Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol.

BACKGROUND: The increasing use of computed tomography (CT) scans in the evaluation of trauma patients has led to increased detection of incidental radiologic findings. Incidental findings (IFs) of the abdominal viscera are among the most commonly discovered lesions and can carry a risk of malignancy. Despite this, patient notification regarding these findings is often inadequate. METHODS: We identified patients who underwent abdominopelvic CTs as part of their trauma evaluation during a recent 1-year period (9/2011-8/2012). Patients with IFs of the kidneys, liver, adrenal glands, pancreas and/or ovaries had their charts reviewed for documentation of the lesion in their discharge paperwork or follow-up. A quality improvement project was initiated where patients with abdominal IFs were verbally informed of the finding, it was noted on their discharge summary and/or were referred to specialists for evaluation. Nine months after the implementation of the IF protocol, a second chart review was performed to determine if the rate of patient notification improved. RESULTS: Of 1,117 trauma patients undergoing abdominopelvic CT scans during the 21 month study period, 239 patients (21.4%) had 292 incidental abdominal findings. Renal lesions were the most common (146 patients, 13% of all patients) followed by hepatic (95/8.4%) and adrenal (38/3.4%) lesions. Pancreatic (10/0.9%) and ovarian lesions (3/0.3%) were uncommon. Post-IF protocol implementation patient notification regarding IFs improved by over 80% (32.4% vs. 17.7% pre-protocol, p = 0.02). CONCLUSION: IFs of the solid abdominal organs are common in trauma patients undergoing abdominopelvic CT scan. Patient notification regarding these lesions is often inadequate. A systematic approach to the documentation and evaluation of incidental radiologic findings can significantly improve the rate of patient notification.

Electronic medical record: research tool for pancreatic cancer?

BACKGROUND: A novel data warehouse based on automated retrieval from an institutional health care information system (HIS) was made available to be compared with a traditional prospectively maintained surgical database. METHODS: A newly established institutional data warehouse at a single-institution academic medical center autopopulated by HIS was queried for International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes for pancreatic neoplasm. Patients with ICD-9-CM diagnosis codes for pancreatic neoplasm were captured. A parallel query was performed using a prospective database populated by manual entry. Duplicated patients and those unique to either data set were identified. All patients were manually reviewed to determine the accuracy of diagnosis. RESULTS: A total of 1107 patients were identified from the HIS-linked data set with pancreatic neoplasm from 1999-2009. Of these, 254 (22.9%) patients were also captured by the surgical database, whereas 853 (77.1%) patients were only in the HIS-linked data set. Manual review of the HIS-only group demonstrated that 45.0% of patients were without identifiable pancreatic pathology, suggesting erroneous capture, whereas 36.3% of patients were consistent with pancreatic neoplasm and 18.7% with other pancreatic pathology. Of the 394 patients identified by the surgical database, 254 (64.5%) patients were captured by HIS, whereas 140 (35.5%) patients were not. Manual review of patients only captured by the surgical database demonstrated 85.9% with pancreatic neoplasm and 14.1% with other pancreatic pathology. Finally, review of the 254 patient overlap demonstrated that 80.3% of patients had pancreatic neoplasm and 19.7% had other pancreatic pathology. CONCLUSIONS: These results suggest that cautious interpretation of administrative data rely only on ICD-9-CM diagnosis codes and clinical correlation through previously validated mechanisms.

Rankings versus reality in pancreatic cancer surgery: a real-world comparison.

