, or BMI>=35 with diabetes or hypertension. 30-day outcomes for morbidly obese patients between 2013 and 2015 (before and after mass implementation) were compared. To control for secular trends in care quality in these hospitals caused by factors other than care map usage, changes in these metrics for morbidly obese patients were compared to those for non-obese patients.

Results:

Of 11,117 surgical cases reviewed in 2013, 16.5% were morbidly obese; of 10,417 cases reviewed in 2015, 17.7% were morbidly obese. For morbidly obese patients, rate of return to operating room (ROR) decreased from 3.3% to 1.7% (p=0.002). Unplanned readmission rate decreased from 7.0% to 4.0% (p<0.001). Average length of stay (LOS) decreased from 3.7 to 2.8 days (p<0.001). Using multivariate analyses that adjusted for differences in patient demographics and preoperative variables between 2013 and 2015, significant decreases were found for morbidly obese patients in ROR (OR=0.47, p=0.002), unplanned readmission (OR=0.59, p<0.001), and LOS (-0.81 days, p<0.001). The decrease in unplanned readmission rate was 28.9% greater for morbidly obese patients than for non-obese patients (p=0.04). LOS for morbidly obese patients decreased by 0.81 more days compared to non-obese patients (p<0.001).

Conclusion:

Unplanned readmission rate, ROR rate, and LOS significantly decreased in morbidly obese patients between 2013 and 2015. Implementation of the obesity care map may have contributed to these favorable outcomes. This care map should be further investigated and considered for more widespread use.

74.01 Preoperative Carbohydrate Loading and Recovery after Surgery – A Multiple Treatments Meta-Analysis

Posted on January 26, 2017

M. A. Amer1,3, M. D. Smith1,4, G. P. Herbison2, L. D. Plank5, J. L. McCall1,3,5,6  1University Of Otago,Department Of Surgical Sciences, Dunedin School Of Medicine,Dunedin, OTAGO, New Zealand 2University Of Otago,Department Of Preventive And Social Medicine, Dunedin School Of Medicine,Dunedin, OTAGO, New Zealand 3Dunedin Hospital,Department Of General Surgery,Dunedin, OTAGO, New Zealand 4Southland Hospital,Department Of General Surgery,Invercargill, SOUTHLAND, New Zealand 5University Of Auckland,Department Of Surgery, School Of Medicine,Auckland, AUCKLAND, New Zealand 6Auckland City Hospital,New Zealand Liver Transplant Unit,Auckland, AUCKLAND, New Zealand

Introduction:

The aim was to determine the effects of preoperative carbohydrate (CHO) administration on clinically relevant postoperative outcomes in adult patients undergoing elective surgery. Three recent meta-analyses have summarized the results of randomized clinical trials (RCTs) that examined this, however, these could not account for the different doses of CHO administered and the different controls used. Multiple-treatments meta-analysis (MTM) allows for robust synthesis of all available evidence in these situations.

Methods:

Article databases were systematically searched for RCTs comparing preoperative carbohydrate administration with water, a placebo drink, or fasting. A four treatment MTM was performed comparing two CHO dose groups (low: 10–44g; high: >45g) with two control groups (fasting; water or placebo). Primary outcomes were length of hospital stay and postoperative complication rate. Secondary outcomes included postoperative insulin resistance, vomiting and fatigue.

Results:

Results 43 trials, involving 3110 participants were included. Compared to fasting, preoperative low dose and high dose CHO administration decreased postoperative length of stay by 0.4 days (95% confidence interval (CI) 0.03 – 0.7) and 0.2 days (95% CI 0.04 – 0.4) respectively. There was no significant decrease in length of stay compared to water or placebo. There was no significant difference in the postoperative complication rate, or in most of the secondary outcomes, between the CHO and control groups.

Conclusion:

CHO loading before elective surgery conferred a small reduction in length of stay when compared to fasting, but no significant difference when compared to water or placebo. No other clinically significant effect on post-operative outcomes was found.

 

73.09 Variation in Post-Acute Care Utilization After Complex Surgery

Posted on January 26, 2017

C. Balentine1,2, M. C. Mason3, P. J. Richardson4, P. Kougias3,4, F. Bakaeen5, A. D. Naik4,6, D. H. Berger3,4, D. A. Anaya7  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Institute For Cancer Outcomes And Survivorship,Birmingham, AL, USA 3Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 4Houston Veterans Affairs Health Services Research And Development Center For Innovations In Quality, Effectiveness And Safety (IQUEST),Houston, TX, USA 5Cleveland Clinic,Department Of Thoracic And Cardiovascular Surgery,Cleveland, OH, USA 6Baylor College Of Medicine,Alkek Department Of Medicine,Houston, TX, USA 7H. Lee Moffitt Cancer Center & Research Institute,Department Of Gastrointestinal Oncology,Tampa, FL, USA

Introduction: Patients value regaining independence and returning home after surgery, but they are frequently discharged to post-acute care facilities including skilled nursing and inpatient rehabilitation hospitals.  Studies of hospital variation in post-acute care use have primarily focused on medical conditions, have been limited to Medicare patients, or have ignored the Veterans Affairs system (the largest healthcare provider in the United States).  Consequently, there is no nationally representative data on how rates of discharge to post-acute care facilities differ across hospitals following complex surgery.  The purpose of this study is to explore hospital-level variation in post-acute care utilization after cardiovascular and abdominal surgery in public, private and Veterans Affairs hospitals.  We hypothesized that there would be significant variation in post-acute care use across hospitals, regardless of the type of health system.

Methods: We performed a retrospective cohort study of 3,487,365 patients from the Nationwide Inpatient Sample and 60,666 from the Veterans Affairs health system who had colorectal surgery, hepatectomy, pancreatectomy, coronary bypass, aortic aneurysm repair, and peripheral vascular bypass between 2008-2011.  For Veterans, 32% were age 70 or older, and 98% were men.  For non-Veterans, 39% were age 70 or older, and 60% were men.  The primary endpoint was hospital-level unadjusted and risk-adjusted observed-to-expected ratios for discharge to post-acute care facilities (skilled nursing or inpatient rehabilitation)

Results: 631,199 (18%) non-Veteran patients and 4,744 (8%) Veterans were discharged to post-acute care facilities.  Hospital rates of discharge to post-acute care facilities varied from 1% to 36% for Veterans hospitals and from 1% to 59% for non-Veteran hospitals.  Risk-adjusted observed-to-expected ratios ranged from 0.10 to 4.15 in the Veterans Affairs and from 0.11 to 4.3 for non-Veteran hospitals.  Variation in post-acute care utilization persisted even among high-volume referral centers.  Rates of discharge to post-acute care facilities for high-volume centers ranged from 1-54% and observed-to-expected ratios ranged from 0.13-2.99 for non-Veteran hospitals and 0.13-3.13 for Veterans.

