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Regionalized rectal cancer surgery may decrease postoperative and long-term cancer-related mortality. However, the regionalization of care may be an undue burden on patients.To assess the cost-effectiveness of regionalized rectal cancer surgery.Tree-based decision analysis.Patients with stage II/III rectal cancer anatomically suitable for low anterior resection.Rectal cancer surgery performed at a high-volume regional center rather than the closest hospital available.Incremental costs ($) and effectiveness (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and effectiveness.Regionalized surgery economically dominated local surgery. Regionalized rectal cancer surgery was both less expensive on average ($50,406 versus $65,430 in present-day costs) and produced better long-term outcomes (10.36 versus 9.51 quality-adjusted life years). The total costs and inconvenience of traveling to a regional high-volume center would need to exceed $15,024 per patient to achieve economic breakeven alone or $112,476 per patient to satisfy conventional cost-effectiveness standards. These results were robust on sensitivity analysis and maintained in 94.6% of scenario testing.Decision analysis models are limited to policy-level rather than individualized decision-making.Regionalized rectal cancer surgery improves clinical outcomes and reduces total societal costs compared to local surgical care. Prescriptive measures and patient inducements may be needed to expand the role of regionalized surgery for rectal cancer. See Video Abstract at http://links.lww.com/DCR/C83.

Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased down-staging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval.To determine the impact of total neoadjuvant therapy on postoperative complications compared to neoadjuvant chemoradiation alone.Retrospective cohort study.Single tertiary referral center.Stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020.Severe postoperative complications (Clavien-Dindo grade ≥3).Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared to 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield compared to neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR = 1.19, p0.001) and estimated blood loss (OR = 1.22, p0.001) and decreased lymph node yield (OR = 0.67, p0.001). There was no difference in severe complications or any complications.Selection bias uncontrolled by modelling.We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy versus neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty as a result of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and therefore should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44.

Background It is unclear what impact centralizing rectal cancer surgery may have on travel burden for patients. Objective This study aimed to determine the impact of centralizing rectal cancer surgery to high-volume centers on patient travel distance. Design This is a population-based study. Settings The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for patients with rectal cancer undergoing proctectomy. Patients Patients with stage I to III rectal cancer who underwent surgical resection between 2004 and 2014 were included. Main outcome measures The outcome of interest was travel distance calculated as the straight-line distance between the centroid of the patient residence zip code and the hospital zip code. Mean distance was compared by using the Student t test. Results A total of 5860 patients met inclusion criteria. The total number of hospitals performing proctectomies for rectal cancer decreased between 2004 and 2014. The average number of proctectomies performed at high-volume centers (20+ resections/year) increased from 16.6 to 24.4 during this time. The average number of miles traveled by patients was 12.1 miles in 2004, and this increased to 15.4 in 2014. If proctectomies were centralized to high-volume centers, there would be 11 facilities. The mean distance traveled would be 24.5 miles. Limitations This study is subject to the limitations of an administrative data set. There are no patient preference or referral data. Conclusions The number of hospitals performing rectal cancer resections in New York State is decreasing and volume by center is increasing. There was a statistically significant difference in the mean distance traveled by patients over time. If rectal cancer resections were centralized to high-volume centers, the mean travel distance would increase by 9.5 miles. There would be a 321% increase in the number of patients having to travel 50+ miles for surgery. Any plan for centralization in New York State will require careful planning to avoid placing undue travel burden on patients. See Video Abstract at http://links.lww.com/DCR/B138. CENTRALIZACION DE LA CIRUGIA DE CANCER RECTAL: ?CUAL ES EL IMPACTO DEL VIAJE PARA LOS PACIENTES?: No esta claro que impacto puede tener la centralizacion de la cirugia de cancer rectal en la carga de viaje para los pacientes.Determinar el impacto de centralizar la cirugia de cancer rectal en centros de alto volumen sobre la distancia de viaje del paciente.Este es un estudio basado en cohorte poblacional.El Registro de Cancer del Estado de Nueva York y el Sistema Cooperativo de Planificacion e Investigacion Estatal fueron consultados para pacientes con cancer rectal sometidos a proctectomia.Pacientes con cancer rectal en estadio I-III que se sometieron a reseccion quirurgica entre 2004-2014.El resultado de interes fue la distancia de viaje calculada como la distancia en linea recta entre el centroide de la residencia del paciente y el codigo postal del hospital. La distancia media se comparo mediante la prueba t de Student.Un total de 5,860 pacientes cumplieron los criterios de inclusion. El numero total de hospitales que realizaron proctectomias para cancer rectal disminuyo entre 2004-2014. El numero promedio de proctectomias realizadas en centros de alto volumen (mas de 20 resecciones/ano) aumento de 16.6 a 24.4 durante este tiempo. El numero promedio de millas recorridas por los pacientes fue de 12.1 millas en 2004 y esto aumento a 15.4 en 2014. Si las proctectomias se centralizaran en centros de alto volumen, habria 11 instalaciones. La distancia media recorrida seria de 24.5 millas.Limitaciones inherentes a un conjunto de datos administrativos. No existen datos sobre preferencia del paciente o sobre referencia de los mismos.El numero de hospitales que realizan resecciones de cancer rectal en Nueva York esta disminuyendo y el volumen por centro esta aumentando. Hubo una diferencia estadisticamente significativa en la distancia media recorrida por los pacientes a lo largo del tiempo. Si las resecciones por cancer rectal se centralizaran en centros de gran volumen, la distancia media de viaje aumentaria 9.5 millas. Habria un aumento del 321% en el numero de pacientes que tienen que viajar mas de 50 millas para la cirugia. Cualquier plan de centralizacion en Nueva York requerira una planificacion cuidadosa para evitar imponer una carga de viaje excesiva a los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B138.

