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Background There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a “textbook outcome” (TO) following hepatopancreatic surgery. Methods Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome. Results Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68–77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2–8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7–26) to 83 (profile 5 IQR: 66–93). The five profiles were grouped into 3 categories based on median composite SVI: “low vulnerability” (profile 1), “average vulnerability” (profiles 2 and 3), or “high vulnerability” (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83–0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15–1.44) versus patients in profile 4. Conclusion Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores. Supplementary Information The online version contains supplementary material available at 10.1007/s11605-022-05245-9.

Determining the impact of county-level upward economic mobility on stage at diagnosis and receipt of treatment among Medicare beneficiaries with pancreatic adenocarcinoma.The extent to which economic mobility contributes to socioeconomic disparities in health outcomes remains largely unknown.Pancreatic adenocarcinoma patients diagnosed in 2004-2015 were identified from the SEER-Medicare linked database. Information on county-level upward economic mobility was obtained from the Opportunity Atlas. Its impact on early-stage diagnosis (stage I or II), as well as receipt of chemotherapy or surgery was analyzed, stratified by patient race/ethnicity.Among 25,233 patients with pancreatic adenocarcinoma, 37.1%(n = 9349) were diagnosed at an early stage; only 16.7%(n = 4218) underwent resection, whereas 31.7%(n = 7996) received chemotherapy. In turn, 10,073(39.9%) patients received any treatment. Individuals from counties with high upward economic mobility were more likely to be diagnosed at an earlier stage (OR 1.15, 95% CI 1.07-1.25), as well as to receive surgery (OR 1.58, 95% CI 1.41-1.77) or chemotherapy (OR 1.51, 95% CI 1.39-1.63). White patients and patients who identified as neither White or Black had increased odds of being diagnosed at an early stage (OR 1.12, 95% CI 1.02-1.22 and OR 1.35, 95% CI 1.02-1.80, respectively) and of receiving treatment (OR 1.73, 95% CI 1.59-1.88 and OR 1.49, 95% CI 1.13-1.98, respectively) when they resided in a county of high vs low upward economic mobility. The impact of economic mobility on stage at diagnosis and receipt of treatment was much less pronounced among Black patients (high vs low, OR 1.28, 95% CI 0.96-1.71 and OR 1.30, 95% CI 0.99-1.72, respectively).Pancreatic adenocarcinoma patients from higher upward mobility areas were more likely to be diagnosed at an earlier stage, as well as to receive surgery or chemotherapy. The impact of county-level upward mobility was less pronounced among Black patients.

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge. The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated. Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07–1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32–1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10–1.23) and patients not discharged home (OR 1.41, 95%CI 1.33–1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87–0.97 and OR 0.22, 95%CI 0.20–0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days. More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Objective The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy. Background The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined. Methods Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed. Results Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11). Conclusion Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.

Introduction Residential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined. Patients and Methods Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO). Results Among the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00). Conclusion Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10316-3.

Racial/ethnic disparities in cancer outcomes may relate to variations in receipt of National Comprehensive Cancer Network (NCCN) guideline compliant care. Patients undergoing resection of cholangiocarcinoma (CCA) between 2004 and 2015 were identified using the National Cancer Database (NCDB). Institutions treating Black and Hispanic patients within the top decile were categorized as minority-serving hospitals (MSH). Factors associated with receipt of NCCN-compliant care, and the impact of NCCN compliance on overall survival (OS), were evaluated. Among 16,108 patients who underwent resection of CCA, the majority of patients were treated at non-MSH (n = 14,779, 91.8%), while a smaller subset underwent resection of CCA at MSH (n = 1329, 8.2%). Patients treated at MSH facilities tended to be younger (MSH: 65 years versus non-MSH: 67 years), Black or Hispanic (MSH: 59.9% versus non-MSH: 13.4%), and uninsured (MSH: 11.6% versus non-MSH: 2.2%). While overall compliance with NCCN care was 73.0% (n = 11,762), guideline-compliant care was less common at MSH (MSH: 68.8% versus non-MSH: 73.4%; p

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined. The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery. The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon’s integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined. Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p