Conclusion:There is substantial variation in post-acute care utilization and rates of home discharge after abdominal and cardiovascular surgery, even among hospitals that specialize in complex surgery.  To help more patients achieve their goal of returning home after surgery it will be important to improve postoperative recovery, develop evidence-based guidelines for the use of post-acute care, and better identify patients with post-acute care needs.

 

73.08 Comprehensive Geriatric Assessment Improves Surgical Outcomes: A Systematic Review and Meta-analysis

Posted on January 26, 2017

G. Eamer1, A. Taheri1, S. S. Chen1, Q. Daviduck1, T. Chambers2, R. G. Khadaroo1  1University Of Alberta,General Surgery,Edmonton, AB, Canada 2University Of Alberta,Libraries,Edmonton, AB, Canada

Introduction:
Aging world populations are increasing the demand for surgical intervention in those over 65 years of age. Older patients experience higher rates of post-operative complications, have longer length of stay, increased cost and are more likely to require institutionalization after discharge. Comprehensive geriatric assessment (CGA) is a multi-faceted approach to in-patient care that addresses medical, functional and psychosocial factors. It is proposed to decrease cost and adverse outcomes in the elderly.

Methods:
A Cochrane systematic search of MEDLINE, CENTRAL, Embase and the EPOC register for randomized controlled trials and controlled before-after studies of CGA versus usual care was conducted by a librarian. Grey literature was also searched. Two reviewers screened titles, full text and extracted data. Inclusion criteria include emergency or elective surgical patients over 65 receiving CGA versus usual care. Exclusion criteria include no patient cohorts over 65, wrong intervention, wrong setting, incorrect study design and incomplete geriatric assessment. Primary outcomes were predefined as mortality and return of pre-morbid function. Secondary outcomes were length of stay, post-operative complication rates, readmission and cost. Meta-analysis was performed assuming random effects and using the longest period from each study. Subgroup analysis analyzed orthopedic studies.

Results:
A total of 12,900 articles were identified; 12,580 were excluded based on abstract review and 310 after full text review. Ten articles from 8 studies were identified for inclusion. All studies were single center randomized controlled trials; 7 in orthopedics trauma and one in surgical oncology. Studies were published between 1988 and 2015. Orthopedic trials were analyzed as a subgroup and are reported below. There was a significant improvement in discharge disposition (OR 0.69, 95% CI 0.48-0.99, p=0.04, 6 studies, high quality evidence) and post-operative delirium (OR 0.52, 95% CI 0.31-0.88, p=0.02, 2 studies, high quality evidence). Mortality neared a significant reduction in the experimental group (OR 0.78, 95% CI 0.59-1.03, p=0.08, 5 studies, high quality evidence). There was no significant change in length of stay (mean difference -2.82, 95% CI -10.30-4.67, p=0.76, 5 studies, high quality evidence) or readmission (OR 0.92, 95% CI 0.53-1.57, p=0.75, 2 studies, moderate quality evidence). Only one study reported aggregate post-operative complications (OR 0.53, 95% CI 0.34-0.82). 

Conclusion:
CGA demonstrates improved return of function and decreased post-operative delirium. Our meta-analysis found significant improvements in outcomes for orthopedic trauma patients over 65 and suggests orthogeriatric care with CGA should become the standard of care. There is insufficient information to determine if this finding applies to other surgical specialties or interventions. Further studies should examine the effectiveness of CGA in other surgical fields. 
 

73.07 Minimally Invasive Pediatric Surgery: Trends in Basic and Advanced Procedures

Posted on January 26, 2017

J. Tashiro1, N. Joudi1, E. A. Perez1, J. E. Sola1  1University Of Miami,Surgery,Miami, FL, USA

Introduction: Minimally invasive surgery has been introduced for a multitude of indications in pediatric surgery. We hypothesized that the use of laparoscopy and thoracoscopy in pediatric surgery is dependent on the complexity of the procedures performed.

Methods: The Kids’ Inpatient Database (1997-2012) was searched for basic (appendectomy, cholecystectomy) and advanced (pull-through rectal resection, lung resection) procedures.

Results: Overall, 583,738 cases were included in the study cohort, performed laparoscopically/thoracoscopically (52%) or open (48%).

Appendectomies (n=500,708) were more frequently performed open (53%) overall, with the remainder were performed laparoscopically (47%). The study period saw an overall increase in the use of laparoscopy from 13% to 81%, p<0.001. A significant increase in the use of laparoscopy was observed over each triennial period, p<0.001. Rates of conversion to open surgery has declined steadily from 5.9% in 2000 to 2.1% in 2012, p<0.001. Incidence of appendectomies also rose, from 1058 to 1164 cases per 100,000 admissions, p<0.001.

Cholecystectomies (n=78,576) were mostly performed laparoscopically (88%), whereas the remainder were performed open (12%). Over the study period, laparoscopy rates increased from 76% to 92%, p<0.001. The triennial periods between 1997 and 2009 were found to increase significantly in the laparoscopy rate, p<0.001; the rate has since reached a plateau between 2009 and 2012. Conversion rates have declined recently, falling from 3.0% in 2006 to 2.0% in 2012, p<0.02. Incidence of cholecystectomy has increased through each triennial period, from 114 to 211 cases per 100,000 admissions, p<0.001.

Pull-through procedure (n=2895) for Hirschsprung’s disease were most frequently performed open (78%), whereas the remainder were performed laparoscopically (22%) between 2009 and 2012. During this period, the rate of laparoscopy increased from 19% to 24%, p=0.001. Conversion and incidence rates were static.

Lung resections (n=1559) for congenital pulmonary airway malformation (748.4) and pulmonary sequestration (748.5) were most frequently performed open (64%); the remainder were performed thoracoscopically (36%) between 2009 and 2012. The rate of thoracoscopic surgery has increased in this period from 24% to 41%, p=0.001. Conversion rates decreased from 8.5% to 4.9%, p<0.001. Case incidence rose from 6 to 17 cases per 100,000 admissions, p<0.001.

