Accessing surgical care for pancreaticoduodenectomy: Patient variation in travel distance and choice to bypass hospitals to reach higher volume centers

BackgroundWhile better outcomes at high‐volume surgical centers have driven regionalization of complex surgical care, access to high‐volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care.MethodsThe California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher‐volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher‐volume center.ResultsAmong 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high‐volume destination hospital. Specifically, average annual PD volume at the nearest “bypassed” vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure‐to‐rescue: 14.5% vs 9.1%). PD at a high‐volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22‐0.95). High‐volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3‐4.4). Among patients who had surgery at a low‐volume center, nearly 20% bypassed a high‐volume hospital in route. Furthermore, among patients who did not bypass a high‐volume hospital, one‐third would have needed to travel only an additional 30 miles or less to reach the nearest high‐volume hospital.ConclusionMost patients undergoing PD bypassed the nearest providing hospital to seek care at a higher‐volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low‐volume center.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/153129/1/jso25750.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153129/2/jso25750_am.pd

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

BACKGROUND: Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS: We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS: Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION: Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS: Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR)

Patterns of readmission among the elderly after hepatopancreatobiliary surgery

Background: The objective of this study was to examine risk factors and outcomes of hospital readmission following complex hepatopancreatobiliary (HPB) surgery among the elderly. Methods: The Nationwide Readmissions Database was queried for patients 65 60 years who underwent HPB surgery during 2010\u20132015. Results: The incidence of 30- and 90-day readmission was similar among patients 60\u201374 vs. 6575 (P > 0.05). Patients age 60\u201374 years with 652 comorbidities had an increased odds of 30-day (OR 1.13, p = 0.021) and 90-day (OR 1.13, p = 0.005) readmission. Patients 6575 years with 652 comorbidities had the highest in-hospital mortality (5%) whereas patients 60\u201374 years with 0 or 1 comorbidity had the lowest in-hospital mortality on readmission (3%). Conclusion: Following an HPB procedure, roughly 1 in 7 elderly patients were readmitted within 30 days and 1 in 4 patients within 90 days. Elderly patients with multiple comorbidities were more likely to be readmitted at non-index hospitals

Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery

Background: Data on skilled nursing facility utilization among patients undergoing pancreatic surgery remain scarce. We sought to define the incidence of utilization of skilled nursing facilities and determine the impact of skilled nursing facility quality markers on postoperative outcomes among patients who underwent pancreatic surgery. Methods: Medicare Standard Analytic Files were used to identify patients who underwent pancreatic resection during 2013\u20132015. Nursing Home Compare datasets were used to examine the influence of skilled nursing facility quality as estimated by quality markers (Medicare star ratings) on postoperative outcomes. Results: Among 13,018 patients who underwent pancreatectomy, 2,247 (17.3%) were discharged to a skilled nursing facility. Compared with patients discharged home, patients discharged to a skilled nursing facility were older (median age: 72 [interquartile range 68\u201376] vs 76 [interquartile range 71\u201380]), more likely female (44.4% vs 56.8%), and had greater Charlson comorbidity index scores (median score: 3 [interquartile range 2\u20138] vs 4 [interquartile range 2\u20138]) (all P < .001). Most patients were discharged to an above-average skilled nursing facility (N = 1,463, 65.1%), and a lesser subset was discharged to a skilled nursing facility with a below-average (N = 490, 21.8%) or average (N = 294, 13.1%) star rating. The 30-day hospital readmission was greatest among patients discharged to a below-average skilled nursing facility (below average N = 217, 44.3%; average N = 110, 37.4%; above average N = 517, 35.3%; P = .002). On multivariate analysis, patients discharged to below-average skilled nursing facilities remained 64% more likely to be readmitted within 30 days (OR 1.64, 1.29\u20132.02, P < .001). In contrast, 30-day mortality was comparable across the skilled nursing facility star rating categories (P = .08). Conclusion: Roughly 1 in 6 patients undergoing pancreatic surgery were discharged to a skilled nursing facility. Patients discharged to a below-average skilled nursing facility were more likely to be readmitted compared with patients discharged to an above-average skilled nursing facility

Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery

Background: Data on predictors of nonroutine discharge among patients undergoing hepatopancreatic surgery remain poorly defined. We sought to define factors associated with nonroutine discharge to home with home health care or to a skilled nursing facility or intermediate care facility and determine the impact of discharge destination on outcomes after hepatopancreatic surgery. Methods: The Nationwide Readmissions Database was queried for individuals who underwent hepatopancreatic surgeries 2010\u20132014 and were discharged home with home health care or to a skilled nursing facility/intermediate care facility. Results: A total of 42,189 patients underwent hepatopancreatic surgery. Of those, 2,825 (6.70%) were discharged to a skilled nursing facility or intermediate care facility, whereas 10,925 (25.9%) were discharged with home health care. A majority of patients underwent major hepatectomy (N = 14,516, 34.4%) or minor pancreatectomy (N = 13,824, 32.8%). Compared with patients discharged home, patients discharged to a skilled nursing facility or intermediate care facility were older (median age: 60 years, interquartile range: 50\u201368 vs 73, 67\u201379) and had more comorbidities (median score: 3, interquartile range: 1\u20138 vs 4, interquartile range: 2\u20138; P < .001). Type of operative procedure was not associated with discharge to a skilled nursing facility versus with home health care. Rather, patients with extreme loss of function, based on preoperative assessment, had 2.76 times higher odds of discharge to a skilled nursing facility or intermediate care facility versus with home health care (odds ratio 2.76, 95% confidence interval 1.98\u20133.85). Similarly, older (odds ratio 1.06, 95% confidence interval 1.06\u20131.07) and female patients (odds ratio 1.37, 95% confidence interval 1.25\u20131.51) were more likely to be discharged to a skilled nursing facility or intermediate care facility versus with home health care. Conclusion: One in four patients undergoing hepatopancreatic surgery were readmitted within 90 days of surgery. Age, severity of comorbidities, and perioperative course, including incidence of complications, were associated with nonroutine discharge

Trends in the Incidence, Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA: Facility Type is Associated with Margin Status, Use of Lymphadenectomy and Overall Survival

Introduction: Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Methods: Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. Results: The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004\u20132009: 8.05 months vs. 2010\u20132015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of 656 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24\u20131.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04\u20131.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001). Conclusions: The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC

Minimally Invasive Liver Resection for Early-Stage Hepatocellular Carcinoma: Inconsistent Outcomes from Matched or Weighted Cohorts

The aim of the current study was to re-evaluate the role of minimally invasive liver resection (MILR) among patients with early-stage (stage I or II) hepatocellular carcinoma (HCC) undergoing partial hepatectomy