BACKGROUND: Patients are increasingly confronted with systems for rating hospitals. However, the correlations between publicized ratings and actual outcomes after pancreatectomy are unknown. METHODS: The Massachusetts Division of Health Care Finance and Policy Hospital Inpatient Discharge Database was queried to identify pancreatic cancer resections carried out during 2005-2009. Hospitals performing fewer than 10 pancreatic resections in the 5-year period were excluded. Primary outcomes included mortality, complications, median length of stay (LoS) and a composite outcomes score (COS) combining primary outcomes. Ranks were determined and compared for: (i) volume, and (ii) ratings identified from consumer-directed hospital ratings including the US News & World Report (USN), Consumer Reports, Healthgrades and Hospital Compare. An inter-rater reliability analysis was performed and correlation coefficients (r) between outcomes and ratings, and between rating systems were calculated. RESULTS: Eleven hospitals in which a total of 804 pancreatectomies were conducted were identified. Surgical volume correlated with overall outcome, but was not the strongest indicator. The highest correlation referred to that between USN rank and overall outcome. Mortality was most strongly correlated with Healthgrades ratings (r = 0.50); however, Healthgrades ratings demonstrated poorer correlations with all other outcomes. Consumer Reports ratings showed inverse correlations. CONCLUSIONS: The plethora of publicly available hospital ratings systems demonstrates heterogeneity. Volume remains a good but imperfect indicator of surgical outcomes. Further systematic investigation into which measures predict quality outcomes in pancreatic cancer surgery will benefit both patients and providers.

Does increasing insurance improve outcomes for US cancer patients?

BACKGROUND: Although debate continues on US healthcare and insurance reform, data are lacking on the effect of insurance on community-level cancer outcomes. Therefore, the objective of the present study was to examine the association of insurance and cancer outcomes. MATERIALS AND METHODS: The US Census Bureau Current Population Survey, Small Area Health Insurance Estimates (2000) were used for the rates of uninsurance. Counties were divided into tertiles according to the uninsurance rates. The data were compared with the cancer incidence and survival for patients residing in counties captured by the Surveillance, Epidemiology, and End Results database (2000-2006). Aggregate patient data were collected of US adults (aged ≥18 y) diagnosed with the following cancers: pancreatic, esophageal, liver or bile duct, lung or bronchial, ovarian, colorectal, breast, prostate, melanoma, and thyroid. The outcomes included the stage at diagnosis, surgery, and survival. Univariate tests and proportional hazards were calculated. RESULTS: The US uninsurance rate was 14.2%, and the range for the Surveillance, Epidemiology, and End Results counties was 8.3%-24.1%. Overall, patients from lower uninsurance rate counties demonstrated longer median survival. Adjusting for patient characteristics and cancer stage (for each cancer), the patients in the higher uninsurance rate counties demonstrated greater mortality (8%-15% increased risk on proportional hazards). The county uninsurance rate was associated with the stage at diagnosis for all cancers, except pancreatic and esophageal, and was also associated with the likelihood of being recommended for cancer-directed surgery (for all cancers). CONCLUSIONS: Health insurance coverage at a community level appears to influence survival for patients with cancer. Additional investigations are needed to examine whether individual versus community associations exist and how best to surmount barriers to cancer care.

Tumor registry versus physician medical record review: a direct comparison of patients with pancreatic neuroendocrine tumors.

PURPOSE: Tumor registry (TR) data are becoming more prominently cited in research through increased use of the National Cancer Database. We aimed to establish the accuracy of TR data by comparing them with physician medical record review (MD review) using pancreatic neuroendocrine tumors (NETs) as an example. METHODS: For MD review, the health information system of an academic medical center was queried for patients with pancreatic International Classification of Diseases, ninth revision (ICD-9), codes from January 2000 to August 2008. A single physician investigator analyzed those medical records and identified patients with pancreatic NETs. For TR data, patients with pancreatic NETs were identified by two separate strategies. For the period of January 2000 to December 2006, patients were identified through manual review of pathology reports, admission and discharge sheets, and clinic visit logs. For January 2007 to August 2008, patients were identified using an automated case-finding program. RESULTS: In MD review, 1,192 patients with pancreatic ICD-9 codes were identified, 34 of whom were found to have pancreatic NETs. The TR indicated 15 patients with pancreatic NETs, four of whom were not identified during MD review. Of the total 38 patients identified by either strategy, pancreatic NET identification rate of the TR was 39.5% compared with 89.5% in MD review. CONCLUSION: Academic TR analysis indicates a substantial proportion of patients with pancreatic NETs are not identified when compared with MD review. Most instances of patients going unidentified are the result of registry time lag and case-finding methodologies; specifically, physicians may define tumors with malignant potential differently. This may be applicable to other individual tumor registries as well as aggregate registry-based national studies.