Conclusion: The introduction of minimally invasive surgery has had a significant impact on both basic and advanced pediatric surgery procedures. Declining minimally invasive to open conversion rates may demonstrate increasing familiarity with laparoscopy/thoracoscopy for difficult cases.

73.06 Pre-Operative Proteinuria Predicts Post-Operative Acute Kidney Injury and Readmission

Posted on January 26, 2017

T. S. Wahl1,2, L. A. Graham2, J. S. Richman1,2, M. S. Morris1,2, R. H. Hollis1,2, K. F. Itani3,4, T. H. Wagner7,8, H. J. Mull3, G. L. Telford5, A. K. Rosen3, L. A. Copeland6, E. A. Burns5, M. T. Hawn7,8  1University Of Alabama Birmingham,Birmingham, AL, USA 2Birmingham VA Medical Center,Birmingham, AL, USA 3VA Boston Healthcare System,Boston, MA, USA 4Harvard Medical School,Boston, MA, USA 5Milwaukee VA Medical Center,Milwaukee, WI, USA 6Central Texas Veterans Healthcare System,Temple, TX, USA 7VA Palo Alto Healthcare System,Palo Alto, CA, USA 8Stanford University,Palo Alto, CA, USA

Introduction: Proteinuria indicates renal dysfunction and is a risk factor for acute kidney injury (AKI) and mortality among medical patients, but less is understood among surgical populations. We hypothesized that pre-operative proteinuria would be associated with post-operative AKI, 30-day unplanned readmission and post-discharge mortality.

Methods: Patients undergoing elective inpatient surgery performed at 118 Veterans Affairs Hospitals from October 2007-September 2014 were examined using Veterans Affairs Surgical Quality Improvement Project (VASQIP) data. The VA Central Data Warehouse domains provided vital sign, laboratory, medication administration, and prior healthcare (emergency or inpatient) utilization data within 6 months. Pre-operative dialysis, septic, cardiac, transplantation, and urologic patients were excluded. Patients having a pre-operative urinalysis with a urine-protein dipstick were examined using closest values within 6-months. Urine-protein dipstick results include negative (0 mg/dL), trace (15-30 mg/dL), 1+ (30-100 mg/dL), 2+ (100-300 mg/dL), or 3+ (>300 mg/dL). Inpatient, pre-discharge AKI was defined as an increase in post-operative serum-creatinine >0.3 mg/dL from the closest pre-operative baseline. Multivariate logistic regression identified predictors of post-operative inpatient AKI, 30-day unplanned readmission, and 30-day post-discharge mortality.

Results: Of 271,149 surgeries, 154,129 met inclusion criteria with the majority orthopedic (37%) followed by general (28.8%), vascular (13.9%), neurosurgery (8.1%), and non-cardiac thoracic (6.6%). 43.8% of the population showed evidence of proteinuria (trace: 20.6%, 1+: 16%, 2+: 5.6%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, having a normal pre-operative estimated glomerular filtration rate (eGFR>60 mL/min/1.73m2). Proteinuria was significantly associated with AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%, p<0.001), readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, p<0.001), and post-discharge mortality (0.5%, 0.9%, 1.3%, 1.5%, 1.1%, respectively, p<0.001). After adjustment, increasing proteinuria was associated with post-operative AKI, readmission, and mortality (Table 1).

Conclusion: Proteinuria was associated with post-operative AKI, 30-day unplanned readmission, and 30-day post-discharge mortality independent of pre-operative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI, readmission, and mortality to guide perioperative management.

73.04 Impact of a Standardized Gastrostomy Tube Education Program on Post-Surgical Resource Utilization

Posted on January 26, 2017

Y. R. Yu1,2, P. I. Abbas1,2, K. M. Murphy1,2, L. J. Stephens1,2, V. A. Victorian1,2, T. C. Lee1,2  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA

Introduction: Our institution created a standardized educational pamphlet and implemented a formal gastrostomy education course for our gastrostomy tube (GT) patients. This study evaluates the impact of this program on post-surgical resource utilization.

Methods: We included children under 18 years old who received a surgical GT from 10/2013-7/2015. Patients were stratified into pre-intervention (pre) (10/2013–9/2014) or post-intervention (post) (10/2014–7/2015) groups. The post cohort was further subdivided into formal education (FE) or nursing discharge education using an educational pamphlet(PE). Unnecessary emergency department (UE) visits were defined as complications amenable to management in clinic or home, such as granulation tissue, dislodgment >6 weeks, or leakage. Clinic visits outside of routine follow-up within 1 year of surgery and telephone calls related to GT care within 30 days and 1 year after surgery were analyzed. Anonymous 5-point Likert scale (5-high understanding to 1-low understanding) surveys were administered to evaluate the formal GT education course. We performed statistical analysis using χ2 test or Fisher’s exact test and Mann-Whitney U where appropriate.

Results:Four hundred nineteen patients were included (245 pre and 174 post); median age 12.2 months (IQR 4.9-59.6) and average follow-up of 219±173 days. Seventy-two (41%) patients attended the gastrostomy education course and 102 (59%) received an educational pamphlet. Overall, there was a significant decrease in rate of UE visits (pre-25% vs. post-13%, p=0.003). This led to a 61.8% reduction in cumulative direct variable costs associated with UE visits (pre-$19,021 vs. post-$7,261). GT related phone call rate within 30 days (pre-9.8% vs post-10.9%, p=0.71) and within a year (pre-26.1% vs. post-19%, p=0.09) of surgery was similar. However, there was a significant decrease in non-routine clinic visits (pre-32.7% vs. post-12.6%, p<0.001) following gastrostomy tube education. Type of education (FE vs. PE) did not affect UE visits, call rate or non-routine clinic visits. Seventy-seven patients completed a course survey; 13 (17%) had FE. FE significantly improved understanding of granulation tissue, troubleshooting a clogged port, and minimized uncertainty with GT care [Table].

Conclusion:A standardized GT education protocol decreases emergency room and non-routine clinic visits. Unnecessary emergency department visits for GT issues that can be safely managed at home, with the appropriate education, has a large impact on healthcare costs. While, there was no difference in post-surgical resource utilization based on educational modality, parents have a better understanding of gastrostomy tube care in a formal class setting.

