Nationwide diffusion of laparoscopic resection improves quality and cost measures for distal pancreatectomy

Vol. 215, No. 3S, September 2012

Abstracts S103

data to estimate odds ratios and confidence intervals. To assess consistency, separate matched analyses were carried out using propensity scores derived from logistic regression and classification trees. RESULTS: Overall adherence to the BB-SCIP was 91.0%. No bivariate association was evident between BB-SCIP adherence and the composite cardiac outcome of MI or cardiac arrest (OR 1.11, p⫽0.73) or 30-day mortality (OR 1.12, p⫽0.61). BB-SCIP adherence was associated with increased risk of Stroke (OR 7.32, p⫽0.027), Sepsis (OR 1.91, p⬍0.01), and Renal Insufficiency (OR 2.34, p⫽0.03). Results of both propensity-matched analyses were consistent with these findings. Unadjusted data BB vs. no BB

Bootstrapped propensity score matching Logistic PS

Classification tree PS

OR

p

OR: median (5%, 95%)

OR: median (5%, 95%)

CVA

7.318

0.027

4.470 (1.26, ⬎100)

3.516 (1.18, ⬎100)

Cardiac

1.106

0.733

0.768 (0.50, 1.25)

0.796 (0.40, 1.56)

30-day mortality

1.124

0.614

0.868 (0.58, 1.35)

0.624 (0.38, 1.05)

1-year mortality

1.235

0.215

0.925 (0.67, .37)

0.833 (0.55, 1.28)

Sepsis

1.906

0.001

1.505 (1.00, 2.41)

1.580 (1.01, 2.56)

Renal insufficiency

2.340

0.033

4.107 (1.57, ⬎100)

3.581 (1.86, 8.81)

Outcome

CONCLUSIONS: Adherence to BB-SCIP measure was not associated with a reduction in peri-operative cardiac events or mortality, but was associated with increased complications. These findings suggest that perioperative beta blocker use may lead to increased postoperative morbidity among patients on chronic beta blocker therapy. Further study is warranted on the safety of this measure.

Rurality and colon cancer care quality measures Christopher J Chow, MD, Waddah Al-Refaie, MD, FACS, Anasooya Abraham, MD, MS, Abraham Markin, BA, Wei Zhong, MS, David A Rothenberger, MD, FACS, Mary Kwaan, MD, MPH, Elizabeth Habermann, PhD, MPH University of Minnesota, Minneapolis, MN, Minneapolis VAMC, Minneapolis, MN INTRODUCTION: Over fifty million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized. We hypothesize that patient rurality impacts colon cancer care quality measures. METHODS: Using the 1996-2008 California Cancer Registry, we identified 123,129 patients with stage 0-IV colon cancer. Rural residence was established based on the patient’s rural or urban medical service study area designation. Baseline characteristics were compared by rurality status. Controlling for covariates, multivariate regression models were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I-III disease and receipt of chemotherapy for stage III disease. Cox proportional hazards modeling was used to examine the impact of rurality on survival in the entire cohort. RESULTS: Of all patients diagnosed with colon cancer, 15% resided in rural areas. Rural residence was associated with white or American Indian race and later stage. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I-III disease and inadequate

receipt of chemotherapy for stage III disease (Table). In addition, rurality was associated with worse cancer specific survival (Table). Table. Multivariate Analyses of Rurality and Colon Cancer Quality Measures Rurality and colon cancer quality measures

OR or HR

95% CI

Late stage at diagnosis*: rural vs. urban residence

OR 1.037

1.001–1.075

Adequate Lymphadenectomy for Stage I-III*: rural vs. urban residence

OR 0.814

0.783–0.847

Receipt of Chemotherapy for Stage III*: rural vs urban residence

OR 0.834

0.773–0.900

Cancer Specific survival**: rural vs. urban residence

HR 1.050

1.015–1.087

*After adjusting for sex, age, race, marital status, payer/insurance status and year of diagnosis. **After adjusting for stage, surgery, grade, age, lymphadenectomy, chemo, sex, race, marital status, insurance status, and year of diagnosis.