Background The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. Methods Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score–adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. Results A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. Conclusions Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Multiple sclerosis (MS) is an inflammatory and demyelinating disease of the central nervous system (CNS) that remains incurable. Herein, we demonstrated that ilepcimide (Antiepilepsirine), an antiepileptic drug used for decades, protects mice from experimental autoimmune encephalomyelitis (EAE), a mouse model of MS. Our studies found that ilepcimide treatment effectively ameliorates demyelination, blood-brain barrier leakage and infiltration of CD4

Background The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival. Methods Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1. Results Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival. Discussion Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.

The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use.Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery.New York's Statewide PlanningResearch Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery.Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD.Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.

Background It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery. Methods The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression. Results Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47–61%, p

We sought to better understand the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) mobility, pain interference (PI) and depressive symptoms scores, as well as determine what patient factors and PROMIS domains were associated with worse pain coping (PROMIS PI), in a pediatric orthopaedic population. Between 27 August 2015 and 30 April 2019, new pediatric orthopaedic patients 18 years or younger (or their guardians as a proxy) were asked to complete PROMIS mobility, PI and depressive symptoms domains at an academic medical center pediatric orthopaedic clinic. Pearson correlation coefficients (r) were calculated between each PROMIS domain. Linear multivariate regression analysis was used to determine patient characteristics and PROMIS domains associated with presenting PROMIS PI scores. There was a strong-moderate correlation between PROMIS mobility and PI (r = -0.66, P < 0.001), while the correlation between PROMIS mobility and depressive symptoms was moderate-poor (r = -0.38, P < 0.001). There was a moderate correlation between PROMIS depressive symptoms and PI (r = 0.54, P < 0.001). In multivariate linear regression analysis, female gender (β = 0.82, P < 0.001), self-reported black race (β = 0.94, P < 0.001), Medicaid insurance (β = 0.82, P < 0.001) and worsening depressive symptoms (β = 0.33, P < 0.001) were associated with worse pain coping mechanisms, while increasing mobility (β = -0.47, P < 0.001) was associated with better pain coping mechanisms. Poor mobility and worse depressive symptoms are associated with worse pain coping mechanisms. Additionally, Medicaid insurance status, black race and female gender are also associated with worse physical limitations secondary to pain.

Rectal cancer surgery has seen significant improvement in recent years. This has been possible in part due to focus on surgeon education and training, specific surgical quality metrics, and longitudinal tracking of data through the use of registries. In countries that have implemented such efforts, data has shown significant improvement in outcomes. However, there continues to be significant variation in rectal cancer outcomes and practices worldwide. Just within the United States, county level mortality rates from rectal cancer range from 8–15 per 100,000 to 38–59 per 100,000. In order to continue to improve rectal cancer patient outcomes, there needs to be evidence based guidelines and standards centered around the framework of structure, process, and outcomes. In addition, there must be a feedback system by which programs can continually assess their performance. Obtaining evidence for specific standards and measures can be challenging and requires analyzing available data and literature, some of which may be conflicting. This article evaluates the evolution of metrics and standards used for quality improvement in rectal cancer and ongoing efforts to further improve patient outcomes.