73.03 Patient and Caregiver Perspectives on Care Coordination During Transitions of Surgical Care

Posted on January 26, 2017

D. S. Swords1, S. L. Slager2, C. R. Weir2, B. S. Brooke1  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Department Of Biomedical Informatics,Salt Lake City, UT, USA

Introduction:  Episodes of care for surgical patients involve multiple transitions between different healthcare settings and providers. While it is recognized that care coordination is often fragmented during transitions of surgical care, it is not clear how this specifically impacts surgical patients and their caregivers. This study was designed to identify themes that define care coordination from patient and caregiver perspectives’ during transitions of surgical care.

Methods:  We performed a cross-sectional qualitative study using transcripts obtained from eight focus group sessions conducted among patients and caregivers from 3 different US states who had recently experienced an episode of surgical care. We used Atlas.ti qualitative software and engaged in an iterative process of thematic analysis of the focus group transcripts among three independent reviewers. 

Results: A total of 114 patients and caregivers were interviewed during focus group sessions who had been exposed to a broad range of different surgical procedures and specialties. After five-rounds of thematic analysis using focus group transcripts, we identified 5 main themes that commonly define care coordination for patients and caregivers during transitions of surgical care: 1) Care coordination is embedded in the unwritten social contract patients share with their healthcare providers; 2) Patients expect that all healthcare providers will be on the same page with each other; 3) Patients are frightened and vulnerable during surgical transitions; 4) Patients want providers to help set accurate expectations of their care processes; and 5) Care coordination relies upon mutual trust between patients and their healthcare providers, which needs to be established and reaffirmed throughout the episode of care (Table). 

Conclusion: Surgical patients and their caregivers expect healthcare providers to engage in comprehensive communication processes to avoid fragmented care coordination during transitions of surgical care. Improving care coordination will require better informatics infrastructure, patient education materials and information exchange between providers. These findings have implications for designing patient-centered interventions to improve coordination of care for surgical patients.

73.02 Keystone Flap Vs. Skin Graft for Extremity Melanoma: Surgical and Functional outcomes comparision.

Posted on January 26, 2017

J. W. Rostas1, N. Bhutiani1, K. M. McMasters1, R. C. Martin1, C. S. Scoggins1, P. Philips1  1University Of Louisville,Surgery, Surgical Oncology,Louisville, KY, USA

Introduction:
Reconstruction after wide local excision of extremity melanoma often requires split thickness skin grafts for the resultant large defects. Keystone fascio-cutaneous island perforator ?ap is a reliable, rapid, simple and versatile reconstructive alternative. There is however, lack of data comparing this technique to skin grafts. The aim of this study is to evaluate and compare the functional, Quality of Life (QoL) and aesthetic outcomes of keystone flaps and skin grafts for extremity melanoma.

Methods:
Thirty-eight consecutive extremity melanoma patients (Keystone flap, n=24, Skin grafts, n=14) with an expected excisional diameter of >4 cm were prospectively enrolled to surgical outcomes study from 2013-2016 at the University of Louisville. Standard surgical techniques were employed and choice of reconstruction left to surgeon's discretion. Surgical outcomes were recorded prospectively. At the 3 month post-surgery follow-up visit, aesthetic and functional outcomes were evaluated using previously validated Wound Evaluation Scale (WES), visual analog score (VAS, 0=worst possible scar, 10: best possible scar), and a 10 point overall patient satisfaction score (OPS, 0=poor, 10 excellent). Quality of life after surgery was scored using 5 point Functional Outcome Measure (FOM:1=severe disability/deformity, 2= restriction even with mild use, 3=restriction in severe exertion, 4=no functional restriction, social restriction, 5= no restriction). Appropriate statistical tests were used.

Results:

Keystone flap group was similar to skin graft group with respect to melanoma thickness (1.75 vs. 2 mm, p=0.227), excision diameters (5.5 mm vs. 5.5 mm, p=0.782), concurrent sentinel lymph node biopsy (96% vs. 100%, p=0.632), completion lymphadenectomy (4 vs. 3, p=0.517), age (54.5 vs 59 years, p=0.227), diabetes and smoking history. Median hospital stay (1 vs. 2 days, p<0.001), return to activities of daily living (1 vs. 4 days, p<0.001), return to work (7 vs. 12.5 days, p<0.001) and duration of limb immobilization (1 vs. 4 days, p<0.001) were significantly lower in the keystone flap group. Keystone flap group had significantly fewer wound infections (n=4 vs. 2, p=0.049) and incomplete wound healing (n=1 vs. 3, p=0.047). The aesthetic and functional outcome scores as measured by WES (median 5 vs.3, p<0.001), patient VAS (median 8 vs. 5, p<0.001), OPS (median 8 vs. 6, p=0.034) and FOM (4 vs. 3, p-0.041) for keystone flap were also significantly superior to skin grafts. No local recurrences were noted and 3 patients at a median follow up of 13 months had distant metastatic disease.

Conclusion:
Keystone flap is an excellent reconstructive technique with cosmetic and aesthetic outcomes that are superior to skin grafts. 

73.01 Surgical Dogma Challenge: Empiric Postnatal Antibiotic Use in Neonatal Surgical Patients

Posted on January 26, 2017

S. K. Walker1, R. L. Massoumi4, E. R. Gross3, M. Knezevich1, M. R. Uhing2, M. J. Arca1  1Medical College Of Wisconsin,Pediatric Surgery/Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Neonatology/Pediatrics,Milwaukee, WI, USA 3University Of Colorado Denver,Surgery/Pediatric Surgery,Aurora, CO, USA 4University Of California – Los Angeles,General Surgery/Surgery,Los Angeles, CA, USA

Introduction: Newborns with congenital anomalies often receive empiric postnatal antibiotics as prophylaxis for possible complications arising from their anomalies. No data exist to support this practice.  We implemented an antibiotic stewardship program in our Neonatal Intensive Care Unit, whereby postnatal antibiotics were given to newborns with congenital anomalies only if specific indications (e.g., chorioamnionitis, fevers) exist and peri-operative antibiotics were standardized to piperacillin/tazobactam given no more than 72 hours postoperatively. We hypothesized that judicious antibiotic use would have no effect on postoperative infectious complications.

