48.19 A feasible and alternative approach for the treatment of internal hemorrhoids

Posted on January 18, 2018

N. HAYASHI1, N. HAYASHI1  1Kinan Hospita,Surgery,Tanabe, WAKAYAMA, Japan

Introduction:
~Sclerotherapy with aluminum potassium tannic acid (ALTA) has been widely accepted for the treatment of internal hemorrhoids because of its effectiveness and low invasiveness. However, it is often difficult to maneuver an anoscope for the precise 4-step injection in a conventional ALTA injection therapy

Methods: ~Sixty eight consecutive patients with symptomatic internal hemorrhoids Golisher grade III or IV were enrolled and divided into two equal groups; the one treated with EI using ALTA, and the other with AI. In each case, ALTA is injected directly into 4 points of an internal hemorrhoid (4-step injection) to induce sclerosis for remission of the hemorrhoids. Surgical outcomes and postoperative complications were retrospectively compared between the two groups.

Results:~ The overall median operative time was shorter in EI group (19±12 min) than AI group (27±15 min) (P<0.05). Postoperative pain was significantly less in EI group than AI group during the first two postoperative days. In AI group, three patients needed further hospital stay for topical pain. No significant difference was observed in other complications between the two groups.

Conclusion:~ALTA therapy with an endoscope in the treatment of symptomatic internal hemorrhoids has the advantage in terms of surgical time and immediate post-operative pain. This method might be a good alternative for conventional ALTA therapy with the rigid anoscope.

 

48.16 Practice Management Guidelines: Treatment of Cardiovascular Implantable Device Pocket Infections

Posted on January 18, 2018

E. Buckarma1, M. Mohan1, L. Baddour2, T. Earnest1, H. Schiller1, E. Loomis1  1Mayo Clinic,Department Of Surgery,Rochester, MN, USA 2Mayo Clinic,Department Of Infectious Diseases,Rochester, MN, USA

Objective: Treatment of CIDPI requires a multimodal approach that includes antimicrobials, device explanation and local wound care.  Our institution implemented a Practice Management Guideline (PMG) to standardize the care of Cardiovascular Implantable Device Pocket Infections (CIDPI) and engage our Acute Care Surgeons in 2013.  Our PMG includes wound culture, complete capsulectomy, pulse lavage and placement of a negative pressure wound therapy device at the time of device extraction.  48 hours later, wounds are irrigated and closed in a delayed primary fashion over drains.  Our objective was to compare the outcomes of patients who underwent cardiovascular device extraction before and after the implementation of the PMG for the treatment of CIDPIs.

Methods: An IRB approved retrospective review of 155 patients at our institution from 2012-2015 who underwent cardiovascular device explanation.  Evaluated outcomes measured included days from device explant to wound closure, post-operative complications (hematoma, surgical site infection, unplanned return to OR) 
Outcomes data was analyzed prior to (Group A) and after (Group B) enactment of the PMGs. 

Results:  58 patients (Group A:  42 male, 16 female; mean age 68) were managed prior to PMG implementation and 97 (Group B: 72 male, 25 female; mean age 67) managed after.  Mean days from device explanation to wound closure were compared (Group A, 6 ± 3.5 and Group B, 2.6 ± 1.8) and time to closure was reduced by 3 days in Group B (p<0.05).  No increase in surgical site infection, unplanned return to OR, hematoma was demonstrated between groups (p<0.05).  

Conclusion:  The implementation of PMGs is effective in reducing the number of days to pocket wound closure; acute care surgeons are well equipped to participate in this practice and improve patient outcomes. 

 

48.17 The Impact of Intravenous Acetaminophen After Abdominal Surgery on Pain: A Meta-Analysis

Posted on January 18, 2018

J. J. Blank1, N. G. Berger1, J. P. Dux1, F. Ali1, K. A. Ludwig2, C. Y. Peterson2  1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,General Surgery, Colorectal Division,Milwaukee, WI, USA

Introduction:  Pain management after surgery relies heavily on opioids despite known adverse effects. While opioid medications are typically the cornerstone of any pain control plan, they come at a cost. Opioids have a profound impact on postoperative gastrointestinal (GI) motility via activation of the mu-opioid receptors of the small and large intestines. Slowed gastrointestinal motility not only causes discomfort and pain, it causes nausea as well. In fact, opioid medications have been shown to increase the incidence of postoperative ileus, a disruption in normal intestinal peristalsis, which can result in longer hospital stays, increased incidence of complications, and decreased patient satisfaction. Additionally, according to the American Society of Addiction Medicine, four of five new heroin users started out misusing prescription pain medications. Therefore, a multi-modal strategy for pain management is optimal. There is limited data on the effectiveness of intravenous acetaminophen in comparison to other non-opioid analgesics after abdominal surgery.

Methods:  PubMed, Scopus and Cochrane databases were queried for keywords acetaminophen, intravenous (IV), and postoperative. Included studies were prospective, had a comparison group receiving alternate medication, used IV acetaminophen for at least 24 hours, and evaluated adult patients having any trans-abdominal intraperitoneal surgery. Outcomes evaluated were study quality, demographic data, surgical technique, postoperative pain scores, and postoperative narcotic consumption. A random effect analysis of mean differences (MD) was performed and heterogeneity was assessed using I2 statistic. 

Results: Seventeen articles were identified with 1,595 patients included. Overall study quality was moderate (mean Jadad score = 5.6 [±1.9], range 0-8). There was no difference in 24H pain scores or narcotic consumption between acetaminophen or any alternative analgesics (MD -0.10[-0.33, 0.14], p=0.42, I2=91%; MD -3.93[-9.12, 1.25], p=0.14, I2=99%, respectively). Subgroup analysis showed reduced 24H narcotic consumption for NSAIDs compared to acetaminophen (MD 11.18 [10.40, 11.96], p<0.001, I2=0%). For open surgery, analysis demonstrated reduced 24H narcotic consumption for acetaminophen compared to alternative medications (MD -7.29[-13.41, -1.16], p=0.02, I2= 99%). There were no differences in 24H pain scores among subgroups. 

