Publications by authors named "Hari Nathan"

104 Publications

The ACA at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

J Surg Res 2021 Feb 25;263:102-109. Epub 2021 Feb 25.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2020.12.056DOI Listing
February 2021

Post-Acute Care Utilization and Episode of Care Payments Following Common Elective Operations.

Ann Surg 2021 Feb 12. Epub 2021 Feb 12.

*Department of Surgery, University of Michigan, Ann Arbor, MI, USA †Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA ‡University of Michigan Medical School, Ann Arbor, MI, USA.

Objective: To describe post-acute care (PAC) utilization and associated payments for patients undergoing common elective procedures.

Summary Background Data: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures.

Methods: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012-2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization.

Results: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7,830, p < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9,439, p < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8,062, p < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR (OR 1.61, 95% CI 1.29-2.02, p < 0.001). Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, p < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, p = 0.039).

Conclusions: We found both modifiable (e.g. obesity) and non-modifiable (e.g. female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors as well as systems and processes to address these factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004814DOI Listing
February 2021

Immunotherapy for pancreatic ductal adenocarcinoma.

J Surg Oncol 2021 Mar;123(3):751-759

Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Pancreatic ductal adenocarcinoma (PDAC) remains a lethal cancer with an urgent need for better medical therapies. Efforts have been made to investigate the efficacy of immunotherapy, particularly given the hallmarks of immune suppression and exhaustion in PDAC tumors. Here, we review the molecular components responsible for the immune-privileged state in PDAC and provide an overview of the immunotherapeutic strategies for PDAC including vaccine therapy, checkpoint blockade, myeloid-targeted therapy, and immune agonist therapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26312DOI Listing
March 2021

Survival benefit with adjuvant radiotherapy after resection of distal cholangiocarcinoma: A propensity-matched National Cancer Database analysis.

Cancer 2020 Dec 15. Epub 2020 Dec 15.

Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Background: No convincing evidence for the benefit of adjuvant radiotherapy (RT) following resection of distal cholangiocarcinoma (dCCA) exists, especially for lower-risk (margin- or node-negative) disease. Hence, the association of adjuvant RT on survival after surgical resection of dCCA was compared with no adjuvant RT (noRT).

Methods: Using National Cancer Database data from 2004 to 2016, patients undergoing pancreatoduodenectomy for nonmetastatic dCCA were identified. Patients with neoadjuvant RT and chemotherapy and survival <6 months were excluded. Propensity score matching was used to account for treatment-selection bias. A multivariable Cox proportional hazards model was then used to analyze the association of adjuvant RT with survival.

Results: Of 2162 (34%) adjuvant RT and 4155 (66%) noRT patients, 1509 adjuvant RT and 1509 noRT patients remained in the cohort after matching. The rates of node-negative disease (N0), node-positive disease (N+), and unknown node status (Nx) were 39%, 51%, and 10%, respectively. After matching, adjuvant RT was associated with improved survival (median, 29.3 vs 26.8 months; P < .001), which remained after multivariable adjustment (HR, 0.86; 95% CI, 0.80-0.93; P < .001). Multivariable interaction analyses showed this benefit was seen irrespective of nodal status (N0: HR, 0.77; 95% CI, 0.66-0.89; P < .001; N+: HR, 0.79; 95% CI, 0.71-0.89; P < .001) and margin status (R0: HR, 0.58; 95% CI, 0.50-0.67; P < .001; R1: HR, 0.87; 95% CI, 0.78-0.96; P = .007). Stratified analyses by nodal and margin status demonstrated consistent results.

Conclusions: Adjuvant RT after dCCA resection was associated with a survival benefit in patients, even in patients with margin- or node-negative resections. Adjuvant RT should be considered routinely irrespective of margin and nodal status after resection for dCCA.

Lay Summary: Adjuvant radiotherapy after resection of distal cholangiocarcinoma was associated with a survival benefit in patients, even in patients with margin-negative or node-negative resections. Adjuvant radiotherapy should be considered routinely irrespective of margin and nodal status after resection of distal cholangiocarcinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.33356DOI Listing
December 2020

Survival Benefit of Adjuvant Chemotherapy After Pancreatoduodenectomy for Ampullary Adenocarcinoma: a Propensity-Matched National Cancer Database (NCDB) Analysis.

J Gastrointest Surg 2020 Nov 23. Epub 2020 Nov 23.

Department of Surgery, 2210A Taubman Health Care Center, University of Michigan, 1500 E Medical Center Dr, SPC 5343, Ann Arbor, MI, 48109-5343, USA.

Background: The benefit of adjuvant chemotherapy (AC) after pancreatoduodenectomy (PD) for ampullary adenocarcinoma is uncertain. We aimed to evaluate the association of AC with survival in patients with resected ampullary adenocarcinoma.

Methods: Using the National Cancer Database (NCDB) data from 2004 to 2016, patients with non-metastatic ampullary adenocarcinoma who underwent PD were identified. Patients with neoadjuvant radiotherapy and chemotherapy and survival < 6 months were excluded. Propensity score matching was used to account for treatment selection bias. A multivariable Cox proportional hazards model was then used to analyze the association of AC with survival.