Malignant intraductal papillary mucinous neoplasm: are we doing the right thing?

BACKGROUND: Because of the malignant potential, resection has been recommended for some intraductal papillary mucinous neoplasms (IPMN). We hypothesize that a large cancer database could be used to evaluate national resection rates and survival for malignant IPMN. MATERIALS AND METHODS: Using the Surveillance Epidemiology and End Results (SEER) database, 1988-2003, cases of malignant IPMN were identified using histology codes. Age-adjusted incidence rates were calculated; Cochran-Armitage tests evaluated trends over time. Predictors of resection were evaluated using χ(2) and logistic regression. Kaplan-Meier curves and Cox models were constructed to evaluate survival. RESULTS: Of 1834 patients, 209 (11.4%) underwent resection. Annual age-adjusted incidence decreased over the study time-course (P<0.05), while annual proportion of patients presenting with localized lesions and the proportion being resected increased (P<0.05). Predictors of resection on multivariate analysis included localized stage [versus distant, adjusted odds ratio (OR) 31; 95% confidence interval (CI) 17-56], and more recent diagnosis [referent 1988-1991; 2000-2003, OR 3.0 (95%CI 1.7-5.3)]. Median survival for resected patients was 16 mo versus 3 mo without resection (P<0.0001). After adjusting for age, gender, stage, year, and tumor location, surgical resection remained a significant predictor of survival [hazard ratio 0.44 (95% CI 0.36-0.54), P<0.0001]. CONCLUSIONS: In this population-based cohort, detection of malignant IPMNs is decreasing, with an increasing proportion of patients diagnosed at local stages and undergoing resection. Increased awareness of IPMN may be contributing to earlier detection, which might include benign/premalignant lesions, and greater utilization of resection for appropriate candidates; thus, we may be improving survival for this most treatable form of pancreatic cancer.

Potential benefit of resection for stage IV gastric cancer: a national survey.

INTRODUCTION: Controversy exists as to whether patients with stage IV gastric cancer should undergo surgical resection. We examined the association of gastrectomy with survival in this population. METHODS: Stage IV gastric cancer diagnoses were identified using the SEER database (1988-2005). Analyses examined three subgroups divided on the basis of whether cancer-directed surgery was recommended and performed. Univariate analyses included chi-square and Kaplan-Meier survival analyses. Cox proportional hazards modeling was performed to assess independent determinants of survival. RESULTS: Of 66,751 identified gastric cancer patients, 23,830 had stage IV disease. Resected patients had a significant survival advantage; survival outcomes of patients who had been recommended for, but had not undergone, surgery were identical to that of patients who had not been recommended (3 months vs. 9 months for resected, p < 0.0001). Furthermore, resection status was the most significant independent predictor of increased risk of death (hazard ratios 2.0 for non-cancer-directed surgery groups). CONCLUSIONS: Patients with stage IV gastric cancer who undergo resection, a highly selected population, have significantly greater survival than unresected patients, including those who were recommended for, but did not receive, resection. Stage IV gastric cancer patients who are reasonable operative candidates should be offered resection.

Complications after pancreatectomy for neuroendocrine tumors: a national study.

BACKGROUND: Although resection of pancreatic neuroendocrine tumors (PNETs) has a demonstrated survival advantage, further evaluation of the overall morbidity of these procedures is needed. Our objective was to examine a composite outcome of major postoperative complications, including in-hospital mortality. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS), 1998-2006, was used to identify all patients with a diagnosis of PNET who had undergone pancreatectomy. Candidate predictors consisted of patient and hospital characteristics. Univariate analyses included chi(2) tests. Multivariate analyses were performed with logistic regression to determine which predictors were independently associated with the composite outcome. RESULTS: A total of 463 (2274 nationally weighted) patients were identified. Overall composite postoperative complication rate was 29.6%. The majority of complications involved infections (11.1%), digestive complications (8.8%), or pulmonary compromise (7.3%). In-hospital mortality rate was 1.7%. High Charlson comorbidity score, procedure type of Whipple or total pancreatectomy, and urban hospital location were all associated with significantly increased complication rate. Logistic regression analysis demonstrated: Charlson score of > or =3 versus score of 0 (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 2.1-8.3), surgery type of Whipple or total pancreatectomy versus partial pancreatectomy (adjusted OR 2.7, 95% CI 1.8-4.1), and hospital location of urban versus rural (adjusted OR 4.5, 95% CI 3.0-6.9). CONCLUSIONS: While in-hospital mortality rates are low for surgical resection of PNETs, there is a considerable overall postoperative complication rate associated with these procedures. Careful patient and surgery selection may be the key to a surgical treatment approach for PNETs that may optimize outcomes.