Conclusion: Both NSAIDs and acetaminophen show benefit in reducing 24-hour narcotic consumption in patients undergoing abdominal surgery with moderate quality evidence and significant heterogeneity amongst studies. Given the current nationwide opioid addiction crisis, there is great need to investigate alternative methods of pain control, such as NSAIDs and acetaminophen, in the postoperative setting. 

 

48.13 Reducing Cost and Improving Operating Room Efficiency: Examination of Surgical Instrument Processing

Posted on January 18, 2018

A. Dyas1, K. Lovell1, C. Balentine1, T. Wang1, J. Porterfield1, H. Chen1, B. Lindeman1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  Operating room efficiency can often be compromised due to delays in processing surgical instruments. We observed that many instruments included in head and neck trays were not routinely used during thyroid and parathyroid surgery at our institution, which increases costs and decreases efficiency. Our objective was to create a streamlined instrument tray to optimize operative efficiency and cost.

Methods:  Head and neck surgical instrument trays were evaluated by operating room team leaders. Instruments within the tray were identified as either necessary or unnecessary based on use during thyroidectomies and parathyroidectomies. The operating room preparation time, tray weights, number of trays, and number of instruments were recorded for both the head and neck tray and the thyroidectomy tray. Cost savings were calculated using Navigant, with estimated reprocessing cost of $0.51 per instrument.

Results: Three of thirteen existing head and neck trays were converted to thyroidectomy/parathyroidectomy trays at no additional hospital cost. Unnecessary instruments were added back to stock for use on other surgical trays. The starting head and neck surgical set was reduced from two trays with 108 total instruments to one tray with 36 instruments. Each operation using the new tray saved $36.72 ($55.08 to $18.36) in reprocessing costs. Projected savings to the hospital with implementation was over $27,000 annually for instrument processing alone. In addition, unmeasured hospital savings include decreased instrument wear and replacement frequency, quicker operating room setup, and decreased decontamination costs. Tray weight decreased from 27 pounds to 10 pounds, and tray preparation time decreased from 8 minutes to 3 minutes.

Conclusion: Optimizing thyroidectomy/parathyroidectomy trays can reduce cost, physical strain, preparation time, decontamination time, and processing times.  Streamlining surgical trays is an effective strategy for hospitals to reduce costs and increase operating room efficiency.
 

48.14 Availability of Common Pediatric Uroradiology Studies: Are Rural Patients at a Disadvantage?

Posted on January 18, 2018

J. A. Whitley1,2, S. Gnaneswaran2,3, M. Thach2,3, K. Kieran2  1Rice University,Houston, TX, USA 2Seattle Children’s Hospital,Seattle, WA, USA 3University Of Washington,Seattle, WA, USA

Introduction:  Many families wish to have radiologic tests performed locally, especially when obtaining these tests in specialized pediatric centers would require long-distance travel and its associated costs and inconveniences.  The differential availability of specialized and common pediatric uroradiographic tests in rural and urban areas has not been described.  We undertook this study to describe the availability of common radiographic tests ordered by pediatric urologists, and to identify disparities in the availability of radiographic tests between urban and rural locations.

Methods:  We surveyed all freestanding hospitals in Washington State (excluding single-specialty hospitals and those serving only adult patients) on the availability of flat plate abdominal X-rays (AXR), renal-bladder ultrasounds (RBUS), voiding cystourethrograms (VCUG), MAG-3 renal scans, and nuclear cystograms (NC) for children.  Age restrictions, and availability of sedation for urology tests, of general and pediatric radiologists, and of services for patients with limited English proficiency (LEP) were recorded.  Rural and urban hospitals were compared on these characteristics.

Results:  74/88 institutions (84.1%) completed the survey; 17 (23.0%) were rural (population <2500), 32 (43.2%) were in urban clusters (population 2500-50,000), and 25 (33.8%) were in urban areas (population >50,000).  73 (98.6%) institutions offered AXR, 68 (91.9%) offered RBUS, 44 (59.5%) offered VCUG, 26 (35.1%) offered MAG-3, and 15 (20.3%) offered NC to children.  All urban and most (16/17; 94.1%) rural institutions had digital imaging capability. AXR (100% vs 96%, p=0.88) and RBUS (70.6% vs 96%, p=0.15) availability was similar in rural and urban settings, while VCUG (11.8% vs 72%, p=0.001), MAG-3 (5.9% vs 60%, p=0.006), and NC (0% vs 44%, p=0.017) were more commonly available in urban settings. Rural hospitals were less likely to employ full-time, in-house radiologists (35.3% vs 96%, p<0.0001) or offer sedation (6.3% vs 36%, p=0.01) for testing, but were equally likely to have age restrictions on the tests offered (17.6% vs 40%, p=0.50).  Fellowship-trained pediatric radiologists (16% vs 0%, p=0.39) and child life specialists (20% vs 0%, p=0.28) worked exclusively in urban settings.  73 hospitals (98.6%) had interpreter services available, but translated written material was available in only 3 hospitals (4.1%). 

Conclusion:  The geographically widespread availability of AXR and RBUS may represent an opportunity to offer families care closer to home, saving money and time.  Anxious children and those requiring more specialized studies may benefit from radiologic testing in urban centers.  The limited written educational materials available for LEP patients is an opportunity for improvement.  The availability of shareable digital imaging may foster collaboration between rural centers and urban-based pediatric radiologists.  Further research is needed to understand what, if any, quality differences exist in radiographic studies obtained outside of urban and specialized pediatric centers.

