73.20 Gender Predicts Discharge Disposition Following Elective Fem-Pop Bypass

Posted on December 22, 2014

D. S. Kauvar1,2, C. L. Osborne3, D. S. Kauvar1,2  1Dwight D. Eisenhower Army Medical Center,Vascular Surgery,Ft. Gordon, GA, USA 2Uniformed Services University Of The Health Sciences,Surgery,Bethesda, MD, USA 3University Of Texas Medical Branch,Rehabilitation Sciences,Galveston, TX, USA

Introduction:  Femoropopliteal bypass (FPB) remains a widely accepted treatment option for symptomatic leg ischemia, even in patients without features of critical limb ischemia (CLI). These patients are revascularized to improve symptoms of exertional limb pain and the goal of such treatment is to increase their ability to ambulate within the community. Therefore, the ideal initial discharge disposition for a patient without CLI undergoing FPB is back to their home. This study examined the disposition at initial discharge of such patients.

Methods:  Data from the 2012 National Surgical Quality Improvement Program (NSQIP) registry was queried for all elective FPB performed in patients without CLI. Analysis was limited to patients surviving to initial discharge who were living independently at home prior to surgery. Initial disposition was defined as to HOME or to a FACILITY (either rehabilitation or skilled nursing); these constituting the study groups. Univariate analysis and multivariable logistic regression were performed to identify patient risk factors for failure to discharge to home. In-hospital and postoperative events were also recorded and compared. Significance was defined at P≤0.05.

Results: 1060 cases of elective FPB in patients without CLI were found in NSQIP 2012. The mean±SD age of the population was 65±9y; 359 (34%) of patients were female; 198 (19%) had a reported race other than white, and most (893, 84%) had hypertension. 60 (6%) patients failed to discharge to home (26 to rehabilitation, 34 to skilled nursing). On univariate analysis, age (FACILITY 68±11y vs HOME 65±9y, P=0.009), female gender (55% vs 37%, P<0.001), nonwhite race (30% vs 18%, P=0.007), and a history of diabetes (48% vs 33%, P=0.01), dialysis (5% vs 1.3%, P=0.02) congestive heart failure (CHF, 5% vs 1.1%, P=0.01), or a stroke (CVA, 5% vs 2.6%, P=0.01) were found to predict failure to discharge to home. On multivariate analysis, female gender (OR 2.4, 95% CI 1.4-4.1, P=0.002), and a history of CHF (OR 4.7, 1.2-18, 0.03) or CVA (OR 3.4, 1.9-9.4, 0.02) independently predicted failure to discharge to home. FACILITY patients had higher rates of infectious complications (8.3% vs 1.4%, P<0.001), myocardial infarction (3.3% vs 0.8%, P=0.05), operative transfusion (22% vs 5.8%, P<0.001), and unplanned reoperation (17% vs 2.4%, P<0.001) during their initial hospitalization.

Conclusion: Elective FPB results in a high rate of initial return to the community in patients without CLI. Female gender and serious comorbidities predict failure to discharge to home, which is associated with a complicated hospital course. The prediction of initial disposition by gender requires further study to improve FPBPG outcomes among female patients.

 

74.01 Application of Value Stream Mapping and Cost Heat Mapping to Reduce Surgical Item Wastage

Posted on December 22, 2014

B. Still1, L. Christianson1, A. Langerman2  2University Of Chicago,Department Of Surgery,Chicago, IL, USA 1University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA

Introduction:  Healthcare spending in the US in 2013 exceeded $3 trillion; it is projected to surpass $5 trillion by 2022. Attempts to curb this unsustainable growth are putting hospitals under increasing pressure to reduce their operating expenses. In the surgical setting, a key avoidable expense is wastage of disposable surgical items, which are often opened in preparation of a case but then go unused. Given that essentially all surgical procedures use disposable items, reducing wastage of these materials presents a promising target for reducing overall costs associated with the operating room. We report the application of Lean value stream mapping and cost heat mapping to identify targets for standardization of surgeon preference cards and streamlining of the item acquisition process.

Methods:  an initial value stream map (VSM) of the acquisition, use, and disposal of surgical items was constructed based on preliminary observation in the operating room. 

Stakeholders from multiple OR roles (surgeons, nurses, schedulers, central sterile processing personnel, surgical item reprocessing personnel, and operations managers) were subsequently interviewed; their feedback was used to modify the VSM. Key obstacles to the effective completion of the process outlined in the VSM were identified.

Data on disposable item cost and surgeon preference cards were then obtained from the Strategic Sourcing department and visualized using the novel technique of cost heat mapping, which visually highlights expensive disposable items and allows comparison of cost data across different surgeons.




 

Results: the completed VSM allowed identification of 18 major obstacles to effective acquisition and use of disposable surgical items. Potential interventions were generated for each obstacle and each intervention was evaluated on its feasibility and impact.

The cost heat maps allowed quick visual identification of high-cost disposable items and comparison of cost data across surgeons. The average cost difference between highest and lowest cost surgeons for the procedures analyzed was $955.18 (range $674.65 – $1245.96).

This information will be used to inform future efforts to standardize preference cards among all surgeons that perform the same procedure.

Conclusion: value stream mapping and cost heat mapping can be used to identify targets for standardization and streamlining of surgeon preference cards and the item acquisition process, reducing costs associated with wastage of disposable surgical items.

74.02 Hospital Readmission After an Initial Emergency Department Visit for Symptomatic Cholelithiasis

Posted on December 22, 2014

T. P. Williams1, D. Adhikari1, J. E. Bargerstock1, T. D. Kimbrough1, T. S. Riall1  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA

Introduction: For patients presenting with symptomatic cholelithiasis, cholecystectomy is the definitive treatment modality. Our goal was to evaluate the surgical follow-up and outcomes in patients seen in the Emergency Department (ED) for an episode of symptomatic cholelithiasis and discharged home for elective follow-up.

