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Context: The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear.Objectives: We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients.Methods: We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings.Results: A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers.Conclusions: Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery., Summary of Background Data: Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown., Methods: Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups., Results: A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval -1.59 to 4.20)., Conclusion: Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.

Importance: The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities., Objectives: To characterize hospitals' readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation., Design, Setting, and Participants: A total of 1315 American College of Surgeons Commission on Cancer-accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018., Exposures: Hospitals' readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards., Main Outcomes and Measures: Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital., Results: Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence., Conclusions and Relevance: Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.

Background: Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home., Objective: We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection., Design: This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns., Settings: Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals., Patients: Patients undergoing colon and rectal resections were included., Main Outcome Measure: The main outcome measure was hospital use patterns of nonhome discharge., Results: Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045)., Limitations: This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size., Conclusions: This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.