Search

Background Under bundled payment initiatives, providers will be held financially responsible for patients' acute and post-acute care costs. Certain patients, termed high utilizers, use disproportionate shares of resources during 1 year. The aim of this study was to identify high utilizers, describe their costs, and determine whether preoperative characteristics predict high utilizer status. Study Design Colectomy patients with 1-year follow-up were identified in a linked clinical (American College of Surgeons NSQIP) and administrative (Medicare inpatient claims) dataset (2005 to 2008). Cost of inpatient care was calculated by multiplying patient Medicare charges in each cost center by cost-to-charge ratios from the Medicare cost reports. A mixed-effects logistic model quantified the association between preoperative characteristics and being a high utilizer after elective and emergent colectomies. Results One thousand and fifty-five of 10,561 colectomy patients accounted for >50% of the inpatient care cost of the entire cohort during 1 year postoperatively. This top decile of patients were labeled high utilizers and had substantially greater costs in the following cost centers: intensive care ($36,322 vs $0), respiratory ($2,875 vs $22), radiology ($649 vs $29), and cardiology ($5,057 vs $166) (all p < 0.001). High utilizers more frequently had emergent index colectomies (43% vs 17%; p < 0.001). Patients with American Society of Anesthesiologists class IV and V had 2-fold increased odds of being high utilizers after both elective (odds ratio = 2.72; 95% CI, 1.89-3.90) and emergent colectomies (odds ratio = 2.09; 95% CI, 1.23-3.55). Conclusions Patients in the top cost decile account for the majority of costs in the year after colectomy, disproportionately accumulate those costs in particular cost centers, and can be identified preoperatively.

Background The use of post-acute care is common among the elderly and accounts for $62 billion in annual Medicare expenditures. However, little is known about post-acute care use after surgery. Study Design Data were merged between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare claims for 2005 to 2008. Post-acute care use, including skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and home health care (HHC) were analyzed for 3 operations: colectomy, pancreatectomy, and open abdominal aortic aneurysm repair. Controlling for both preoperative risk factors and the occurrence of postoperative complications, we used multinomial logistic regression to estimate the odds of use for each type of post-acute care after elective surgery compared with home discharge. Results Post-acute care was used frequently for patients undergoing colectomy (40.0%; total n = 10,932), pancreatectomy (46.0%; total n = 2,144), and open abdominal aortic aneurysm (AAA) repair (44.9%; total n = 1,736). Home health was the most frequently reported post-acute care service for each operation (range 23.2% to 31.5%) followed by SNF (range 12.0% to 15.0%), and then by IRF (range 2.5% to 5.4%). The majority of patients with at least 1 inpatient complication were discharged to post-acute care (range 58.6% for open AAA repair to 64.4% for colectomy). In multivariable analysis, specific preoperative risk factors, including advanced age, poor functional status, and inpatient complications were significantly associated with increased risk-adjusted odds of discharge to post-acute care for each operation studied. Conclusions Among elderly patients, post-acute care use is frequent after surgery and is significantly associated with several preoperative risk factors and postoperative inpatient complications. Further work is needed to ensure that post-acute care services are used appropriately and cost-effectively.

Background Currently, hospital benchmarking organizations are often limited to short-term surgical quality comparisons among hospitals. The goal of this study was to determine whether long-term rates of incisional hernia repair after common abdominal operations could be used to compare hospital long-term surgical quality. Study Design This was a cohort study with up to 4 years of follow-up. Patients who underwent 1 of 5 common inpatient abdominal operations were identified in 2005-2008 American College of Surgeons NSQIP data linked to Medicare inpatient records. The main outcomes included occurrence of an incisional hernia repair. A multivariable, shared frailty Cox proportional hazards regression was used to compare each hospital's incisional hernia rate with the overall mean rate for all hospitals and control for American College of Surgeons NSQIP preoperative clinical variables. Results A total of 37,134 patients underwent 1 of 5 common inpatient abdominal operations, including colectomy, small bowel resection, ventral hernia repair, pancreatic resection, or cholecystectomy, at 1 of 216 hospitals participating in American College of Surgeons NSQIP during the 4-year period. There were 1,474 (4.0%) patients who underwent an incisional hernia repair, at a median follow-up time of 16 months (interquartile range 8 to 25 months) after initial abdominal surgery. After risk adjustment, there was no significant difference in the ratio of any one hospital's adjusted hazard rate for incisional hernia repair vs the average hospital adjusted hazard rate. Conclusions Risk-adjusted hospital rates of incisional hernia repair do not vary significantly from the average. This suggests that incisional hernia repair might not be sensitive enough as a long-term quality metric for benchmarking hospital performance.

