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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

Results: 

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

Conclusion: 

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

73.07 Impact of ERAS Implementation on Racial Disparities at the VA

Posted on January 31, 2019

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

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

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

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

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

 

73.06 Characterization of Wound Misclassification in Common Surgical Procedures

Posted on January 31, 2019

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

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

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

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

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

 

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

73.05 Predicting the Need for Operative Management of Small Bowel Obstruction with Machine Learning

Posted on January 31, 2019

J. D. Bozzay1,19, P. F. Walker1,19, V. Khatri1,17,19, M. Zielinski2, S. Wydo3, D. Cullinane4, J. Dunn5, T. Duane6, D. Turay7, K. Inaba8, R. Lesperance9, M. Rosenthal10, J. Watras11, A. Pakula12, K. A. Widom13, J. Cull14, E. Toschlog15, T. Z. Hayward16, S. Schobel-Mchugh1,17,19, E. A. Elster1,17,19, C. J. Rodriguez1,19, M. J. Bradley1,17,18,19  1Walter Reed National Military Medical Center,Department Of Surgery,Bethesda, MD, USA 2Mayo Clinic,Department Of Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Surgery,Camden, NJ, USA 4Marshfield Clinic,Department Of Surgery,Marshfield, WI, USA 5UC Health Northern Colorado,Department Of Surgery,Loveland, CO, USA 6John Peter Smith,Department Of Surgery,Forth Worth, TX, USA 7Loma Linda University Health,Department Of Surgery,Loma LInda, CA, USA 8Keck School of Medicine of USC,Department Of Surgery,Los Angeles, CA, USA 9San Antonio Military Medical Center,Department Of Surgery,Fort Sam Houston, TX, USA 10Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 11Inova Fairfax Hospital,Department Of Surgery,Falls Church, VA, USA 12Kern Medical Center,Department Of Surgery,Bakersfield, CA, USA 13Geisinger Medical Center,Department Of Surgery,Danville, PA, USA 14Greenville Memorial Hospital,Department Of Surgery,Greenville, SC, USA 15East Carolina University,Department Of Surgery,Greenville, NC, USA 16Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 17Surgical Critical Care Initiative,Bethesda, MD, USA 18Naval Medical Research Center,Department Of Regenerative Medicine,Bethesda, MD, USA 19Uniformed Services University Of The Health Sciences,Bethesda, MD, USA

Introduction: Identifying candidates who will require therapeutic surgery (TS) for non-emergent small bowel obstruction (SBO) remains challenging.  Machine learning models can elicit complex dependencies and may perform better than traditional regression models. The objective of this study was to compare both strategies to best identify patients who would require TS for the management of SBO.

Methods: A prospectively maintained multi-institutional database from the Eastern Association for the Surgery of Trauma was reviewed. Presence of peritonitis, closed loop obstruction on imaging, virgin abdomen, or patients with data paucity were excluded, leaving 566 patients for analysis. Random Forest (RF) and logistic regression (LR) models were generated separately for both gastrografin challenge (GC) and non-GC patients.

Results: 156 (27.6%) patients underwent TS. The non-GC RF model produced an area under the curve (AUC) of 0.68, sensitivity of 0.64, and specificity of 0.70. The non-GC LR model produced an AUC of 0.62, sensitivity of 0.59, and specificity of 0.65. The GC RF model produced an AUC of 0.89, sensitivity of 0.86, and specificity of 0.89. The GC LR model produced an AUC of 0.89, sensitivity of 0.87, and specificity of 0.87. Predictive variables for therapeutic surgical intervention for the GC RF and LR models included GC test result,  systolic blood pressure, presence of intraperitoneal fluid, presence of CT transition point, and previous occurrence of at least of 1 of the following: Crohn’s disease, enterocutaneous fistula, gastric bypass, metastatic cancer, small bowel obstruction, or ventral hernia. In the GC RF and LR models, removal of the GC test result as a predictor, substantially lessened performance metrics for both the RF (AUC of 0.59, sensitivity of 0.57, specificity of 0.64) and LR models (AUC of 0.61, sensitivity of 0.62, specificity of 0.65). The GC test result alone had a sensitivity of 0.7 and specificity of 0.93.

Conclusion: An accurate model for predicting the need for SBO TS was developed using a combination of clinical and radiographic data. Furthermore, incorporation of the GC significantly improves model performance and is an important clinical test during the workup of non-emergent SBO. The improved performance for GC patients is critically dependent on the inclusion of GC result as a predictor. This type of predictive modeling may be a useful adjunct to support future clinical decision-making. Evaluation with an external validation dataset is required to assess the generalizability of model performance.