Results: Of 3186 (43%) AC and 4172 (57%) no AC (noAC) patients, 1720 AC and 1720 noAC patients remained in the cohort after matching. Clinicopathologic variables were well balanced after matching. After matching, AC was associated with improved survival (median 47.5 vs 39.6 months, p = 0.003), which remained after multivariable adjustment (HR: 0.83, CI: 0.76-0.91, p < 0.001). Multivariable interaction analyses showed that this benefit was seen irrespective of nodal status: N0 (HR: 0.81, CI: 0.68-0.97, p < 0.001), N1 (HR: 0.65, CI: 0.61-0.70, p < 0.001), N2 (HR: 0.73, CI: 0.59-0.90, p = 0.003), N3 (HR: 0.59, CI: 0.44-0.78, p < 0.001); and margin status: R0 (HR: 0.85, CI: 0.77-0.94, p < 0.001), R1 (HR: 0.69, CI: 0.48-1.00, p < 0.001). Stratified analyses by nodal and margin status demonstrated consistent results.

Conclusion: In this large retrospective cohort study, AC after resected ampullary adenocarcinoma was associated with a survival benefit in patients, including patients with node-negative and margin-negative disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-020-04879-xDOI Listing
November 2020

Variation in Surgical Spending Among the Highest Quality Hospitals for Cancer Surgery.

Ann Surg 2020 Nov 18. Epub 2020 Nov 18.

University Of Michigan, Department of Surgery, Ann Arbor, MI, USA.

Objective: This study evaluates the variation in spending by the highest-quality hospitals performing complex cancer surgery in the United States.

Summary Background Data: As mortality rates for high-risk cancer surgery have improved, increased attention has focused on other elements of quality, such as complications. However, high-value surgical care requires both high-quality care and cost savings. Therefore, understanding any residual cost variation among high-quality hospitals is essential in order to better direct efforts to achieve efficient, high-value care.

Methods: Medicare beneficiaries age 65 to 99 who underwent surgery for pancreas, esophageal, lung, rectal, and colon cancer from 2014 to 2016 were identified. The highest-quality hospitals were identified as those in the quintile with the lowest risk- and reliability-adjusted serious complication rates for each operation. Within this cohort of high-quality hospitals, thirty-day total episode, index hospitalization, physician, postacute care, and readmission spending was analyzed. Logistic regression models were utilized to estimate the probability of postoperative outcomes and post-discharge resource utilization.

Results: 43,007 Medicare patients underwent either pancreas, esophageal, lung, rectal, or colon resection for cancer at a hospital within the highest-quality quintile. Among the highest quality hospitals, total episode spending ranged from $18,712 for colectomy to $38,054 for esophagectomy. Spending between the lowest- and highest spending hospitals varied from $1,207 (CI95% $1,195 to $1,220) or 6.6% of total episode spending in the lowest tertile for colectomy to $5,706 (CI95% $5,506 to $5,906) or 16.1% of total episode spending in the lowest tertile for esophagectomy. The largest component of variation was from postacute care spending followed by readmission. For all operations the risk-adjusted rate of postacute care facility utilization was lower among the lowest spending hospitals compared to the highest spending hospitals. For example, for pancreas the lowest-spending hospitals on average discharged patients to a postacute care facility at a rate of 18,6% (CI95% 16.2 to 20.9) compared to 31.0% (CI95% 28.2 to 33.9) in the highest-spending hospitals. In all operations, the risk-adjusted readmission rate was lower among the lowest-spending hospitals compared to the highest-spending hospitals. For instance, within the esophagus cohort, the lowest-spending hospitals had an average risk-adjusted readmission rate of 17.3% compared to 29.4% in the highest spending hospitals (p < 0.001).

Conclusions And Relevance: Even among the highest-quality hospitals, significant cost variation persists among cancer operations. Post-acute care variation, rather than residual variation in complication rates, explains the majority of this variation and represents an immediately actionable target for increased cost efficiency.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004641DOI Listing
November 2020

Challenges and Opportunities for the Academic Mission Within Expanding Health Systems: A Qualitative Study.

Ann Surg 2020 Nov 12. Epub 2020 Nov 12.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Objective: To explore challenges and opportunities for surgery departments' academic missions as they become increasingly affiliated with expanding health systems.

Summary Background Data: Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments' academic missions is unknown.

Methods: Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis.

Results: Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments' research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees.

Conclusions: Though health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems' reach and resources in order to support their academic missions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004462DOI Listing
November 2020

Sources of Hospital Variation in Postacute Care Spending After Cardiac Surgery.

Circ Cardiovasc Qual Outcomes 2020 11 12;13(11):e006449. Epub 2020 Nov 12.

Department of Cardiac Surgery (M.P.T., R.L.P., F.D.P., D.S.L.), University of Michigan Medical School, Ann Arbor.

Background: Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization.

Methods And Results: A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes.

Conclusions: There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCOUTCOMES.119.006449DOI Listing
November 2020

Variations in surgical spending within hospital systems for complex cancer surgery.

Cancer 2021 Feb 3;127(4):586-597. Epub 2020 Nov 3.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.

Background: Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery.

Methods: Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels.

Results: Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy.

Conclusions: In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.33299DOI Listing
February 2021

Recanalization of the bile duct by using percutaneous and endoscopic methods after iatrogenic injury.