Methods: We performed a retrospective review of consecutive patients seen in the ED for cholelithiasis and discharged without hospital admission between August 2009 and May 2014. All patients were followed six months from the date of initial ED visit. We evaluated outpatient surgeon visits, elective and emergent cholecystectomy rates, and additional ED visits. Cumulative incidence and Kaplan-Meier curves were used to examine the time from the initial ED visit to outpatient surgeon evaluation and the time from initial ED visit to ED readmission.

Results: Seventy-one patients were discharged from the ED with a diagnosis of symptomatic gallstones. 11.3% of patients had an elective cholecystectomy in the six months after the initial visit. In this group, the mean time from the initial ED visit to outpatient surgeon follow-up was 7.9 days and all elective cholecystectomies occurred within one month of the initial visit. Of the 62 patients who did not have an elective cholecystectomy, only 11.3% of patients in this group had outpatient surgeon follow-up at mean time of 39.7 days from the initial ED visit for symptomatic gallstones. In addition, 37.1% of patients in this group had additional ED visits for gallstone-related symptoms, with 17.7 % of patients having two or more additional ED visits,    and 14.5% required emergent/urgent cholecystectomy. 43.5% of additional ED visits occurred within one month and 60.9% within three months of their initial ED visit. In patients with additional ED visits for symptomatic cholelithiasis, 60.9% had more than one abdominal Ultrasound (US) or Computed Tomography (CT) scan during the course of multiple visits.

Conclusion: Failure to achieve a timely surgical follow-up leads to multiple ED readmissions and emergent gallstone related hospitalizations, including emergency cholecystectomy. System-level interventions to ensure outpatient surgical follow-up within one to two weeks of the initial ED visit has the potential to improve outcomes for patients with symptomatic biliary colic.

 

74.03 Predicting Potentially Avoidable Serious Postoperative Complications

Posted on December 22, 2014

J. Martin1, Y. Li3, V. A. Ferraris1, S. P. Saha1, E. Q. Ballert1, R. Freyberg4, J. W. Harris1, P. L. Almenoff5  1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 3University Of Washington,VHA OAR, OIA,Seattle, WA, USA 4University Of Cincinnati,VHA OAR, OIA,Cincinnati, OH, USA 5University Of Missouri,VA Center Of Innovation,Columbia, MO, USA

Introduction:  Serious postoperative complications (SPC) nearly always precede operative mortality.  Early identification of patients likely to have SPC provides an opportunity to intervene and to limit morbidity and mortality.  Furthermore, failure to rescue patients having SPC from postoperative mortality (FTR) occurs may be a quality indicator.

Methods: We evaluated surgical admissions to 110 Veterans Affairs (VA) medical centers from 10/2012-9/2013.  We used VA administrative databases to identify risk factors for SPC and to measure SPC by the presence of five serious treatable complications (pneumonia, PE/DVT, sepsis, shock/cardiac arrest, GI hemorrhage/acute ulcer) developed by the AHRQ.    To predict the risk of developing SPC during a hospitalization, we conducted hierarchical logistic regressions with a random intercept at the hospital level on the development sample and validated the models using the validation sample. 

Results:  Of 38,840 surgical admissions, 2.73% of patients developed SPC.  Among these, 17.42% died, compared to 1.22% for patients who had no SPC.  The risk prediction model for SPC had a c-statistics of 0.91 (95%CI=0.89-0.92).  Increased risk is associated with being 65 years and older, direct admission to ICUs, having pulmonary circulation, peripheral vascular, and fluid/electrolyte disorders, and the proportion of patients who had the same DRG and developed a SPC.  Ninety percent of the patients with FTR were in the highest risk quintile for SPC.     

Conclusions:   Our risk model predicts SPC with good accuracy.  Our model provides a framework to test usefulness of therapeutic interventions to decrease morbidity and mortality and to limit FTR in high risk populations.

74.04 Impact of Clostridium Difficile Infection on Healthcare Resource Utilization: A Statewide Analysis

Posted on December 22, 2014

A. N. Kulaylat1, D. B. Stewart1, C. S. Hollenbeak2  1Penn State Hershey Medical Center,Division Of Colon And Rectal Surgery, Department Of Surgery,Hershey, PA, USA 2Penn State Hershey Medical Center,Division Of Outcomes, Research And Quality, Departments Of Surgery And Public Health Sciences,Hershey, PA, USA

Introduction:  Clostridium difficile infection (CDI) is the most common nosocomial diarrheal disease in the United States, imposing substantial morbidity to patients. Less is known about the influence of CDI on healthcare resource utilization following surgical or procedure-based interventions.  Our aim was to determine the incidence of CDI across a variety of procedures and evaluate the impact of CDI on discharge status, readmission, and length of stay (LOS) among patients in Pennsylvania. 

Methods:  Data were obtained from the Pennsylvania Health Care Cost Containment Council (PHC4) during 2011. PHC4 collects discharge information for all patients undergoing treatment at general acute care hospitals (excluding VA hospitals). Patients with an ICD-9 procedure code were included (n=580,754), organized by procedure category. The presence of a CDI on discharge diagnosis was abstracted using an ICD-9 diagnosis code of 008.45, and based on this stratification, patient demographics and characteristics were compared with standard univariate statistics. Logistic regression was used to model the impact of CDI on discharge status and readmission, while generalized linear regression was used to model the effects of CDI on LOS. 

Results: The overall incidence of CDI across all procedures was 0.58%.  The highest rates of CDI were among hematologic/lymphatic (1.3%), gastrointestinal (1.2%), respiratory tract (1.1%), cardiovascular (1.0%), and integument (0.7%) procedures. After controlling for patient demographics, admission type, comorbidities, operation type and postoperative complications (excluding CDI), CDI was associated with an increased odds of requiring additional care on discharge (e.g. skilled nursing or intermediate care facility, visiting nurses, etc.) (OR 3.18, p<0.001), as well as 30-day readmission (OR 1.82, p<0.001). The occurrence of a CDI protracted the LOS by 5.3 days (p<0.0001). 

Conclusion: The development of CDI poses a substantial burden to healthcare resource utilization. As the incidence of CDI varies by procedure, targeted efforts to address CDI rates will need to account for various specialties and the spectrum of surgical and procedure-based interventions. 