 

48.15 Therapeutic strategies of early laparoscopic cholecystectomy for acute cholecystitis

Posted on January 18, 2018

T. Kohmura1, J. Yasutomi1, K. Kusashio1, M. Matsumoto1, T. Suzuki1, A. Iida1, K. Fushimi1, S. Irabu1, N. Yamamoto1, N. Imamura1, R. Harano1, A. Yoshizumi1, R. Takayanagi1, I. Udagawa1  1Chiba Rosai Hospital,Surgery,Ichihara, CHIBA, Japan

Introduction:

Tokyo Guidelines 2013 (TG 13) recommend an early operation within 72 hours of the onset of mild or moderate cholecystitis.

Recent?randomized clinical trials have shown that early laparoscopic cholecystectomy shortened hospital stay and the mortality rate and indicated that the complication rate did not increase if laparoscopic cholecystectomy was performed within 7 days of the onset (Br J Surg. 2015 Oct; 102 (11): 1302 -13.).

There has been a controversy regarding early laparoscopic cholecystectomy performed within 7 days of the onset.?In cases of acute cholecystitis, at our hospital, we employ a strategy to perform laparoscopic cholecystectomy under emergency or semi-emergency conditions as long as it is within 7 days of the onset without patients being held without operations for 72 hours. In this study, we investigated if outcomes of our strategy are acceptable.?

Methods:

A retrospective study was conducted on a primary cohort of 168 patients with acute cholecystitis who underwent early laparoscopic cholecystectomy in our institute between 2012 April and 2016 March.

We analyzed the operation time, the amount of bleeding, the conversion to laparotomy, postoperative complications, and postoperative hospital stay. The characteristics were compared and examined in each group based on severity classification by TG 13 and time from onset to surgery.?

Results:

Continuous variables were expressed as median (range). One-hundred and sixty-eight patients underwent laparoscopic surgery (1 case of laparotomy transition). Operation time was 104.5 minutes (33 to 196),amount of bleeding was 10 ml (0 to 1550),postoperative complications occurred in 9 cases, postoperative hospital stay was 5 days (2 to 15).?

In the comparison among the 3 groups according to severity in TG 13, there were no significant differences in the operation time, the rate of transference of the laparotomy, and postoperative complications. A significant difference between the amount of bleeding and the postoperative hospital stay was observed between both severity groups (p <0.01). There was no significant association between the time from the onset to surgery, the bleeding amount, the rate of laparotomy transition, postoperative complications, and postoperative hospital stay.?

Conclusion:In accordance with previous studies, we found that our strategy for early laparoscopic cholecystectomy yields relatively good and acceptable outcomes.

48.12 Racial Disparities in Incidence of Rectal Cancer in Patients with IBD

Posted on January 18, 2018

D. Sessinou1, D. Chen1, V. Pandit1, C. Charlton1, A. Cruz1, P. Vij1, V. N. Nfonsam1, V. N. Nfonsam1  1University Of Arizona,Medicine,Tucson, AZ, USA

 

Introduction: Rectal cancer (RC) continues to be prevalent among patients with inflammatory bowel disease (IBD). Disparities in patients with RC are well known however there is paucity of data on patient with IBD developing RC. The aim of this study was to assess racial disparities in patients with IBD developing RC.

Methods: Using the National Inpatient Sample (NIS) from the year 2011, we included patients with age ≥ 18 with IBD. Patients with RC were assessed. Patients were stratified by race. Statistical analysis was performed to assess difference in groups.

Results:: A total number of 57,358 patients with IBD were assessed of which 172 had RC.
79.9% were white and 11.3% were black. Patients with IBD were more likely to develop RC (p=0.001). Among patient developing RC, they were more likely to be Whites and Asians/Pacific Islanders. Out of the patients with both IBD and RC, there were more males (65.1%) than females (34.9%) (p=0.0001). 

Conclusion:The results of this study suggest that people with a history of IBD are at an increased risk of developing RC, which is supported by the literature. We also see that Whites have the highest incidence of IBD and RC, followed by Asians/Pacific Islanders. These differences may be due to healthcare disparities and lower utilization of screening tests observed among racial groups. Future studies in other years could establish whether there is a trend in incidence. 

48.11 Increasing Compensation Gaps for Younger General Surgeons May Increase Dissatisfaction and Attrition

Posted on January 18, 2018

D. S. Strosberg1, S. Brathwaite1, S. Prakash1, J. Hazey1, B. Satiani1  1Ohio State University,Columbus, OH, USA

Introduction:

Comparison of compensation between academic versus private practice General Surgeons (GS) and relationship of compensation to career satisfaction is not well known. The objective of this study was to compare trends in compensation between academic versus private practice GS, assess satisfaction of academic GS with their compensation, and compare their reported salary to nationally collected data.

Methods:

Compensation data for academic and private practice GS were obtained from the Association of American Medical Colleges (AAMC) and Medical Group Management Association (MGMA), respectively. Comparisons of nominal annual compensation data were made between Group A (assistant professor GS versus private practice GS in practice for <7 years), Group B (associate professor GS versus private practice GS in practice for 8 to 17 years), and Group C (professor GS versus private practice GS in practice for >18 years) from 2003 to 2012. A 13 question survey regarding compensation and satisfaction was emailed to GS who completed training at a single academic institution over the past 20 years. 

Results:

The AAMC median salary for GS in 2012 was $276,000 for assistant professors (n=686), $340,000 for associate professors (n=359) and $369,000 for full professors (n=380), while the MGMA private practice median salary was $353,425 for 3-7 years of experience (n=113), $373,174 for 8-17 years of experience (n=215), and $355,965 for greater than 17 years of practice (n=244). The difference in compensation over 10 years, with a rising difference in Group A, is depicted in Fig 1. 26 GS completed the survey (45.6% response rate), with 14 GS in academic practice (53.8%) and 12 in private practice (46.1%). The median years of experience was 4 (1.5-17). For respondents, the median salary for academic GS was $275,000 ($200,000- $600,000) compared to $352,500 ($315,000- $700,000) for GS in private practice (p=0.15). 12 academic GS (85.7%) believed they earned a total annual compensation less than GS with an identical length of experience in a private practice setting. 30.7% of academic GS would relinquish their academic career if offered a salary increase of 50% or more. 