Background: Although squamous cell carcinoma of the anus (SCCA) is a relatively uncommon malignancy in the United States, it continues to increase in incidence. Treatment for locoregional disease includes mitomycin and 5-fluorouracil with radiation. This combination is associated with significant toxicity, limiting its use in patients who are older or have certain comorbidities. Carboplatin and paclitaxel (C/P) is an accepted treatment regimen for metastatic SCCA. We aim to evaluate the efficacy and toxicity of weekly C/P given with radiation for patients unable to receive standard chemoradiation for SCCA., Methods: From our cancer registry, adult patients who received weekly intravenous C/P concurrent with standard-dose radiation for localized SCCA were included in this study. Clinical response was determined based on the evidence of disease on imaging and/or anoscopy. Toxicities were graded according to the CTCAE v5., Results: Ten patients were included; eight were female, and the median age was 75.5 years (54-87). Six had T2 disease, and four had T3 tumors. Four had node-positive disease. The majority (70%) of patients were dosed at standard C (AUC 2) and P (50 mg/m 2 ), with a limited subset requiring dose reduction for baseline performance status. Patients completed a mean of 78.3% (40-100%) of the intended treatments. A total of 89% of the patients achieved a complete clinical response. With a median follow-up of 25.8 months (3.4-50.4 months), 67% of the patients are alive and without recurrence. Two patients have had local recurrence, and one patient had metastatic progression. The most common toxicities of any grade included leukopenia (100%), anemia (100%), radiation dermatitis (100%), diarrhea (100%), and fatigue (100%). Grade 3 or higher toxicities included neutropenic fever (20%), neutropenia (30%), and anemia (30%)., Conclusions: This study demonstrates promising tolerability and efficacy for weekly C/P chemoradiation for patients with anal cancer unable to receive mitomycin and 5-fluorouracil. This regimen merits further investigation in prospective clinical trials.

Management of patients with rectal cancer can be complex, requiring significant care coordination and decisions that balance functional and oncologic outcomes., Objective: To characterize care coordination occurring during surgical consultation for rectal cancer and consequences of using face-to-face time in clinic for care coordination., Methods: Secondary analysis was performed on audio recordings of clinic visits with colorectal surgeons to discuss surgery for rectal cancer at 5 academic medical centers. Analysis included the content of communication related to types of care coordination, specific details and conditions under which care coordination was conducted, and consequences., Results: The cohort included 18 patients seen by 8 surgeons. Care coordination consumed much of the conversation; on average 23.7% (SD 14.6) of content. Communication about care coordination included gathering information from work-up already performed, logistics for completing further work-up, gathering multidisciplinary opinions, and logistics for treatment planning. Obtaining imaging results was particularly challenging and surgeons went to great lengths to gather this information. To mitigate information gaps, surgeons asked patients about critical clinical details. Patients expressed remorse when they could not provide needed information, relay technical details, or had missing reports. Surgeons voiced frustration at the system related to the need to gather information from multiple sources and coordinate logistics. Surgeons worked to inform patients about their disease and discuss important lifestyle and cancer-related tradeoffs. However, the ability to solicit patient input and engage in shared decision making was often limited by incomplete data or conditioned on approval by a multidisciplinary tumor board., Conclusion: Much of the conversation between surgeons and patients with rectal cancer is consumed by care coordination. Organizing care coordination outside of the clinic visit would likely improve the experience for both patients and surgeons, addressing both clinician burnout and variation in management and outcomes., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes., Methods: Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured., Results: A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028)., Conclusion: In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention., (Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear., Methods: Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments., Results: 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000., Conclusion: MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objectives: Key stakeholders agree better data on patients' language are needed to effectively address language-related barriers to timely, highquality healthcare. Our objective was to describe health plan efforts to collect language data from its members, provide language services, and improve the provision of culturally and linguistically appropriate services (CLAS)., Study Design: National surveys in 2003, 2006, and 2008., Methods: Surveys were administered to health plans offering commercial, Medicaid, and/or Medicare Advantage products., Results: 123 health plans responded to the 2008 survey (50% response rate), including 65 commercial (50%), 46 Medicaid (53%), and 12 Medicare plans (44%), representing a total enrollment of 133.8 million Americans. In 2008, 74.0% of health plans collected language data (commercial 60.0%, Medicaid 89.1%, Medicare 91.7%), which is an increase for each plan type since 2003. Health plans used direct and indirect collection methods. Nearly all health plans reported offering language services, the most common being telephonic interpreting, multilingual member materials, and access to bilingual providers. A variety of strategies for improving CLAS were cited by health plans, including improving health plan communication materials, health literacy initiatives for members, and targeted training for providers and staff., Conclusions: Health plans have made substantial progress in the collection of language data and many are offering options for language services. With the rapid growth in Medicaid participation and newly insured individuals anticipated under the Affordable Care Act, health plans may be uniquely positioned to implement and test interventions that aim to improve appropriate utilization of language services by providers and patients.