Methods: We conducted an IRB-approved retrospective chart review of all neonates born with esophageal atresia +/- tracheoesophageal fistula, duodenal atresia, intestinal atresia, anorectal malformations, congenital diaphragmatic hernia, omphalocele, and cloacal anomaly in the time periods before (1/1/2009-6/30/2012) and after (7/1/12-3/30/14) antibiotic protocol implementation.  Outcome measures were the development of surgical site infections (SSI) and hospital acquired infections (HAI) including those with multidrug resistant organisms (MDRO). Statistical analyses were performed using Student’s t-test for continuous variables and Chi-square for categorical variables.

Results: The study population consists of 160 pre-protocol and 136 post-protocol newborns. There were no statistical differences in birth weight, gender, inborn status, delivery methods, maternal group B Streptococcal status, cardiac and non-cardiac comorbidities, or individual diagnoses. The average pre-protocol gestational age was younger than the post-protocol group (36.56 +/- 2.58 vs 37.12 +/- 2.35 weeks, p=0.04). Day of surgery variables such as weight, day of life, and ASA status were not statistically significant between groups. Pre-protocol, 57.5% received perinatal antibiotics compared to 39% post-protocol (p=0.001) The pre-protocol group received antibiotics longer (2.99 +/- 1.26 days) than the post-protocol group (2.40 +/- 1.06 days, p=0.004).  We observed more SSI’s in the pre-protocol period (16% vs. 9%, p=0.046). Operative intervention for SSI was required in 29.6% of the pre-protocol patients, while none was required in the post-protocol group. There was no difference in HAI between the groups (13.8% vs. 11.8%, p=0.42), but there was a difference in number of patients with MDRO (7.5% vs. 2%, p=0.04). When we compared the subgroups that both received antenatal antibiotics, higher SSI was noted in the pre-protocol group (17% vs. 5.7%, p =0.04).

Conclusion: The implementation of an antibiotic protocol in newborns with congenital anomalies requiring operative intervention resulted in decreased frequency and duration of antibiotic use postnatally. This change in practice may be associated with decreased incidence of SSI and isolation of MDRO without an increased risk of other HAI.

 

72.10 Disparities in Surgical Outcomes in Patients with Co-morbid Mental Illness

Posted on January 26, 2017

E. A. Bailey1, C. E. Sharoky1, C. Wirtalla1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics, Department Of Surgery,Philadelphia, PA, USA

Introduction:  The link between mental and physical health is poorly understood. Patients with mental health disorders have worse oncologic and chronic disease management and experience excess mortality compared to those without a mental health comorbidity. This study aims to evaluate the relationship between mental health comorbidities and surgical outcomes.

Methods:  We conducted a retrospective cohort study using the 2009-2011 National Inpatient Sample (NIS) database. All patients aged 18-90 who underwent one of the top four most common general surgery procedures (cholecystectomy, colectomy, small bowel resection/lysis of adhesions, and appendectomy) were included. Patients were classified as having a mental health diagnosis if they had a DSM IV diagnosis present on admission. Diagnosis categories included anxiety, mood, impulse control disorders, substance abuse, and schizophrenia. Descriptive statistics were performed. Multivariable regression examined post-operative outcomes including length of stay (LOS), in-hospital mortality, and complications while controlling for age, sex, race, admission status, non-mental health co-morbidities, insurance status, and income quartile by zipcode.

Results: 579,851 patients were included. 38,702 patients (6.67%) had a concurrent mental health diagnosis on admission. Of these, mood disorders were most prevalent at 58.7% (n=22,717) followed by substance abuse (23.8%, n=9,206), schizophrenia (13.5%, n=5,234), anxiety disorders (11.6%, n=4,484), and impulse control disorders (5.3%, n=2,059). Patients with mental health disorders were significantly younger than those without a mental health diagnosis (median 52 v 54 years; p<0.001). Those in the mental health cohort were significantly more likely to be female (61.1% v 57.6%), white (77.8% v 69.2%), and have a greater number of non-mental health comorbidites. They were also more likely to be admitted urgently or emergently (73.9% v 70.1%), insured by either Medicare or Medicaid (53.2% v 43.4%), and in the lowest income quartile by zipcode (27.8% v 24.9%). LOS for patients with co-morbid mental illness was 0.8 days longer (p <0.001). Co-morbid mental illness was significantly associated with any post-operative complication and specifically wound infection, ileus, small bowel obstruction, need for parenteral nutrition, and abdominal pain (Table 1). Odds of death were slightly lower in the mental health diagnosis cohort.

Conclusion: Patients who undergo the most common general surgery procedures with co-morbid mental health conditions experience a greater incidence of post-operative complications and longer hospitalizations. Recognizing disparate outcomes is the first step in understanding how to optimize care for this often marginalized population.

 

72.09 Insurance, Not Race, Is Associated With Transfer From Pennsylvania Level 2 and 3 Trauma Centers.

Posted on January 26, 2017

A. N. Kulaylat1, M. Linskey1, S. B. Armen1, C. S. Hollenbeak1, R. E. Cilley1, B. W. Engbrecht1  1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA

Introduction: Disparities in trauma care based on race and insurance status have been well-documented.  This study was designed to evaluate if insurance status or race is associated with transfer of patients from Level 2 or 3 Trauma Centers to another Trauma Center using a state database.

Methods: The Pennsylvania Trauma Systems Foundation maintains a statewide database for all patients at accredited Trauma Centers that meet certain requirements.  This is a retrospective review of that database for adult (≥ 18 yo) patients initially evaluated at Level 2 or Level 3 Adult Trauma Centers between July 1, 2008, and June 30, 2012.  Multivariate analysis was used to assess for variables that might be associated with transfer to another Trauma Center, with p<0.05 considered significant.

Results:5% of Level 2 patients (n=37136) and 36% of Level 3 patients (n=2873) were transferred during the time studied.  Factors associated with transfer included increasing ISS and Self-Pay status (OR 1.30 for Level 2, OR 1.36 for Level 3).  Race had either no association or a negative association for transfer.  Intracranial injury was associated with transfer from Level 3 Trauma Centers, but not Level 2 Trauma Centers.  Age > 49 yo, female sex, and operation at the initial Trauma Center had negative associations with transfer.  When stratified by race, insurance status maintained a significant association with transfer for White patients, but not for other Race/Ethnic groups.