Twenty-nine percent of postileostomy discharges are readmitted, most commonly because of dehydration. However, there is a lack of detailed data specifically evaluating factors associated with readmission with dehydration. In addition, patients with a history of an ileostomy have often been excluded from previous studies and therefore represent a group of understudied ileostomates.This study aimed to evaluate factors available at discharge associated with 30-day readmission for dehydration, rather than all-cause readmissions.This was a retrospective cohort study.Study patients received ileostomies at a tertiary academic medical center from 2014 to 2016.Patients with a preexisting ileostomy that was not recreated per the operative note were excluded, whereas those who received a new ileostomy were included.The primary outcome measured was 30-day readmission for dehydration as defined by objective clinical criteria.A total of 262 patients underwent ileostomy creation and were discharged alive. Twenty-five percent were ≥65 years of age, 53% were men, 14% had a history of ileostomy, 18% had a creatinine1.0 on discharge, and 26% had high ileostomy output at any time during the index admission. Among all ileostomates, the all-cause readmission rate was 30%. Mean days to readmission for any cause was 8.5, whereas for dehydration it was 11.6 days. Of the readmissions, 37% were readmitted with a diagnosis of dehydration, and dehydration was the sole reason in 26%. Among those with dehydration, the most common length of stay was 2 days. In multivariable logistic regression, 30-day readmission with dehydration was associated with older age, male sex, history of an ileostomy, high ileostomy output during index admission, and a discharge creatinine1.0.This study was limited by its retrospective design.Ileostomy dehydration efforts have focused on new ileostomy patients; however, our data suggest that patients with a history of an ileostomy are actually at risk for readmission with dehydration. Further studies aimed at the reduction of readmission with dehydration after ileostomy are warranted and should include patients with a history of an ileostomy. See Video Abstract at http://links.lww.com/DCR/A643.

BackgroundStudies examining long-term outcomes following resolution of an acute diverticular abscess have been limited to single-institution chart reviews. This observational cohort study compared outcomes between elective colectomy and non-operative management following admission for an initial acute diverticular abscess.MethodsThe Statewide Planning and Research Cooperative System was queried for unscheduled admissions for an initial acute diverticular abscess in 2002–2010. Bivariable and propensity-matched multivariable analyses compared stoma rates and use of healthcare in patients who had an elective resection and those receiving non-operative management. Diverticulitis recurrence rates were analysed for non-operative management.ResultsAmong 10 342 patients with an initial acute diverticular abscess, one-third (3270) underwent surgical intervention within 30 days despite initial non-operative management. Of the remaining 7072 patients, 1660 had an elective colectomy within 6 months. Of 5412 patients receiving non-operative management, 1340 (24·8 per cent) had recurrence of diverticulitis within 5 years (median 278 (i.q.r. 93·5–707) days to recurrence). Elective colectomy was associated with higher stoma rates (10·0 per cent, compared with 5·7 per cent for non-operative observation, P < 0·001; odds ratio 1·88, 95 per cent c.i. 1·50 to 2·36), as well as more inpatient hospital days for diverticulitis-related admissions (mean 8·0 versus 4·6 days respectively, P < 0·001; incidence rate ratio (IRR) 2·16, 95 per cent c.i. 1·89 to 2·47) and higher mean diverticulitis-related cost (€70 107 versus €24 490, P < 0·001; IRR 3·11, 2·42 to 4·01).ConclusionObservation without elective colectomy following resolution of an initial diverticular abscess is a reasonable option with lower healthcare costs than operation.

Background In an effort to improve the quality of rectal cancer care in the US, the American College of Surgeons Commission on Cancer has developed the National Accreditation Program for Rectal Cancer (NAPRC). We aimed to describe the current status of rectal cancer care before implementation of the NAPRC. Study Design The 2011-2014 National Cancer Database was queried for non-metastatic rectal cancer patients who underwent proctectomy. The NAPRC process measures evaluated included clinical staging completion, treatment starting fewer than 60 days from diagnosis, CEA level drawn before treatment, tumor regression grading, and margin assessment. The NAPRC performance measures included negative proximal, distal, and circumferential margins, and ≥12 lymph nodes harvested during resection. Results There were 39,068 patients identified (mean age 62 years, 61.6% male sex). In >85% of patients, clinical staging was completed, treatment was started within 60 days, and all tumor margins were assessed. Pretreatment CEA level (64.6% complete) was the process measure most often omitted. However, completion of all included process measures occurred in only 28.1% of patients. All pathologic margins were negative in 79.8% of patients and 73.2% of specimens reported ≥12 lymph nodes. Overall, 56.3% of patients achieved all performance measures. Patients treated at high-volume centers (>30 cases/year) had higher odds of meeting all performance measures (odds ratio 1.42; p Conclusions Overall, very few patients achieved all of the proposed quality measures for rectal cancer care. It will be important to re-evaluate these data after the implementation of the NAPRC.