A neoadjuvant strategy for pancreatic adenocarcinoma increases the likelihood of receiving all components of care: lessons from a single-institution database.

BACKGROUND: Recent studies have shown adjuvant therapy improves outcomes from pancreatic cancer (PC). This study investigates receipt and timing of PC treatments, and association with outcomes. METHODS: The analysis cohort consisted of patients with newly-diagnosed PC at a single institution over 5 years. Primary Endpoints were (i) receipt of recommended therapy, and (ii) overall survival (OS). RESULTS: Among 102 patients, 52 underwent resection. Out of 36 localized resected and 16 locally advanced resected (LAR) patients, 26 and 13, respectively, received adjuvant therapy. Six of the latter group received neoadjuvant therapy. Median OS for resected patients was 15.7 months (range 0.6-51.4), compared with 7.7 for unresected patients (range 0.4-32.0) (P < 0.001), and 14.0 months for patients with resection alone (range 0.6-24.4) vs. 16.1 for patients who also received adjuvant therapy (range 3.2-51.4) (P= 0.027). Out of 46 patients undergoing up-front resection, 33 had R0 surgical margins. For the six LAR patients undergoing neoadjuvant therapy, all margins were R0. CONCLUSION: After resection, a substantial proportion of patients do not receive adjuvant therapy, and have worse survival. In this study, neoadjuvant treatment increased both the proportion of patients receiving all components of recommended therapy and the R0 resection rate.

A national propensity-adjusted analysis of adjuvant radiotherapy in the treatment of resected pancreatic adenocarcinoma.

BACKGROUND: The benefit of adjuvant radiotherapy (RT) for resected pancreatic adenocarcinoma remains controversial after randomized clinical trials. In this national-level US study, a propensity score (conditional probability of receiving RT) was used to adjust for potential confounding in nonrandomized designs from treatment group differences. METHODS: Patients were identified from the Surveillance, Epidemiology, and End Results (SEER) registry (1988-2005 dataset). Multivariate analyses to determine the effect of RT on overall survival were performed using propensity-adjusted Cox proportional hazards and Kaplan-Meier analyses. RESULTS: In total, 5676 patients with resected pancreatic adenocarcinoma were identified, and 40.8% of those patients had received adjuvant RT. Univariate predictors of survival included age, race, marital status, disease stage, tumor size, tumor extension, tumor grade, lymph node status, year of diagnosis, type of resection, and receipt of RT (all P < .002). In a Cox model, independent predictors of improved survival included white race, married status, earlier stage, smaller tumors, well differentiated tumors, negative lymph node (N0) status, recent diagnosis, and receipt of RT (all P < .05). In a propensity-adjusted proportional hazards regression, the benefit of adjuvant treatment that included RT remained significant after adjusting for the likelihood of receiving RT (hazard ratio, 0.773; 95% confidence interval, 0.714-0.836; P < .0001). Within all 5 propensity strata, Kaplan-Meier survival differed significantly (P < .0001 [lowest and highest probability strata] and P = .0165 [middle stratum with a "pseudorandom" probability of RT]). CONCLUSIONS: Adjuvant RT for resected pancreatic adenocarcinoma was associated with a significant survival advantage in a large national database, even after using propensity score methods to adjust for differences between treatment groups. The authors concluded that adjuvant RT should be considered for all appropriate patients who have resected pancreatic adenocarcinoma.

Surgery and radiotherapy for retroperitoneal and abdominal sarcoma: both necessary and sufficient.