 

72.11 Worse Outcomes In Patients Presenting With Primary Liver Cancer At Safety-Net Hospitals

Posted on December 22, 2014

A. Mokdad1, A. Singal1, J. Mansour1, G. Balch1, M. Choti1, A. Yopp1  1University Of Texas Southwestern Medical Center,Surgery Oncology,Dallas, TX, USA

Introduction:  Primary liver cancer is the fastest growing cause of cancer related deaths in the United States and affects patients disproportionately in lower socioeconomic classes.  The purpose of this study was to determine if patients with primary liver cancer who present at safety-net hospitals (SNHs) have a different presentation and prognosis compared to those presenting at non-SNHs.

Methods:  We conducted a retrospective analysis of patients with primary liver cancer identified in the Texas Cancer Registry between 1995 and 2010. SNH was defined as a hospital with a Disproportionate Share Hospital index greater than 0.15. Demographics, tumor characteristics, treatment regimens, and survival were compared between patients presenting at SNHs and non-SNHs. Univariate analyses were conducted using student’s t-test and log-rank test. Statistically significant variables were included in a Cox-regression model.

Results: Of the 20,259 patients diagnosed with primary liver cancer, 4,580 (24.3%) presented to SNHs. Patients presenting at a SNH were more likely to be Hispanic (61% vs. 29%, p<0.001) and have lower socioeconomic status (63% vs. 35%, p<0.001) compared to patients presenting at non-SNH. Tumor stage at presentation was similar in both hospital categories; 7,149 (51.9%) presented with local disease, 3,369 (24.5%) with regional spread, and 3,249 (23.6) with metastasis. Patients were 1.5 times (OR = 1.53, P < 0.001) more likely to have a procedure or receive chemotherapy and/or radiotherapy at a non-safety net hospital. The median survival for patients with liver cancer at a SNH was 33 days shorter compared that at non-safety net hospitals, 137 versus 170 days, respectively (P < 0.001). Survival was associated with age, sex, race, tumor stage, socioeconomic status, and treatment. After adjusting for patient demographics and tumor characteristics, patients in safety-net hospitals had an 8%  (HR = 1.08, P = 0.001) increased mortality compared to patients in non-safety net hospitals. This greater risk was rendered non-significant (HR = 1.01, P = 0.82) when reception of a procedure, radiation, and/or chemotherapy was accounted for. 

Conclusion: Patients with primary liver cancer who present to a SNH are more likely to be Hispanic and have a worse overall survival despite similar stage of tumor presentation.

 

72.12 Guideline Adherence Update in Stage II and III Patients Undergoing Colon Cancer Resection

Posted on December 22, 2014

R. L. Hoffman1, K. D. Simmons1, R. E. Roses1, N. N. Mahmoud1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:
Adherence to guideline-based care for colon cancer patients has been shown to result in decreased costs, shorter durations of inpatient stays, and improved survival. Surgeons play an integral role in the management of colon cancer. The aim of this study was to examine adherence to NCCN guidelines amongst colon resection patients by demographic and clinical characteristics.

Methods:
Patients aged 65-84 years diagnosed with AJCC stage II and III colon cancer who underwent a colon resection were identified in the SEER-Medicare database (2005-2009). High risk (HR) stage II disease was defined as those with a T4 tumor, poor differentiation and <12 lymph nodes examined. Adherence was classified as undertreatment (UT), overtreatment (OT) or concordant care (CC) using stage- and grade-specific NCCN guidelines in combination with chemotherapy and radiation codes from Medicare claims files. Comorbidities were determined using ICD-9 codes from AHRQ predefined category buckets based on diagnoses present in Medicare Outpatient claims at or before the time of colon cancer diagnosis. Descriptive statistics were computed to determine adherence patterns.

Results:
A total of 13017 stage II and III patients who underwent colectomy were identified; 3618 (27.8%) were categorized as stage IIA/B low risk (LR), 3314 (35.5%) as stage IIA/B HR, and 6085 (46.7%) as stage IIIA/B/C. There were a total of 2287 patients ages 65-69, 3,206 ages 70-74, 3,807 ages 75-79 and 3717 ages 80-84 years. Males constituted 43.2% of the cohort (5619). White patients made up 82.5% (10743) and black 9.2% (1200). A total of 8322 (63.9%) patients had one or more comorbidities, with hypertension and iron deficiency anemia being the most common. CC was noted in 6348 cases (48.8%), UT in 5837 (44.8%) and OT in 832 (6.4%). CC was the most likely treatment for stage IIA/B LR patients (87.2%, 3153), patients under the age of 80 (52.3%, 4860), white patients (49.2%, 5280), black patients (47.6%, 571), Asian patients (48.8%, 238) and patients with 1+ comorbidities (52.8%, 4393). Location of residence was not associated with the likelihood of CC.  UT was most common amongst stage IIA/B HR patients (80.1%, 2671), stage III patients (54.2%; 3166), patients ages 80-84 (35.9%; 2098), Hispanics (48.9%; 112), and patients without documented comorbidity (53.1%, 2492). OT was less frequent than UT. Patients over 79 years of age (35.9%) and women (59.3%) were over-represented in the UT group; men (50.8%) and patients ages 70-74 (30.7%) were over-represented in the OT group.

Conclusion:
Stage IIA/B low-risk patients were most likely to receive concordant care. The lower rate of CC among stage IIA/B high-risk and stage III is likely attributable to multiple factors, including clinical judgment based on the strength of evidence presented in the guidelines. Understanding the nuances of treatment adherence across different groups will allow a more targeted focus of efforts to decrease disparities in care.

72.13 Outpatient Thyroidectomy: Current Practice and Utilization Trends in california

Posted on December 22, 2014

J. B. Hamner1, P. Ituarte1, L. Goldstein1, L. Kruper1, S. Chen1, J. Yim1  1City Of Hope National Medical Center,Division Of Surgical Oncology,Duarte, CA, USA

Introduction:   Multiple factors including cost and patient motivation have resulted in an increase in the number of thyroidectomies performed in ambulatory settings.  Information on practice patterns and rates of outpatient thyroidectomy are limited, however.

