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Shifting Risk Profiles: Trends in Mortality Risk in the American College of Surgeons NSQIP Cohort
Vol. 223, No. 4S2, October 2016
Scientific Forum: 2016 Clinical Congress
surgery. We examined 30-day mortality and hospital readmission rates, stratified by procedure type (lumpectomy, mastectomy, and axillary lymph node dissection with either lumpectomy or mastectomy [LND]). In multivariate analysis, we examined factors associated with 1-year mortality and functional trajectories. Functional status was measured by assessing the degree of dependence in seven activities of daily living (Minimum Data Set-Activities of Daily Living [MDS-ADL] scale 0-28; higher scores indicating greater functional difficulty; 2 point difference as clinically significant). RESULTS: We identified 4,180 nursing home residents who underwent inpatient breast cancer surgery (age: 82 7, 84% white, 48% dementia). On average, residents experienced significant functional decline after surgery; 30-day readmission, 30-day mortality and 1-year all-cause mortality were high (Table). In a multivariate analysis, poor baseline MDS-ADL score before surgery was strongly associated with 1-year mortality-lumpectomy: HR 2.60 (95% CI:1.53-4.41), mastectomy: HR 2.09 (95% CI:1.49-2.94), LND: HR 1.92 (95% CI:1.50-2.46). Table. Postoperative Outcomes in Nursing Home Residents after Breast Cancer Surgery
Outcome 1-year MDS-ADL functional decline* 30-day readmission 30-day mortality 1 year all-cause mortality
Lumpectomy Mastectomy (N ¼ 493) (N ¼ 1107) 3.4 points 2.9 points 26% 9% 42%
14% 4% 31%
Lumpectomy or Mastectomy with Lymph Node Dissection (N ¼ 2580) 2.5 points 15% 2% 26%
*MDS-ADL: 2 point decline is clinically significant
CONCLUSIONS: Among nursing home women residents who undergo breast cancer surgery, 30-day hospital readmission and mortality are high, as is 1-year all-cause mortality. Poor baseline function prior to surgery was strongly associated with 1-year mortality. Individualized goal-oriented care (ie hormonal therapy or symptom management only) should be considered.
Population-Based Trends of Thyroid Cancer in the Elderly Forecast the Demand for More Endocrine-Focused Surgeons across the United States Vikram D Krishnamurthy, MD, Melissa Boltz, MBA, Judy Z Jin, MD, Joyce J Shin, MD, FACS, Eren Berber, MD, FACS, Allan Siperstein, MD Cleveland Clinic, Cleveland, OH, Penn State Hershey Medical Center, Hershey, PA
e35
intervals per state using SEER, Census, CMS, and American College of Surgeons workforce atlases data. Statistical analysis was performed with JMP Pro v10. RESULTS: In 2012 there were 8,465 estimated new cases of PTC in eMCB with 2,303 TT (27%) performed by 138 HVS. By 2030, population-adjusted trends predict 14,116 new cases and 150 HVS. At minimum, a 46% increase in TT performed per HVS or 55% increase in the number of HVS will be necessary to maintain the 27% of TT performed by HVS in 2012. In 2012, there were 17 states with stable/rising PTC rates where less than 25% of TT were performed by HVS. By 2030, this number will increase to 18 states, of which the majority will be located in the West compared to the South (50% vs 6%, p¼.003567). CONCLUSIONS: The projected demand for higher volume surgeons performing thyroidectomies in the US is substantial. This data supports continuous medical education in best practices for thyroid cancer directed at all surgeons and incentivizes the recruitment of endocrine-focused surgeons to areas most in need, increasing elderly access to specialty surgery. Shifting Risk Profiles: Trends in Mortality Risk in the American College of Surgeons NSQIP Cohort Vamsi V Alli, MD, Jie Yang, PhD, Jianjin Xu, Aurora D Pryor, MD, FACS, Mark A Talamini, MD, FACS, Dana A Telem, MD, FACS Stony Brook Medicine, Stony Brook, NY INTRODUCTION: Given the increased attention to quality and outcomes, we sought to assess the impact of operative intervention in patients at high risk for mortality. METHODS: From 2005-2012, 2,972,860 records were identified from the ACS-NSQIP dataset. Patients were stratified into mortality risk quartile (MRQ: <25%, 25-50%, 50-75%, >75%), using the ACS-NSQIP mortality risk index (MRI) and substratified by age, sex, and acuity of operation. Observed mortality was compared to expected mortality. Log-linear models were used for analyzing trends over time and are reported as relative risks (RR) with 95% confidence interval. Wilcoxon signed rank test was used to determine difference between mortality risk and observed mortality.