Conclusion:

Assistant professors in GS report consistently lower total compensation compared to their private practice peers. Although compensation alone is not often the main reason for attrition, increasing gaps between academic and private practice compensation may especially affect younger faculty. Academic leadership should consider optimizing non-financial incentives and narrowing compensation gaps to improve academic surgeon retention. 

48.09 Shisong Cardiac Center: Kumbo, Cameroon

Posted on January 18, 2018

N. T. Kontchou1,2, K. Schulman1,3  1Harvard Business School,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Duke University Medical Center,Durham, NC, USA

Introduction: With 23·4 million inhabitants, Cameroon's rate of 1·5 health workers per 1,000 people falls short of the World Health Organization’s recommended minimum of 2·3 per 1,000. The country’s 1·2 surgical specialists per 100,000 people again does not meet the Lancet Commission of Global Surgery’s estimated minimum need of 20 surgical, anesthetic, and obstetric physicians per 100,000 people for effective, sustainable surgical care. Though alarmingly low, this figure is not uncommon in sub-Saharan Africa. 

In 2005, cardiac surgeons from San Donato Policlinico in Milan, Italy partnered with religious leaders in Kumbo, Cameroon to construct Shisong Cardiac Center and address the surgical workforce shortage in the region. Now one of the primary cardiac surgery referral centers in Cenral Africa, Shisong Cardiac Center has only one local cardiac surgeon and still operates under a commuter care delivery model, relying heavily on foreign surgeons to deliver care to a vastly uninsured population with a GDP per capita of $1,250 USD. The pressure to build continuity of care, increase local workforce, secure sustainable financing sources, and fill the operating rooms are ever-present.  

Methods:  A literature review was performed to evaluate the global surgical disease burden, the epidemiology of disease in Cameroon, and the country’s healthcare system financing sources. Interviews were conducted with Cameroon's Minister of Health, local World Bank Health Specialists, founders of Shisong Cardiac Center, the center’s chief executive officer, and its cardiac surgery providers. These interviews were audio-recorded and transcribed manually. An on-site visit of the hospital was completed to obtain key images. 

Results: Since 2009, post-surgical mortality ranged from a high of 10.6% to 6.7% in 2014-15, with the most recent mortality rate of 7.1% for 2015-16. Since 2009, only 5 out of 610 (0.82%) patients required reoperation, but this number does not capture those who died prior to reoperation or who were unable to afford a second surgery. With a fixed price of $4,750 per cardiac surgery and 80% of patients lacking funding, Shisong loses over $3,000 with every pediatric surgery. These external constraints restrict the hospital to one hundred operations a year, or less than twenty percent of its full capacity. Despite these challenges, the hospital still achieved a positive margin of $19,000 in the 2015-2016 fiscal year. 

Conclusion: The solidarity, goodwill, and humanitarian values upon which Shisong Cardiac Center was founded have sustained this initiative for almost a decade. However, the intensity of care required to treat cardiac disease surgically, patients’ insufficient financial means, difficult access by road, limited governmental financial support, and Shisong’s inadequate access to essential specialty physicians make sustaining this innovative program a continuing challenge despite its success.

 

 

48.10 Trend in Socioeconomic Disparities Among Uncomplicated and Complicated Hernia Repairs

Posted on January 18, 2018

M. F. Nunez1, G. Ortega1, L. G. Souza Mota3, I. Yi3, S. Timberline3, E. S. Bauer1, T. M. Fullum1,2, D. Tran1,2  1Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Washington, DC, USA

Introduction:
Hernia repair is one of the most common elective procedures performed worldwide. Most hernias are treated and managed in an outpatient setting. Our objective was to determine the characteristics and relationship between demographics, socioeconomic status, insurance status, and complexity at presentation among a national sample of emergency department patients. 

Methods:
A retrospective analysis of 2006–2014 data from the Nationwide Emergency Department Sample, were queried to identify adult patients presenting to the emergency department with a diagnosis of inguinal, femoral, and umbilical hernia. Cases were dichotomized according with the type of presentation: complicated or acute (with gangrene and/or obstruction) and uncomplicated hernia. The two groups were compared with unadjusted and adjusted analyses to determine the socioeconomic factors that influence presentation and admission.

Results:
A total of 597,246 patients were included, the majority were male (73%), and had a mean age of 55 years. Most patients had Medicare (37%), followed by Private insurance (27%), uninsured (20%), and Medicaid (16%). With respect to median household income (MHI) the majority were in the lowest income quartile (32%). Most were treated at an urban hospital (86%), and most had uncomplicated hernias (84%). Of those that were uncomplicated most were male (74%), the majority had Medicare (34%), and 33% were in the lowest income quartile. Most of the complicated hernias, were male (66%), the majority had Medicare (51%), and 27% were in the lowest quartile. Uninsured patients made up 22% of the uncomplicated hernia group vs 12% of the complicated hernia group (p= <0.05). Of the complicated hernia group, 75% were admitted. On adjusted analysis, there was a higher likelihood of presenting as uncomplicated hernia for patients with Medicaid (OR 1.45 95%CI 1.41- 1.50), uninsured (OR 1.54 95%CI 1.50-1.58), and Medicare (OR 1.02  95%CI 0.99-1.05). And less likely if they were in the third and fourth MHI quartile (OR 0.86 95%CI 0.84-0.88 and OR 0.77 95%CI 0.75-0.78), respectively. Among patients who were admitted, the likelihood of presenting with a complicated hernia was higher if the patient was uninsured (OR 1.34 95%CI 1.28-1.40) and was lower for Medicare (OR 0.73 95%CI 0.69-0.76) and Medicaid (OR 0.81 95%CI 0.84-0.88).

Conclusion:
Uninsured and publicly insured patients were more likely to present to emergency departments with an uncomplicated hernia. This may represent a lack of access to primary surgical care for non-urgent surgical diseases. However, among patients already admitted, those with public insurance were less likely to have complicated hernias while uninsured patients were more likely to have complicated hernias. 
 