OBJECTIVE: To evaluate the effect of surgical resection and radiotherapy (RT) in retroperitoneal or abdominal sarcoma. DESIGN: Retrospective cohort. SETTING: Surveillance, Epidemiology, and End Results, 1988-2005. PATIENTS: Patients 18 years or older with initial diagnosis of primary retroperitoneal and nonvisceral abdominal sarcoma. MAIN OUTCOME MEASURES: Survival for 2 years after diagnosis. Kaplan-Meier survival was stratified based on surgery and RT status. Cox proportional hazards model was used to assess adjusted effects of surgery and RT on survival in patients with locoregional disease. RESULTS: Of 1901 patients with locoregional disease, 1547 (81.8%) underwent resection; 447 (23.5%) received RT. Overall, patients who received both surgery and RT demonstrated improved survival compared with patients who underwent either therapy alone; patients undergoing monotherapy in turn had more favorable survival compared with patients who received neither therapy (P < .001, log rank). Cox analysis demonstrated that surgical resection (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.21-0.29; P < .001) and RT (0.78; 0.63-0.95; P = .01) independently predicted improved survival in locoregional disease only. In adjusted analyses stratified for American Joint Commission on Cancer (AJCC) stage, for stage I disease (n = 694), RT provided an additional benefit (HR, 0.49; 95% CI, 0.25-0.96; P = .04) independent of that from resection (0.35; 0.21-0.58; P < .001). For stage II/III (n = 552), resection remained protective (HR, 0.24; 95% CI, 0.18-0.32; P < .001); however, RT was no longer associated with a significant benefit (0.78; 0.58-1.06; P = .11). CONCLUSIONS: In a national cohort of retroperitoneal and abdominal sarcomas, surgical resection was associated with significant survival benefits for AJCC disease stages I to III. Radiotherapy provided additional benefit for patients with stage I disease. Resection should be offered to reasonable surgical candidates with nonmetastatic retroperitoneal/abdominal sarcomas; radiotherapy may most benefit patients with early-stage disease.

Trends in adrenalectomy: a recent national review.

BACKGROUND: Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality. METHODS: The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated. RESULTS: Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82). CONCLUSION: Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.

Progress for resectable pancreatic [corrected] cancer?: a population-based assessment of US practices.

BACKGROUND: : Pancreatic adenocarcinoma is a deadly disease; however, recent studies have suggested improved outcomes in patients with locoregional cancer. Progress was evaluated at a national level in resected patients, as measured by the proportion who received guideline-directed treatment and trends in survival. METHODS: : The linked Surveillance, Epidemiology, and End Results and Medicare databases were queried to identify resections for pancreatic adenocarcinoma performed between 1991 and 2002. Receipt and timing of chemotherapy and radiation with respect to time-trend were assessed. Using logistic regression, factors associated with adjuvant combination chemoradiotherapy were identified. Kaplan-Meier curves stratified by year and treatment were used to assess survival. RESULTS: : Of the 1910 patients, 47.9% (n = 915) received some form of adjuvant therapy within the first 6 months postoperatively; 34.4% (n = 658) received combination chemoradiotherapy (chemoRT). ChemoRT demonstrated a significant increase, from 29.2% to 37.5% (P < .0001). Neoadjuvant therapy was used in 5.7% (n = 108) of patients; no trend was observed during the study (P = .1275). The in-hospital mortality rate was 8.0% (n = 153 patients); no significant trend was noted (P = .3116). Kaplan-Meier survival, stratified by year group of diagnosis, did not change significantly over time (log-rank test, P = .4381), even with comparisons of the first 3 years with the last 3 years of the study (log-rank test, P = .3579). CONCLUSIONS: : Adherence to guideline-directed care isimproving in the United States; however, the pace is slow, and overall survival has yet to be impacted significantly. Both increased use of adjuvant therapy and the development of more promising systemic treatments are necessary to improve survival for patients with resectable pancreatic cancer. Cancer 2010. (c) 2010 American Cancer Society.

A simple risk score to predict in-hospital mortality after pancreatic resection for cancer.