INTRODUCTION: Rates of papillary thyroid cancer (PTC) are increasing rapidly, and the highest incidence and mortality are in the elderly. We projected future PTC burden and surgeon supply for elderly Medicare beneficiaries, intimated in prior studies to undergo thyroidectomies at lower volume centers and experience worse outcomes.
RESULTS: No significant change in operative rate was noted in patients with low MRQ (<25%) whether emergent (RR: 1.0086, p¼0.44) or nonemergent surgery (RR: 1.0079, p¼0.74), while operative rates decreased significantly with higher MRQs (RR:<0.942, p<0.001, all groups). This finding held true for both sex and age >55. Additionally, observed mortality rate was underestimated by the NSQIP calculated mortality index for the <25% MRQ (p¼0.0039), while overestimating mortality risk (p¼0.0039) in both high-risk and very high MRQs (50% to 75% and >75%).
METHODS: Trends in PTC, total thyroidectomies (TT), and high-volume general surgeons/otolaryngologists (HVS) for elderly Medicare Part B beneficiaries (eMCB) were forecasted in 5-year
CONCLUSIONS: Operative interventions on patients at high risk for mortality, as defined by the NSQIP MRI, have decreased significantly over time in patients with mortality risk >25%. This held
e36
J Am Coll Surg
Scientific Forum: 2016 Clinical Congress
true following patient stratification. Interestingly, observed mortality was significantly less than expected in high and very high MRQ. This may be a function of increasing attention to patient selection in high risk categories, leading to better mortality outcomes. Socioeconomic Disparities Lead to Underutilization of Treatment for Gastric Cancer among the Elderly in the United States Anne O Lidor, MD, FACS, Daniela Molena, MD, Miloslawa Stem, Amanda Blackford, Timothy M Pawlik, MD, MPH, PhD, FACS Johns Hopkins University School of Medicine, Baltimore, MD, University of Wisconsin, Madison, WI, Memorial Sloan Kettering Cancer Center, New York, NY INTRODUCTION: In the US, a large number of elderly patients do not receive any treatment following the diagnosis of gastric cancer. We sought to characterize the impact of racial and socioeconomic disparities on under-treatment of gastric cancer in this population. METHODS: Elderly patients ( 65 years) who were diagnosed with local or regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall 5-year survival was analyzed using the Kaplan-Meier method. RESULTS: Among 12,086 patients with local or regional gastric cancer, 4,022 (33.3%) received no treatment. Median age was 78 years and 53.7% of patients were male. On multivariable analysis, factors most strongly associated with lack of therapy included demographic as well as tumor specific characteristics. As expected, patients who received therapy had a better overall survival (log-rank test, p<0.001). Specifically, median survival and 5-year survival among treated patients were 12.2 months and 11.4%, respectively, compared with 5.2 months and 7.7% among patients not treated. CONCLUSIONS: Elderly patients with gastric adenocarcinoma have improved 5-year survival when undergoing treatment for their cancer. Disparities in the utilization of treatment for curable cancers are associated with regional, socioeconomic, racial, and clinical factors.