Conclusion:The decision to transfer a patient from one Trauma Center to another Trauma Center is multifactorial.  Insurance status, but not race, appears to be a factor in the decision to transfer a patient from Pennsylvania Level 2 and 3 Trauma Centers to another Trauma Center.  The financial implications that this has on Level 1 Trauma Centers should be evaluated.

 

72.08 Evolving Trends in Racial Disparities for Perioperative Outcomes with the Kidney Allocation System

Posted on January 26, 2017

D. Sanchez1, D. Dubay1, P. Baliga1, D. J. Taber1  1Medical University Of South Carolina,Division Of Transplant Surgery,Charleston, Sc, USA

Introduction:  To make kidney allocation for transplantation as effective and equitable as possible, a new Kidney Allocation System (KAS) was implemented on December 14, 2014. The purpose of this study was to assess the impact of KAS on perioperative outcomes and if changes differed by race/ethnicity. 

Methods:  This was a time series analysis using aggregated data acquired in monthly intervals from October 1, 2012 through September 30, 2015. The analysis included all data reported to the University HealthSystem Consortium (UHC) by accredited US Kidney Transplantation Centers for adult solitary kidney recipients of deceased donor transplants. 

Results:  The 35-month time frame included 25 months of pre-KAS data and 10 months of post-KAS data. A total of 28,809 deceased donor kidney transplants were included. After KAS implementation, the estimated transplant rate per month decreased significantly for Caucasians by 17.6 cases per month (p=0.0001, Figure 1), and increased significantly for AAs by 37.8 (p=0.0001), Hispanics by 16.3 (p=0.0001), and other races by 8.2 cases per month (p=0.0001). Delayed graft function (Figure 2), 7 and 14-day readmissions significantly increased after KAS, but this did not vary by race. Hispanics saw a 7.7% decrease in ICU admissions after KAS, which differed as compared to other racial/ethnic cohorts (p=0.0026). Costs increased significantly after KAS in all groups except Hispanics. Mortality, length of stay, in-hospital complications and 30-day readmissions were not significantly impacted by KAS. 

Conclusion:  These results demonstrate that KAS has substantially impacted transplant rates, which differed by race/ethnicity. KAS also led to increased costs, readmissions and DGF which did not differ by race. The impact of KAS on ICU cases, which was different in Hispanics requires further investigation into potential etiologies.    

 

72.07 Process Adherence for Enhanced Recovery After Surgery Reduces Disparities in Surgical Outcomes

Posted on January 26, 2017

I. L. Leeds1, D. R. Hobson1, J. E. Efron1, E. C. Wick2, F. M. Johnston1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA

Introduction:
Short-term surgical outcomes at high-quality centers are not affected by race, but racial groups have been found to have differences in care processes. Enhanced Recovery After Surgery (ERAS) pathways have been proposed as one means of standardizing care to eliminate process disparities. The purpose of this study was to demonstrate the relationship between process measures for ERAS pathways and postoperative outcomes.

Methods:
National Surgical Quality Improvement Program (NSQIP) data for a single academic medical center’s colorectal surgery practice was queried for patients undergoing elective colon and rectal resections prior to (Jan 2013-Dec 2013) and following (Jan 2014-June 2016) implementation of a colorectal ERAS pathway. Outcomes for white and non-white patients were analyzed using Chi-square and Wilcox-Mann-Whitney tests to compare pre- and post-implementation surgical outcomes. Then, a prospective ERAS quality monitoring database with specific ERAS pathway process measures was linked to patients’ NSQIP outcomes. ERAS pathway adherence was then further compared to patients’ surgical outcomes with respect to race using logistic regression.

Results:
A total of 357 colon and rectal resections were identified in the institution’s NSQIP database (84 pre-ERAS era, 273 ERAS era). Prior to ERAS implementation average lengths of stay, complication rate, and total number of complications were not statistically different between white and non-white patients. Following ERAS implementation, lengths of stay improved in both whites (-3.3 days, p<0.001) and non-whites (-2.5 days, p=0.002).  Complication rates in both racial groups were no different (p=0.304) and trended down after ERAS implementation (25.0% to 19.8%, p=0.304) as well as the average number of complications per surgery (0.33 to 0.27, p=0.335).

A subset of 259 cases (64%) from the ERAS implementation era were identified with complete process measure information.  32 process measures were individually examined with no statistically significant difference between white and non-white patients. Between racial groups within ERAS patients, there was no significant difference in average lengths of stay, complication rates, or number of complications. Length of stay was unaffected by process measure adherence, but adherence was protective for complications of surgery (OR = 0.89, p=0.001).

Conclusion:
When adherence to ERAS pathway processes are followed, surgical outcomes are similar regardless of race. ERAS processes both maintain outcomes parity between racial groups while further improving overall quality outcomes.
 

72.06 Socioeconomic Disparities Among Adolescent Bariatric Surgery Patients.

Posted on January 26, 2017

G. Ortega1,2, N. R. Changoor1, C. K. Zogg3, R. Altafi2, H. Naseem7, F. G. Qureshi5,6  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Outcomes Research Center Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Yale University School Of Medicine,New Haven, CT, USA 4Howard University College Of Medicine,Washington, DC, USA 5University Of Texas Southwestern Medical Center,Dallas, TX, USA 6Children’s Medical Center,Dallas, Tx, USA 7Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA

Introduction: Despite data to suggest that weight loss surgery has the best long-term success in adolescents with complicated obesity, the number of procedures performed remains stagnant.  As obesity is disproportionately prevalent in minority groups, we sought to determine if the utilization of bariatric surgery differs by socioeconomic and demographic categorization among morbidly obese adolescent patients.

Methods: We conducted a retrospective review of the 2009 and 2012 Kids Inpatient Database, selecting for adolescent patients aged 15-21y with diagnoses of morbid obesity. Differences in receipt vs. non-receipt of bariatric surgery were compared using descriptive statistics in order to assess for differences in patient demographics, socioeconomic factors, comorbid conditions, and in-hospital morbidity and mortality. Multivariable logistic regression was then used to assess for risk-adjusted differences in bariatric surgery utilization based on variations in socioeconomic and demographic parameters.