73.04 Treatment Goal Concordance Among Patients and Health Surrogates in the Perioperative Setting

Posted on January 31, 2019

B. V. Udelsman1, N. Govea3, Z. Cooper4, A. Bader5, M. Meyer2  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Massachusetts General Hospital,Anesthesiology,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA 4Brigham And Women’s Hospital,Surgery,Boston, MA, USA 5Brigham And Women’s Hospital,Anesthesiology,Boston, MA, USA

Introduction:

            Under sedation patients temporarily surrender decisional capacity. Thus, the health decision surrogate can have an especially important role in the perioperative period.   Prior studies of general medical and intensive care unit patients have demonstrated poor concordance between patients and their surrogates in regards to treatment priorities.  The aim of this study was to determine the degree of concordance in the perioperative setting and to identify areas for improvement.

 

Methods:   

Prospective cohort study set in the preoperative clinic.  Patients (>55 years) and their surrogates (dyads) who presented to the preoperative clinic were eligible for participation.  Patients who presented without a surrogate were excluded. Dyads were asked multiple choice questions about the patient’s care preferences using domains typically included in advance directives: resuscitation, intubation, hemodialysis, artificial nutrition, physical disability, cognitive disability, and chronic pain.  Concordance was defined as the surrogate correctly predicting patient treatment preferences. Dyads were also surveyed on socio-demographics and quality of life.  

            

Results:

            36 pairs completed the survey.  The median patient age was 68 (IQR 60, 77).  Most patients were white (91%), had graduated high-school (94%), and had an ASA score of 3 or greater (86%).  Surrogates were either a spouse (81%), an adult son/daughter (14%), or a sibling of the patient (5%).  The majority of patients (78%) and surrogates (83%) reported having prior conversations regarding the patients’ goals of care.  Most patients (86%) reported being “very confident” in their surrogates understanding of their health care preferences, while most surrogates (86%) reported similar confidence in their knowledge of the patient’s preferences.  Concordance regarding major treatment domains ranged from 86% for resuscitation to 39% for artificial nutrition.  Prior conversations regarding treatment preferences did not significantly effect concordance between patients and surrogates in any domain (Table 1).

 

Conclusions:

            Concordance between patients and surrogates regarding major treatment preferences is highly variable the perioperative setting.  This discordance may limit patient autonomy and result in non-beneficial treatment that is not concordant with patient goals. Conversations regarding treatment preferences did not significantly improve concordance, signifying the need for targeted conversations potentially facilitated by a health care professional.

73.03 Differential Responses of Operating Room Personnel to Behaviors of Male and Female Surgeons

Posted on January 31, 2019

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

Introduction:
To date, several qualitative studies have been conducted assessing the relationships between physicians and registered nurses (RN), with special attention paid to the dynamics between females working together. However, while surgeon demographics have shifted in recent decades to include more women, the female-to-female relationship in the operating room (OR) remains largely unstudied. Furthermore, stereotypical surgeon-specific behavior may stand at odds with societal expectations for appropriate behavior of women. Therefore, we sought to examine biases related to surgeon sex within the environment of the operating room, paying special attention to views of female allied health professionals.

Methods:
We performed a prospective, randomized study in which OR support staff, including RN, surgical technologists (ST), and surgical assistants (SA), were asked to assess questionable surgeon behaviors across a standardized set of five scenarios via online survey. Respondents were randomized to surveys that either described a female or male surgeon, with all other aspects of the survey identical. For each scenario, respondents were asked to identify the behavior as Acceptable; Unacceptable but would ignore; Unacceptable and would confront surgeon directly; or Unacceptable and would report to OR management. Analyses included comparisons of respondents’ assessments of surgeon behaviors with the sexes of both the surgeon and respondents; χ2 was used to identify associations among these variables.

Results:

There were 3,186 responses (response rate=4.5%). 81% of respondents were female, 54% were RN, 55% reported working in the OR for greater than 15 years, 41% were Baby Boomers, and 94% worked in the United States. When evaluating across all scenarios and both surgeon sexes, female respondents were more likely to find the surgeon’s behaviors inappropriate than male respondents (p=0.001), (Figure). Sex of the surgeon did not appear to play a role in the assessment of appropriateness of the surgeon’s behaviors when evaluated across all respondents (p=0.322), male respondents (p=0.980), or female respondents (p=0.265). Similarly, sex of the respondent did not impact the likelihood to report the surgeon, regardless of surgeon sex (p=0.499).

Conclusion:
Our results suggest that ancillary OR staff of either sex do not have an inherent bias towards male or female surgeons when assessing behaviors via survey. However, female OR support staff appear to be more critical in their evaluation of surgeons across both sexes. Future investigations should aim to capture more subtle differences in responses and behaviors in the OR, such as body language, tone of voice, and type of language used.