There is a paucity of real-world data regarding surgeon utilization of sacral nerve stimulation for fecal incontinence compared with anal sphincteroplasty.This study aims to examine trends in sacral nerve stimulation use compared with sphincteroplasty for fecal incontinence and surgeon-level variation in progression to implantation of the pulse generator.This is a population-based study.Patients with fecal incontinence between 2011 and 2014 in New York who underwent stage 1 of the sacral nerve stimulation procedure were selected. For the comparison with sphincteroplasty, patients with fecal incontinence who underwent anal sphincteroplasty between 2008 and 2014 were included.The main outcomes after sacral nerve stimulation generator placement were unplanned 30-day admission, emergency department visit within 30 days, revision or explant of leads or generator, and 30-day mortality.Six hundred twenty-one patients with fecal incontinence underwent a stage 1 procedure with 79.7% progressing to stage 2. There has been an increase in the number of sacral nerve stimulation cases per year as well as the number of surgeons performing the procedure. The rate of progression to stage 2 among patients treated by colorectal surgeons was 80.2% compared with 77.0% among those treated by noncolorectal surgeons. Among those who completed stage 2, there were 3 (0.5%) unplanned 30-day admissions, 24 (4.4%) emergency department visits within 30 days, and 0 mortalities within 30 days. Thirty-two (6.5%) patients had their leads or pulse generator revised or explanted. There was a significant decrease in annual sphincteroplasty cases and the number of providers performing the procedure starting in 2011.We lacked data regarding patient and physician decision making and the severity of disease.Sacral nerve stimulation for fecal incontinence is increasing in popularity with an increasing number of surgeons utilizing sacral nerve stimulation for fecal incontinence rather than sphincteroplasty. See Video Abstract at http://links.lww.com/DCR/A450.

Background No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair. Methods The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003–2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence. Results Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models. Conclusion The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.

Background Little is known regarding recent trends in the rate of nonelective colon cancer resection in the United States and its impact on both short-term and long-term outcomes. Methods The New York State Cancer Registry and Statewide Planning & Research Cooperative System identified stage I–III colon cancer resections from 2004–2011. Propensity-matched analyses assessed differences in short-term adverse outcomes and 5-year disease-specific and overall survival between elective and nonelective colon cancer operations. Further analyses assessed the association among patient, surgeon, and hospital-level factors and outcomes within the nonelective operation group. Results Among 26,420 patients, 26.5% underwent nonelective operations. There was no significant change in the rate of nonelective resection from 2004–2011 (P = .25). Nonelective operations were independently associated with greater odds of 30-day mortality (odds ratio [OR] = 3.42, 95% confidence interval [CI] = 2.87–4.06), stoma creation (OR = 4.49, 95% CI = 3.95–5.09), intensive care unit admission (OR = 1.68, 95% CI = 1.53–1.84), complications (OR = 2.34, 95% CI = 2.18–2.52), and discharge to another health care facility (OR = 2.46, 95% CI = 2.26–2.68), longer duration of stay (incidence rate ratio = 1.79, 95% CI = 1.76–1.83), and worse disease-specific (hazard ratio = 1.74, 95% CI = 1.61–1.88) and overall survival (hazard ratio = 1.64, 95% CI = 1.55–1.75). Other than an association among high-volume surgeons, adequate lymph node yield, and receipt of adjuvant chemotherapy and lower mortality, no other potentially modifiable factors were associated with survival after nonelective operations. Conclusion Nonelective colon cancer resection remains a concerning public health issue with >25% of cases being performed on a nonelective basis and an independent association with poor short-term and long-term survival compared with elective operations. Given that few potentially modifiable factors appear to have an impact on survival after nonelective operations, these findings highlight the importance of adherence to colon cancer screening guidelines to limit the number of nonelective colon cancer resections.

Purpose: Although radiation therapy (RT) can provide palliative benefits for patients with metastatic rectal cancer, its role at the end of life remains unclear. The objective of this study was to assess sociodemographic and clinical factors associated with the use of RT during the last 30 days of life and to evaluate yearly time trends in RT utilization among stage IV patients with rectal cancer. Methods: The 2004 to 2012 National Cancer DataBase was queried for patients with metastatic rectal cancer who had a documented death during follow-up. A Bayesian multilevel logistic regression model was used to characterize predictive factors and yearly time trends associated with RT use in the last 30 days of life. Results: Among 10 431 patients who met inclusion criteria, 345 (3%) received RT during the last 30 days of life. Factors independently associated with RT use included older age, female sex, African American race, nonprivate insurance, higher comorbidity burden, and worse grade. The odds of RT use at the end of life decreased by 28% between 2007 and 2009 (odds ratio [OR] = 0.72, 95% Credible Interval (CI) = 0.58-0.93), but then increased by 16% from 2010 to 2012 (OR = 1.16, 95% CI = 1.13-1.33), relative to 2004 to 2006. Conclusion: Radiation therapy use for patients with metastatic rectal cancer is beneficial, and efforts to optimize its appropriate use are important. Several factors associated with RT use during the last 30 days of life included disparities in sociodemographic and clinical subgroups. Research is needed to understand the underlying causes of these inequalities and the role of predictive models in clinical decision-making.