CONCLUSIONS: A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with later stage, poor adherence to quality measures and poorer survival. Future quality improvement measures should specifically target rural patients to ensure both that structure of care is optimal and that appropriate processes of care are followed.

Nationwide diffusion of laparoscopic resection improves quality and cost measures for distal pancreatectomy Hop S Tran Cao, MD, David C Chang, PhD, MPH, MBA, Kerrin L Palazzi, MPH, Andrew M Lowy, MD, FACS, Michael Bouvet, MD, FACS, J K Parsons, MD, MHS, Mark A Talamini, MD, FACS, Jason K Sicklick, MD University of California San Diego, La Jolla, CA INTRODUCTION: Laparoscopic distal pancreatectomy (LDP) was first reported in 1996. Since then, all publications evaluating LDP have consisted of institutional case series. We hypothesized that a national database inquiry could offer insight into the application and outcomes of LDP. METHODS: The Nationwide Inpatient Sample (NIS) was queried for patients undergoing DP between 1998-2009. Multivariate analyses were performed using logistic regression models, adjusting for age, gender, ethnicity, comorbidities, year of procedure, and hospital settings to assess perioperative outcomes. RESULTS: 42,320 open DP (ODP) and 1,908 LDP were performed between 1998-2009.The proportion of DPs performed laparoscopically increased from 2.5% to 7.3%. The groups were comparable for gender and Charlson comorbidity index, while LDP patients were 1.5 years older (p⫽0.002). LDP was associated with significantly lower transfusion requirements (11.0% vs. 17.9%), sepsis rates (0.7% vs. 2.3%), and length of stay (LOS; 8.6- vs. 10.8-days). On multivariate analyses, LDP offered statistically significant advantages over ODP including: lower mortality (OR 0.36); shorter LOS (1.48-days); lower total charges ($10,909.52); lower sepsis rates (OR 0.246); and fewer transfusion requirements (OR 0.538). There were no differences in complication rates, including fistulae, infections/abscesses, hemorrhage/hematomas, inadvertent organ injuries, wound complications, organ dysfunction, or thromboembolic events.

S104

Abstracts

CONCLUSIONS: The application of LDP has tripled in practice from 1998-2009. We confirmed reports of LDP’s advantages of shorter LOS and lower blood loss, and identified novel advantages, including lower mortality and sepsis rates, as well as lower total charges. LDP has evolved into a safe and potentially more costeffective option in the treatment of pancreatic diseases.

Analysis of defined mortality for patent ductus arteriosus: Implications for measuring quality in neonatal surgical care Danielle M Hsu, MD, Lingling Li, MD, MS, Chi-Hong Tseng, PhD, Lorraine I Kelley-Quon, MD, Stephen B Shew, MD, FACS UCLA, Los Angeles, CA INTRODUCTION: Primary in-hospital mortality has been employed as an outcome measure for neonatal care, yet 30-day mortality may be more reflective of perioperative factors contributing to quality of surgical care. To compare 30-day versus in-hospital mortality outcome measures, we used ligation of patent ductus arteriosus (PDA) as a representative disease process. METHODS: Birth/discharge records of very-low-birth-weight (VLBW) infants with PDA without congenital heart disease were extracted from the California Linked-Birth Dataset (1999-2007). Survival analysis 30 days post-operatively versus to first discharge of infants with PDA, along with logistic regression of the surgical cohort, were performed controlling for co-morbidities and neonatal intensive care unit (NICU) level. RESULTS: Among infants diagnosed with PDA (N⫽10,780), ligation was performed in 23% (N⫽2,497; 13% mortality with 2/3 of deaths occurring within 30 days of surgery). In survival analysis, infants undergoing PDA ligation had increased likelihood of mortality within 30 days following surgery compared to those who did not have surgery (HR 1.21, p⫽0.03). This effect was not seen with in-hospital mortality (HR 0.83, p⫽0.12). PDA ligation at NICU level 3A (OR 2.72, 95% CI 1.34-5.52) increased likelihood of 30day mortality compared to level 3C. No difference existed for inhospital mortality (OR 1.81, p⫽0.31). CONCLUSIONS: In patients undergoing PDA ligation, significant differences in 30-day mortality were related to specific variables including surgical vs. non-surgical management and NICU level. These differences were not apparent when in-hospital mortality was utilized as the outcome measure. In defining outcomes for quality care in neonatal surgery, 30-day mortality may be a more robust quality indicator.

