Does Hospital Transfer Impact Outcomes After Colorectal Surgery?

BACKGROUND: With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion. OBJECTIVE: We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables. DESIGN: We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database. SETTINGS: The study was conducted at a tertiary care hospital. PATIENTS: All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility. MAIN OUTCOME MEASURES: Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality. RESULTS: A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001). LIMITATIONS: We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer. CONCLUSIONS: Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.

Colorectal Surgery Outcomes in Chronic Dialysis Patients: An American College of Surgeons National Surgical Quality Improvement Program Study.

BACKGROUND: More than 450,000 US patients with end-stage renal disease currently dialyze. The risk of morbidity and mortality for these patients after colorectal surgery has been incompletely described. OBJECTIVE: We analyzed the 30-day morbidity and mortality rates of chronic dialysis patients who underwent colorectal surgery. DESIGN: This was a retrospective analysis. SETTINGS: Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program were included. PATIENTS: The study included adult patients who underwent emergency or elective colon or rectal resection between 2009 and 2014. MAIN OUTCOME MEASURES: Baseline characteristics were compared by dialysis status. The impact of chronic dialysis on 30-day mortality and serious postoperative morbidity was examined using multivariate logistic regression. RESULTS: We identified 128,757 patients who underwent colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database. Chronic dialysis patients accounted for 1% (n = 1285) and were more likely to be older (65.4 vs 63.2 years; p < 0.0001), black (27.2% vs 8.7%; p < 0.0001), preoperatively septic (22.1% vs 7.1%; p < 0.0001), require emergency surgery (52.0% vs 14.7%; p < 0.0001), have ischemic bowel (15.7% vs 1.6%; p < 0.0001), or have perforation/peritonitis (15.5% vs 4.2%; p < 0.0001). Chronic dialysis patients were also less likely to have a laparoscopic procedure (17.3% vs 45.0%; p < 0.0001). Chronic dialysis patients had higher unadjusted mortality (22.4% vs 3.3%; p < 0.0001), serious postoperative morbidity (47.9% vs 18.8%; p < 0.0001), and median length of stay (9 vs 6 days; p < 0.0001). In emergent cases (n = 19,375), multivariate logistic regression models demonstrated a higher risk of mortality for dialysis patients (OR = 1.73 (95% CI, 1.38-2.16)) but not for serious morbidity. Models for elective surgery demonstrated a similar effect on mortality (OR = 2.47 (95% CI, 1.75-3.50)) but also demonstrated a higher risk of serious morbidity (OR = 1.28 (95% CI, 1.04-1.56)). LIMITATIONS: The postoperative 30-day window may underestimate the true incidence of serious morbidity and mortality. CONCLUSIONS: Chronic dialysis patients undergoing elective or emergent colorectal procedures have a higher risk-adjusted mortality.

The impact of perioperative warm-up jackets on surgical site infection: cost without benefit?

BACKGROUND: On July 1st, 2012, the University of Minnesota Medical Centers adopted a policy requiring all personnel to wear cover jackets in perioperative areas. This policy is based on the Association of Perioperative Registered Nurses recommended practice for cover jacket usage. We hypothesized that the cover jacket policy had no effect on the surgical site infection rate. METHODS: We compared surgical site infection data from 1 year before the policy and 1 year after the policy. Twenty six thousand three hundred procedures were included: 13,302 before the policy and 12,998 after the policy. Rates between periods were compared using the z-test for proportions. RESULTS: The SSI rate precover and postcover jacket policy was 2.42% and 2.76% respectively. The P value was .1998. Our hypothesis was rejected because the change in rate was not statistically significant. CONCLUSIONS: This study demonstrates that there was not a decrease in SSI rates with this cover jacket policy; in fact, the data show a trend toward an increase in SSI rate thus making the argument for the abandonment of the cover up jackets.

Does patient rurality predict quality colon cancer care?: A population-based study.

BACKGROUND: More than 50 million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening. OBJECTIVE: Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care. DESIGN: We constructed a retrospective cohort of 123,129 patients with stage 0 to IV colon cancer. Rural residence was established based on the patient medical service study area designated by the registry. SETTINGS: The study was conducted using the 1996-2008 California Cancer Registry. PATIENTS: All of the patients diagnosed between 1996 and 2008 with tumors located in the colon were eligible for inclusion in this study. MAIN OUTCOME MEASURES: Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I to III disease, and receipt of chemotherapy for stage III disease. Proportional-hazards regression was used to examine the impact of rurality on cancer-specific survival. RESULTS: Of all of the patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I to III disease, and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer-specific survival. LIMITATIONS: We could not account for socioeconomic status directly, although we used insurance status as a surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities, or complications. CONCLUSIONS: A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures, and survival. Future endeavors should help improve care to this vulnerable population (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A143).

Are right-sided colectomy outcomes different from left-sided colectomy outcomes?: study of patients with colon cancer in the ACS NSQIP database.