Background We examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. Methods Patients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. Results Among 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). Conclusions Although extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.

To identify sources of variation in the use of minimally invasive surgery (MIS) for colectomy.MIS is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study identified factors explaining variation in MIS use for colectomy.The Statewide Planning and Research Cooperative System was queried for scheduled admissions in which a colectomy was performed for neoplastic, diverticular, or inflammatory bowel disease between 2008 and 2015. Mixed-effects analyses were performed assessing surgeon, hospital, and geographic variation and factors associated with an MIS approach.Among 45,714 colectomies, 68.1% were performed using an MIS approach. Wide variation in the rate of MIS was present across 1253 surgeons (median 50%, interquartile range 10.9%-84.2%, range 0.3%-99.7%). Calculating intraclass correlation coefficients after controlling for case-mix, 62.8% of the total variation in MIS usage was attributable to surgeon variation compared with 28.5% attributable to patient variation, 7% attributable to hospital variation, and 1.6% attributable to geographic variation. Surgeon-years in practice since residency/fellowship completion explained 19.2% of the surgeon variation, surgeon volume explained 5.2%, hospital factors explained 0.1%, and patient factors explained 0%.Wide surgeon variation exists regarding an MIS approach for colectomy, and most of the total variation is attributable to individual surgeon practices-much of which is related to year of graduation. As increasing surgeon age is inversely proportional to the rate of MIS, patient referral and/or providing tailored training to older surgeons may be constructive targets in increasing the use of MIS and reducing healthcare utilization.

The Commission on Cancer recently released quality-of-care measures regarding adequate lymphadenectomy for colon, gastric, lung, and bladder cancer. There is currently little information regarding variation in adequate lymph node yield (ALNY) for gastric, lung, and bladder cancer. The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I–III gastric, stage I–II lung, and stage II–III bladder cancer resections from 2004 to 2014. Hierarchical models assessed factors associated with ALNY (gastric ≥ 15; lung ≥ 10; bladder ≥ 2). Additionally, the proportions of variation attributable to surgeons, pathologists, and hospitals were estimated among Medicare patients. Among 3716 gastric, 18,328 lung, and 1512 bladder cancer resections, there were low rates of ALNY (gastric = 53%, lung = 36%, bladder = 67%). When comparing 2004–2006 and 2012–2014, there was significant improvement in ALNY for gastric cancer (39% vs. 68%), but more modest improvement for lung (33% vs. 38%) and bladder (65% vs. 71%) cancer. Large provider-level variation existed for each organ system. After controlling for patient-level factors/variation, the majority of variation was attributable to hospitals (gastric: surgeon = 4%, pathologist = 2.8%, hospital = 40%; lung: surgeon = 13.8%, pathologist = 1.5%, hospital = 18.3%) for gastric and lung cancer. For bladder cancer, most of the variation was attributable to pathologists (surgeon = 3.3%, pathologist = 10.5%, hospital = 6.2%). ALNY rates are low for gastric, lung, and bladder cancer, with only modest improvement over time for lung and bladder cancer. Given that the proportion of variation attributable to the surgeon, pathologist, and hospital is different for each organ system, future quality improvement initiatives should target the underlying causes, which vary by individual organ system.

Background The role of primary tumor resection (PTR) for asymptomatic stage IV colon cancer with unresectable metastases remains unclear. Increasingly there has been a trend away from resection. The aim of this study was to examine trends in the treatment of stage IV colon cancers, impact of different treatments on long-term mortality, and factors associated with receipt of postoperative chemotherapy. Methods The 2006-2012 National Cancer Data Base was queried for stage IV colon cancer patients. Treatments were grouped into PTR and chemotherapy, PTR only, chemotherapy only, and no treatment. A descriptive analysis was performed examining patient and hospital characteristics associated with different treatments. A Cox regression analysis was used to assess the adjusted effect of different treatments on long-term survival. A multivariable logistic regression was used to examine factors associated with postoperative chemotherapy. Results Of 31,310 patients, who met inclusion criteria, 22% of the patients underwent PTR and chemotherapy, 37.5% received chemotherapy only, 11.9% underwent PTR, and 28.6% received no treatment. Patients who received no treatment had the highest hazard of death at 1, 3, and 5 y, followed by PTR only, and chemotherapy only compared with PTR combined with chemotherapy. Patients who were older and had more comorbidities were less likely to receive postoperative chemotherapy. Conclusions Primary tumor resection in conjunction with postoperative chemotherapy among stage IV colon cancer patients with unresectable metastases was associated with a long-term survival benefit compared with other treatment options. Efforts should be made to increase the use of postoperative chemotherapy where feasible.