VideoGIE 2020 Jul 14;5(7):308-310. Epub 2020 May 14.

Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.vgie.2020.03.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332833PMC
July 2020

Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing.

JAMA Netw Open 2020 04 1;3(4):e203850. Epub 2020 Apr 1.

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice.

Objective: To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone.

Design, Setting, And Participants: This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019.

Main Outcomes And Measures: Thirty-day mortality and complications.

Results: The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies.

Conclusions And Relevance: In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.3850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191322PMC
April 2020

Evaluating the ACS-NSQIP Risk Calculator in Primary GI Neuroendocrine Tumor: Results from the United States Neuroendocrine Tumor Study Group.

Am Surg 2019 Dec;85(12):1334-1340

From the *Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.

The ACS established an online risk calculator to help surgeons make patient-specific estimates of postoperative morbidity and mortality. Our objective was to assess the accuracy of the ACS-NSQIP calculator for estimating risk after curative intent resection for primary GI neuroendocrine tumors (GI-NETs). Adult patients with GI-NET who underwent complete resection from 2000 to 2017 were identified using a multi-institutional database, including data from eight academic medical centers. The ability of the NSQIP calculator to accurately predict a particular outcome was assessed using receiver operating characteristic curves and the area under the curve (AUC). Seven hundred three patients were identified who met inclusion criteria. The most commonly performed procedures were resection of the small intestine with anastomosis (N = 193, 26%) and partial colectomy with anastomosis (N = 136, 18%). The majority of patients were younger than 65 years (N = 482, 37%) and ASA Class III (N = 337, 48%). The most common comorbidities were diabetes (N = 128, 18%) and hypertension (N = 395, 56%). Complications among these patients based on ACS NSQIP definitions included any complication (N = 132, 19%), serious complication (N = 118, 17%), pneumonia (N = 7, 1.0%), cardiac complication (N = 1, 0.01%), SSI (N = 80, 11.4%), UTI (N = 17, 2.4%), venous thromboembolism (N = 18, 2.5%), renal failure (N = 16, 2.3%), return to the operating room (N = 27, 3.8%), discharge to nursing/rehabilitation (N = 22, 3.1%), and 30-day mortality (N = 9, 1.3%). The calculator provided reasonable estimates of risk for pneumonia (AUC = 0.721), cardiac complication (AUC = 0.773), UTI (AUC = 0.716), and discharge to nursing/rehabilitation (AUC = 0.779) and performed poorly (AUC < 0.7) for all other complications Fig. 1). The ACS-NSQIP risk calculator estimates a similar proportion of risk to actual events in patients with GI-NET but has low specificity for identifying the correct patients for many types of complications. The risk calculator may require modification for some patient populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
December 2019

Wide Variation in Surgical Spending Within Hospital Systems: A Missed Opportunity for Bundled Payment Success.

Ann Surg 2019 Dec 10. Epub 2019 Dec 10.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.

Objective: We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems.

Summary Of Background Data: Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost.

Methods: Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level.

Results: Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272-$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545-$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals.

Conclusions: Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003741DOI Listing
December 2019

Interleukin 22 Signaling Regulates Acinar Cell Plasticity to Promote Pancreatic Tumor Development in Mice.

Gastroenterology 2020 04 14;158(5):1417-1432.e11. Epub 2019 Dec 14.

Department of Surgery, University of Michigan, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan. Electronic address:

Background & Aims: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that invades surrounding structures and metastasizes rapidly. Although inflammation is associated with tumor formation and progression, little is known about the mechanisms of this connection. We investigate the effects of interleukin (IL) 22 in the development of pancreatic tumors in mice.

Methods: We performed studies with Pdx1-Cre;LSL-Kras;Trp53;Rosa26 (PKCY) mice, which develop pancreatic tumors, and PKCY mice with disruption of IL22 (PKCY Il22mice). Pancreata were collected at different stages of tumor development and analyzed by immunohistochemistry, immunoblotting, real-time polymerase chain reaction, and flow cytometry. Some mice were given cerulean to induce pancreatitis. Pancreatic cancer cell lines (PD2560) were orthotopically injected into C57BL/6 mice or Il22mice, and tumor development was monitored. Pancreatic cells were injected into the tail veins of mice, and lung metastases were quantified. Acini were collected from C57BL/6 mice and resected human pancreata and were cultured. Cell lines and acini cultures were incubated with IL22 and pharmacologic inhibitors, and protein levels were knocked down with small hairpin RNAs. We performed immunohistochemical analyses of 26 PDACs and 5 nonneoplastic pancreas specimens.