Methods: The Healthcare Cost and Utilization Project (HCUP) captures inpatient hospital and ambulatory surgery center data. We evaluated HCUP data for 5 years in California to identify all patients undergoing thyroidectomy. Influence of patient type, hospital, disease and surgery (total vs. partial thyroidectomy) characteristics by year and visit type (inpatient vs. outpatient) were determined by bivariate analysis using Chi-Square test and non-parametric test for trend. A multivariate logistic regression model was used to examine predictors of outpatient thyroidectomy.

Results: 37,188 thyroidectomies were identified with 9,319 (25%) conducted in outpatient settings.  Outpatient thyroidectomy accounted for 19.3% of thyroidectomies in 2005, increasing to 30.6% by 2009.  Outpatient thyroidectomy was associated with a lower rate of post-operative complications vs. inpatient (1.17% vs. 4.22%, p<0.01).  Predictors of outpatient thyroidectomy included younger age and fewer comorbidities.  Racial minorities [p-value<0.01] and Medicaid recipients [OR=0.55, p<0.01]  had lower odds of outpatient thyroidectomy.  Hospital volume influenced outpatient thyroidectomy with intermediate volume centers having higher odds of outpatient thyroidectomy than low or high volume centers (OR=1.18 vs. 0.69 and 0.72). 

Conclusion: Outpatient thyroidectomy rates have increased in California, and have fewer recorded complications than inpatient thyroidectomies.  This supports the practice of outpatient thyroidectomy in appropriately selected patients.  Interestingly, racial minorities and Medicaid recipients had lower odds of outpatient care.  These findings suggest that there are multiple systemic factors beyond socioeconomic factors in the selection of patients for outpatient thyroidectomy. 

 

72.14 Geospatial Travel Patterns of Major Cancer Surgery Patients within a Regionalized Health System

Posted on December 22, 2014

A. K. Smith1, N. Shara2,4, A. Zeymo2, R. Estes2, K. Harris1,2, L. Johnson1,3, W. Al-Refaie1,3  1MedStar Georgetown Surgical Outcomes Research Center,Surgery,Washington, DC, USA 2MedStar Health Research Institute,Biostatistics,Hyatsville, MARYLAND, USA 3Georgetown University Medical Center,Lombardi Comprehensive Cancer Center,Washington, DC, USA 4Georgetown University Medical Center,Georgetown-Howard Universities Center For Clinical And Translational Sciences,Washington, DC, USA

Introduction: Regionalization of complex surgeries has led patients to travel longer distances for surgical care. This may be burdensome to vulnerable populations, including older adults and ethnic/racial minorities, who may lack the means to travel long distances. To date, little is known about travel patterns of patients undergoing major cancer surgery in a regionalized care setting. To inform this issue, we sought to map travel patterns among these vulnerable populations who received major cancer surgery within a large, regionalized healthcare system.

Methods: We identified 6,120 patients who underwent lung, esophageal, gastric, liver, pancreatic and colorectal resections from 2002 to 2014 within our large and diverse multi-hospital healthcare system. Patients’ age, race/ethnicity and insurance status were extracted from our electronic health records. We then used Geographic Information System (GIS) software in R to map the distribution of patients’ addresses based on cancer surgery type and vulnerability characteristics. We used visual inspection to assess the distribution and magnitude of travel distances between cancer surgery and each patient characteristic.

Results: 48.2% were non-white, 49.9% were >65 years old and 54.9% of patients had private insurance. Results from the maps showed that for all six oncologic resections, patients over 50 years and whites tend to travel further than younger patients and other racial/ethnic groups for surgery (see figure).Conversely, mapping patients by insurance status did not demonstrate similar geospatial patterns.  

Conclusion: These maps offer a preliminary understanding into variations of geospatial travel patterns to receive major cancer surgery in a regionalized setting. Future research should focus on quantifying differences in travel distances and its impact on timely delivery of surgical care.

 

72.15 Delay in Breast Cancer Diagnosis and Treatment: a Retrospective Review to Identify Risk Factors

Posted on December 22, 2014

N. M. Zaremba1, M. Martin1, A. T. Davis1, P. Haan1, H. L. Bumpers1  1Michigan State University,Department Of Surgery,Lansing, MI, USA

Introduction: It is well known that breast cancer mortality is higher in African American (AA) and young women than in White and older women. This disparity has been attributed to delayed diagnosis, treatment, and follow-up of breast abnormalities. Neither age nor race have been shown to be independent risks for delayed diagnosis or treatment, but socioeconomic status supplants race in some studies. AA women present younger and with later stage disease compared to Whites. Precise factors accounting for these delays have not been defined. This is Phase I of a multi-institutional study to identify risk factors for delays in diagnosis and treatment. Phase II will compare with a large metropolitan hospital caring for the underserved. 

Methods: A retrospective chart review of 107 consecutive patients with a diagnosis of DCIS or invasive breast cancer was performed at a single Midwestern institution where the majority of patients are White and middle class. Delayed diagnosis was defined as 60 days or greater from sign/symptom onset to biopsy and delayed treatment was 60 days or more from tissue diagnosis to first treatment (surgery or neoadjuvant therapy). Income estimates were based on zip code and 2010 US Census. Univariate analysis was performed. This study was approved by the Michigan State University Institutional Review Board. 

Results: Age ranged from 24 to 91 years. Fifteen (14.0%) patients had delayed diagnosis and 10 (9.3%) had delayed treatment. Patients without a family history of cancer had higher risk for diagnostic delay, RR 5.4 (95% CI 1.9-15.8), than patients with a family history of cancer, p =0.001. Similarly, patients without a family history of breast cancer had higher risk for delayed diagnosis, RR 6.9 (95% CI 1.6-29.0) than patients with a family history of breast cancer, p =0.001. As expected, palpable masses and large tumors (T3-4) were associated with delayed diagnosis, RR 4.7 (95% CI 1.4-15.8), p = 0.004 and RR 4.4 (95% CI 1.8-10.7), p =0.014, respectively. Advanced stages (III-IV) were also associated with diagnostic delays, RR 3.1 (95% CI 1.2-8.1), p =0.049. Those with a lower estimated income had significantly delayed treatment, RR 3.8 (95% CI 1.03-13.7), p =0.042. On univariate analysis, none of the following parameters were significantly associated with a delay in diagnosis or treatment: age, race, insurance status, marital status, employment, smoking, menopausal status, or HRT. Diagnostic delays were also due to patients (fear of physicians, misconceptions about cure with healthy lifestyle, personal issues) and physicians (low suspicion, inconclusive imaging, need for medical intervention prior to treatment). 