48.06 Racial and Ethnic Postoperative Outcomes from a Statewide Database: the Hispanic Paradox

Posted on January 18, 2018

E. Eguia1, A. Cobb1, E. Kirshenbaum1, P. C. Kuo1  1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA

Introduction: The Hispanic/Latino population in the United States have previously been shown to have, in some cases, better health outcomes than non-Hispanic Whites despite having lower socioeconomic status and greater frequency of comorbidities. This epidemiologic finding has been coined the “Hispanic Paradox” dating back to 1986. Disparities in social determinants of health between ethnic groups also exist in surgical patients but few studies have evaluated if the Hispanic Paradox exists in this cohort. The aim of our study was to examine postoperative complications between Hispanic and non-Hispanic patients undergoing high and low risk procedures. 

Methods: We conducted a retrospective cohort study analyzing adult patients who underwent high (Esophagectomy, Pancreatectomy, Abdominal Aortic Aneurysm Repair (AAA)) and low risk procedures (Appendectomy and Cholecystectomy).  The patient cohort was derived from the California Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) between 2006 and 2011. Patient administrative data were linked with baseline characteristics from the American Hospital Association Database. Candidate variables for the adjusted model were determined a priori and included patient demographics with ethnic group as the exposure of interest.  Analysis was performed in a mixed effects multivariable logistic regression. 

Results: Hispanic patients had lower median income and greater proportions with Medicaid or no insurance. In adjusted analysis, Hispanics had lower odds of post-operative complications from high-risk procedures such as Esophagectomy, Pancreatectomy and AAA repair (0.74 CI 0.57-0.96, 0.47 CI 0.28-0.76, 0.35 CI 0.26-0.45).  The odds ratio for major post-operative complications from both low and high-risk procedures were no different between Hispanics and non-Hispanics. Hispanics had greater odds of in-hospital death after an Esophagectomy but no difference after Appendectomy, Pancreatectomy or AAA repair when compared to non-Hispanics. In contrast, Hispanics had lower odds of in-hospital death after Cholecystectomy (0.69 CI 0.48-0.98). 

Conclusion: Hispanics had a lower odds risk or no differences in odds risk for in-hospital death or developing postoperative complications compared to non-Hispanic patients suggestive of a Hispanic paradox in surgical outcomes. Future studies are needed to further elucidate these mechanism given that US Hispanic/Latino surgical population is a diverse race which come from a variety of cultures, backgrounds, immigrant generational status and socioeconomic characteristics. Lastly, given the limited health data on Hispanics, Surgical Disparities Research should focus on improving data collection strategies. 

 

48.07 The Surgical Management of Diverticulitis

Posted on January 18, 2018

A. Mehta1, J. K. Canner2, D. T. Efron2, J. Efron2, J. V. Sakran2  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction: Diverticulitis remains a common problem for patients with diverticular disease. This study compared outcomes between elective and emergent bowel resections for diverticulitis.

Methods:  We used the 2005-2011 California State Inpatient Database to identify patients who had elective or emergent large bowel resections for diverticulitis (without hemorrhage). Primary outcomes included in-hospital mortality, complications, and extended length of stay (LOS, defined as >8 days). Secondary outcomes included 30-day inpatient readmissions and predictors of emergent repairs. Analyses adjusted for clinical factors and accounted for hospital clusters.

Results: We identified 28,813 patients undergoing large bowel resections for diverticulitis (2.0% mortality rate, 17.0% complication rate, and 22.6% extended LOS rate). Among all resections, one-third (31.8%) were performed emergently and one-quarter (23.2%) included a colostomy (6.1% of elective, 60.0% of emergent). Of the 911 patients with inpatient readmissions within 30 days of discharge, 211 (23.2%) presented to a different hospital. After multivariable logistic regression, emergent resections relative to elective resections were associated with significantly higher odds of death (aOR 2.85 [95%-CI 2.16-3.76]), complications (2.01 [1.85-2.18]), and extended LOS (1.75 [1.61-1.92]) (Figure). Emergent resections were also trending towards both greater 30-day readmissions (1.19 [0.96-1.46], P=0.08) and being readmitted to a different hospital (1.45 [0.96-2.18], P=0.07). Hispanic (1.19 [1.11-1.27]), self-pay (3.68 [3.62-4.08]), and Medicaid patients (1.19 [1.08-1.30]) were associated with emergent repairs.

Conclusion: One-third of patients undergoing surgical management for diverticulitis had emergent bowel resections, which were associated with worse postoperative outcomes and were trending towards increased 30-day readmissions. Additionally, a quarter of readmitted patients presented to a different hospital and differences in surgical care existed by race and payer.

48.08 Racial/Ethnic Disparities in Surgical Outcomes for Patients with Diverticular Disease

Posted on January 18, 2018

M. Ma1, K. Feng1, L. E. Goss1, L. N. Wood1, J. S. Richman1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, D. I. Chu1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: The US incidence of diverticular disease is increasing and surgery remains a key treatment option. While racial/ethnic disparities in surgical outcomes have been observed for diseases such as cancer, it remains unclear if surgical disparities exist for diverticular patients. This study aims to characterize racial/ethnic disparities that may exist between Caucasian-, African-, and Asian-Americans who have undergone surgery for diverticular disease. We hypothesized that disparities would exist with certain racial/ethnic groups having worse outcomes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 2011-2015 was queried for patients who underwent surgery for diverticular disease. Patient and procedure-level characteristics were included. The primary outcomes were 30-day mortality, 30-day readmission, post-operative complications (POCs), and length-of-stay (LOS). Bivariate tests and adjusted logistic and negative binomial regression were used to identify associations between racial/ethnic status and these outcomes.

