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Background: The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion., Study Design: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes., Results: Along with increased Medicaid coverage (DID = 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID = 2.97; p = 0.035), distance traveled (miles, DID = 6.67; p = 0.005), and treatment at integrated network programs (DID = 2.67; p = 0.045). More early-stage patients were treated within 30 days (DID = 7.24; p = 0.035) and more stage IV patients received palliative care (DID = 5.01; p = 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID = -5.88; p = 0.008) and more minimally invasive surgery (DID = 5.00; p = 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy., Conclusions: Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Enhanced recovery pathways (ERPs) aim to reduce length of stay without adversely affecting short-term outcomes. High pharmaceutical costs associated with ERP regimens, however, remain a significant barrier to widespread implementation. We hypothesized that ERP would reduce hospital costs after elective colorectal resections, despite the use of more expensive pharmaceutical agents., Study Design: An ERP was implemented in January 2016 at our institution. We collected data on consecutive colorectal resections for 1 year before adoption of ERP (traditional, n = 160) and compared them with consecutive resections after universal adoption of ERP (n = 146). Short-term surgical outcomes, total direct costs, and direct hospital pharmacy costs were compared between patients who received the ERP and those who did not., Results: After implementation of the ERP, median length of stay decreased from 5.0 to 3.0 days (p < 0.01). There were no differences in 30-day complications (8.1% vs 8.9%) or hospital readmission (11.9% vs 11.0%). The ERP patients required significantly less narcotics during their index hospitalization (211.7 vs 720.2 morphine equivalence units; p < 0.01) and tolerated a regular diet 1 day sooner (p < 0.01). Despite a higher daily pharmacy cost ($477 per day vs $318 per day in the traditional cohort), the total direct pharmacy cost for the hospitalization was reduced in ERP patients ($1,534 vs $1,859; p = 0.016). Total direct cost was also lower in ERP patients ($9,791 vs $11,508; p = 0.004)., Conclusions: Implementation of an ERP for patients undergoing elective colorectal resection substantially reduced length of stay, total hospital cost, and direct pharmacy cost without increasing complications or readmission rates. Enhanced recovery pathway after colorectal resection has both clinical and financial benefits. Widespread implementation has the potential for a dramatic impact on healthcare costs., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hepatocellular carcinoma (HCC) patients with Medicaid or no health insurance have inferior survival compared with privately insured patients. Safety-net hospitals that care for these patients are often criticized for their inferior outcomes. We hypothesized that HCC survival was related to appropriate surgical management., Study Design: The American College of Surgeons National Cancer Database was queried for patients diagnosed with HCC (n = 111,481) from 1998 to 2010. Hospitals were stratified according to safety-net burden, defined as the percentage of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared with lower-burden hospitals with regard to patient demographics, cancer presentation, surgical management, and survival., Results: Patients at safety-net hospitals were less often white, had less income and education, but presented with similar stage HCC. Safety-net hospital patients were less likely to receive surgery (odds ratio 0.77; p < 0.01), and among curable patients (stages 1 and 2) who underwent surgical intervention, liver transplantation and resection were performed less often at safety-net hospitals than at other hospitals (50.7% vs 66.7%). Procedure-specific mortality rates were also higher at safety net hospitals (p < 0.01). However, multivariate analysis adjusting for cancer stage and type of surgery revealed similar survival for safety-net hospital patients who had surgery and survived for longer than 30 days (p = 0.73)., Conclusions: Vulnerable patients with HCC are commonly treated at safety-net hospitals, are less likely to receive curative surgery, and have worse short-term outcomes. However, safety-net patients who can endure liver surgery have a similar prognosis as patients at nonsafety-net hospitals. Providing equal access to surgery may improve survival for vulnerable populations of HCC patients., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The rate and consequences of reoperation after liver transplantation (LT) are unknown in the United States., Study Design: Adult patients (n = 10,295; 45% of all LT) undergoing LT from 2009 through 2012 were examined using a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases providing recipient, donor, center, hospitalization, and survival details. Median follow-up was 2 years. Reoperations were identified within 90 days after LT., Results: Overall 90-day reoperation rate after LT was 29.3%. Risk factors for 90-day reoperation included recipients with a history of hemodialysis, severely ill functional status, government insurance, increasing Model for End-Stage Liver Disease score, and increasing donor risk index. Reoperation within 90 days was found to be an independent predictor of adjusted 1-year mortality (odds ratio = 1.8; 95% CI, 1.5-2.1), as was government-provided insurance and increasing donor risk index. Additionally, patients undergoing delayed reoperative intervention (after 30 days) were found to have increased risk of 1-year mortality compared with those undergoing early reoperative intervention (odds ratio = 1.96; 95% CI, 1.4-2.7; p < 0.01)., Conclusions: This is the first national study reporting that nearly one-third of transplant recipients undergo reoperation within 90 days of LT. Although necessary at times, reoperation is associated with increased risk of death at 1 year; however, it appears that the timing of these interventions can be critical, due to the type of intervention required. Early reoperative intervention does not appear to influence long-term outcomes, and delayed intervention (after 30 days) is strongly associated with decreased survival., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although donation after cardiac death (DCD) liver allografts have been used to expand the donor pool, concerns exist regarding primary nonfunction and biliary complications. Our aim was to compare resource use and outcomes of DCD allografts with donation after brain death (DBD) liver allografts., Study Design: Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 11,856 patients who underwent deceased donor liver transplantation (LT) from 2007 to 2011. Patients were divided into 2 cohorts based on type of allograft (DCD vs DBD). Matched pair analysis (n = 613 in each group) was used to compare outcomes of the 2 donor types., Results: Donation after cardiac death allografts comprised 5.2% (n = 613) of all LTs in the studied cohort; DCD allograft recipients were healthier and had lower median Model of End-Stage Liver Disease (MELD) score (17 vs 19; p < 0.0001). Post LT, there was no significant difference in length of stay, perioperative mortality, and discharge to home rates. However, DCD allografts were associated with higher direct cost ($110,414 vs $99,543; p < 0.0001) and 30-day readmission rates (46.4% vs 37.1%; p < 0.0001). Matched analysis revealed that DCD allografts were associated with higher direct cost, readmission rates, and inferior graft survival., Conclusions: While confirming the previous reports of inferior graft survival associated with DCD allografts, this is the first national report to show increased financial and resource use associated with DCD compared with DBD allografts in a matched recipient cohort., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)