Conclusion: This group of patients had little delay in diagnosis and treatment. The individual parameters significantly associated with delayed diagnosis and treatment were lack of family history of breast cancer or any cancer, and lower estimated household income. Phase II of this study will be done for comparisons.

72.16 Insurance Disparities in the Treatment and Outcome of Colon Cancer Patients

Posted on December 22, 2014

C. M. Kiernan1, K. Idrees2, N. B. Merchant2, A. A. Parikh2  1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Surgical Oncology,Nashville, TN, USA

Introduction:
Prior studies have demonstrated that uninsured or underinsured cancer patients are more likely to receive substandard treatment and to have worse outcomes. The purpose of this study was to evaluate the impact of type of health insurance on treatment and survival in colon cancer patients, utilizing a large population database.

Methods:
Using the National Cancer Database, we identified 702,892 patients diagnosed with colon cancer from 2003-2011. Patients were stratified into 5 cohorts: Private, Medicare, Military, Medicaid, and Uninsured to test the association of health insurance type with receipt of adjuvant chemotherapy (2003-2011) in patients with stage 3 disease by multivariable logistic regression as well as overall survival in patients with stage 1, 2 and 3 disease by Cox-Proportional regression.  Patients with metastatic disease were excluded.

Results:
Within the cohorts of the Uninsured and Medicaid-insured, a higher proportion of patients were African American (AA) or Hispanic.  Patients in these cohorts were more likely to present with higher stage tumors, were more often treated at academic centers, and were less likely to undergo surgical resection (p<0.001). By multivariable analysis, stage III patients who were uninsured [OR 0.55, 0.51-0.60, p<0.001], on Medicaid [OR 0.51, CI 0.51-0.60, p<0.001], or AA [OR 0.82, CI 0.79-0.85, p<0.001] were less likely to receive adjuvant chemotherapy. By Cox-Proportional regression, lack of insurance [HR 1.64, CI 1.54-1.75, p <0.001], Medicaid [HR 1.80, CI 1.71-1.90, p<0.001], Medicare [HR 1.08, CI 1.05-1.10, p<0.001], military insurance [HR 1.20, CI 1.05-1.37], AA race [HR 1.24, CI 1.20-1.27, p<0.001], as well as stage 2 [HR 1.47, CI 1.43-1.50, p<0.001] and stage 3 [HR 2.35, CI 2.29-2.41, p<0.001] disease were independently associated with worse overall survival.

Conclusion:
In addition to racial disparities, insurance disparities contribute to inequality in the utilization and distribution of health care.  Uninsured and Medicaid patients present with advanced stage disease, appear less likely to undergo surgical resection or receive adjuvant chemotherapy, and have worse overall survival.  Insurance disparities should be further investigated and followed, independent of race, as the healthcare climate in the US changes and evolves.
 

72.17 Feasibility of a Web-based Intervention in Breast Cancer Patients

Posted on December 22, 2014

J. G. Bruce1, N. Steffens3, J. Tucholka3, H. B. Neuman1,2,3  1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Carbone Cancer Center,Madison, WI, USA 3University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery, School Of Medicine And Public Health,Madison, WI, USA

Introduction:  The Internet is a frequently used resource for breast cancer patients seeking information about their diagnosis and treatment options. While the Internet is a convenient information source, access and literacy vary widely. Our objective was to evaluate the feasibility of delivering online information to breast cancer patients in the setting of a clinical trial and assess for disparities in care.

Methods:  We evaluated breast cancer patients (Stage 0-3) participating in a clinical trial investigating the delivery of Internet information prior to surgical consultation. Following their diagnosis phone call, women were emailed links to web-based information. A validated questionnaire was completed prior to their first surgical consult assessing breast cancer knowledge, goals for treatment, time spent reviewing the links, education history, and baseline Internet use. Descriptive statistics were performed.

Results:  To date, 46 women have been approached to participate and 35 have enrolled (76%). Five of the approached women were found to be ineligible and an additional 7 declined due to issues related to access to or comfort with the Internet (n=5) and emotional distress (n=2). Non-participants citing Internet access/comfort issues had a median age of 73 [63-81] years.

Median participant age was 57 (29-78) years. The majority had Stage 1 breast cancer (64% Stage I, 15% Stage 2, 6% Stage 3, 15% DCIS). Two patients did not complete survey data. Of the remaining 33, 65% had at least a college degree, 29% had some college, and 6% had high school or less. Internet use was described as multiple times daily (68%), once daily (23%) or a couple of times per week (9%).

The median time between study email and surgeon consult was 4 (1-13) days; 7 women had ~24 hours prior to the consult. 26 women (79%) reviewed the emailed material (62% for >1 hour, 31% for 15-60 minutes, 7% for <15 minutes). Cited reasons for no review included no access to Internet following receipt of emailed links (n=2), not receiving study email (n=1), insufficient time before surgeon visit (n=1), finding it unnecessary (n=1) and unknown (n=1). No relationship was observed between likelihood to review websites and age, education or Internet use. 

Conclusion:  We determined that delivery of Internet breast cancer information via email is feasible. Disparities in Internet access and literacy are concerns for web-based interventions. However, we were able to successfully enroll 76% of women approached.  Specific challenges included spam filters blocking study emails and short intervals between diagnosis and surgeon consult. Additionally, older patients were more likely to decline participation due to lack of comfort with or access to the Internet, and may require alternative interventions. Final study analysis will determine the impact delivery of this online information has on women’s experience with breast cancer surgery decision-making.
 