Results: Of 20,318 patients who underwent surgery for diverticular disease, 91.5% were Caucasian-American (CA), 7.4% African-American (AfA), and 1.1% Asian-American (AsA). Asian-Americans were more likely to be normal weight (defined as 18<BMI<25; 36.6% versus 15.6%–AfA and 23.4%–CA, p<0.001), not smoke (86.9% versus 73%–AfA and 79.3%–CA, p<0.001), have lower ASA score of 1-2 (57.5% versus 41.5%–AfA and 56.4%–CA, p<0.001), and shorter operation-time (150 min versus 190 min—AfA and 166 min—CA, p<0.001). There were no differences in 30-day mortality, but African-Americans had longer post-operative LOS and higher 30-day readmission rates. African-Americans had higher rates of ileus, respiratory complications, sepsis, and bleeding requiring transfusion. On multivariate analyses—with Caucasian-Americans as reference category—African-American race remained independently associated with more post-operative ileus (OR=1.85, p<0.001), respiratory (OR=1.50, p=0.0004), sepsis (OR=1.63, p<0.001), and bleeding complications (OR=2.17, p<0.001). With African-American race as reference group, it remained independently associated with an 8% increase in LOS as compared to Caucasian-American patients (IRR 1.08, p<0.001).

Conclusion: African-Americans undergoing surgery for diverticular disease had the highest rates of 30-day readmission, LOS, and POCs including ileus, respiratory, sepsis, and bleeding complications when compared to Caucasian- and Asian-Americans. Further studies are needed to understand these observations and to develop interventions to eliminate these disparities.

48.04 Factors Associated with the Interhospital Transfer of Emergency General Surgery Patients

Posted on January 18, 2018

A. M. Ingraham1, S. Fernandes-Taylor1, J. Schumacher1, X. Wang1, M. Saucke1, C. C. Greenberg1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers. Determining these factors represents a critical first step in identifying who necessitates transfer and minimizing delays to definitive care.

Methods:  Adult EGS patients (defined by American Association for the Surgery of Trauma ICD-9 diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (NIS) (n=17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model. Because patients may succumb to death or discharge to other locations rather than transfer, a competing risks analysis considering the NIS design assessed the effect of risk factors for transfer. In addition to variables in the Table, the model included patient-level characteristics (sex, age, race, insurance, patient income based upon zip code, Charlson Comorbidity Index [CCI], EGS diagnosis, procedures performed, day of admission) and two hospital-level factors (total number of discharges and region).

Results: 1.8% of patients were transferred (n=317,357). Transferred patients were on average 62 years old and most commonly had Medicare (52.9% [n=167,921]), private (26.7% [n=84,851]), or Medicaid insurance (10.7% [n=34,020]). 67.8% were white. The most common EGS diagnoses among transferred patients were related to hepatopancreatobiliary (n=90,734 [28.6%]) and upper gastrointestinal tract (n=59,958 [18.9%]) conditions. Most transferred patients (n=269,215 [84.8%]) did not have a procedure prior to transfer. Transfer was more likely if patients were in small or medium versus large facilities, government versus private facilities, and rural or urban non-teaching versus urban teaching facilities (Table). Patient-level factors associated with transfer included male sex (Hazard Ratio [HR] 1.09 [95% Confidence Intervals (CI) 1.07-1.11]), CCI (HR CCI of 2 1.01 [95% CI 1.04-1.11] and HR CCI of 3 1.17 [95% CI 1.13-1.20]), and admission on a Saturday or Sunday (HR 1.04 [95% CI 1.02-1.06]).

Conclusion: We identified patient- and hospital-level characteristics of EGS transfers to another acute care hospital. Hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers at non-tertiary centers as they care for EGS patients in the context of the resources and capabilities of their local institutions may reduce time to definitive care and improve patient outcomes.

 

48.05 Racial Disparities in Surgical Outcomes Following Colorectal Surgery for Inflammatory Bowel Disease

Posted on January 18, 2018

M. Ma1, K. Feng1, L. N. Wood1, L. E. Goss1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: At least 3.1 million people in the US suffer from IBD, which includes Crohn’s Disease and Ulcerative Colitis. While racial/ethnic disparities in surgical outcomes have been observed in many diseases such as cancer, it is unclear if surgical disparities exist in IBD. The objective of this study was to investigate racial/ethnic disparities in surgical outcomes in a contemporary population of Caucasian-, African-, and Asian-Americans patients. We hypothesized that disparities would exist with certain racial/ethnic groups having worse outcomes. 

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 2011-2015 was queried for all patients who underwent surgery for IBD. Patient and procedure-level characteristics were included. The primary outcomes were post-operative complications (POCs) and length-of-stay (LOS). Bivariate tests and adjusted logistic and negative binomial regression were used to identify associations between racial/ethnic status and these outcomes. 

Results: Of 7,091 patients who underwent colorectal surgery for IBD, racial/ethnic groups included Caucasian-Americans (CA, 90.3%), African-Americans (AfA, 8.63%) and Asian-Americans (AsA, 1.07%). Asian-Americans were more likely to be normal weight (defined as 18<BMI<25; 50.7% versus 40.1%–AfA and 42.9%–CA, p<0.001), not smoke (94.7% versus 74.2%–AfA and 80%–CA, p<0.001), and have lower ASA score of 1 or 2 (61.8% versus 52.8%–AfA and 57.4%–CA, p<0.001). African-Americans had the highest rates of complication due to ileus, sepsis, and bleeding requiring transfusion. Asian- and African-American patients comparatively also had longer post-operative LOS. On multivariate analyses—with Caucasian-Americans as reference category—African-American race remained independently associated with more post-operative ileus (OR=1.43, p=0.0005), sepsis (OR=1.71, p<0.001), and bleeding complications requiring transfusion (OR=1.65, p<0.001). With Asian-American race as reference group, it remained independently associated with a 14% increase in LOS as compared to Caucasian-American patients (IRR 1.14, p<0.001). 

Conclusion: African-Americans undergoing surgery for IBD had higher rates of POCs including ileus, sepsis, and bleeding requiring transfusion when compared to Caucasian- and Asian-Americans. This population may represent a particularly high-risk group for poor outcomes and further studies are needed to understand and develop interventions to improve these outcomes.