IMPORTANCE: Optimization of surgical outcomes after colectomy continues to be actively studied, but most studies group right-sided and left-sided colectomies together. OBJECTIVE: To determine whether the complication rate differs between right-sided and left-sided colectomies for cancer. As a secondary analysis, we investigated hospital length of stay. DESIGN: We identified patients who underwent colectomy for colon cancer in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database and stratified cases by right and left side. Preoperative, intraoperative, and postoperative factors were compared. Multivariable techniques were used to assess the impact of the side of colectomy on operative outcome measures, adjusting for covariates. SETTING: Hospitals within the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We identified 4875 patients who underwent elective laparoscopic or open colectomy for right-sided or left-sided colon cancer in the database. MAIN OUTCOMES AND MEASURES: Major complications and surgical site infection (SSI) rates. RESULTS: In the 4875 colectomies studied, a laparoscopic approach was used in 42% of cases and at similar frequency in right-sided and left-sided colectomies. Thirty-day mortality (1.5%) was similar in both groups. Major complications were seen in 17% of patients in each group. Superficial SSI was more likely to occur in patients who underwent left-sided colectomy (8.2% vs 5.9%). Among patients with postoperative sepsis or deep or organ space SSIs, more patients in the left-sided colectomy group underwent reoperation compared with the right-sided colectomy group (56% vs 30%). Laparoscopic right-sided colectomy patients were more likely to have a prolonged hospital length of stay than laparoscopic left-sided colectomy patients (odds ratio, 1.39; 95% CI, 1.09-1.78). CONCLUSIONS AND RELEVANCE: The outcomes after colectomy for cancer are comparable in right-sided and left-sided resections, except for in the case of superficial SSI, which is less common in right-sided resections. Further research on SSI after colectomy should incorporate right vs left side as a potential preoperative risk factor.

Does enrollment in cancer trials improve survival?

BACKGROUND: Stakeholders derive many benefits from cancer clinical trials, including guidance for future oncologic treatment decisions. However, whether enrollment in cancer trials also improves patient survival independently of trial outcomes remains underinvestigated. We hypothesized that cancer trial enrollment is not associated with patient survival outcomes. STUDY DESIGN: Using the 2002 to 2008 California Cancer Registry, we identified 555,469 patients with stage I to IV solid organ tumors. Baseline characteristics were compared by trial participation status. Logistic regression determined predictors of trial enrollment. Multivariate Cox proportional hazards regression examined the impact of trial participation on overall and cancer-specific mortality with adjustment for covariates. RESULTS: Only 0.33% of our cohort was enrolled in clinical trials. Trial participants were likely to be younger than 65 (odds ratio [OR] 2.13; 95% CI 1.90 to 2.38), Hispanic rather than non-Hispanic white (OR 0.78; 95% CI 0.67 to 0.90), and have breast cancer (OR 3.14; 95% CI 2.62 to 3.77). Multivariate survival analyses demonstrated that enrollment in cancer trials predicted a lower hazard of death. However, when stratified by disease site, this survival benefit was observed only in lung, colon, and breast cancers. Sensitivity and interaction analyses confirmed these relationships. CONCLUSIONS: In this first population-based study examining trial effect in solid organ cancers, enrollment into cancer trials predicted lower overall and cancer-specific mortality among common cancer sites. Although these findings may demonstrate a survival benefit due to trial enrollment, they likely also reflect the favorable attributes of trial enrollees. Once corroborated, stakeholders must consider broader cancer trial designs representative of the cancer burden treated in the real world.

Rurality and cancer surgery in the United States.

BACKGROUND: Rurality adversely impacts the continuum of cancer care. However, investigations of rural cancer surgery are notably absent. We examined patterns and outcomes of oncologic resections at rural US hospitals. METHODS: We identified 928,370 hospital admissions in which 1 of 20 oncologic resections was performed using the 1998 to 2009 Nationwide Inpatient Sample. Logistic regression examined predictors of rurality and the adjusted likelihood of in-hospital mortality at rural and urban hospitals. RESULTS: The fraction of procedures performed at rural hospitals decreased from 12% to 6%. Older age, non-Hispanic white race, and fewer comorbidities predicted rurality. Rural hospitals did not have worse mortality, however, rurality significantly augmented mortality among recipients of complex cancer surgery. CONCLUSIONS: Rural hospitals had comparable mortality overall, but delivered poorer outcomes for certain groups. Future research should explore these variations as cancer care is increasingly centralized.

Colorectal surgeons teaching general surgery residents: current challenges and opportunities.

Effective teaching for general surgery residents requires that faculty members with colorectal expertise actively engage in the education process and fully understand the current context for residency training. In this article, we review important national developments with respect to graduate medical education that impact resident supervision, curriculum implementation, resident assessment, and program evaluation. We argue that establishing a culture of respect and professionalism in today's teaching environment is one of the most important legacies that surgical educators can leave for the coming generation. Faculty role modeling and the process of socializing residents is highlighted. We review the American College of Surgeons' Code of Professional Conduct, summarize some of the current strategies for teaching and assessing professionalism, and reflect on principles of motivation that apply to resident training both for the trainee and the trainer.