Results: We observed increased expression of IL22 and the IL22 receptor (IL22R) in the pancreas compared with other tissues in mice; IL22 increased with pancreatitis and tumorigenesis. Flow cytometry indicated that the IL22 was produced primarily by T-helper 22 cells. PKCY Il22mice did not develop precancerous lesions or pancreatic tumors. The addition of IL22 to cultured acinar cells increased their expression of markers of ductal metaplasia; these effects of IL22 were prevented with inhibitors of Janus kinase signaling to signal transducer and activator of transcription (STAT) (ruxolitinib) or mitogen-activated protein kinase kinase (MEK) (trametinib) and with STAT3 knockdown. Pancreatic cells injected into Il22 mice formed smaller tumors than those injected into C57BL/6. Incubation of IL22R-expressing PDAC cells with IL22 promoted spheroid formation and invasive activity, resulting in increased expression of stem-associated transcription factors (GATA4, SOX2, SOX17, and NANOG), and increased markers of the epithelial-mesenchymal transition (CDH1, SNAI2, TWIST1, and beta catenin); ruxolitinib blocked these effects. Human PDAC tissues had higher levels of IL22, phosphorylated STAT3, and markers of the epithelial-mesenchymal transition than nonneoplastic tissues. An increased level of STAT3 in IL22R-positive cells was associated with shorter survival times of patients.

Conclusions: We found levels of IL22 to be increased during pancreatitis and pancreatic tumor development and to be required for tumor development and progression in mice. IL22 promotes acinar to ductal metaplasia, stem cell features, and increased expression of markers of the epithelial-mesenchymal transition; inhibitors of STAT3 block these effects. Increased expression of IL22 by PDACs is associated with reduced survival times.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.gastro.2019.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197347PMC
April 2020

Employee Healthcare Travel Programs: Promise or Hype?

Ann Surg 2020 05;271(5):815-816

Department of Surgery, University of Michigan, Ann Arbor, MI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003728DOI Listing
May 2020

Appendiceal Neuroendocrine Tumors: Does Colon Resection Improve Outcomes?

J Gastrointest Surg 2020 09 20;24(9):2121-2126. Epub 2019 Nov 20.

Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.

Background: Appendiceal neuroendocrine tumors (A-NETs) are rare neoplasms of the GI tract. They are typically managed according to tumor size; however, the impact of surgical strategy on the short- and long-term outcomes is unknown.

Methods: All patients who underwent resection of A-NET at 8 institutions from 2000 to 2016 were analyzed retrospectively. Patient clinicopathologic features and outcomes were stratified according to resection type.

Results: Of 61 patients identified with A-NET, mean age of presentation was 44.7 ± 16.0 years and patients were predominantly Caucasian (77%) and female (56%). Mean tumor size was 1.2 ± 1.3 cm with a median of 0.8 cm. Thirty-one patients (51%) underwent appendectomy and 30 (49%) underwent colonic resection. The appendectomy group had more T1 tumors (87% vs 42%, p < 0.01) than the colon resection group. Of patients in the colon resection group, 27% had positive lymph nodes and 3% had M1 disease. R0 resections were achieved in 90% of appendectomy patients and 97% of colon resection patients. Complications occurred with a higher frequency in the colon resection group (30%) compared with those in the appendectomy group (6%, p = 0.02). The colon resection group also had a longer length of stay, higher average blood loss, and longer average OR time. Median RFS and OS were similar between groups.

Conclusion: A-NET RFS and OS are equivalent regardless of surgical strategy. Formal colon resection is associated with increased length of stay, OR time, higher blood loss, and more complications. Further study is warranted to identify patients that are likely to benefit from more aggressive surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-019-04431-6DOI Listing
September 2020

Who Will be the Costliest Patients? Using Recent Claims to Predict Expensive Surgical Episodes.

Med Care 2019 11;57(11):869-874

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Introduction: Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential.

Design: Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014.

Results: All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile.

Conclusions: A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MLR.0000000000001204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814263PMC
November 2019

Phase 2 Trial of Neoadjuvant FOLFIRINOX and Intensity Modulated Radiation Therapy Concurrent With Fixed-Dose Rate-Gemcitabine in Patients With Borderline Resectable Pancreatic Cancer.

Int J Radiat Oncol Biol Phys 2020 01 5;106(1):124-133. Epub 2019 Sep 5.

University of Michigan, Ann Arbor, Michigan.

Purpose: Preoperative therapy in borderline resectable pancreatic cancer (BRPC) is intended to increase R0 resection rates. An optimal approach in BRPC is yet to be defined.

Methods And Materials: Patients with BRPC, confirmed adenocarcinoma, performance status ≤1, and adequate organ function enrolled in a single-institution, phase 2 trial. Patients received FOLFIRINOX × 6 cycles, then radiation therapy (50 Gy in 25 fractions) concurrent with fixed-dose rate gemcitabine (1 g/m over 100 minutes) followed by 2 additional gemcitabine infusions. Computed tomography scans were performed at 2-month intervals during treatment. Patients without distant disease were offered surgical exploration. The primary objective was R0 resection rate with an alternate hypothesis of 55%. Secondary objectives included median progression-free survival (PFS), median overall survival (OS), response rate, and safety. The trial registration number is NCT01661088.

Results: Twenty-five patients with median age of 60 years (range, 47-77 years) enrolled from November 2011 through January 2017. Twenty-one (84%) completed FOLFIRINOX and 19 (76%) completed all protocol therapy. Treatment-related grade 3 to 4 toxicities included neutropenia (40%), nausea and vomiting (28%), diarrhea (16%), and fatigue (12%). Eighteen patients (72%) underwent laparotomy, 13 (52%) were resected (all R0). The median PFS and OS in 25 patients were 13.1 months (95% confidence interval [CI], 7.3-24.7) and 24.4 months (95% CI, 12.6-40.0), respectively. For resected patients, median PFS was 21.6 months (95% CI, 8.2-37.1) and OS was 37.1 months (95% CI, 15.4-not reached).