72.18 Race/Ethnicity Has No Impact on Outcome for Stage III Breast Cancer

Posted on December 22, 2014

B. P. Townsend1, K. Miller1, Q. Chu1  1LSU Health,Surgery,Shreveport, LA, USA

Introduction: African-American (AA) women have a higher breast cancer mortality rate than Caucasian (C) women, despite having a lower incidence rate. There is a paucity of data examining whether such a disparity exists among patients with stage III breast cancer who were treated at an open access, academic, charity hospital.

Methods: 135 patients with stage III breast cancer were identified from a prospective breast cancer database. All had standardized treatments. Primary endpoint was death from any cause. Overall survival (OS) was calculated from date of diagnosis to date of death or date of last follow-up.  Statistical analyses included log-rank test, Kaplan-Meier survival analysis, and Cox Proportional Hazard Model. A p ≤ 0.05 was deemed statistically significant.

Results: 83 patients (61%) were AA. Comparing the two groups, there were no differences in t-stage distribution (p=0.18), nodal distribution (p=0.73), tumor grade (p=0.43), hormone receptor statuses (p=0.06), and HER-2 status (p=0.81).  The 5-year OS for AA and C was 41% and 44%, respectively (p=0.34). On multivariate analysis, only HER-2 was a predictor of OS (p=0.04).

Conclusion: Race/ethnicity has no impact on outcome of patients with stage III breast cancer who were treated at an open access, academic cancer center.

 

72.19 Disparities in Colorectal Cancer among Different Races in the State of Arizona

Posted on December 22, 2014

M. R. Torres1, H. Aziz1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

Introduction:

Colorectal cancer (CRC) is the third most occurring diagnosed cancer and the third leading cause of cancer related deaths. Despite the efforts to improve preventive methods and treatments, disparities still remain in CRC incidence among different races, particularly focusing on stage at presentation and anatomic location of the cancer. This study assesses the disparity in incidence of CRC among different races in the state of Arizona.

Methods:

 A retrospective analysis of CRC data from the Arizona Cancer Registry (1995-2010) was performed. Races identified from the database were: White, African American, Hispanic, Native Americans, Asian, and Pacific Islander (PI). Early stage colon cancer was defined as stage I and II, while advance stage was defined as III and IV. Using logistic regression modeling, differences in tumor characteristics were assessed among different races in Arizona.

Results:

There were 39,623 reported incident cases of colorectal cancer during the study period. There was a significant decrease in overall incidence of CRC among different races. The Hispanic population presents an increase in incidence of early stage Colon Cancer (3.8/100,000 to 4.7/100,000) and a decrease in the advance stage Colon cancer (10.6/100.000 to 5.6/100,000). The African American population has an increase in the early stage (10.3/100,000 to 11.1/100,000) and a decrease in the advance stage (17.4/100,000 to 15.4/100,000). The Native American population shows an increase in the early stage (4.6/100,000 to 8.7/100,000) and an increase in the advance stage colon cancer (10/100,000 to 10.4/100,000). Asian/Pacific Islanders have an increase in the early stage incidence (2.8/100,000 to 6.3/100,000) and a decline in the advance stage Colon Cancer (10/100,000 to 9.5/100,000).

Conclusions:

Overall CRC incidence is trending down for Whites, Hispanics, African Americans, and Asian/PIs, except for the Native American group.

 

72.20 Healthcare Disparities in Severe Acute Maternal Morbidity – An Analysis of National Data

Posted on December 22, 2014

A. Ranjit1, S. Selvarajah1, C. K. Zogg1, E. B. Schneider1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA

Introduction:  Racial disparities in obstetrics exist in the US, but underlying factors for these are unknown. In countries with low maternal mortality, study of Severe Acute Maternal Morbidity (SAMM) is an effective method of evaluating obstetric care. Use of SAMM, defined as “acute organ dysfunction, which if not treated appropriately, could result in death” allows us to further explore known obstetrics disparities. This study aimed to determine if there are racial disparities in SAMM outcomes using the Nationwide Inpatient Sample (NIS). 

Methods:  Using 2007-2011 NIS, white, black or Hispanic women of reproductive age (15-49 years) who had normal delivery [ICD-9 diagnosis code V270, 650] were identified. World Health Organization (WHO) proposed criteria was used to identify SAMM. Patient age, insurance status, income, hospital location/type and complications during pregnancy (such as pregnancy induced hypertension (PIH), gestational diabetes (GDM), obesity, renal disease, heart disease) were compared across racial groups. Logistic regression controlling for patient and hospital factors examined race-based differences in the occurrence of SAMM. Complications were examined as follows: 1) any complication qualifying as SAMM, 2) organ specific SAMM or, 3) systemic SAMM.

Results: Among 3,362,976 women identified for analysis, 1,737,861 (51.6%) were white, 462,434(13.75%) black and 792,612(23.57%) Hispanic. White patients were more likely to be older than black and Hispanic patients (mean age 28.1 vs. 25.89 and 26.67 years, respectively, p<0.001).  Black patients were more likely to have PIH, obesity and previous cesarean section while Hispanic patients were more likely to have had GDM. A total of 46,489(1.38%) had at least one SAMM; 21,427(0.64%) women had at least one systemic SAMM; and 25,062(0.75%) women had at least one organ-specific SAMM. Black patients were more likely to have any SAMM complication compared to whites, but after adjusting for patient and hospital factors, the difference diminished (table). In contrast, Hispanic patients consistently displayed lower odds of developing any SAMM complications when compared to whites in both univariable and multivariable analysis. When stratified by type of SAMM complication, black patients had greater odds of organ specific SAMM, while Hispanic patients had lower odds of systemic SAMM compared with white patients.

Conclusion: Our findings suggest that race is associated with the odds of developing SAMM during childbirth. It is possible that unexplored pre and perinatal conditions, represented unequally across race groups, may partially explain our findings. Further research is warranted to best understand the relationships between race and maternal health in pregnancy.