Mycobacterium tuberculosis infects one-third of the world's population and causes two million deaths annually. The unusually low permeability of its cell wall contributes to the ability of M. tuberculosis to grow within host macrophages, a property required for pathogenesis of infection. Mycobacterium marinum is an established model for discovering genes involved in mycobacterial infection. Mycobacterium marinum mutants with transposon insertions in the beta-ketoacyl-acyl carrier protein synthase B gene (kasB) grew poorly in macrophages, although growth in vitro was unaffected. Detailed analyses by thin-layer chromatography, nuclear magnetic resonance (NMR), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, infrared spectroscopy, and chemical degradations showed that the kasB mutants synthesize mycolic acids that are 2-4 carbons shorter than wild type; the defect was localized to the proximal portion of the meromycolate chain. In addition, these mutants showed a significant (approximately 30%) reduction in the abundance of keto-mycolates, with a slight compensatory increase of both alpha- and methoxy-mycolates. Despite these small changes in mycolate length and composition, the kasB mutants exhibited strikingly altered cell wall permeability, leading to a marked increase in susceptibility to lipophilic antibiotics and the host antimicrobial molecules defensin and lysozyme. The abnormalities of the kasB mutants were fully complemented by expressing M. tuberculosis kasB, but not by the closely related gene kasA. These studies identify kasB as a novel target for therapeutic intervention in mycobacterial diseases.

Pathogenic mycobacteria survive and replicate within host macrophages, but the molecular mechanisms involved in this necessary step in the pathogenesis of infection are not completely understood. Mycobacterium marinum has recently been used as a model for aspects of the pathogenesis of tuberculosis because of its close genetic relationship to Mycobacterium tuberculosis and because of similarities in the pathology and course of infection caused by this organism in its natural hosts, fish and frogs, with tuberculosis in humans. In order to advance the utility of the M. marinum model, we have developed efficient transposon mutagenesis of the organism by using a Drosophila melanogaster mariner-based transposon. To determine the efficiency of transposition, we have analyzed pigmentation mutants from the transposon mutant library. In addition to insertions in four known genes in the pathway of pigment biosynthesis, two insertions in novel genes were identified in our mutant library. One of these is in a putative inhibitor of the carotenoid biosynthesis pathway. The second unexpected insertion is in an intergenic region between two genes homologous to Rv2603c and Rv2604c of M. tuberculosis. In addition to a pigmentation defect, this mutant showed increased susceptibility to singlet oxygen and grew poorly in murine macrophages. Complementation with M. tuberculosis genomic DNA encompassing Rv2603c to Rv2606c corrected the pigmentation and growth defects of the mutant. These data demonstrate the utility of mariner-based transposon mutagenesis of M. marinum and that M. marinum can be used to study the function of M. tuberculosis genes involved in intracellular survival and replication.

Virulence of Vibrio cholerae depends on secretion of cholera toxin (CT), which is encoded within the genome of a filamentous phage, CTXphi. Release of CT is mediated by the extracellular protein secretion (eps) type II secretion system. Here, the outer membrane component of this system, EpsD, was shown to be required for secretion of the phage as well. Thus, EpsD plays a role both in pathogenicity and in horizontal transfer of a key virulence gene. Genomic analysis suggests that additional filamentous phages also exploit chromosome-encoded outer membrane channels.