73.02 Disparities in Outcomes of Emergency General Surgery for Children Stratified by Socioeconomic Status

Posted on January 31, 2019

G. J. Lee1, C. Ezeibe2, C. Zogg2, A. H. Haider2, G. Ortega2  1Harvard School Of Public Health,Health Policy,Boston, MA, USA 2Center for Surgery and Public Health,Department Of Surgery,Boston, MA, USA

Introduction:  Socioeconomic status plays a direct factor in accessibility to consistent health services and various studies have examined its outcomes on surgical care in adults. Our study aims to evaluate the impact of socioeconomic status on mortality among children in a national database.

Methods: We utilized the Kids' Inpatient Database for the year 2012 and selected children who underwent a surgical procedure and were admitted with a primary emergency general surgery (EGS) diagnosis. Patients without insurance or median household income (MHI) data were excluded. Patients were stratified by insurance status (Private, Medicaid, Uninsured) and MHI quartile. Multivariable logistic regression was performed with moratility as the outcome for each insurance and MHI group while adjusting for patient and hospital charactersitics.  

Results:

137,013 met our inclusion criteria, with mean age 11.1 years (SD=6.7), 74,868 (54.6%) males and 62,145 (45.4%) females. The most common races were White (50.7%) followed by Hispanic (27.4%) and followed by Blacks (12.7%). With respect to insurance rates, patients were privately insured (48.7%), had Medicaid (46.0%), or were uninsured (5.4%). Median household income ranges were from lowest at $1 to $38,999 (29.6%), low-medium at $39,000 to $47,999 (24.1%), medium-high at $48,000 to $62,999 (23.9%), and highest at $63,000 and more (22.4%). Mortality rates during hospitalization according to insurance status demonstrated the lowest for private insurance (0.75%), followed by uninsured (0.88%), with the highest rate in those with Medicaid (1.30%). Mortality rates during hospitalization according to insurance status demonstrated increasing mortality rates indirectly proportional to income status. Those with the lowest income quartile had a mortality rate of 1.2%, followed by low-medium (1.2%), followed by medium-high (0.9%), and highest (0.7%). On adjusted analysis, the odds ratio for privately insured patients was 1.29 (p = 0.00, 95% CI 1.15 to 1.45), compared to Medicaid patients was 1.93 (p = 0.00, 95% CI 1.48 to 2.51). Separately, on adjusted analysis, the odds ratio for low-medium household income was 0.94 (p = 0.401, 95% CI 0.82 to 1.08), for medium-high household income was 0.76 (p = 0.00, 95% CI 0.65 to 0.87), and highest household income was 0.65 (p = 0.00, 95% CI 0.55 to 0.76).

Conclusion:

Insurance status and MHI have an impact on children undergoing EGS. More studies are necessary to elucidate these disparities. 

73.01 Early Transition to Comfort Measures After Emergency General Surgery: An Opportunity for Improvement

Posted on January 31, 2019

A. Briggs1,2, V. Anto1, R. Handzel1, A. Peitzman1, R. Forsythe1  1University of Pittsburgh Medical Center,Pittsburgh, PA, USA 2Dartmouth Hitchcock Medical Center,Lebanon, NH, USA

Introduction:

Critically ill patients undergoing emergency general surgery procedures have significant risk of mortality. Perioperative patient and family conversations in this population can be difficult, as they can require not only discussion of the clinical situation, but also quality of life prior to the acute illness, assessment of patient goals for future quality of life and end of life care. The aim of this study was to analyze goals of care discussions in EGS patients in the intensive care unit (ICU).

 

Methods:
Emergency general surgery patients originating in or admitted to the medical and surgical intensive care units from 2010 to 2016 who underwent abdominal surgery were identified from a prospective, electronic record based registry. Postoperative deaths during admission were identified. Charts were reviewed to determine code status at the time of admission, changes in during the hospital stay, and at the time of death. Involvement of palliative care or ethics services was recorded. 

 

Results:

During this time period, 799 patients underwent abdominal procedures. The unadjusted mortality rate was 24.2% (193/799). Of those patients who died, 97.4% (188/193) were full code at the time of admission, although in 33.7% of cases (65/193) there was no documentation of a detailed discussion of code status prior to the index procedure. At the time of death, 79.3% (153/193) had been transitioned to ‘comfort measures only’ (CMO). Palliative care or ethics services were involved in 14.5% of cases. During admission, 25.4% of patients had multiple changes in code status, with the majority transitioning from full code to ‘do not resuscitate’ (DNR) and then ultimately to CMO prior to death. In 6 patients, code status was decided at the time of arrest. Within the first 48 hours, 26.9% of deaths occurred, with 73.1% of these as patients transitioned to CMO, 11.5% as DNR and 15.4% with full code. In this early mortality population, 36.5% of patients did not have a documented preoperative discussion of code status.