BACKGROUND: Pancreatectomy for cancer continues to have substantial perioperative risk, and the factors affecting mortality are ill defined. An integer-based risk score based on national data might help clarify the risk of in-hospital mortality in patients undergoing pancreatic resection. METHODS: Records with the diagnosis of pancreatic cancer were queried from the Nationwide Inpatient Sample for 1998-2006. Procedures were categorized as proximal, distal, or nonspecified pancreatectomies on the basis of ICD-9 codes. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of in-hospital mortality using patient demographics, comorbidities (Charlson comorbidity score), procedure, and hospital type. A random sample of 80% of the cohort was used to create the risk score with a 20% internal validation set. RESULTS: A total of 5715 patient discharges were identified. Composite in-hospital mortality was 5.8%. Predictors used for the final model were age group, Charlson score, sex, type of pancreatectomy, and hospital volume status (low-, medium-, or high-volume center). Integer values were assigned to these characteristics and then used for calculating an additive score. Three clinically useful score groups were defined to stratify the risk of in-hospital mortality (mortality was 2.0, 6.2, and 13.9%, respectively; P < 0.0001), with a 6.95-fold difference between the low- and high-risk groups. There was sufficient discrimination of both the derivation set and the validation set, with c statistics of 0.71 and 0.72, respectively. CONCLUSIONS: An integer-based risk score can be used to accurately predict in-hospital mortality after pancreatectomy and may be useful for preoperative risk stratification and patient counseling.

Racial differences in cancer specialist consultation, treatment, and outcomes for locoregional pancreatic adenocarcinoma.

BACKGROUND: Blacks have a higher incidence of pancreatic adenocarcinoma and worse outcomes compared to whites. Identifying barriers in pancreatic cancer care may explain survival differences and provide areas for intervention. METHODS: Pancreatic adenocarcinoma patients were identified in the Surveillance, Epidemiology, and End Results Registry (1991-2002). Treatment and outcome data were obtained from the linked Surveillance, Epidemiology, and End Results Registry-Medicare databases. Logistic regression was used to assess race as a predictor of specialist consultation/receipt of therapy. Kaplan-Meier survival curves were compared. Cox proportional hazard analyses were performed to estimate survival after adjustment for patient and treatment characteristics. RESULTS: A total of 13,230 white patients (90%) and 1478 black patients (10%) were identified. Clinical/pathologic factors were compared by race. When we compared whites and blacks by univariate analyses, blacks had lower rates of specialist consultation (P<.01), chemotherapy (P<.01), and resection (P<.01). On multivariate analyses predicting consultation with a cancer specialist, black race negatively predicted consultation with a medical oncologist (adjusted odds ratio [AOR] .74, P<.01), radiation oncologist (AOR .75, P<.01), and surgeon (AOR .71, P<.01). For predicting receipt of therapy after consultation, blacks were less likely to undergo chemotherapy (AOR .59, P<.01) and resection (AOR .79, P=.05). Blacks had worse overall survival on Kaplan-Meier survival curves (log rank, P<.0001). On Cox proportional hazard modeling evaluating survival, black race was no longer independently associated with worse survival after adjustment for resection and adjuvant therapy (hazard ratio, 1.08; 95% confidence interval, .99-1.19). CONCLUSIONS: Racial disparities exist in pancreatic cancer specialist consultation and subsequent therapy use. Because receipt of care is fundamental to reducing outcome discrepancies, these barriers serve as discrete intervention points to ensure all locoregional pancreatic adenocarcinoma patients receive appropriate specialist referral and subsequent therapy.

Predicting major complications after laparoscopic cholecystectomy: a simple risk score.