Objective:To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.Summary Background Data:Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and

BACKGROUND National Comprehensive Cancer Network treatment guidelines for patients with locally advanced rectal cancer include neoadjuvant chemoradiation followed by total mesorectal excision and adjuvant chemotherapy. The objective of the current study was to examine the rate of adjuvant chemotherapy and associated survival in patients with stage II/III rectal cancer. METHODS The 2006 to 2011 National Cancer Data Base was queried for patients with AJCC clinical stage II/III rectal cancer who underwent neoadjuvant chemoradiation and surgical resection. A mixed effects multivariable logistic regression identified factors associated with the receipt of adjuvant chemotherapy. A mixed effects Cox proportional hazards model was used to estimate the adjusted effect of receiving adjuvant therapy on 5-year overall survival (OS). RESULTS A total of 14,742 patients were included; 68% of the cohort did not receive adjuvant chemotherapy. When controlled for clinical stage of disease, patients who were aged >70 years, had a higher comorbidity score, and had a pathologic complete response had lower odds of receiving adjuvant therapy. There was a 22-fold difference in the risk-adjusted rate of adjuvant therapy use among hospitals (3.1%-67.7%). Adjuvant therapy was associated with increased 5-year OS when controlled for patient factors, stage of disease, and pathologic response (hazard ratio, 0.65; 95% confidence interval, 0.59-0.71). The greatest survival benefit was noted among patients who achieved a pathologic complete response (hazard ratio, 0.40; 95% confidence interval, 0.23-0.67). CONCLUSIONS There is poor compliance to National Comprehensive Cancer Network guidelines for adjuvant chemotherapy in patients with locally advanced rectal cancer after neoadjuvant chemoradiation and surgery. Adjuvant therapy appears to be independently associated with improved OS regardless of stage of disease, pathologic response, and patient factors. The greatest survival benefit was observed in patients who were complete responders. Age and comorbidities were found to be significantly associated with nonreceipt of adjuvant therapy. Improved rehabilitation and physical conditioning may improve the odds of patients receiving adjuvant therapy. Cancer 2016. © 2016 American Cancer Society.

Background Postoperative readmission after colorectal resection is common. It is unknown whether patients who receive readmission care from the surgeon who performed the index surgery have improved mortality. This study evaluated whether postdischarge continuity of care, defined at the hospital and surgeon level, was associated with decreased mortality after colorectal surgery. Methods The Statewide Planning and Research Cooperative System was queried for patients who had colorectal resections from 2004 to 2014, and were readmitted within 30 days of discharge. Propensity-adjusted logistic regression analysis was used to evaluate the association between 30-day mortality and readmission care continuity. Results A total of 20 016 patients readmitted within 30 days of discharge were eligible for analysis. Some 39·5 per cent of readmitted patients experienced hospital and surgeon care continuity, 47·1 per cent hospital but not surgeon continuity, 1·0 per cent surgeon but not hospital continuity, and 12·4 per cent neither hospital nor surgeon care continuity. A total of 1349 patients (6·7 per cent) died within 30 days of readmission. Patients readmitted with absence of surgeon but not of hospital care continuity had 2·04 (95 per cent c.i. 1·72 to 2·42) times the risk of 30-day mortality compared with those who experienced surgeon and hospital continuity. Absence of both surgeon and hospital care continuity was associated with 2·65 (2·18 to 3·30) times the risk of death compared with presence of both. Conclusion Readmission after colorectal resection not under the care of the index operating surgeon is associated with an increased risk of 30-day mortality. Addressing processes of care that are affected by surgeon care continuity may decrease surgical deaths.