 

Conclusions:

The majority of ICU patients who died after EGS procedures had been transitioned to CMO status prior to death. In patients who died within 48 hours, one-third had no documented preoperative discussion of code status. An understanding of patient goals of care is vital in the perioperative management of critically ill EGS patients. Further study is required to determine whether an increase in the preoperative discussion of code status would yield different decisions regarding pursuit of emergency procedures in this high-risk population.  

72.10 Trends of Anticoagulant Use Among Surgical Patients in the Era of Direct Oral Anticoagulants

Posted on January 31, 2019

N. Thalji1, D. Kor2, M. Warner2, M. Zielinski1  2Mayo Clinic,Department Of Anesthesiology And Perioperative Medicine,Rochester, MN, USA 1Mayo Clinic,Department Of Surgery,Rochester, MN, USA

Introduction:  Patterns of anticoagulant use in surgical patients are poorly characterized. Contrasting warfarin, direct oral anticoagulants (DOACs) offer rapid onset and obviate monitoring needs, but cannot be rapidly reversed. We aimed to define the prevalence, indications and temporal trends of anticoagulant use in surgical patients, with a focus on DOACs.

Methods:  We studied adult non-cardiac surgical cases at our institution from 2007-2017. Cases on preoperative anticoagulation including DOACs (i.e. apixaban, dabigatran, edoxaban, rivaroxaban) were identified. Anticoagulated vs non-anticoagulated patients were compared using t-test/chi-square. We analyzed temporal trends in anticoagulation use by the Cochran Armitage trend test (significance p<0.05).

Results: A total of 361,360 cases were studied. Median (IQR) age was 59yrs (47–70) and 48% (172,355) were male. Overall, 8% (29,220) of cases received anticoagulation, representing 21,303 unique patients. Compared to 224,928 non-anticoagulated patients (332,140 cases), anticoagulated subjects were older (69 vs 59yrs), more frequently male (56% vs 47%), and had more comorbidities (Median [IQR] Charlson Index 5 [4–7] vs 3 [1–5]) (all p<0.001). Of anticoagulated subjects, AFib was present in 38%, DVT in 30%, PE in 10%, and prosthetic heart valves in 9%. From 2007-2017, the proportion of anticoagulated cases increased 32% (2007=6.7%, 2017=8.9%; p<0.001) (Fig1A). Of anticoagulated cases, 10% (2,865) were on DOACs, with most on apixaban (48%) or rivaroxaban (42%). In 2017, 31% of anticoagulated cases were on DOACs (Fig1B).

Conclusion: Operative cases for patients on home anticoagulation represent a significantly comorbid and increasing proportion of surgical volume. Widespread adoption of novel anticoagulants has culminated in DOAC use in 1/3 of contemporarily anticoagulated cases. Studies delineating perioperative risks for patients on DOAC therapy are increasingly relevant.

 

72.09 Surgeon Specific Outcomes Do Not Reliably Assess Quality

Posted on January 31, 2019

B. T. Fry1,2, S. P. Shubeck2,3, J. R. Thumma2, J. B. Dimick2,3  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3Michigan Medicine,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Individual surgeon performance data has become increasingly available to patients and providers alike. Additionally, there is a push at many institutions for internal reporting of surgeon outcomes to promote quality improvement. However, major concerns exist over the reliability of using surgeon specific data to detect differences in performance. No study has comprehensively evaluated the effect of low surgeon volume on multiple surgical outcomes across a wide variety of procedures.

Methods:  Using 2014 data from the State Inpatient Database, we calculated population level average mortality and complication rates across five surgical procedures: coronary artery bypass grafting, colectomy, pancreatectomy, total hip replacement, and bariatric procedures. We then calculated the minimum surgeon volume necessary to detect a doubling of each outcome rate at an alpha level of 0.05 and power level of 80%. Finally, we used annual individual surgeon caseloads to determine the proportion of surgeons who met or exceeded these minimum volumes. We then performed a sensitivity analysis to examine the proportion of surgeons who met the minimum volume threshold when aggregating caseloads over 3 years. 

Results: Surgeon specific data was available for 13,708 surgeons who performed a total of 236,413 cases in 8 states. Average mortality rates ranged from 0.05% for bariatric procedures to 4.1% for colectomy. Average complication rates ranged from 2.2% for bariatric procedures to 31.3% for pancreatectomy. Virtually 0% (1 of 13,708) of all surgeons performed an adequate number of cases annually to detect a doubling of the average mortality rate, while 9% (1,280) of surgeons performed enough annual cases to detect a doubling of the average complication rate. When examining estimated 3-year aggregate caseloads, 0.3% (48) of surgeons would perform enough cases to detect a doubling in mortality, while 25% (3,414) of surgeons would perform enough cases to detect a doubling in complication rates.

Conclusion: The majority of surgeons do not perform an adequate number of procedures to detect differences in individual mortality and complication rates. These results suggest that surgeon level outcome data cannot reliably assess performance and quality.

 

« Previous Page
Next Page »