Inter-hospital transfer (IHT) may help reduce failure-to-rescue (FTR) by transferring patients to centers with a higher level of expertise than the index hospital. We sought to identify factors associated with an IHT and examine if IHT was associated with improved outcomes after complex gastrointestinal cancer surgery. Medicare Inpatient Standard Analytic Files were utilized to identify patients with >1 postoperative complication following resection for esophageal, pancreatic, liver, or colorectal cancer between 2013 and 2017. Multivariable logistic regression was used to examine the association of different factors with the chance of IHT, as well as the impact of IHT on failure-to-rescue (FTR) and expenditures. Among 39,973 patients with >1 postoperative complications, 3090 (7.7%) patients were transferred to a secondary hospital. The median LOS at the index hospital prior to IHT was 10 days (IQR, 6–17 days). Patients who underwent IHT more often had experienced multiple complications at the index hospital compared with non-IHT patients (57.7% vs. 38.9%) (p

Post-acute care (PAC) services can include home healthcare, long-term care hospitals, and skilled nursing facilities. We sought to define factors associated with PAC discharge disposition among Medicare beneficiaries who underwent hepatectomy for hepatocellular carcinoma (HCC). Data for Medicare beneficiaries with a diagnosis of HCC and who underwent a hepatectomy between 2004 and 2015 were retrieved from the SEER-Medicare database. Discharge disposition was defined as routine (HSC: discharged to home) or non-routine (SNF/ICF, discharged to skilled nursing/intermediate care facilities, or HHA, discharge to home with home health agency). The Cochran-Mantel-Haenszel test and multivariable logistic regression were used to assess trends in discharge disposition. Among 1305 patients, the median patient age at diagnosis was 72 years (IQR: 68–76). Approximately 4 in 5 patients were discharged to HSC (77.4%; n = 1010). The odds of a non-routine discharge decreased by 7.0% annually from 2004 to 2015 (ORtrend, 0.93; 95%CI, 0.89–0.97; ptrend = 0.001). Several factors were associated with non-routine discharge, including patient age (OR 1.06, 95%CI 1.04–1.09) and longer LOS (OR 1.07, 95%CI 1.05–1.10). In contrast, patients who had a minor hepatectomy (OR 0.69, 95%CI 0.52–0.93) at a teaching hospital (OR 0.63, 95%CI 0.45–0.89) had lower odds of a non-routine discharge (all P < 0.05). HSC discharge increased over time (2004–2007 (n = 205, 68.1%) vs. 2008–2011 (n = 330, 77.8%) vs. 2012–2015 (n = 475, 81.9%); ptrend < 0.001). Over the same time period, there was a decreasing trend in 90-day readmission (2004–2007 (n = 91, 30.2%) vs. 2008–2011 (n = 107, 25.2%) vs. 2012–2015 (n = 129, 22.2%); ptrend = 0.03). Utilization of PAC services following hepatic resection of HCC decreased by 57.0% between 2004 and 2015. These data highlight that decreased PAC utilization was not generally associated with higher readmission rates following resection of HCC.

The aim of the current study was to determine the impact of neighborhood characteristics on textbook outcome (TO) following surgery.Medicare beneficiaries undergoing AAA repair, CABG, colectomy, or lung resection. Neighborhood characteristics associated with TO were identified.Among 852,128 Medicare beneficiaries, a 10% increase in the mean percentage of college or advanced degree residents (OR:1.04, 95% CI = 1.04-1.05) was associated with 4% greater odds of a TO, whereas 2% lower odds of TO were noted with a 10% increase in the mean percentage of single-parent households (OR: 0.98, 95% CI = 0.97-0.99). Of note, the highest odds of an extended LOS (OR:1.06, 95% CI: 1.05-1.06) and 90-d mortality (OR: 1.05, 95% CI: 1.04-1.06) were observed with single-parent households.Among patients undergoing a range of common surgical procedures, increases in college or advanced degrees residents and a decrease in single-parent households led to significantly higher odds of achieving a TO.

ImportanceGestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening.ObjectiveTo describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum.Design, Setting, and ParticipantsThis cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022.Main Outcomes and MeasuresPrimary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively.ResultsA total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum.Conclusions and RelevanceIn this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach.Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission.Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14).MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.