Rectal cancer patients who are understaged may not be offered the highest quality treatment modalities, which are based on an accurate assessment of preoperative staging. The objective of this study was to evaluate heterogeneity in the probability of being understaged at Commission on Cancer hospitals in the United States and to assess how this variation affects outcomes. The 2006–2013 National Cancer Data Base was queried for clinical stage I–III rectal cancer patients who underwent resection. The initial clinical stage was compared with the “gold standard,” pathological stage. A Bayesian multilevel logistic regression model was used to characterize variation in hospital-specific probabilities of being understaged (clinical stage

BACKGROUND It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection. OBJECTIVE The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers. DESIGN This was a population-based study. SETTINGS The National Cancer Database was queried for patients with rectal cancer. PATIENTS Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included. MAIN OUTCOME MEASURES The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival. RESULTS A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group. LIMITATIONS We lacked data regarding patient and physician decision making and surgeon-specific factors. CONCLUSIONS Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at http://links.lww.com/DCR/A446.

6585 Background: The Leapfrog group recently released surgeon and hospital procedure volume standards for several surgical oncology procedures. This study investigated trends in volume and whether high-volume surgeons at low-volume hospitals achieve equivalent outcomes to high-volume surgeons at high-volume hospitals. Methods: New York’s Statewide Planning and Research Cooperative System was queried for esophagectomy, lung resection, pancreatectomy, and proctectomy for cancer from 2004-2015. Mixed-effects analyses assessed the association among Leapfrog surgeon/hospital volume standards and 90-day mortality. Results: Among 55,528 cases, high-volume surgeons performed 64.7% of cases (esophagectomy = 52%; lung resection = 75.6%; pancreatectomy = 56.7%; proctectomy = 53%), and high-volume hospitals performed 59.5% of cases (esophagectomy = 55.5%; lung resection = 58.3%; pancreatectomy = 63.4%; proctectomy = 61%). After risk-adjustment, high-volume surgeons at high-volume hospitals had lower odds of 90-day mortality compared to high-volume surgeons at low-volume hospitals for each organ system except for pancreas. Despite trends toward regionalization, between 2012-2015, there were large differences in the number of hospitals and median annual case number between high-volume and low-volume centers for esophagectomy (8 vs. 56 hospitals; 31.5 vs. 3 cases), lung resection (22 vs. 89 hospitals; 69.5 vs. 7 cases), pancreatectomy (15 vs. 56 hospitals; 36 vs. 3 cases), and proctectomy (38 vs. 117 hospitals; 28 vs. 3 cases). Conclusions: This study supports the Leapfrog initiative for performance of high-risk surgical oncology procedures by high-volume surgeons at high-volume hospitals. However, it remains unclear whether full regionalization to high-volume centers is feasible. [Table: see text]

The purpose of this study was to examine the long-term overall survival (OS) of colon cancer patients who underwent emergent resection versus patients who were resected electively. The 2006–2012 National Cancer Data Base was queried for colon cancer patients who underwent surgical resection. Emergent resection was defined as resection within 24 h of diagnosis. A mixed-effects logistic regression was used to estimate the effect of emergent resection on 30- and 90-day mortality. A propensity score-matched mixed-effects Cox proportional-hazards model was used to estimate the effect of emergent resection on 5-year OS. Two hundred fourteen thousand one hundred seventy-four patients met inclusion criteria, 30% of the cohort had an emergent resection. After controlling for patient and hospital factors, pathological stage, lymph node yield, margin status, and adjuvant chemotherapy, emergent resection was associated with increased odds of 30-day mortality (OR = 1.69, 95% CI = 1.60, 1.78) and hazard of death at 5 years (HR = 1.13, 95% CI = 1.09, 1.15) compared to elective resections. Emergent resection for colon cancer is independently associated with poor short-term outcomes and decreased 5-year OS compared to elective resection. With 30% of cases in this study emergent, these findings underlie the importance of adherence to colon cancer screening guidelines to limit the need for emergent resections.

There is a paucity of literature quantifying the extent to which time to adjuvant chemotherapy for stage III colon cancer patients varies between individual surgeons, medical oncologists, and hospitals. A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System and Medicare claims to identify stage III colon cancer patients from 2004 to 2009 who underwent resection and received adjuvant chemotherapy. Multilevel logistic regression models characterized variation in delayed time to adjuvant chemotherapy (>8 weeks vs. ≤8 weeks). Multilevel competing-risks Cox proportional hazards models assessed the effect of delayed time to adjuvant chemotherapy on disease-specific survival. The proportion of delayed time to adjuvant chemotherapy was 36 % in 1133 patients treated by 516 surgeons and 351 medical oncologists at 163 hospitals. After controlling for case-mix, the majority of the clustering variation (72 %) in delayed time to adjuvant chemotherapy is attributed to differences between medical oncologists. Risk-adjusted surgeon-specific, medical oncologist-specific, and hospital-specific probabilities of delayed time to adjuvant chemotherapy ranged from 30 to 38, 17 to 59, and 27 to 43 %, respectively. Delayed time to adjuvant chemotherapy was associated with disease-specific survival (hazard ratio [HR] 1.24, 95 % confidence interval [CI] 1.07–1.45). These findings suggest there is substantial variation in time to adjuvant chemotherapy among stage III colon cancer patients. Reasons for delays may be due to system factors that influence individual providers to make varying decisions on the time of initiation. Future research should identify what these factors may be and how to address them to promote better delivery of care.