Strategies for Reducing Population Surgical Costs in Medicare: Potential Benefit of Selective Referral to Low-Cost Hospitals Hari Nathan, MD, PhD, Edward C Norton, PhD, Huiying Hy Yin, Jyothi R Thumma, MPH, Justin B Dimick, MD, MPH, FACS University of Michigan, Ann Arbor, MI INTRODUCTION: Increasing consolidation of healthcare systems and innovative payment experiments (ie Accountable Care Organizations) have highlighted the need for population-based approaches to reducing healthcare costs for services such as inpatient surgery. Medicare expenditures are known to vary across hospitals, but the
potential benefit of selectively referring patients from high-cost to lower-cost hospitals within the same region has not been explored. METHODS: We included patients 65 to 99 years old undergoing 7 elective procedures during 2010-2012: colectomy, lung resection, AAA repair, CABG, knee replacement, hip replacement, and bariatric surgery. Using 100% Medicare claims data, we calculated risk- and reliability-adjusted payments for 30-day episodes of care using hierarchical regression models. We identified hospitals in each metropolitan statistical area (MSA) that were significantly more expensive than the cheapest hospital in that MSA and calculated excess expenditures and potential savings. RESULTS: The proportion of hospitals identified as “high-cost” ranged from 11% (lung resection) to 64% (hip replacement) (Table). The proportion of patients treated at high-cost hospitals ranged from 22% (colectomy, lung resection) to 73% (hip replacement). Excess expenditures due to care at high-cost hospitals ranged from $5655/case (lung) to $9927/case (CABG). Population savings with selective referral would range from 5.2% (colectomy) to 25.7% (bariatrics). Mortality was not significantly different at high-cost vs lower-cost hospitals. Table. Excess Expenditures at High-Cost Hospitals and Potential Population Savings
Procedure Colectomy Lung resection AAA repair CABG Knee replacement Hip replacement Bariatric surgery
Number of patients 57,600 37,772 51,983 62,521 266,144 578,918 13,330
High-cost/ total hospitals 337 / 3328 182 / 1676 339 / 1662 348 / 1036 1651 / 3169 2136 / 3333 311 / 1355
Excess per case, $ 5842 5655 7208 9927 6069 6085 8653
Population savings, $millions (% of Total) 74.1 (5.2) 61.1 (5.8) 134.4 (8.8) 232.9 (9.9) 1,045.3 (18.0) 2,585.0 (21.3) 56.1 (25.7)
CONCLUSIONS: Within local health care markets, there is substantial variation in Medicare expenditures for common, resource-intensive surgical procedures. The magnitude of excess Medicare expenditures varies significantly by procedure. Population surgical costs could potentially be reduced without impacting outcomes through a selective referral strategy based on cost. Surgeon Availability and Utilization of Bariatric Surgery in the United States Sarah E Billmeier, MD, MPH, Rachel K Brickman, Gina L Adrales, MD, MPH, FACS Dartmouth Hitchcock Medical Center, Lebanon, NH, Geisel School of Medicine, Hanover, NH INTRODUCTION: Bariatric surgery is the most effective long-term treatment for morbid obesity, yet is under-utilized. This study examines the association between surgeon availability and utilization of bariatric surgery among nine US census divisions. METHODS: The 2013 Nationwide Inpatient Sample was used to determine the incidence of bariatric procedures using ICD-9 codes.
Scientific Forum: 2016 Clinical Congress
surgery. We examined 30-day mortality and hospital readmission rates, stratified by procedure type (lumpectomy, mastectomy, and axillary lymph node dissection with either lumpectomy or mastectomy [LND]). In multivariate analysis, we examined factors associated with 1-year mortality and functional trajectories. Functional status was measured by assessing the degree of dependence in seven activities of daily living (Minimum Data Set-Activities of Daily Living [MDS-ADL] scale 0-28; higher scores indicating greater functional difficulty; 2 point difference as clinically significant). RESULTS: We identified 4,180 nursing home residents who underwent inpatient breast cancer surgery (age: 82 7, 84% white, 48% dementia). On average, residents experienced significant functional decline after surgery; 30-day readmission, 30-day mortality and 1-year all-cause mortality were high (Table). In a multivariate analysis, poor baseline MDS-ADL score before surgery was strongly associated with 1-year mortality-lumpectomy: HR 2.60 (95% CI:1.53-4.41), mastectomy: HR 2.09 (95% CI:1.49-2.94), LND: HR 1.92 (95% CI:1.50-2.46). Table. Postoperative Outcomes in Nursing Home Residents after Breast Cancer Surgery
Outcome 1-year MDS-ADL functional decline* 30-day readmission 30-day mortality 1 year all-cause mortality
Lumpectomy Mastectomy (N ¼ 493) (N ¼ 1107) 3.4 points 2.9 points 26% 9% 42%
14% 4% 31%
Lumpectomy or Mastectomy with Lymph Node Dissection (N ¼ 2580) 2.5 points 15% 2% 26%
*MDS-ADL: 2 point decline is clinically significant
CONCLUSIONS: Among nursing home women residents who undergo breast cancer surgery, 30-day hospital readmission and mortality are high, as is 1-year all-cause mortality. Poor baseline function prior to surgery was strongly associated with 1-year mortality. Individualized goal-oriented care (ie hormonal therapy or symptom management only) should be considered.