Upward economic mobility represents the ability of children to surpass their parents financially and improve their economic status. The extent to which it contributes to socioeconomic disparities in health outcomes remains largely unknown.Patients diagnosed with hepatocellular carcinoma (HCC) in 2004-2015 were identified from the SEER-Medicare linked database. Information on county-level upward economic mobility was obtained from the Opportunity Atlas, and its impact on early-stage diagnosis (tumor size ≤ 5 cm, no nodal involvement or distant metastases, no major vascular invasion or extrahepatic extension) and receipt of curative-intent treatment (resection, transplantation, or ablation) was examined.Among 9190 Medicare beneficiaries diagnosed with HCC, the majority were White (64.9%, n = 5965). Overall, 44.7% (n = 4105) of patients were diagnosed with early-stage HCC and 29.7% (n = 2731) underwent curative-intent treatment. While higher upward economic mobility was not associated with HCC diagnosis at an early stage (OR 0.94, 95% CI 0.83-1.06), patients with early-stage HCC from areas of high upward economic mobility had increased odds of undergoing curative-intent treatment (OR 1.25, 95% CI 1.03-1.51). Upward economic mobility had no impact on the likelihood to undergo curative-intent treatment for early-stage HCC among White (OR 1.15, 95% CI 0.91-1.45), Black (OR 1.94, 95% CI 0.85-4.45) or Asian patients (OR 0.77, 95% CI 0.44-1.36). In contrast, non-White patients other than Blacks or Asians diagnosed with early-stage HCC had markedly higher odds of receiving curative-intent treatment if the individual resided in an area characterized by higher versus lower upward economic mobility (OR 2.58, 95% CI 1.50-4.46).While community-level economic mobility was not associated with stage of diagnosis, it affected the likelihood of undergoing curative-intent treatment for early-stage HCC, especially among minority patients other than Black or Asian patients.

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P.05).Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy.The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined.Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed.Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11).Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.

Background Care patterns among patients diagnosed with pancreatic adenocarcinoma remain poorly defined. Methods Cluster analysis was performed on patients with pancreatic adenocarcinoma to assess time from diagnosis to death spent in different care settings (home self-care-dominant[HSC], acute in-hospital care-dominant[ACS], hospice care-dominant[HC] or mixed home and hospice care[MHH]). Results Among 32,816 patients, most belonged to the HSC group (n = 13,459, 41%), followed by MHH (n = 9,091, 28%), ACS (n = 5,737, 18%) and HC (n = 4,529, 14%). Only about 1 in 3 patients in the HSC (n = 4,028, 30%) or ACS (n = 2,206, 35%) received hospice services for at least one week before death. 16% of patients (n = 5,188) died in the hospital, which was most common among ACS patients (n = 1,640, 29%). Median daily expenditures varied according to health care utilization (HSC, $44.6, IQR 12.3–130.1 vs MHH, $162.3, IQR 60.5–351.9 vs ACS, $489.7, IQR 243.2–856.8 vs HC, $306.1, IQR 132.3–580.0; p Conclusions Pancreatic adenocarcinoma patients differed with regards to health care utilization, hospice use and expenditures following diagnosis.

Introduction While the impact of demographic factors on postoperative outcomes has been examined, little is known about the intersection between social vulnerability and residential diversity on postoperative outcomes following cancer surgery. Methods Individuals who underwent a lung or colon resection for cancer were identified in the 2016-2017 Medicare database. Data were merged with the Centers for Disease Control and Prevention social vulnerability index and a residential diversity index was calculated. Logistic regression models were utilized to estimate the probability of postoperative outcomes. Results Among 55 742 Medicare beneficiaries who underwent lung (39.4%) or colon (60.6%) resection, most were male (46.6%), White (90.2%) and had a mean age of 75.3 years. After adjustment for competing risk factors, both social vulnerability and residential diversity were associated with mortality and other postoperative outcomes. In assessing the intersection of social vulnerability and residential diversity, synergistic effects were noted as patients from counties with low social vulnerability and high residential diversity had the lowest probability of 30-day mortality (3.2%, 95% confidence interval [CI]: 3.0-3.5) while patients from counties with high social vulnerability and low diversity had a higher probability of 30-day postoperative death (5.2%, 95% CI: 4.6-5.8; odds ratio: 1.02, 95% CI: 1.01-1.03). Conclusion Social vulnerability and residential diversity were independently associated with postoperative outcomes. The intersection of these two social health determinants demonstrated a synergistic effect on the risk of adverse outcomes following lung and colon cancer surgery.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. The Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. Among 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194–1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04–6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39–30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11–1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04–1.13), nonelective surgery (HR 1.19, 95%CI 1.14–1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05–1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29–6.61) and non-cancer patients (HR 6.98, 95%CI 6.37–7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08–28.02), as well as non-cancer (HR 30.81, 95%CI 27.01–35.15) patients. Patients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1–2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge.The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated.Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07-1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32-1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10-1.23) and patients not discharged home (OR 1.41, 95%CI 1.33-1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87-0.97 and OR 0.22, 95%CI 0.20-0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days.More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Background Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery. Methods Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined. Results Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69–77]FPC vs 72 years [interquartile range: 68–77]non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2–8]FPC vs 3 [interquartile range: 2–8]non-FPC) (both P Conclusion Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

