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Association Between Treatment and End-of-Life Outcomes after Hospitalization for Bowel Obstruction among Older Cancer Patients: A Retrospective Cohort Study Using a National Population-Based Registry
GERIATRIC AND PALLIATIVE CARE during the last 12 months of life, surgery is associated with worse end-of-life care than VPEG. More work is needed to improve endof-life care for patients who undergo surgery.
Association Between Treatment and End-ofLife Outcomes after Hospitalization for Bowel Obstruction among Older Cancer Patients: A Retrospective Cohort Study Using a National Population-Based Registry Elizabeth J Lilley, MD, MPH*, Christy E Cauley, MD, Joel E Goldberg, MD, MPH, Navin R Changoor, MD, John W Scott, MD, MPH, Brittany L Smalls, PhD, MHSA, Joel Weissman, PhD, David L Hepner, MD, MPH, Angela M Bader, MD, MPH, Zara Cooper, MD, FACS Center for Surgery and Public Health, Boston, MA, Brigham and Women’s Hospital, Boston, MA, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ
Effect of Pre-Admission Beta-Blocker Use on Outcomes in a National Sample of Elderly Americans Admitted with Traumatic Brain Injury Courtney Collins, MD, Julie M Flahive, Fred A Anderson, Jr, PhD, Heena P Santry, MD, FACS University of Massachusetts Medical School, Worcester, MA INTRODUCTION: Elderly patients are at increased risk of adverse outcomes after trauma often due to cardiac comorbidities. We examined the effect of pre-admission beta-blocker (BB) use on traumatic brain injury (TBI) outcomes in a national sample of elderly Medicare beneficiaries.
INTRODUCTION: Bowel obstruction is a common, late occurrence in patients with metastatic cancer. Palliative interventions, including venting percutaneous endoscopic gastrostomy (VPEG) and surgery, aim to reduce symptom burden and alleviate suffering near the end of life. However, there is a dearth of evidence examining the association between treatment and end-of-life outcomes. This study examined the association between treatment modality and quality of end-of-life care.
METHODS: We queried a 5% random sample of Medicare data (2009-2011) for patients > 65 years of age admitted for TBI with/ without pre-admission BB use. Demographic, clinical, and pre-admission BB variables were obtained from Part A/B/D claims. Outcomes (ICU stay, length of stay (LOS), in-hospital and 30-day mortality) were compared by pre-admission BB usage (none, BB, BB discontinued >30days pre-admission). A multivariable model investigated the effect of pre-admission BB use on in-hospital and 30-day mortality after TBI.
METHODS: Decedents > 65 years of age with metastatic colorectal, ovarian, and pancreatic malignancies, who were admitted for bowel obstruction within 12 months preceding death, were identified from the 2001-2012 Surveillance, Epidemiology, and End Results (SEER)Medicare linked dataset. Based on National Quality Forum metrics, indicators for low quality end-of-life care included never enrolling in hospice, ICU care in the last 30 days of life, and death in an acute-care hospital. Multivariable logistic regression compared the association between type of treatment (bowel obstruction surgery, VPEG placement, or medical management) with end-of-life outcomes.
RESULTS: Of 5,921 TBI patients, 1,852 (31%) were currently on BB, 592 (10%) had discontinued BBs, and 3,477 (59%) had never received a BB. There was no significant difference between BB groups in LOS or need for ICU care despite increased in-hospital and 30-day mortality rates for those with recently discontinued BB. On multivariable analysis, discontinuation of a BB increased the odds of in-hospital mortality by 70% compared with non-BB users (odds ratio [OR] 1.7, 95% CI 1.3-2.3); current BB users had no difference in in-hospital mortality (OR 1.2, 95% CI 0.9-1.5). Discontinuation of BB conferred a similar increase in 30-day mortality (OR 1.7, 95% CI 1.3-2.2) compared with non-BB users, and current BB use showed no increased risk (OR 1.1, 95% CI 0.9-1.3).