Population-Based Trends of Thyroid Cancer in the Elderly Forecast the Demand for More Endocrine-Focused Surgeons across the United States Vikram D Krishnamurthy, MD, Melissa Boltz, MBA, Judy Z Jin, MD, Joyce J Shin, MD, FACS, Eren Berber, MD, FACS, Allan Siperstein, MD Cleveland Clinic, Cleveland, OH, Penn State Hershey Medical Center, Hershey, PA
e35
intervals per state using SEER, Census, CMS, and American College of Surgeons workforce atlases data. Statistical analysis was performed with JMP Pro v10. RESULTS: In 2012 there were 8,465 estimated new cases of PTC in eMCB with 2,303 TT (27%) performed by 138 HVS. By 2030, population-adjusted trends predict 14,116 new cases and 150 HVS. At minimum, a 46% increase in TT performed per HVS or 55% increase in the number of HVS will be necessary to maintain the 27% of TT performed by HVS in 2012. In 2012, there were 17 states with stable/rising PTC rates where less than 25% of TT were performed by HVS. By 2030, this number will increase to 18 states, of which the majority will be located in the West compared to the South (50% vs 6%, p¼.003567). CONCLUSIONS: The projected demand for higher volume surgeons performing thyroidectomies in the US is substantial. This data supports continuous medical education in best practices for thyroid cancer directed at all surgeons and incentivizes the recruitment of endocrine-focused surgeons to areas most in need, increasing elderly access to specialty surgery. Shifting Risk Profiles: Trends in Mortality Risk in the American College of Surgeons NSQIP Cohort Vamsi V Alli, MD, Jie Yang, PhD, Jianjin Xu, Aurora D Pryor, MD, FACS, Mark A Talamini, MD, FACS, Dana A Telem, MD, FACS Stony Brook Medicine, Stony Brook, NY INTRODUCTION: Given the increased attention to quality and outcomes, we sought to assess the impact of operative intervention in patients at high risk for mortality. METHODS: From 2005-2012, 2,972,860 records were identified from the ACS-NSQIP dataset. Patients were stratified into mortality risk quartile (MRQ: <25%, 25-50%, 50-75%, >75%), using the ACS-NSQIP mortality risk index (MRI) and substratified by age, sex, and acuity of operation. Observed mortality was compared to expected mortality. Log-linear models were used for analyzing trends over time and are reported as relative risks (RR) with 95% confidence interval. Wilcoxon signed rank test was used to determine difference between mortality risk and observed mortality.
INTRODUCTION: Rates of papillary thyroid cancer (PTC) are increasing rapidly, and the highest incidence and mortality are in the elderly. We projected future PTC burden and surgeon supply for elderly Medicare beneficiaries, intimated in prior studies to undergo thyroidectomies at lower volume centers and experience worse outcomes.
RESULTS: No significant change in operative rate was noted in patients with low MRQ (<25%) whether emergent (RR: 1.0086, p¼0.44) or nonemergent surgery (RR: 1.0079, p¼0.74), while operative rates decreased significantly with higher MRQs (RR:<0.942, p<0.001, all groups). This finding held true for both sex and age >55. Additionally, observed mortality rate was underestimated by the NSQIP calculated mortality index for the <25% MRQ (p¼0.0039), while overestimating mortality risk (p¼0.0039) in both high-risk and very high MRQs (50% to 75% and >75%).
METHODS: Trends in PTC, total thyroidectomies (TT), and high-volume general surgeons/otolaryngologists (HVS) for elderly Medicare Part B beneficiaries (eMCB) were forecasted in 5-year
CONCLUSIONS: Operative interventions on patients at high risk for mortality, as defined by the NSQIP MRI, have decreased significantly over time in patients with mortality risk >25%. This held
e36
J Am Coll Surg
Scientific Forum: 2016 Clinical Congress
true following patient stratification. Interestingly, observed mortality was significantly less than expected in high and very high MRQ. This may be a function of increasing attention to patient selection in high risk categories, leading to better mortality outcomes. Socioeconomic Disparities Lead to Underutilization of Treatment for Gastric Cancer among the Elderly in the United States Anne O Lidor, MD, FACS, Daniela Molena, MD, Miloslawa Stem, Amanda Blackford, Timothy M Pawlik, MD, MPH, PhD, FACS Johns Hopkins University School of Medicine, Baltimore, MD, University of Wisconsin, Madison, WI, Memorial Sloan Kettering Cancer Center, New York, NY INTRODUCTION: In the US, a large number of elderly patients do not receive any treatment following the diagnosis of gastric cancer. We sought to characterize the impact of racial and socioeconomic disparities on under-treatment of gastric cancer in this population. METHODS: Elderly patients ( 65 years) who were diagnosed with local or regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall 5-year survival was analyzed using the Kaplan-Meier method. RESULTS: Among 12,086 patients with local or regional gastric cancer, 4,022 (33.3%) received no treatment. Median age was 78 years and 53.7% of patients were male. On multivariable analysis, factors most strongly associated with lack of therapy included demographic as well as tumor specific characteristics. As expected, patients who received therapy had a better overall survival (log-rank test, p<0.001). Specifically, median survival and 5-year survival among treated patients were 12.2 months and 11.4%, respectively, compared with 5.2 months and 7.7% among patients not treated. CONCLUSIONS: Elderly patients with gastric adenocarcinoma have improved 5-year survival when undergoing treatment for their cancer. Disparities in the utilization of treatment for curable cancers are associated with regional, socioeconomic, racial, and clinical factors.