AimsLymph node yield (LNY) is used as a marker of adequate oncological resection. The American Joint Committee on Cancer (AJCC) currently recommends that at least 12 nodes are necessary to confirm node-negative disease for rectal cancer. A LNY of 12 is not always achieved, particularly in patients who have undergone neoadjuvant treatment. This study attempts to examine factors associated with LNY and its prognostic impact following neoadjuvant chemoradiation in rectal cancer.MethodsThe 2006–2011 National Cancer Data Base was queried for patients with clinical stage I–III rectal cancer who underwent a proctectomy. Suboptimal LNY was defined as Results25 447 patients met inclusion criteria. Overall, 62% of the cohort received neoadjuvant chemoradiation and 32% had suboptimal LNY. The median LNY for patients who received neoadjuvant therapy was 13 (IQR: 9–18) and for patients who did not receive neoadjuvant therapy was 15 (IQR: 12–21). After risk adjustment, there was a 3.5-fold difference in the rate of suboptimal LNY among individual hospitals (27%–95%). Suboptimal LNY was independently associated with an 18% increased hazard of death among patients who did not receive neoadjuvant treatment and a 20% increased hazard of death among those who did receive neoadjuvant treatment when controlled for adjuvant treatment, staging, proximal/distal margins and other patient factors.ConclusionsSuboptimal LNY is independently associated with worse overall survival regardless of neoadjuvant therapy, pathological staging and patient factors in rectal cancer. This finding underlies the importance and challenge of an optimal lymph node evaluation for prognostication, especially for patients receiving neoadjuvant therapy.

National Comprehensive Cancer Network treatment guidelines for patients with locally advanced rectal cancer include neoadjuvant chemoradiation followed by total mesorectal excision and adjuvant chemotherapy. The objective of the current study was to examine the rate of adjuvant chemotherapy and associated survival in patients with stage II/III rectal cancer.The 2006 to 2011 National Cancer Data Base was queried for patients with AJCC clinical stage II/III rectal cancer who underwent neoadjuvant chemoradiation and surgical resection. A mixed effects multivariable logistic regression identified factors associated with the receipt of adjuvant chemotherapy. A mixed effects Cox proportional hazards model was used to estimate the adjusted effect of receiving adjuvant therapy on 5-year overall survival (OS).A total of 14,742 patients were included; 68% of the cohort did not receive adjuvant chemotherapy. When controlled for clinical stage of disease, patients who were aged70 years, had a higher comorbidity score, and had a pathologic complete response had lower odds of receiving adjuvant therapy. There was a 22-fold difference in the risk-adjusted rate of adjuvant therapy use among hospitals (3.1%-67.7%). Adjuvant therapy was associated with increased 5-year OS when controlled for patient factors, stage of disease, and pathologic response (hazard ratio, 0.65; 95% confidence interval, 0.59-0.71). The greatest survival benefit was noted among patients who achieved a pathologic complete response (hazard ratio, 0.40; 95% confidence interval, 0.23-0.67).There is poor compliance to National Comprehensive Cancer Network guidelines for adjuvant chemotherapy in patients with locally advanced rectal cancer after neoadjuvant chemoradiation and surgery. Adjuvant therapy appears to be independently associated with improved OS regardless of stage of disease, pathologic response, and patient factors. The greatest survival benefit was observed in patients who were complete responders. Age and comorbidities were found to be significantly associated with nonreceipt of adjuvant therapy. Improved rehabilitation and physical conditioning may improve the odds of patients receiving adjuvant therapy. Cancer 2017;52-61. © 2016 American Cancer Society.

Little is known about between-hospital differences in the rate of suboptimal lymphadenectomy. This study characterizes variation in hospital-specific rates of suboptimal lymphadenectomy and its effect on overall survival in a national hospital-based registry. Stage I–III colon cancer patients were identified from the 2003–2012 National Cancer Data Base. Bayesian multilevel logistic regression models were used to assess the impact of patient- and hospital-level factors on hospital-specific rates of suboptimal lymphadenectomy (