Conclusions: Neoadjuvant therapy with FOLFIRINOX, followed by intensity modulated radiation therapy concurrent with fixed-dose-rate gemcitabine in BRPC is feasible and tolerated. Although the alternate hypothesis was not met, the OS of the resected cohort was favorable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijrobp.2019.08.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245020PMC
January 2020

Association of Discretionary Hospital Volume Standards for High-risk Cancer Surgery With Patient Outcomes and Access, 2005-2016.

JAMA Surg 2019 11;154(11):1005-1012

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Various clinical societies and patient advocacy organizations continue to encourage minimum volume standards at hospitals that perform certain high-risk operations. Although many clinicians and quality and safety experts believe this can improve outcomes, the extent to which hospitals have responded to these discretionary standards remains unclear.

Objective: To evaluate the association between short-term clinical outcomes and hospitals' adherence to the Leapfrog Group's minimum volume standards for high-risk cancer surgery.

Design, Setting, And Participants: Longitudinal cohort study using 100% of the Medicare claims for 516 392 patients undergoing pancreatic, esophageal, rectal, or lung resection for cancer between January 1, 2005, and December 31, 2016. Data were accessed between December 1, 2018, and April 30, 2019.

Exposures: High-risk cancer surgery in hospitals meeting and not meeting the minimum volume standards.

Main Outcomes And Measures: Patients having surgery in hospitals meeting the volume standard and 30-day and in-hospital mortality and complication rates.

Results: Overall, a total of 516 392 procedures (47 318 pancreatic resections, 29 812 esophageal resections, 116 383 rectal resections, and 322 879 lung resections) were included in the study, and patient mean (SD) age was 73.1 (7.5) years. Outcomes improved over time in both hospitals meeting and not meeting the minimum volume standards. Mortality after pancreatic resection decreased from 5.5% in 2005 to 4.8% in 2016 (P for trend <.001). Mortality after esophageal resection decreased from in 6.7% 2005 to 5.0% in 2016 (P for trend <.001). Mortality after rectal resection decreased from 3.6% in 2005 to 2.7 % in 2016 (P for trend <.001). Mortality after lung resection decreased from 4.2% in 2005 to 2.7 % in 2016 (P for trend <.001). Throughout the study period, there were no statistically significant differences in risk-adjusted mortality between hospitals meeting and not meeting the volume standards for esophageal, lung, and rectal cancer resections. Mortality rates after pancreatic resection were consistently lower at hospitals meeting the volume standard, although mortality at all hospitals decreased over the study period. For example, in 2016, risk-adjusted mortality rates for hospitals meeting the volume standard were 3.8% (95% CI, 3.3%-4.3%) compared with 5.7% (95% CI, 5.1%-6.5%) for hospitals that did not. Although an increasing majority of patients underwent surgery in hospitals meeting the Leapfrog volume standards over time, the overall proportion of hospitals meeting the standards in 2016 ranged from 5.6% for esophageal resection to 23.3% for pancreatic resection.

Conclusions And Relevance: Although volume remains an important factor for patient safety, the Leapfrog Group's minimum volume standards did not differentiate hospitals based on mortality for 3 of the 4 high-risk cancer operations assessed, and few hospitals were able to meet these standards. These findings highlight important tradeoffs between setting effective volume thresholds and practical expectations for hospital adherence and patient access to centers that meet those standards.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2019.3017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694402PMC
November 2019

Surgical Hot Spotting: Who Becomes a Super-Utilizer After Surgery?

JAMA Surg 2019 11;154(11):1021-1022

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2019.2999DOI Listing
November 2019

Dose Escalation Trial of the Wee1 Inhibitor Adavosertib (AZD1775) in Combination With Gemcitabine and Radiation for Patients With Locally Advanced Pancreatic Cancer.

J Clin Oncol 2019 10 9;37(29):2643-2650. Epub 2019 Aug 9.

University of Michigan, Ann Arbor, MI.

Purpose: AZD1775 (adavosertib) is an inhibitor of the Wee1 kinase. In this study, we built on our preclinical studies to evaluate the safety and efficacy of AZD1775 in combination with gemcitabine and radiation in patients with newly diagnosed locally advanced pancreatic cancer.

Patients And Methods: Thirty-four patients with locally advanced pancreatic cancer were enrolled with the intention to receive four 21-day cycles of gemcitabine (1,000 mg/m days 1 and 8) with AZD1775 (once daily on days 1, 2, 8, and 9). Cycles 2 and 3 were administered concurrently with radiation, and cycles 5 to 8 were optional. AZD1775 was dose escalated using a time-to-event continual reassessment method on the basis of the rate of dose-limiting toxicities within the first 15 weeks of therapy. The primary objective was to determine the maximum tolerated dose of AZD1775 given in conjunction with gemcitabine and radiation. Secondary objectives were to estimate overall and progression-free survival and determine pharmacodynamic activity of AZD1775 in surrogate tissues.