Strategies for Reducing Population Surgical Costs in Medicare: Potential Benefit of Selective Referral to Low-Cost Hospitals Hari Nathan, MD, PhD, Edward C Norton, PhD, Huiying Hy Yin, Jyothi R Thumma, MPH, Justin B Dimick, MD, MPH, FACS University of Michigan, Ann Arbor, MI INTRODUCTION: Increasing consolidation of healthcare systems and innovative payment experiments (ie Accountable Care Organizations) have highlighted the need for population-based approaches to reducing healthcare costs for services such as inpatient surgery. Medicare expenditures are known to vary across hospitals, but the
potential benefit of selectively referring patients from high-cost to lower-cost hospitals within the same region has not been explored. METHODS: We included patients 65 to 99 years old undergoing 7 elective procedures during 2010-2012: colectomy, lung resection, AAA repair, CABG, knee replacement, hip replacement, and bariatric surgery. Using 100% Medicare claims data, we calculated risk- and reliability-adjusted payments for 30-day episodes of care using hierarchical regression models. We identified hospitals in each metropolitan statistical area (MSA) that were significantly more expensive than the cheapest hospital in that MSA and calculated excess expenditures and potential savings. RESULTS: The proportion of hospitals identified as “high-cost” ranged from 11% (lung resection) to 64% (hip replacement) (Table). The proportion of patients treated at high-cost hospitals ranged from 22% (colectomy, lung resection) to 73% (hip replacement). Excess expenditures due to care at high-cost hospitals ranged from $5655/case (lung) to $9927/case (CABG). Population savings with selective referral would range from 5.2% (colectomy) to 25.7% (bariatrics). Mortality was not significantly different at high-cost vs lower-cost hospitals. Table. Excess Expenditures at High-Cost Hospitals and Potential Population Savings
Procedure Colectomy Lung resection AAA repair CABG Knee replacement Hip replacement Bariatric surgery
Number of patients 57,600 37,772 51,983 62,521 266,144 578,918 13,330
High-cost/ total hospitals 337 / 3328 182 / 1676 339 / 1662 348 / 1036 1651 / 3169 2136 / 3333 311 / 1355
Excess per case, $ 5842 5655 7208 9927 6069 6085 8653
Population savings, $millions (% of Total) 74.1 (5.2) 61.1 (5.8) 134.4 (8.8) 232.9 (9.9) 1,045.3 (18.0) 2,585.0 (21.3) 56.1 (25.7)
CONCLUSIONS: Within local health care markets, there is substantial variation in Medicare expenditures for common, resource-intensive surgical procedures. The magnitude of excess Medicare expenditures varies significantly by procedure. Population surgical costs could potentially be reduced without impacting outcomes through a selective referral strategy based on cost. Surgeon Availability and Utilization of Bariatric Surgery in the United States Sarah E Billmeier, MD, MPH, Rachel K Brickman, Gina L Adrales, MD, MPH, FACS Dartmouth Hitchcock Medical Center, Lebanon, NH, Geisel School of Medicine, Hanover, NH INTRODUCTION: Bariatric surgery is the most effective long-term treatment for morbid obesity, yet is under-utilized. This study examines the association between surgeon availability and utilization of bariatric surgery among nine US census divisions. METHODS: The 2013 Nationwide Inpatient Sample was used to determine the incidence of bariatric procedures using ICD-9 codes.