48.02 Racial Differences in Complications Following Emergency General Surgery: Who Your Surgeon Is Matters

Posted on January 18, 2018

R. Udyavar1, A. Salim2, E. Cornwell3, Z. Hashmi1, J. Havens1,2, A. Haider1,2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:  Understanding the mechanisms that lead to health care disparities is necessary to create robust solutions and ensure that all patients receive the best possible care. Many factors, including patients’ clinical/demographic characteristics and socioeconomic issues have been examined, but the extent to which surgeon-level factors contribute to disparities has not been established. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing Emergency General Surgery (EGS). 

Methods:  We analyzed the Florida State Inpatient Database (SID) and extracted all patients who underwent 1 or more of 7 EGS procedures from 2010-2014. These procedures (laparotomy, cholecystectomy, small bowel resection, colectomy, peptic ulcer disease repair, lysis of adhesions, and appendectomy) represent 80% of all EGS cases performed in the U.S. Our outcome of interest was postoperative complications, including pulmonary embolism, infection, and anastomotic leak.  To determine the individual surgeon effect, we performed multi-level random effects modeling, adjusting for clinical and hospital factors, such as comorbidities, illness severity, and hospital volume. This allowed us to determine if there was an increased adjusted odds of developing complications for black patients attributable to the individual provider.

Results: The study sample consisted of 291,497 cases performed by 1,736 surgeons at 205 hospitals. Black patients comprised 21.5% of the sample. On unadjusted analysis, the overall complication rate was 12.7%. For white patients, this was 10.7%, but for black patients, the complication rate increased to 31.2%. Black patients had a higher adjusted risk of having a complication than white patients (OR 1.32, 95% confidence interval [CI] 1.02-1.85). Between surgeons, the complication rate ranged from 3.02% and 21.7%. The proportion of the overall surgeon-level variation explained by measured clinical and hospital-level factors was 23.8%, and the proportion attributable to the individual surgeon effect was only 2.3%. However, when comparing patients according to race, the proportion of the between-surgeon variation due to the individual surgeon increased to 11.7%. This multifold increase suggests that the individual surgeon influences the degree to which black patients are more susceptible to experiencing a complication than their white counterparts.

Conclusion: This multi-institution analysis within a single large state demonstrates that not only do black patients have a higher risk than white patients of developing a complication after undergoing EGS, surgeon-level effects account for a larger proportion of the between-surgeon variation when comparing the two demographics. This suggests that there are factors both measurable and unmeasurable at the individual surgeon level that contribute to racial disparities in EGS.  

 

48.03 Survey of Surgeons’ Perspectives of Wound Care Centers for Chronic Wound Care

Posted on January 18, 2018

V. Rendell1, T. J. Esposito2, A. Gibson1  2UnityPoint Health,Wound Care And Hyperbaric Medicine,Peoria, ILLINOIS, USA 1University Of Wisconsin,Department Of General Surgery,Madison, WI, USA

Introduction: Chronic wounds affect an estimated 6.5 million patients in the United States (US). The aging population and obesity epidemic in the US are expected to intensify the burden of disease from chronic wounds. Comprehensive wound care centers have been well described to improve patient outcomes. Despite this, little is known regarding surgeon participation in wound centers, particularly surgeons’ opinions of their potential role in wound care centers.

Methods:  The memberships of the American College of Surgeons and the American Association for the Surgery of Trauma were solicited via email to participate in an online Qualtrics survey as a convenience sample. The survey consisted of 60 multiple choice and Likert scale type questions covering demographics, characterization of wound centers at the surgeons’ practices, and surgeons’ professional experiences with wound centers. Results were reported as percentages out of total responses or means with standard deviations (SD). 

Results: A total of 364 surgeons responded to the survey. Respondents were mostly male (83%) with a mean age 57.4 years (SD 10.7yr). Respondents were in practice 24.6 years on average (SD 11.7yr). General surgeons represented 34% of respondents while 26% classified themselves as acute care surgeons, 21% plastic surgeons, 9% vascular surgeons, and 10% burn surgeons or other. The majority (73%) were in group practice with over half (58%) in a hospital based setting. Nearly all were board certified (98%), but only 6% were certified by the American Board of Wound Management. A wound center existed where 69% of the respondents practiced, and 61% utilized the centers. The majority of wound center directors were general surgeons (49%) followed by plastic surgeons (20%). Respondents’ perceptions of wound care centers are summarized in Figure 1. Respondents had a mostly favorable experience with wound centers and indicated interest in participating in a wound practice. Most respondents (53%) were interested in formal wound care/hyperbaric oxygen therapy certification. Respondents were overall unsure of the financial aspects of running a wound center and indicated concern for increased cost to patients. Respondents generally perceived a benefit of wound centers for patient care and wound healing time. 

Conclusion: With increasing burden of disease from chronic wounds in the US, there exists an unmet need for comprehensive wound care management. Surgeons are interested in transitioning their focus to wound care as part of their career and pursuing advanced wound care training. Further efforts are needed to educate surgeons with interest in wound care specialization and create a pathway for surgeons to become directors of wound centers.

48.01 Changes in General Surgery: Market Share, Billing Practices, and Social Disparities in Price

Posted on January 18, 2018

J. Tseng1, B. Loper1, A. V. Lewis1, E. Ngula1, R. F. Alban1  1Cedars-Sinai Medical Center,Department Of Surgery,Los Angeles, CA, USA

Introduction:
Healthcare is one of the largest sectors in the economy, and its expenditures are rapidly growing.  Nationwide efforts are being directed to curb waste and incentivize high value care.  Hospital chargemaster prices are being criticized for their lack of transparency, and are also potential targets for cost savings.   Physician fees for surgical procedures are similarly scrutinized.  To better understand general surgery as a practice, we analyzed financial data of the Medicare Fee for Service program and its relationship to provider characteristics and patient demographics.