Results: A total of 27,403 adolescents with morbid obesity were identified. The majority was female (72%) with a mean age of 17±4y. A total of 1,726 patients (6%) underwent bariatric surgery. Those receiving operations were more likely to be non-Hispanic White (59 vs. 41%, p<0.001), female (77 vs. 72%, p<0.001), older (mean age 16.9 vs. 18.6y, p<0.001), of higher income (33 vs. 54%, p<0.001), and privately insured (72 vs 33%, p<0.001). Risk-adjusted analyses demonstrated that relative to non-Hispanic White patients, morbidly obese non-Hispanic Black (OR 0.45, 95%CI 0.39-0.54), Asian/Pacific Islander (0.54, 0.30-0.99) and Native American (0.43, 0.21-0.88) patients were each significantly less likely to undergo bariatric surgery. There was no difference among Hispanic patients (OR 0.99, 95%CI: 0.86-1.15). When considered by income, no differences in utilization within the lowest two incomes quartiles were found; however, patients from households in the third (OR 1.58, 95%CI 1.35-1.85) and fourth (2.34, 1.99-2.75) quartiles were each more likely to have bariatric surgery than those in the lowest income quartile. Adolescents with private insurance were markedly more likely to have bariatric surgery when compared to adolescents with public insurance (4.73, 4.18-5.36).

Conclusion: Assessment of bariatric surgery utilization among adolescents demonstrated significant differences in weight loss procedures among patients based on race/ethnicity, income and insurance status. Patients who were non-Hispanic White or Hispanic, from a higher median household income and with private insurance were more likely to undergo surgery. These findings suggest an opportunity to expand access to weight loss surgery to all adolescents who may benefit from it.

72.05 Mapping Surgical Access in Malawi: A Geospatial Analysis of Facilities Providing Safe Surgical Care

Posted on January 26, 2017

M. M. Esquivel1, J. A. Henry2, E. Frenkel3, C. Goddia4, T. Uribe-Leitz1, G. Rosenberg1, N. Garland1, T. G. Weiser1  4Queen Elizabeth Central Hospital,School Of Anaesthesia,Blantyre, BLANTYRE, Malawi 1Stanford University,General Surgery,Palo Alto, CA, USA 2University Of Chicago,General Surgery,Chicago, IL, USA 3Gradian Health Systems,New York, NEW YORK, USA

Introduction:  Strong health systems require timely and safe surgical care to function, though many developing countries lack the human resources, supplies and infrastructure to provide this care. We completed a geospatial analysis to examine the surgical infrastructure and availability of essential surgery in Malawi and identified key priority areas for health system strengthening.

Methods:  We identified all hospitals providing surgical care and collected on-site data using in-person interviews and surveys at each facility from November 5, 2012 to January 21, 2013. Surveys included information on location and type of facility, human resources, procedure availability, supplies and infrastructure. Data were geocoded and analyzed in Redivis, an online data visualization platform. We analyzed the catchment population that lived within a 2-hour travel time to these facilities, as recommended by the Lancet Commission on Global Surgery. We then evaluated the change in timely access when excluding facilities that lacked 24/7 access to three essential surgical procedures: emergency cesarean section, treatment of open fracture and laparotomy. We also analyzed the change in catchment population when excluding facilities that lacked consistent availability of eight minimum requirements for safe surgery: pulse oximetry, oxygen, adult bag mask, suction, intravenous fluids, sterile gloves, functioning sterilizer, and operating theater lights. 

Results: We collected data from all 38 facilities that offered surgical care; 98.7% of the population (15,792,000 people) lived within 2-hours to these facilities. Even after excluding the 6 facilities that did not offer constant access to the three essential surgical procedures, there was no change in timely access. However, when we excluded facilities that did not have 24/7 access to the eight minimum requirements for safe surgery, only 34.0% (5,508,000 people) lived within 2-hours of a surgical facility meeting minimum safety standards.

Conclusion: The distribution of surgical facilities across Malawi is sufficient to cover the vast majority of the population, with most facilities offering the three essential procedures we evaluated. However, the basic infrastructure and supplies to provide safe surgery at these facilities is greatly lacking, and nearly 10.3 million people lose access when considering core requirements for safe surgery. This study highlights the need to strengthen surgical care and anesthesia in existing facilities. Geospatial techniques assist in identifying key facilities that would most greatly impact Malawi’s general population with improved resources for surgery.

 

72.04 The CAGE Distance Framework as a Starting Point for the Assessment of Cultural Competency Education

Posted on January 26, 2017

G. Tortorello1,3, C. Wirtalla2,3, E. Bailey2,3, R. Hoffman2,3, C. Sharoky2,3, R. Kelz1,2,3  1University Of Pennsylvania,Perelman School Of Medicine,Philadelphia, PA, USA 2University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 3University Of Pennsylvania,Center For Surgery And Health Economics,Philadelphia, PA, USA

Introduction:
Disparities in surgical outcomes have been well documented. Programs designed to improve provider knowledge on cultural competency (CC) have focused on minority health. We sought to examine provider-population distance using the CAGE Framework in the setting of programs designed to teach CC in an effort to identify an efficient strategy for future programmatic development.

Methods:
The CAGE Framework, originally designed to assess similarity across nations using 4 individual indices, was adapted for use in the healthcare setting (See Table). A systematic review to identify CC curricula in undergraduate and graduate medical education programs identified 13 such programs. Trainee characteristics of participants were abstracted. To approximate the patient characteristics, population statistics for each local city were taken from the US Census Bureau Report 2010.  Trainee characteristics were compared with patient characteristics using the Wilcoxen rank-sum. The correlation between CAGE score and program success was assessed with the sample Pearson correlation coefficient.

Results:
The participants at each study site and the respective city populations varied on all CAGE characteristics. Across all sites, when compared to patients, a greater proportion of trainees were white/Caucasian (67.3% vs 46.7%, p=0.0587), insured (13.8% vs. 0%, p<0.0001), more highly educated (100% vs. 41.9% with Bachelor's degree, p<0.0001), and had greater median incomes ($198,545 vs. $60,594, p<0.0001). The median scores by CAGE index can be seen in the Table with larger numbers representing greater dissimilarity between patients and trainees. The mean Hospital Referral Region for the study cities was 6,185 sq. miles (median 3,441; min 212; max 20,939). Following the CC program, the mean increase in post-test score was 32% (median 18%; min 8%; max 88%). The post-test scores and CAGE distance were not significantly correlated, r=-0.12 (p=0.714).