Results: The recommended phase II dose of AZD1775 was 150 mg/d. Eight patients (24%) experienced a dose-limiting toxicity, most commonly anorexia, nausea, or fatigue. The median overall survival for all patients was 21.7 months (90% CI, 16.7 to 24.8 months), and the median progression-free survival was 9.4 months (90% CI, 8.0 to 9.9 months). Hair follicle biopsy samples demonstrated evidence of Wee1 inhibition with decreased phosphorylation of cyclin-dependent kinase 1 staining by immunohistochemistry after AZD1775 administration at the recommended phase II dose.

Conclusion: AZD1775 in combination with gemcitabine and radiation therapy was well tolerated at a dose that produced target engagement in a surrogate tissue. The overall survival is substantially higher than prior results combining gemcitabine with radiation therapy and warrants additional investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JCO.19.00730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006846PMC
October 2019

Interaction of race and pathology for neuroendocrine tumors: Epidemiology, natural history, or racial disparity?

J Surg Oncol 2019 Nov 6;120(6):919-925. Epub 2019 Aug 6.

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia.

Background And Objectives: Although minority race has been associated with worse cancer outcomes, the interaction of race with pathologic variables and outcomes of patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is not known.

Methods: Patients from the US Neuroendocrine Study Group (2000-2016) undergoing curative-intent resection of GEP-NETs were included. Given few patients of other races, only Black and White patients were analyzed.

Results: A total of 1143 patients were included. Median age was 58 years, 49% were male, 14% Black, and 86% White. Black patients were more likely to be uninsured (7% vs 2%, P = .011), and to have symptomatic bleeding (13% vs 7%, P = .009), emergency surgery (7% vs 3%, P = .006), and positive lymph nodes (LN) (47% vs 36%, P = .021). However, Black patients had improved 5-year recurrence-free survival (RFS) (90% vs 80%, P = .008). Quality of care was comparable between races, seen by similar LN yield, R0 resections, postoperative complications, and need for reoperation/readmission (all P > .05). While both races were more likely to have pancreas-NETs, Black patients had more small bowel-NETs (22% vs 13%, P < .001). LN positivity was prognostic for pancreas-NETs (5-year RFS 67% vs 83%, P = .001) but not for small-bowel NETs.

Conclusions: Black patients with GEP-NETs had more adverse characteristics and higher LN positivity. Despite this, Black patients have improved RFS. This may be attributed to the epidemiologic differences in the primary site of GEP-NETs and variable prognostic value of LN-positive disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.25662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791745PMC
November 2019

Centralization of High-Risk Cancer Surgery Within Existing Hospital Systems.

J Clin Oncol 2019 12 28;37(34):3234-3242. Epub 2019 Jun 28.

Department of Surgery, University of Michigan, Ann Arbor, MI.

Purpose: Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. We evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes.

Patients And Methods: We merged data from the American Hospital Association's annual survey on hospital system affiliation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which systems centralized each procedure by calculating the annual proportion of surgeries performed at the highest-volume hospital within each system. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and readmissions after accounting for patient, hospital, and system characteristics.

Results: The average degree of centralization varied from 25.2% (range, 6.6% to 100%) for colectomy to 71.2% (range, 8.3% to 100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.1% (95% CI, 0.8% to 1.4%) absolute reduction in 30-day mortality after pancreatectomy for each 20% increase in the degree of centralization within systems. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was two times higher in the least centralized systems than in the most centralized systems (8.9% 3.7%, < .01). Centralization was not associated with better outcomes for colectomy or proctectomy.

Conclusion: Greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these systems may also present unique opportunities to improve the quality of high-risk cancer care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JCO.18.02035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351344PMC
December 2019

Hospital factors strongly influence robotic use in general surgery.

Surgery 2019 11 14;166(5):867-872. Epub 2019 Jun 14.

Department of Surgery, City of Hope, Duarte, CA. Electronic address:

Background: We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic operations are performed, suggesting that hospital-related factors are important for choice of usage of minimally invasive platforms.

Methods: We queried the National Inpatient Sample from 2010 to 2014 for patients who underwent stomach, gallbladder, pancreas, spleen, colon and rectum, or hernia (general surgery), prostate or kidney (urologic surgery), and ovarian or uterine surgery (gynecologic surgery). Hospitals were grouped into quartiles according to percent volume of robotic urologic or gynecologic operations. Multivariable logistic regression modeling determined independent variables associated with robotics.

Results: Survey-weighted results represented 482,227 open, 240,360 laparoscopic, and 42,177 robotic general surgical operations at 3,933 hospitals. Robotics use increased with each year studied and was more likely to be performed on younger men with private insurance. The odds of a general surgery patient receiving a robotic operation increased with urologic and gynecologic use at the hospital. Patients at top quartile hospitals for robotic urologic surgery had 1.34 times greater odds of receiving robotic general surgery operations (confidence interval 1.15-1.57, P < .001) and 1.53 times greater odds (confidence interval 1.32-1.79, P < .001) at top quartile robotic gynecologic hospitals. These findings were independent of study year, surgical site, insurance type, and hospital type and persisted when only comparing laparoscopic to robotic procedures.