73.01 Strategies for Securing Funding for Global Health in Trauma and Acute Care Surgery

Posted on December 22, 2014

J. Puyana1, N. Carney1, A. Sanchez3, A. Rubiano1, A. Garcia3, C. Ordoñez3, A. Peitzman1  1University Of Pittsburgh,Trauma & Acute Care Surgery,Pittsburgh, PA, USA 2Oregon Health And Science University,Informatics,Portland, OR, USA 3Universidad Del Valle,Surgery,Cali, Valle, Colombia

Introduction: International programs promoting global health-“surgery” in low and middle-income countries (LMICs) continue to sprout across many academic centers in the United States. This development has been driven in part by the enormous and ever growing interest voiced by medical students and young surgical residents to engage in “global surgery” activities. This interest has resulted from an increasing awareness of the impact of trauma and suboptimal acute care surgery as major burdens of disease around the world. We have created an innovative "cross sectional" strategy combining clinical research training, capacity building and clinical mentoring overseas in order to strengthen the academic components of such international activities. This strategy has secured continuous funding by NIH sponsored global health programs over an 8 year period. This approach has opened a new realm of opportunities by identifying long term funding mechanisms that directly impact trauma care under a number of programs not originally targeted for trauma/injury research initiatives

Methods:

After obtaining an initial D43 training grant aimed at supporting capacity building in injury research, our multidisciplinary team identified other NIH sponsored programs in the following areas: Informatics training for global health, Brain disorders in the developing world: Research across the lifespan, Global Health Research Training eCapacity and Mobile Health: Technology and Outcomes in LMICs.

Results:

Funding has been procured from four of these five programs ($US 2.5 Million). We generated research projects including the development of mobile technology based trauma information tools, web based platforms for trauma registries in underserved areas and a multicenter clinical trial in the form of pilot R21 for capacity building in traumatic brain injury. Seven students obtained a Master’s degree and one a PhD. All these students have returned to their country of origin. There has been an incremental increase in the number of contributions from LMIC trainees to several trauma/injury related academic societies. Trainee – initiated research endeavors have generated, 30 manuscripts published in peer review journals, 7 manuscripts submitted for publication, 6 publications in textbooks and 45 abstracts. This research output in trauma and acute care surgery is unprecedented in most LMICs.

Conclusion:

A multidisciplinary collaboration between health professionals from the US and LMIC has resulted in significant trauma research contributions relevant to LMICs and opened the doors for bilateral exchange and mutual benefit in both clinical and research areas. Furthermore, a new modality of global surgery is emerging supported by long term relationships with strong academic platforms that have the potential for expanding other global health ventures and providing new avenues for the development of true academic careers in global surgery.

 

73.02 The Utility of the Verbal Autopsy Technique to Assess Pre-hospital Trauma-mortality Burden

Posted on December 22, 2014

J. S. Qureshi1, G. Mulima2, S. Zadrozny1, B. Cairns1, A. G. Charles1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Lilongwe, , Malawi

Introduction:
Trauma, particularly Road Traffic Injury (RTI), is a leading cause of global death and disability. Africa has one of the highest RTI related mortality in the world, at 28.3 deaths per 100 000 population, however, this may be underestimated as only 7% of cause of death information is obtained from population based vital registration systems. We herein compare pre-hospital to in-hospital trauma-mortality burden using a validated verbal autopsy tool in an urban sub-Saharan African setting.

Methods:
A modified World Health Organization (WHO) VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe, Malawi to family members of deceased from outside the hospital (referred to as ‘brought in dead’; BID) over three months. These results were compared to validated VA assessment of inpatient deaths to compare differences in disease burden in these two settings.

Results:
The top five categories of mortality were the same for both the inpatient population studied in the validation phase and the BID population. According to Physician Coded Verbal Autopsy (PCVA), infectious diseases remained the highest cause of mortality in BID patients followed by injury, gastrointestinal disease, cancer and cardiovascular disease. However, injury constituted a higher percentage of deaths in the BID population than in the inpatient population, particularly road traffic injury. (Table: Burden of Traumatic Injury in Brought-In-Dead Patients)

Conclusion:
Global burden of trauma-mortality is underestimated in resource poor settings if only hospital registries are used. Verbal autopsy provides a novel adjunct to traditional hospital-based trauma registries to assess community trauma burden, particularly road traffic injuries. Our study reveals that road traffic injury constitutes the majority of prehospital trauma death in a resource poor urban setting. Efforts to improve prehospital care are imperative to reduce the burden of trauma mortality.
 

73.03 Design and Implementation of an Electronic Trauma Registry: A Partnership with the Panamerican Trauma Society

Posted on December 22, 2014

M. B. Aboutanos1, S. Jayaraman1, L. V. Mata1, E. B. Rodas2, C. A. Ordoñez4, F. Mora6, C. Morales5, M. Quiodettis3, M. Duong1, R. Ivatury1  1Virginia Commonwealth University,Acute Care Surgical Services/ Depart. Surgery,Richmond, VA, USA 2Hospital Vicente Corral Moscoso And Hospital Universitario Del Rio,Surgery,Cuenca, AZUAY, Ecuador 3Hospital Santo Tomas,Trauma,Panama, , Panama 4Hospital Universitario Del Valle And Fundacion Valle De Lili,Trauma,Cali, , Colombia 5San Vicente De Paul,Cirugia,Medellin, , Colombia 6Cinterandes Foundation Mobile Surgical Program,Cuenca, , Ecuador

Introduction:

Injury is a major cause of death and disability in low and middle income countries (LMICs). A major impediment to trauma system development is lack of basic injury data. We aimed to create an injury surveillance system that could be implemented at every level of health facilities in LMICs and which would allow communication across facilities to track injury morbidity and mortality, allow monitoring, evaluation and auditing of trauma care and identify opportunities for intervention. 

Methods:

A multi-disciplinary team of program staff, statistician and information technology staff was created and led by a trauma surgeon with previous experience with paper registries in Central America. The team created an electronic trauma registry for low-resource settings that can be used on and offline, in English and Spanish, and covers trauma care from the prehospital trauma setting, initial trauma management, through hospitalization until discharge. The registry consists of two tiers: an essential element tier with 25 variables and a comprehensive tier with 250 variables, uses ICD-10 codes with a built-in search box and calculates injury severity scores (AIS, ISS, RTS and OIS).  An integrated quality control system limits incorrect data entry and a report generator allows for pre-specified basic reports and advanced customizable reporting. Specific user roles can be established to control accessibility and facilitate access from any network. A pilot program was implemented with concomitant training in: basic epidemiology and injury surveillance, use of a standardized trauma assessment form, registry access and data entry, analysis and report generation, periodic auditing and quality improvement.