INTRODUCTION: Reported morbidity varies widely for laparoscopic cholecystectomy (LC). A reliable method to determine complication risk may be useful to optimize care. We developed an integer-based risk score to determine the likelihood of major complications following LC. METHODS: Using the Nationwide Inpatient Sample 1998-2006, patient discharges for LC were identified. Using previously validated methods, major complications were assessed. Preoperative covariates including patient demographics, disease characteristics, and hospital factors were used in logistic regression/bootstrap analyses to generate an integer score predicting postoperative complication rates. A randomly selected 80% was used to create the risk score, with validation in the remaining 20%. RESULTS: Patient discharges (561,923) were identified with an overall complication rate of 6.5%. Predictive characteristics included: age, sex, Charlson comorbidity score, biliary tract inflammation, hospital teaching status, and admission type. Integer values were assigned and used to calculate an additive score. Three groups stratifying risk were assembled, with a fourfold gradient for complications ranging from 3.2% to 13.5%. The score discriminated well in both derivation and validation sets (c-statistic of 0.7). CONCLUSION: An integer-based risk score can be used to predict complications following LC and may assist in preoperative risk stratification and patient counseling.

Pancreatic resection: a key component to reducing racial disparities in pancreatic adenocarcinoma.

BACKGROUND: Blacks are affected disproportionately by pancreatic adenocarcinoma and have been linked with poor survival. Surgical resection remains the only potential curative option. If surgical disparities exist, then they may provide insight into outcome discrepancies. METHODS: Patients with pancreatic adenocarcinoma were identified using the National Cancer Institute's Surveillance, Epidemiology, and End Results data from 1992 to 2002. Univariate analyses were used to compare demographics, tumor characteristics, and surgical data; and logistic regression was used to determine independent predictors for recommendation/performance of surgery. Kaplan-Meier survival was assessed, and a Cox proportional hazards model was used to examine adjusted predictors of survival. RESULTS: In total, 27,828 patients were identified; 81.4% were white, 11.5% were black, 7.2% were of other race. White patients and black patients presented with similar stage and had surgery recommended at similar rates (34.5% vs 34%, respectively; P = .57). Black patients underwent fewer resections (10.6% vs 12.7%; P < .001). Multivariate analysis confirmed that black patients were less likely to undergo resection (adjusted odds ratio, 0.69; 95% confidence interval [95% CI], 0.57-0.84). Overall, black patients had worse univariate survival. The survival among black patients who underwent resection did not differ statistically from the survival of similar white patients, although the median survival trended lower (11 months vs 13 months; P = .13). In a multivariate Cox model, black race predicted worse survival (hazards ratio, 1.11; 95% CI, 1.07-1.16), and pancreatic resection was protective (hazards ratio, 0.56; 95% CI, 0.53-0.59). CONCLUSIONS: Black and white patients with pancreatic adenocarcinoma presented with similar stages and were recommended for pancreatectomy at similar rates, yet black patients underwent fewer resections. After resection, crude survival did not differ significantly between white and black patients, although multivariate analysis demonstrated a survival disadvantage for blacks despite adjusting for resection. The current results suggested that pancreatectomy may be underused for blacks. Maximizing resection rates for appropriate patients may be an important component in reducing outcome disparities for pancreatic adenocarcinoma.

Pancreatic neuroendocrine tumors: the impact of surgical resection on survival.

BACKGROUND: Although surgical resection is generally recommended for patients with localized pancreatic neuroendocrine tumors (PNETs), the impact of resection on overall survival is unknown. The authors investigated the survival advantage of pancreatic resection using a national database. METHODS: This is a retrospective survival analysis of patients with PNETs from the Surveillance, Epidemiology, and End Results database (1988-2002). RESULTS: A total of 728 patients with PNETs were identified with a median survival of 43 months using Kaplan-Meier survival methods. Resection of tumor was associated with significantly improved survival compared with those patients who were recommended for but did not undergo resection (114 months vs 35 months; P < .0001). This survival benefit was demonstrated for patients with localized, regional, and metastatic disease. A multivariable Cox proportional hazards model was constructed to assess the overall effect of surgical resection on survival, and demonstrated an adjusted odds ratio of 0.48 (95% confidence interval, 0.35-0.66) compared with those who were recommended for surgery but did not proceed to surgery. CONCLUSIONS: The authors have demonstrated in a large national study that resection of primary tumor in patients with PNETs is associated with improved survival across all disease stages. Patients with localized, regional, and metastatic PNETs who are reasonable operative candidates should be considered for resection of their primary tumors.