RESULTS: Among 15,741 patients in the cohort, 41.4% underwent operation and 4.5% underwent VPEG placement, and 54.1% had medical management. In multivariate analysis, surgery was associated with increased odds of never receiving hospice, receiving ICU care, and dying in-hospital (Table). In contrast, VPEG was associated with reduced odds of never receiving hospice, receiving ICU care, and in-hospital death.
CONCLUSIONS: Noncompliance with BB therapy puts elderly TBI patients at substantially increased risk of mortality. Traumatologists and primary care physicians should pay special attention to medication adherence in this vulnerable population.
Table. Multivariate Binary Logistic Regression of Quality of Death Outcomes among Medicare Decedents with Colorectal, Pancreatic, and Ovarian Cancer Hospitalized with Bowel Obstruction During the Last Year of Life (n ¼ 15,741)
Adjusted for age, sex, race, Charlson comorbidity index, and cancer site. All values statistically significant, p < 0.05. OR, odds ratio.
One-Year Mortality after Elective Colectomy for Benign Disease: Not a Benign Outcome Zhaomin Xu, MD, Geoffrey C Williams, MD, PhD, Christopher T Aquina, MD, Adan Z Becerra, Bradley J Hensley, MD, MBA, Reza Arsalani-Zadeh, MD, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester, Rochester, NY
CONCLUSIONS: Among older patients with metastatic colorectal, ovarian, and pancreatic cancer hospitalized with bowel obstruction
INTRODUCTION: There is a lack of data for long-term outcomes in patients who undergo elective colectomy for benign disease. This
No hospice enrollment ICU in last 30 d Died in-hospital Treatment Adjusted OR [CI] Noninvasive (reference) e Surgery 1.29 [1.21e1.38] VPEG 0.60 [0.50e0.71]
Adjusted OR [CI] Adjusted OR [CI] e e 2.00 [1.86e2.15] 1.16 [1.08e1.25] 0.67 [0.54e0.83] 0.44 [0.35e0.54]
S63
http://dx.doi.org/10.1016/j.jamcollsurg.2016.06.119 ISSN 1072-7515/16
Association Between Treatment and End-ofLife Outcomes after Hospitalization for Bowel Obstruction among Older Cancer Patients: A Retrospective Cohort Study Using a National Population-Based Registry Elizabeth J Lilley, MD, MPH*, Christy E Cauley, MD, Joel E Goldberg, MD, MPH, Navin R Changoor, MD, John W Scott, MD, MPH, Brittany L Smalls, PhD, MHSA, Joel Weissman, PhD, David L Hepner, MD, MPH, Angela M Bader, MD, MPH, Zara Cooper, MD, FACS Center for Surgery and Public Health, Boston, MA, Brigham and Women’s Hospital, Boston, MA, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ
Effect of Pre-Admission Beta-Blocker Use on Outcomes in a National Sample of Elderly Americans Admitted with Traumatic Brain Injury Courtney Collins, MD, Julie M Flahive, Fred A Anderson, Jr, PhD, Heena P Santry, MD, FACS University of Massachusetts Medical School, Worcester, MA INTRODUCTION: Elderly patients are at increased risk of adverse outcomes after trauma often due to cardiac comorbidities. We examined the effect of pre-admission beta-blocker (BB) use on traumatic brain injury (TBI) outcomes in a national sample of elderly Medicare beneficiaries.
INTRODUCTION: Bowel obstruction is a common, late occurrence in patients with metastatic cancer. Palliative interventions, including venting percutaneous endoscopic gastrostomy (VPEG) and surgery, aim to reduce symptom burden and alleviate suffering near the end of life. However, there is a dearth of evidence examining the association between treatment and end-of-life outcomes. This study examined the association between treatment modality and quality of end-of-life care.