Results:

The registry and a standardized trauma patient assessment form were implemented across nine hospitals in three member countries of the Panamerican Trauma Society: Ecuador, Colombia and Panama. Implementation included sessions for a total of 62 hospital staff including clinicians, hospital administrators and data entry personnel. Since implementation, 28,698 injured patients have been entered into the registry across the nine sites: 6,911 at five hospitals in Ecuador; 20,795 across three hospitals in Colombia; and 992 in Santo Tomas Hospital in Panama. Site-specific analysis is under way.

Conclusion:
LMIC governments practice with significant resource constraints and yet need to develop high quality trauma and emergency systems. This injury registry was created through highly innovative collaboration between clinicians and health informatics experts and can be used capture reliable and accurate data, determine the burden of injury morbidity and mortality and identify opportunities to improve trauma and emergency care. Investment in such information infrastructure has potential to improve resource allocation and facilitate trauma system development in LMICs.
 

73.04 Trauma Training Among Physicians in Haiti

Posted on December 22, 2014

J. K. Bagley4, C. M. McCullough4, M. E. Quinn4, J. Srinivasan1, V. DeGennaro2,3, J. Sharma1  1Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 2University Of Florida,Department Of Medicine, College Of Medicine,Gainesville, FL, USA 3Project Medishare For Haiti,Port Au Prince, , Haiti 4Emory University School Of Medicine,Atlanta, GA, USA

Introduction:  The burden of trauma is disproportionally greater in low and middle-income countries (LMIC) such as Haiti. As a follow up to a previous survey in Haiti’s Central Plateau, this study was designed with the goal of addressing the current state of trauma training among practitioners in hospitals throughout Haiti.

Methods:  A survey was designed to globally assess the needs of trauma-related care in Haiti, comprised of 13 sections containing a total of 260 questions. A total of 14 questions were prepared with the goal of quantifying trauma training among physicians staffing Emergency Departments (ED) and general surgeons. Medical directors, hospital administrators, surgeons, and physicians staffing the ED were questioned via interpreter to complete the survey based on interviewee knowledge and availability. Formal trauma training was defined as having taken a course in Advanced Trauma Life Support (ATLS) or ATLS-equivalent.

Results: The survey was administered at 11 major hospitals in 9 (of 10) Departments in Haiti. Of 10 hospitals for which the survey is complete, two had ED physicians with trauma training. At those two facilities, an average of 40% of all ED physicians had trauma training. 3 hospitals had general surgeons with trauma training. At those three facilities, 50% of all general surgeons had trauma training. 2 hospitals have offered ATLS or an ATLS-equivalent course to hospital staff. 9 hospitals have access to in-service training by visiting medical teams or hospital staff, and 2 of those indicate trauma as a previous topic of training. 

Conclusion: Formal training in trauma care is infrequent or absent in many large hospitals in Haiti, despite an increased burden of disease compared to high-income counties. Though ATLS has not been correlated to outcomes in injury-related care in LMIC, we believe that formal, applied trauma training would be of benefit to victims of injury in Haiti.  This information was gathered with the cooperation of the Haitian Ministry of Health in efforts to improve hospital care and outcomes of trauma victims.

 

73.05 Creating an mHealth solution to improve prehospital trauma care in urban Bangladesh

Posted on December 22, 2014

J. T. Farrell1, M. Swaroop2, M. Bhuiyan4, R. R. Chakraborty3, K. Rakshand5, B. M. Jaffe1  4Bangabandhu Sheikh Mujib Medical University,Dhaka, , Bangladesh 5JAAGO Foundation,Dhaka, , Bangladesh 1Tulane University School Of Medicine,New Orleans, LA, USA 2Northwestern University, Feinberg School Of Medicine,Division Of Trauma & Critical Care,Chicago, IL, USA 3Chittagong Medical College Hospital,Chittagong, , Bangladesh

Introduction:

Currently no organized Emergency Medical System exists in Bangladesh and the mortality of road traffic accidents in Bangladesh is estimated to be between 12,000-20,000 people annually. Studies show that well-trained and rapidly dispatched lay first responders have a significant impact on improving health outcomes and reducing mortality. To improve trauma outcomes in Bangladesh, a non-profit social enterprise called CriticaLink has been developed to fill the gap in pre-hospital care by training first responders in preparation for the launch of a mobile health application (mHealth app) using GPS and a location based emergency response system with implementation of an emergency number.

Methods:

Volunteers were recruited through partnerships with several large youth volunteer organizations in Bangladesh, including JAAGO’s Volunteer for Bangladesh. Volunteers were trained in 1-2 day first responder courses developed by members of the Tulane University team based on published recommendations from the International Red Cross, Red Crescent and other first responder curriculums published in peer-reviewed journals.  The training course was further modified after analysis of qualitative and quantitative feedback from the trainees in the CriticaLink program. 

Results:

During the pilot phase of the CriticaLink First Responder System, over 585 volunteers have registered and more than 200 have been selected and trained to serve on one of seven location-based teams in Dhaka.  Each team consists of two team leaders and certified First Responders who will respond to emergencies in seven of Dhaka’s most populated areas (Dhanmondi, Gulshan/Banani, Uttara, Mirpur, Mohammadpur, Old Dhaka, and Lalbagh).  In order to connect First Responders with accident victims, an emergency number, call center, and dispatch system has been established to report accidents in Dhaka. The mHealth app, created on an Android platform, will serve as both a dispatch and patient data collection tool for First Responders. 

Conclusion:

The combination of well-trained first responders and an innovative location-based mHealth dispatch system has the potential to significantly improve trauma outcomes in urban Bangladesh. The location data will also be important to help focus accident prevention efforts.  Once the pilot phase is formally launched in Dhaka, the system will be prospectively evaluated with the possibility to extend CriticaLink to other cities, not only in Bangladesh, but in any country lacking a formal Emergency Medical System.

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