Methods:
Using the Medicare Provider Fee-For-Service Utilization and Payment Data Public Use Files from 2012-2015, we identified providers who billed for common general surgical operations, including appendectomies, cholecystectomies, colectomies, hernia repair, and small bowel resection.  Markup ratios, defined as the amount charged divided by the amount allowed by Medicare, were calculated.  Provider zip codes were matched to census data from the 2011-2015 American Community Survey.  Provider and patient demographic data were obtained and compared to markup ratios.

Results:
Male surgeons performed the majority of general surgical operations (89.3%) in comparison to females (4.6%) and ambulatory surgical centers (6.1%).  Females and ASC’s consistently increased their market share annually to a peak of 6.0% and 6.7% in 2015.  This trend was most dramatic in hernia repairs, where women increased their market share by 77% from 2012 to 2015.  Colorectal surgeons also increased their share of cases from 46.1% to 52.0% in the same time period.  Billing practices did not vary between male and female surgeons (3.71 vs 3.70, p=0.961), while ASC’s billed at higher markup ratios for all procedures (4.80 vs 3.71, p<.001).  Markup ratios were highest at both ends of the income spectrum (3.6 and 5.49), and lowest at the 50th percentile (3.33, p<.001).  Markup ratios were highest in populations with the most minorities (4.05 for Latinos and 4.3 for Asians, respectively), and were lowest in neighborhoods that were predominantly White (3.32).  Areas with more than 30% uninsured had higher markup ratios (4.28).  Markup ratios decreased as the proportion of publically insured patients increased (5.73 in 0-10% versus 2.92 in 75-100% uninsured).

Conclusion:
General surgery is a rapidly changing, yet imbalanced field of medicine.  While male surgeons still perform the majority of cases, females, ASC’s, and specialists claim a larger bite of market share every year.  Though billing practices do not vary between males and females, ASC’s consistently bill more than individual surgeons.  Finally, providers appear to adjust charges based on patient socioeconomic demographics such as age, race, insurance status and income.  These patterns may reflect a combination of maximizing revenue by capitalizing on wealth, while charging higher prices to in areas at higher risk of nonpayment.
 

47.18 Neurosurgonomics: Trends of the Neurosurgical Economy in the United States

Posted on January 18, 2018

W. C. Johnson1, A. Seifi2  1University Of Texas Health Science Center At San Antonio,School Of Medicine,San Antonio, TX, USA 2University Of Texas Health Science Center At San Antonio,Neurosurgery,San Antonio, TX, USA

Objective:

The objective of this study was to identify the neurosurgical MS-DRGs highest national bills and to analyze economic, demographic, and patient outcome trends, which we named “Neurosurgonomics.”

Methods:

This retrospective cohort study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All MS-DRG codes for the years 2014 were ranked based on total aggregate charges, and the highest ranked relevant to neurosurgery were identified and retrospectively reviewed to 2008. The data was analyzed by Z-test.

Results:

In 2014, NIS reported the neurosurgical MS-DRG with the highest national bill of $22,894,340,928 was “Spinal Fusion Except Cervical without MCC,” which also had the largest rise over the cohort period, increasing from $15,853,679,222 in 2008 (p<.001). It was also the MS-DRG with the highest incidence, totaling 1,443,112 discharges over the cohort, increasing from 190,692 in 2008 to 214,100 in 2014 (p<.10). “Craniotomy with major Device Implant/Acute Complex CNS Procedure w/ MCC or Chemo Implant” had the longest length of stay (LOS) with a mean patient stay of 12.9 days over the cohort. This MS-DRG also had the oldest patient population mean age of 57.5 years old. “Craniotomy & Endovascular Intracranial Procedures with MCC” had the most in-hospital deaths totaling 28,707 over the cohort, that increased significantly from 3602 in 2008 to 4410 in 2014 (p<.05).

Conclusions:

"Spinal fusion except cervical without MCC," had the highest national bill in the USA over the period of the cohort. Healthcare organizations can benefit from awareness of this “Neurosurgonomic” information by using it to establish the most efficient healthcare investments and preparing a health-care roadmap for the following deca

47.19 When are we operating on kids? A simple intervention to improve outcomes in developing countries.

Posted on January 18, 2018

V. N. O’Reilly-Shah1,2, G. Easton3, S. Gillespie4  1Emory University School Of Medicine,Anesthesiology,Atlanta, GA, USA 2Children’s Healthcare Of Atlanta,Pediatric Anesthesiology,Atlanta, GA, USA 3Emory University Goizueta Business School,Information Systems & Operations Management,Atlanta, GA, USA 4Emory University School Of Medicine,Pediatrics,Atlanta, GA, USA

Introduction: According to the Lancet Commission on Global Surgery, over 5 billion people have deficient access to basic surgical and anesthetic care. The rapid global adoption of mobile health (mHealth) smartphone apps by healthcare providers provides opportunities to study global medical practice patterns, track access to care, and disseminate best practice information. App analytics, combined with in-app demographic surveys, can provide powerful tools for the collection of data in these areas.

Methods: We studied users of a free anesthesia calculator app used in nearly every country in the world. We combined traditional app analytics, with in-app surveys, to collect user demographics and feedback.

Results: Mining data on ~389k patient entries from 42,389 subjects in 206 countries, we found that most app uses were associated with the care of pediatric patients: ~79k (20%) of patient records were less than one month old, and ~281k (72%) were less than twelve years old. We observed significant differences in age of the patients (for which the app was consulted) as a function of country income level. Specifically, the proportion of neonates, infants, and toddlers was higher in lower income countries. We also observed significant differences in the hour of the day when the app was used; for neonates, infants, and toddlers, app uses were observed at a significantly higher rate in the evenings and at night in lower income countries.

Conclusions: Country income level appears to be an important predictor of the use of mHealth clinical decision support, which may suggest higher need for decision support in the care of this vulnerable population. Due to lack of available assistance, the increased rate of evening and nighttime procedures in lower income countries is potentially a very easy target for intervention in improving outcomes.

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