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Introduction: Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer. Methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer. County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level. Results: Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55–0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52–2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07–1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy. Conclusion: Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer. [ABSTRACT FROM AUTHOR]

Sixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. Medicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). Patients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). Only a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery. [ABSTRACT FROM AUTHOR]

Introduction: Many patients who present for complex surgery have underlying medical comorbidities. While surgeons often refer these patients to medical appointments for preoperative "optimization" or "clearance," the actual impact of these visits remains poorly examined. The objective of the current study was to define the potential benefit of preoperative medical appointments on outcomes and costs associated with hepatopancreatic (HP) surgery. Methods: Patients with modifiable comorbidities undergoing HP surgery were identified in the Medicare claims data. The association of preoperative non-surgical visit and postoperative outcomes and expenditures was assessed using inverse propensity treatment weighting analysis and multivariable logistic regression. Results: Among the 5574 Medicare beneficiaries who underwent a hepatopancreatic surgery, one in seven patients (n = 830, 14.9%) was "optimized" preoperatively. On multivariable logistic regression analysis, age (OR 1.02; 95% CI 1.01–1.03; p = 0.006) and higher comorbidity burden (OR 1.03; 95% CI 1.01–1.05; p = 0.007) were associated with modest increased odds of being referred in the preoperative period for a non-surgical evaluation; the factor most associated with preoperative non-surgical visit was male patient sex (OR 1.33; 95% CI 1.14–1.56; p < 0.001). After adjustment for competing risk factors and random site effect, patients with an "optimization" visit had 28% lower odds (OR 0.72; 95% CI 0.59–0.86; p < 0.001) of experiencing an operative complication. Additionally, patients who had a non-surgical visit had 13% higher median total expenditures compared with individuals who did not undergo an "optimization" visit (p < 0.05). Conclusion: In conclusion, roughly one in seven Medicare beneficiaries who underwent HP surgery may have been risk stratified by a non-surgical provider prior to surgery. Preoperative evaluation was associated with modestly lower odds of complications following HP surgery and higher Medicare expenditures. Further research is needed to determine its routine utility as a means to decrease the morbidity surrounding HP surgery. [ABSTRACT FROM AUTHOR]

Among patients with pancreatic cancer, the association of pre-existing mental illness with long-term outcomes remains unknown. Individuals diagnosed with pancreatic adenocarcinoma were identified in the SEER-Medicare database. Patients were classified as having mental illness if an ICD9/10CM code for anxiety, depression, bipolar disorder, schizophrenia or other psychotic disorder was recorded. Among the 54,234 Medicare beneficiaries with pancreatic cancer, roughly 1 in 12 (n = 4793, 8.83%) individuals had a diagnosis of a mental illness. The majority (n = 4029, 84.1%) had anxiety or depression, while 16% (n = 764) had bipolar/schizophrenic disorders. On multivariable analysis, among patients with early stage cancer, individuals with pre-existing anxiety/depression and bipolar/schizophrenic disorders had 22% (OR 0.78, 95% CI 0.69–0.86) and 46% (OR 0.54, 95% CI 0.42–0.70) reduced odds, respectively, to undergo cancer-directed surgery. Furthermore, patients with a pre-existing history of bipolar/schizophrenic disorders had a 20% (HR 1.20, 95% CI 1.21–1.40) higher risk of all-cause mortality and 27% (HR 1.27, 95% CI 1.17–1.37) higher risk of pancreatic cancer-specific mortality compared to individuals without a history of mental illness. One in twelve patients with pancreatic cancer had a pre-existing mental illness. Individuals with mental illness were more likely to have worse overall and cancer-specific long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: We sought to define the incidence and characterize the timing of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. Methods: The Medicare Standard Analytic Files from 2013 to 2017 were used to identify patients with pancreatic cancer who underwent a pancreatectomy. Logistic regression was utilized to identify the association between race and patterns of hospice utilization among deceased individuals. Results: Among the 14,495 individuals (median age 73; 52.3% female; 6.8% racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 47% (n = 6859) died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 4978, 72.6%) used hospice leading up to the time of death. Racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities n = 301, 67% vs. whites: n = 4677, 73%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 22% less likely than whites to initiate hospice services prior to death (OR 0.78, 95% CI 0.63–0.96). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e., within 3 days of death) versus white patients (OR 1.5, 95% CI 0.73–1.50). Discussion: While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, racial/ethnic minorities were less likely to use hospice services than whites. [ABSTRACT FROM AUTHOR]

Background: We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume.Methods: Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated.Results: Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86).Conclusion: Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio. [ABSTRACT FROM AUTHOR]

Background: The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes.Methods: Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC.Results: Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality.Conclusion: Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR). Methods: Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3–5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined. Results: Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055). Conclusion: Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons. [ABSTRACT FROM AUTHOR]

An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown. The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy. Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71–80] vs. 71 [IQR 68–76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32–15.29, p = 0.016). While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days. [ABSTRACT FROM AUTHOR]

Keywords: Risk factors; Post-discharge healthcare cost; Healthcare cost EN Risk factors Post-discharge healthcare cost Healthcare cost 1863 1865 3 07/29/20 20200801 NES 200801 Introduction Cancer treatment, particularly for patients with pancreatic cancer, is resource- and cost-intensive, with episodes of surgical care being financially expensive.[1],[2] While previous studies have characterized healthcare utilization patterns and associated costs, data on super-utilization relative to surgical patients undergoing cancer-directed therapies have been more limited. Risk factors, Post-discharge healthcare cost, Healthcare cost. [Extracted from the article]

Minimally invasive liver surgery (MILS) has been increasingly adopted in clinical practice; yet, inter-surgeon variability in operative approach (MILS vs. open), as well as the impact of providers on the likelihood of undergoing MILS have not been well characterized. The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent hepatectomy between 2013 – 2017. The impact of patient- and procedure- related factors on the likelihood of MILS was investigated. Overall 12,110 (91.6%) patients underwent open liver resection, while 1,112 (8.4%) patients had MILS. Based on total MILS volume, surgeons were categorized into average (1–3 cases), above average (4–7 cases) and high (>8 or more cases) MILS volume surgeons. While male patients (OR = 0.85, 95%CI 0.75–0.97) were less likely to undergo MILS, patients operated on more recently (year 2017; OR = 1.72, 95%CI 1.38–2.14) for a cancer indication (OR = 1.23, 95%CI 1.05–1.42) had a higher chance of MILS. After controlling for patient- and procedure-related characteristics, there was almost a two-fold variation in the odds that a patient underwent MILS versus open hepatectomy based on the individual surgeon provider (MOR = 1.75, 95%CI 1.48–1.99). Patients who had a MILS performed by a high-volume MILS surgeon had 36% lower odds of death within 90-days (OR = 0.64, 95%CI 0.51–0.79). The likelihood of undergoing MILS, as well as post-operative mortality, was heavily influenced by the individual surgeon provider rather than patient- or procedure-related factors. [ABSTRACT FROM AUTHOR]