Can we measure the quality of complex cancer surgery? Comparison of patients and outcomes at National Cancer Institute Designated Cancer Centers (NCI-CC) vs. NonNCI centers Ryan P Merkow, MD, MSHS, David J Bentrem, MD, MS, FACS, Warren B Chow, MD, MS, MSHS, Clifford Y Ko, MD, FACS, Karl Y Bilimoria, MD, MS Division of Research and Optimal Patient Care, American College

J Am Coll Surg

of Surgeons, Chicago, IL, Northwestern University, Feinberg School of Medicine Chicago IL, University of Colorado School of Medicine, Aurora, CO INTRODUCTION: With increasing interest in measuring hospital quality for cancer surgery, concern exists that the complexity of patients and cases at NCI-CCs is under appreciated, resulting in inadequate risk adjustment of outcomes. Our objectives were to assess differences in patient demographics and comorbidities and to compare short-term outcomes using case-complexity adjustment between NCI-CC and non-NCI centers. METHODS: From ACS-NSQIP, patients were identified who underwent colorectal, pancreatic, or esophagogastric resection for cancer (2007-2011). Regression methods were used to evaluate patient characteristics associated with undergoing treatment at NCI-CCs and case-complexity adjusted 30-day mortality, serious morbidity, superficial/deep SSI, organ space SSI, and VTE at NCI-CC vs. nonNCI centers. RESULTS: 69,374 patients underwent colorectal (n⫽52,265), pancreatic (n⫽12,285) or esophagogastric (n⫽4,824) surgery for cancer, of which 17,780 (25.8%) were treated at a NCI-CC (45/62 centers participate in ACS-NSQIP). Patients treated at NCI-CCs were more likely younger, white, or with fewer comorbidities, but were more likely to perform procedures with higher complexity scores (all p⬍0.05; Table). NCI-CCs had lower riskadjusted mortality for colorectal (OR 0.78, 95%CI 0.62-0.99) and pancreatic (OR 0.74, 95%CI 0.56-0.97) but not esophagogastric surgery. Risk of superficial/deep SSI was increased at NCICCs for colorectal surgery only (OR 1.38, 95%CI 1.12-1.68). No differences existed for the remaining complications by NCI-CC designation status. Table. Predictors of Undergoing Colorectal, Pancreatic or Esophagogastric Resection for Cancer at National Cancer Institute Cancer Centers. Characteristic

Adjusted OR (95% CI)

Age (vs. ⬍55)

Characteristic

Adjusted OR (95% CI)

Functional status (vs. independent)

55–69

0.88 (0.84–0.93)

Dependent

0.86 (0.77–0.95)

ⱖ70

0.72 (0.69–0.76)

Copd

0.75 (0.68–0.82)

Weight loss

1.12 (1.04–1.19)

Race (vs. white) Black

0.90 (0.84–0.96)

Diabetes

0.92 (0.88–0.97)

Hispanic

0.65 (0.59–0.72)

Disseminated cancer

1.36 (1.26–1.47)

ASA class (vs. I/II)

Complexity score

III

1.06 (1.02–1.10)

Colorectal

1.28 (1.23–1.32)

IV

0.69 (0.62–0.76)

Pancreatic

1.07 (1.02–1.12)

Albumin <3.0 g/dL

0.57 (0.52–0.62)

Esophagogastric

1.33 (1.24–1.43)

CONCLUSIONS: NCI-CCs treated younger, healthier patients, but performed more complex procedures. Patients treated at NCI-CCs had lower mortality risk for colorectal and pancreatic resection, but morbidity was similar to non-NCI centers. Comparison of cancer surgery hospital quality should adjust for differences in patient demographics, comorbidities, and case-complexity.