Conclusion:
The CAGE distance between trainees enrolled in CC curricula and their patient populations illustrates the dissimilarity between the two cohorts across multiple heterogeneous sites within the United States. As the CAGE distance between providers and their patients varies significantly between training sites, both the content and intensity of CC training may need to be locally determined.  CC programs need to enable cultural dexterity among providers to encourage the respectful care of patients that may be unfamiliar based on dissimilar backgrounds.

72.03 Socioeconomic Disparities in Extent of Surgery in Young Women with Stage I Dysgerminoma

Posted on January 26, 2017

L. Stafman1, I. Maizlin1, K. Gow2, M. Goldfarb3, J. G. Nuchtern4, M. Langer5, S. Vasudevan4, J. Doski6, A. Goldin2, M. Raval7, E. Beierle1  1University Of Alabama,Birmingham, Alabama, USA 2University Of Washington,Seattle, WA, USA 3Providence Saint John’s Health Center,Santa Monica, CA, USA 4Baylor College Of Medicine,Houston, TX, USA 5Maine Medical Center,Portland, ME, USA 6University Of Texas Health Science Center At San Antonio,San Antonio, TX, USA 7Emory University School Of Medicine,Atlanta, GA, USA

Introduction:

Dysgerminoma accounts for two thirds of ovarian malignancies in adolescents and young adults (AYAs). Survival rates for Stage I dysgerminomas are excellent. Because dysgerminoma primarily affects females of childbearing age and younger, treatment must consider future fertility. Since socioeconomic factors have proven to be barriers in the receipt of conservative treatment in other cancers (e.g. breast-conserving therapy in breast cancer), we aimed to evaluate whether similar socioeconomic disparities exist in the receipt of fertility-sparing (FS) vs. non-fertility-sparing (NFS) surgery for Stage I dysgerminoma in AYA women.

Methods:
The National Cancer Data Base (NCDB) was used to identify all AYA females (14-39 years old) with dysgerminoma from 1998 to 2012, who were then stratified based on stage at presentation. Three socioeconomic surrogate variables were identified – insurance type, median income in the patient’s ZIP code, and percent of people with no high school degree in the patient’s ZIP code. NFS surgery was defined as any procedure including bilateral oophorectomy and/or hysterectomy. FS surgery was defined as unilateral or partial oophorectomy. Within each stage, χ 2 and t-tests were used to compare rates of FS and NFS within each variable, controlling for age and race.

Results:
Of the 1247 AYA females with ovarian dysgerminoma in the NCDB, 687 (55.1%) had Stage I disease. Amongst these Stage I patients, there was a significant difference in surgical therapy (FS vs. NFS) for all three socioeconomic surrogate variables (Table 1). The uninsured had higher NFS rates (30.2%) compared to those with government (21.3%) or private (19.3%) insurance (p=0.036). Those living in ZIP codes in the lowest median income quartile had almost twice the rate of NFS operations (31.4%) compared with those in the highest median income quartile (17.4%). For those living in the least educated regions, 23.6% underwent NFS surgery whereas only 14.5% underwent NFS surgery in areas with the most educated population (p=0.027).  There was no significant difference in rates of FS and NFS surgery based on race (p=0.17). Additionally, there was no significant difference between FS and NFS rates based on the same variables in Stage II-IV dysgerminomas.

Conclusion:
Based on all three socioeconomic surrogate variables – insurance, income, and education – AYA women from lower socioeconomic strata were more likely to undergo NFS surgery for Stage I dysgerminoma than those in higher strata. Given that most dysgerminomas are diagnosed at Stage I, it is concerning that a disparity exists affecting future fertility. These data provide an opportunity for education and quality improvement for the treatment of this population.

72.02 A World Apart: Quantifying Racial Discordance Between Surgeons And Their Patients

Posted on January 26, 2017

R. Udyavar1, D. Smink1, J. Mullen3, T. Kent2, W. A. Davis1, A. Green3, N. Changoor1,2,4, A. Haider1  1Brigham And Women’s Hospital,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Boston, MA, USA 3Massachusetts General Hospital,Boston, MA, USA 4Howard University College Of Medicine,Washington, DC, USA

Introduction:
Racial discordance between patients and providers is associated with poor patient satisfaction, decreased compliance, and overall worse health care outcomes in minority patients. General surgery and surgical subspecialties appear consistently less diverse than other medical disciplines, but the degree of racial discordance observed among surgeons has not been quantified. We sought to establish the degree of racial dissimilarity between surgical patients and surgeons in training, to determine if potential differences would be decreasing as the surgical workforce diversifies. 

Methods:
Racial demographic information for patients who underwent one or more representative inpatient surgical procedures, which were categorized according to the clinical classifications software (CCS), was obtained from the Nationwide Inpatient Sample (NIS) (2005-2011). These data were compared to the racial demographic information for residents on duty in General Surgery, Neurologic Surgery, Otolaryngology, Orthopedic Surgery, and Urology, as well as Integrated Cardiothoracic, Vascular, and Plastic and Reconstructive Surgery programs as reported by the corresponding annual Graduate Medical Education (GME) surveys. 

Results:
Across all surgical disciplines, Black and Hispanic residents were consistently underrepresented relative to the patient population. Black patients represented 11.46% of all patients who underwent one or more of the selected procedures, but Black residents constituted only 3.38% of surgical residents on duty (p<0.001). Hispanic patients comprised 9.79% of surgical patients, while only 1.25% of surgical residents were Hispanic (p=0.001). Asian/Pacific Islander patients comprised only 2.29% of surgical patients, while 18.16% of surgical residents were Asian/Pacific Islander (p<0.0001). There was no observed difference between White surgery residents and White patients (65.88% and 72.63%, p=0.08). Among all the surgical subspecialties, the Orthopedic Surgery work force was the most racially discordant, with Blacks (p<0.0001), Hispanics (p<0.0001), and Native Americans (p=0.0127) disproportionately underrepresented. Over the 7-year study period, no upward trend was seen in the percentages of Black, Hispanic, or Native American general surgical residents, while the percentages of White and Asian/Pacific Islander residents continued to increase. 

Conclusion:
Despite efforts to encourage racial diversity among health care professionals, including with resident recruitment, general surgery and surgical subspecialties remain more racially homogenous than the surgical patient population. We found no evidence to suggest that diversity is increasing over time. Quantifying racial discordance in surgery reinforces the importance of augmenting recruitment efforts to achieve a more racially balanced cohort of surgical residents, as well as incorporating cultural competency training, in order to mitigate racial disparities in surgical care.
 

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