Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission.

BACKGROUND: While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair. METHODS: Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code. RESULTS: A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175). CONCLUSION: The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.

Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma.

BACKGROUND: Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery. RESULTS: 2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001). CONCLUSIONS: Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.

Specialization and the current practices of general surgeons.

BACKGROUND: The impact of specialization on the practice of general surgery has not been characterized. Our goal was to assess general surgeons' operative practices to inform surgical education and workforce planning. STUDY DESIGN: We examined the practices of general surgeons identified in the 2008 State Inpatient and Ambulatory Surgery Databases of the Healthcare Cost and Utilization Project for 3 US states. Operations were identified using ICD-9 and CPT codes linked to encrypted physician identifiers. For each surgeon, total operative volume and percentage of practice that made up their most common operation were calculated. Correlation was measured between general surgeons' case volume and the number of other specialists in a health service area. RESULTS: There were 1,075 general surgeons who performed 240,510 operations in 2008. The mean operative volume for each surgeon was 224 annual procedures. General surgeons performed an average of 23 different types of operations. For the majority of general surgeons, their most common procedure constituted no more than 30% of total practice. The most common operations, ranked by the frequency they appeared as general surgeons' top procedure, included cholecystectomy, colonoscopy, endoscopy, and skin excision. The proportion of general surgery practice composed of endoscopic procedures inversely correlated with the number of gastroenterologists in the health service area (rho = -0.50; p = 0.005). CONCLUSIONS: Despite trends toward specialization, the current practices of general surgeons remain heterogeneous. This indicates a continued demand for broad-based surgical education to allow future surgeons to tailor their practices to their environment.

Impact of neoadjuvant chemotherapy on wound complications after breast surgery.

BACKGROUND: Use of neoadjuvant chemotherapy for breast cancer is increasing. The objective was to examine risk of postoperative wound complications in patients receiving neoadjuvant chemotherapy for breast cancer. METHODS: Patients undergoing breast surgery from 2005 to 2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were included if preoperative diagnosis suggested malignancy and an axillary procedure was performed. We performed a stepwise multivariable regression analysis of predictors of postoperative wound complications, overall and stratified by type of breast surgery. Our primary variable of interest was receipt of neoadjuvant chemotherapy. RESULTS: Of 44,533 patients, 4.5% received neoadjuvant chemotherapy. Wound complications were infrequent with or without neoadjuvant chemotherapy (3.4% vs. 3.1%; P = .4). Smoking, functional dependence, obesity, diabetes, hypertension, and mastectomy were associated with wound complications. No association with neoadjuvant chemotherapy was seen (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.78-1.32); however, a trend was observed toward increased complications in neoadjuvant patients undergoing mastectomy with immediate reconstruction (OR, 1.58; 95% CI, 0.98-2.58). CONCLUSION: Postoperative wound complications after breast surgery are infrequent and not associated with neoadjuvant chemotherapy. Given the trend toward increased complications in patients undergoing mastectomy with immediate reconstruction, however, neoadjuvant chemotherapy should be among the many factors considered when making multidisciplinary treatment decisions.

Lead exposures from varnished floor refinishing.

We evaluated the presence of lead in varnish and factors predicting lead exposure from floor refinishing and inexpensive dust suppression control methods. Lead in varnish, settled dust, and air were measured using XRF, laboratory analysis of scrape and wipe samples, and National Institute for Occupational Safety and Health (NIOSH) Method 7300, respectively, during refinishing (n = 35 homes). Data were analyzed using step-wise logistic regression. Compared with federal standards, no lead in varnish samples exceeded 1.0 mg/cm(2), but 52% exceeded 5000 ppm and 70% of settled dust samples after refinishing exceeded 40 µg/ft(2). Refinishing pre-1930 dwellings or stairs predicted high lead dust on floors. Laboratory analysis of lead in varnish was significantly correlated with airborne lead (r = 0.23, p = 0.014). Adding dust collection bags into drum sanders and HEPA vacuums to edgers and buffers reduced mean floor lead dust by 8293 µg Pb/ft(2) (p<0.05) on floors and reduced most airborne lead exposures to less than 50 µg/m(3). Refinishing varnished surfaces in older housing produces high but controllable lead exposures.

Factors associated with the seasonality of blood lead levels among preschool Wisconsin children.

CONTEXT: Aggregate blood lead testing data for Wisconsin children younger than age 6 exhibit seasonal trends in both average blood lead levels and in the percent of those tested and found to have blood lead levels in excess of the 10 mcg/dL threshold for poisoning. Blood lead levels and poisoning rates typically peak during the late summer and early fall months, and are at their minimum during the late winter. METHOD: Blood test data was analyzed to determine variations by month and age. RESULTS: Seasonal variations are evident even among the very young: infants younger than 10 months who likely have limited opportunity to encounter lead hazards within their home or in the outdoor soil. Seasonal periodicity is most evident among infants who reside in very urban and very rural communities. The observed seasonal periodicity might be associated with the seasonal availability of lead within the children's environment. Particulate matter data measured at several ambient air quality monitoring stations exhibit a similar periodic seasonality, suggesting a possible relationship between blood lead levels and the availability of dust and airborne particulates during the summer months. CONCLUSION: Clinicians should consider the seasonality of blood lead levels when scheduling tests and interpreting test results.

Exposure to lead and length of time needed to make homes lead-safe for young children.

OBJECTIVES: We determined the length of time needed to make homes lead-safe in a population of children aged 0 to 6 years with blood lead levels (BLLs) of 20 micrograms per deciliter (mug/dL) or greater. Reducing this time would reduce children's exposure to lead. METHODS: Data came from the Wisconsin Childhood Lead Poisoning Prevention Program's comprehensive blood lead surveillance system. Analysis was restricted to children whose first BLL test value during 1996-1999 was between 20 and 40 mug/dL and for whom housing intervention data were available (n=382). RESULTS: The median length of time required to make a home lead-safe was 465 days. Only 18% of children lived in homes that were made lead-safe within 6 months; 45% lived in homes requiring more than 18 months to be lead-safe. CONCLUSIONS: Efforts are needed to reduce the time it takes to make a home lead-safe. Although abatement orders always include time limits, improved compliance with the orders must be enforced. Greater emphasis should be placed on securing lead-safe or lead-free housing for families, thus reducing lead exposure.