METHODS: We queried a 5% random sample of Medicare data (2009-2011) for patients > 65 years of age admitted for TBI with/ without pre-admission BB use. Demographic, clinical, and pre-admission BB variables were obtained from Part A/B/D claims. Outcomes (ICU stay, length of stay (LOS), in-hospital and 30-day mortality) were compared by pre-admission BB usage (none, BB, BB discontinued >30days pre-admission). A multivariable model investigated the effect of pre-admission BB use on in-hospital and 30-day mortality after TBI.
METHODS: Decedents > 65 years of age with metastatic colorectal, ovarian, and pancreatic malignancies, who were admitted for bowel obstruction within 12 months preceding death, were identified from the 2001-2012 Surveillance, Epidemiology, and End Results (SEER)Medicare linked dataset. Based on National Quality Forum metrics, indicators for low quality end-of-life care included never enrolling in hospice, ICU care in the last 30 days of life, and death in an acute-care hospital. Multivariable logistic regression compared the association between type of treatment (bowel obstruction surgery, VPEG placement, or medical management) with end-of-life outcomes.
RESULTS: Of 5,921 TBI patients, 1,852 (31%) were currently on BB, 592 (10%) had discontinued BBs, and 3,477 (59%) had never received a BB. There was no significant difference between BB groups in LOS or need for ICU care despite increased in-hospital and 30-day mortality rates for those with recently discontinued BB. On multivariable analysis, discontinuation of a BB increased the odds of in-hospital mortality by 70% compared with non-BB users (odds ratio [OR] 1.7, 95% CI 1.3-2.3); current BB users had no difference in in-hospital mortality (OR 1.2, 95% CI 0.9-1.5). Discontinuation of BB conferred a similar increase in 30-day mortality (OR 1.7, 95% CI 1.3-2.2) compared with non-BB users, and current BB use showed no increased risk (OR 1.1, 95% CI 0.9-1.3).
RESULTS: Among 15,741 patients in the cohort, 41.4% underwent operation and 4.5% underwent VPEG placement, and 54.1% had medical management. In multivariate analysis, surgery was associated with increased odds of never receiving hospice, receiving ICU care, and dying in-hospital (Table). In contrast, VPEG was associated with reduced odds of never receiving hospice, receiving ICU care, and in-hospital death.
CONCLUSIONS: Noncompliance with BB therapy puts elderly TBI patients at substantially increased risk of mortality. Traumatologists and primary care physicians should pay special attention to medication adherence in this vulnerable population.
Table. Multivariate Binary Logistic Regression of Quality of Death Outcomes among Medicare Decedents with Colorectal, Pancreatic, and Ovarian Cancer Hospitalized with Bowel Obstruction During the Last Year of Life (n ¼ 15,741)
Adjusted for age, sex, race, Charlson comorbidity index, and cancer site. All values statistically significant, p < 0.05. OR, odds ratio.
One-Year Mortality after Elective Colectomy for Benign Disease: Not a Benign Outcome Zhaomin Xu, MD, Geoffrey C Williams, MD, PhD, Christopher T Aquina, MD, Adan Z Becerra, Bradley J Hensley, MD, MBA, Reza Arsalani-Zadeh, MD, Katia Noyes, PhD, MPH, John R Monson, MD, MB BCH, FRCS, FACS, Fergal Fleming, MD University of Rochester, Rochester, NY
CONCLUSIONS: Among older patients with metastatic colorectal, ovarian, and pancreatic cancer hospitalized with bowel obstruction
INTRODUCTION: There is a lack of data for long-term outcomes in patients who undergo elective colectomy for benign disease. This
No hospice enrollment ICU in last 30 d Died in-hospital Treatment Adjusted OR [CI] Noninvasive (reference) e Surgery 1.29 [1.21e1.38] VPEG 0.60 [0.50e0.71]
Adjusted OR [CI] Adjusted OR [CI] e e 2.00 [1.86e2.15] 1.16 [1.08e1.25] 0.67 [0.54e0.83] 0.44 [0.35e0.54]
S63
http://dx.doi.org/10.1016/j.jamcollsurg.2016.06.119 ISSN 1072-7515/16