Conclusion: Use of robotics in general surgery is independently associated with use in urologic and gynecologic surgery at a hospital, suggesting that institutional factors are important drivers of use when considering laparoscopy versus robotics in general surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2019.05.008DOI Listing
November 2019

Regional and racial variations in the utilization of endoscopic retrograde cholangiopancreatography among pancreatic cancer patients in the United States.

Cancer Med 2019 07 14;8(7):3420-3427. Epub 2019 May 14.

Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.

Background: Pancreatic cancer is projected to become the second leading cause of cancer-related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as first-line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer.

Methods: Retrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients diagnosed with pancreatic cancer from 2003-2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any non-ERCP biliary intervention.

Results: Of the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32).

Conclusion: Racial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cam4.2225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601581PMC
July 2019

Local Referral of High-Risk Pancreatectomy Patients to Improve Surgical Outcomes and Minimize Travel Burden.

J Gastrointest Surg 2020 04 9;24(4):882-889. Epub 2019 May 9.

Department of Surgery, University of Michigan, Ann Arbor, MI, USA.

Background: Referring patients to high-quality hospitals for complex procedures may improve outcomes. This is most feasible within small geographic areas. However, access to specialized surgical procedures may be an implementation barrier. We sought to determine the availability of high-quality hospitals performing pancreatectomy and the potential benefit and travel burden of referral within small geographic areas.

Methods: We identified elderly Medicare beneficiaries undergoing pancreatectomy between 2012 and 2014. Hospitals were stratified into quintiles of quality based on postoperative complication rates. Patient risk was assessed by modeling the predicted risk of developing a postoperative complication. The geographic unit of analysis was Metropolitan Statistical Area (MSA). Hospitals were categorized into MSA by zip code. Travel distance was calculated using patient and hospital zip code.

Results: Among high-risk patients, 40.7% received care at the lowest-quality hospitals even though 80% had a high-quality hospital in the same MSA. Shifting these patients from low- to high-quality hospitals would decrease serious complications from 46.6 to 21.9% (P < 0.001) and mortality from 10.9 to 8.9% (P = 0.047). Three quarters of high-risk patients treated at low-quality hospitals could reach a high-quality hospital by extending their travel < 5 miles, and nearly 60% traveled farther to a low-quality hospital than was necessary to reach a high-quality hospital.

Conclusions: High-risk pancreatectomy patients often receive care at low-quality hospitals despite the availability of high-quality hospitals in the area or within an acceptable distance. Referral of high-risk patients to high-quality hospitals within small geographic areas may be an effective strategy to improve outcomes following pancreatic surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-019-04245-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842080PMC
April 2020

Evaluating the ACS NSQIP Risk Calculator in Primary Pancreatic Neuroendocrine Tumor: Results from the US Neuroendocrine Tumor Study Group.

J Gastrointest Surg 2019 11 2;23(11):2225-2231. Epub 2019 Apr 2.

Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.

Background: In a changing health care environment where patient outcomes will be more closely scrutinized, the ability to predict surgical complications is becoming increasingly important. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) online risk calculator is a popular tool to predict surgical risk. This paper aims to assess the applicability of the ACS NSQIP calculator to patients undergoing surgery for pancreatic neuroendocrine tumors (PNETs).

Methods: Using the US Neuroendocrine Tumor Study Group (USNET-SG), 890 patients who underwent pancreatic procedures between 1/1/2000-12/31/2016 were evaluated. Predicted and actual outcomes were compared using C-statistics and Brier scores.

Results: The most commonly performed procedure was distal pancreatectomy, followed by standard and pylorus-preserving pancreaticoduodenectomy. For the entire group of patients studied, C-statistics were highest for discharge destination (0.79) and cardiac complications (0.71), and less than 0.7 for all other complications. The Brier scores for surgical site infection (0.1441) and discharge to nursing/rehabilitation facility (0.0279) were below the Brier score cut-off, while the rest were equal to or above and therefore not useful for interpretation.

Conclusion: This work indicates that the ACS NSQIP risk calculator is a valuable tool that should be used with caution and in coordination with clinical assessment for PNET clinical decision-making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-019-04120-4DOI Listing
November 2019

Variation in Surgical Outcomes Across Networks of the Highest-Rated US Hospitals.

JAMA Surg 2019 06;154(6):510-515

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Hospitals are rapidly consolidating into regional delivery networks. To our knowledge, whether these multihospital networks leverage their combined assets to improve quality and provide a uniform standard of care has not been explored.

Objective: To evaluate the extent to which surgical outcomes varied across hospitals within the networks of the highest-rated US hospitals.

Design, Settings, And Participants: This longitudinal analysis of 87 hospitals that participated in 1 of 16 networks that are affiliated with US News & World Report Honor Roll hospitals used data from Medicare beneficiaries who were undergoing colectomy, coronary artery bypass graft, or hip replacement between 2005 and 2014 to evaluate the variation in risk-adjusted surgical outcomes at Honor Roll and affiliated hospitals within and across networks. The data were analyzed between April 20, 2018, and June 25, 2018.

Main Outcomes And Measures: Thirty-day postoperative complications, mortality, failure to rescue, and readmissions.

Results: Of 143 174 patients, 68 718 (48.0%) were men, 124 427 (86.9%) were white, and the mean (SD) age was 71.8 (9.9) years and 73.5 (9.1) years in Honor Roll and affiliated hospitals, respectively. Outcomes were not consistently better at Honor Roll hospitals compared with network affiliates. For example, Honor Roll hospitals had lower failure to rescue rates (13.3% vs 15.1%; odds ratio, 0.92; 95% CI, 0.86-0.98) but higher complication rates (22.1% vs 18.0%; odds ratio, 1.11; 95% CI, 1.03-1.19). Within networks, risk-adjusted outcomes varied widely across affiliated hospitals. The differences in failure to rescue varied by as little as 1.1-fold (range, 12.7%-14.3%) in some networks to as much as 4.9-fold (range, 7.6%-37.3%) in others. Similarly, complication rates varied by 1.1-fold (range, 21%-23%) to 4.3-fold (range, 6%-26%) across all networks.

Conclusions And Relevance: Surgical outcomes vary widely across hospitals affiliated with the US News & World Report Honor Roll hospitals. Public reporting mechanisms should provide patients with information on the quality of all network-affiliated hospitals. Networks should monitor variations in outcomes to characterize and improve the extent to which a uniform standard of care is being delivered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2019.0090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583390PMC
June 2019

Association of Adjuvant Radiotherapy With Survival After Margin-negative Resection of Pancreatic Ductal Adenocarcinoma: A Propensity-matched National Cancer Database (NCDB) Analysis.

Ann Surg 2021 03;273(3):587-594

Department of Surgery, University of Michigan, Ann Arbor, MI.

Introduction: There is conflicting evidence for the benefit of adjuvant radiotherapy (RT) after resection of pancreatic ductal adenocarcinoma (PDAC), especially for margin-negative (R0) resections. We aimed to evaluate the association of adjuvant RT with survival after R0 resection of PDAC.

Methods: Using National Cancer Database (NCDB) data from 2004 to 2013, we identified patients with R0 resection of nonmetastatic PDAC. Patients with neoadjuvant radiotherapy and chemotherapy and survival <6 months were excluded. Propensity score matching was used to account for treatment selection bias. A multivariable Cox proportional hazards model was then used to analyze the association of RT with survival.

Results: Of 4547 (36%) RT and 7925 (64%) non-RT patients, 3860 RT and 3860 non-RT patients remained in the cohort after matching. Clinicopathologic and demographic variables were well balanced after matching. Lymph node metastases were present in 68% (44% N1, 24% N2). After matching, RT was associated with higher survival (median 25.8 vs 23.9 mo, 5-yr 27% vs 24%, P < 0.001). After multivariable adjustment, RT remained associated with a survival benefit (HR 0.89, 95% CI 0.84-0.94, P < 0.001). Stratified and multivariable interaction analyses showed that this benefit was restricted to patients with node-positive disease: N1 (HR: 0.68, CI95%: 0.62-0.76, P = 0.007) and N2 (HR: 0.59, CI95%: 0.54-0.64, P = 0.04).

Conclusions: In this large retrospective cohort study, adjuvant RT after R0 PDAC resection was associated with a survival benefit in patients with node-positive disease. Adjuvant RT should be considered after R0 resection of PDAC with node-positive disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003242DOI Listing
March 2021

Gastric carcinoids: Does type of surgery or tumor affect survival?

Am J Surg 2019 05 28;217(5):937-942. Epub 2018 Dec 28.

Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA. Electronic address:

Background: Gastric carcinoids are rare neuroendocrine tumors of the gastrointestinal tract. They are typically managed according to their etiology. However, there is little known about the impact of surgical strategy on the long-term outcomes of these patients.

Methods: All patients who underwent resection of gastric carcinoids at 8 institutions from 2000 to 2016 were analyzed retrospectively. Tumors were stratified according to subtype (I, II, III, IV) and resection type (local resection, LR or formal gastrectomy, FG). Clinicopathological parameters, recurrence-free (RFS) and overall survival (OS) were compared between groups.

Results: Of 79 patients identified with gastric carcinoids, 34 had type I lesions associated with atrophic gastritis, 4 had type II lesions associated with a gastrinoma, 37 had type III sporadic lesions, and 4 had type IV poorly-differentiated lesions. The mean age of presentation was 56 years in predominantly Caucasian (77%) and female (63%) patients. Mean tumor size was 2.4 cm and multifocal tumors were found in 24 (30%) of patients with the majority occurring in those with type I tumors. Lymph node positive tumors were seen in 15 (19%) patients and 7 (8%) had M1 disease; both most often in type IV followed by type III tumors. R0 resection was achieved in 56 (71%) patients while 15 (19%) had R1 resections and 6 (8%) R2 resections. Patients with type I and III tumors were equally likely to have a LR (50% and 43% respectively) compared to FG while those with type II and IV all had FG with one exception. Type IV tumors had the poorest RFS and OS while Type II tumors had the most favorable RFS and OS (p < 0.04 and p < 0.0004, respectively). While there was no difference in RFS in those patients undergoing FG versus LR, OS was worse in the FG group (p < 0.017). This trend persisted when type II and type IV groups were excluded (p < 0.045).

Conclusion: Gastric carcinoid treatment should be tailored to tumor type, as biologic behavior rather than resection technique is the more important factor contributing to long-term outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2018.12.057DOI Listing
May 2019