Racial/ethnic disparities in cancer outcomes may relate to variations in receipt of National Comprehensive Cancer Network (NCCN) guideline compliant care.Patients undergoing resection of cholangiocarcinoma (CCA) between 2004 and 2015 were identified using the National Cancer Database (NCDB). Institutions treating Black and Hispanic patients within the top decile were categorized as minority-serving hospitals (MSH). Factors associated with receipt of NCCN-compliant care, and the impact of NCCN compliance on overall survival (OS), were evaluated.Among 16,108 patients who underwent resection of CCA, the majority of patients were treated at non-MSH (n = 14,779, 91.8%), while a smaller subset underwent resection of CCA at MSH (n = 1329, 8.2%). Patients treated at MSH facilities tended to be younger (MSH: 65 years versus non-MSH: 67 years), Black or Hispanic (MSH: 59.9% versus non-MSH: 13.4%), and uninsured (MSH: 11.6% versus non-MSH: 2.2%). While overall compliance with NCCN care was 73.0% (n = 11,762), guideline-compliant care was less common at MSH (MSH: 68.8% versus non-MSH: 73.4%; p 0.001). On multivariable analyses, the odds of receiving non-NCCN compliant care remained lower at MSH (OR 0.76, 95% CI 0.65-0.88). While white patients had similar odds of NCCN-compliant care with minority patients when treated at MSH (OR 0.98, 95% CI 0.75-1.28), minority patients had lower odds of receiving guideline-compliant care when treated at non-MSH (OR 0.85, 95% CI 0.75-0.96). Failure to comply with NCCN guidelines was associated with worse long-term outcomes (HR 1.60, 95% CI 1.52-1.69).Patients treated at MSH had decreased odds to receive NCCN-compliant care following resection of CCA. Failure to comply with guideline-based cancer care was associated with worse long-term outcomes.

Inter-hospital transfer (IHT) may help reduce failure-to-rescue (FTR) by transferring patients to centers with a higher level of expertise than the index hospital. We sought to identify factors associated with an IHT and examine if IHT was associated with improved outcomes after complex gastrointestinal cancer surgery.Medicare Inpatient Standard Analytic Files were utilized to identify patients with1 postoperative complication following resection for esophageal, pancreatic, liver, or colorectal cancer between 2013 and 2017. Multivariable logistic regression was used to examine the association of different factors with the chance of IHT, as well as the impact of IHT on failure-to-rescue (FTR) and expenditures.Among 39,973 patients with1 postoperative complications, 3090 (7.7%) patients were transferred to a secondary hospital. The median LOS at the index hospital prior to IHT was 10 days (IQR, 6-17 days). Patients who underwent IHT more often had experienced multiple complications at the index hospital compared with non-IHT patients (57.7% vs. 38.9%) (p0.001). Transferred patients more commonly had undergone surgery at a low-volume index hospital (n=218, 60.2%) compared with non-IHT (n=10,351, 25.9%) patients (p0.001). On multivariate analysis, hospital volume remained strongly associated with transfer to an acute care hospital (ACH) (OR 5.53; 95% CI 3.91-7.84; p0.001), as did multiple complications (OR 2.01, 95% CI 1.56-2.57). The incidence of FTR was much higher among IHT-ACH patients (20.2%) versus non-IHT patients (11.5%) (OR 1.51, 95% CI 1.11-2.05) (p0.001). Medicare expenditures were higher among patients who had IHT-ACH ($72.1k USD; IQR, $48.1k-$116.7k) versus non-IHT ($38.5k USD; IQR, $28.1k-$59.2k USD) (p0.001).Approximately 1 in 13 patients had an IHT after complex gastrointestinal cancer surgery. IHT was associated with high rates of FTR, which was more pronounced among patients who underwent surgery at an index low-volume hospital. IHT was associated with higher overall CMS expenditures.

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined.The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery.The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined.Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities.Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.

The use of composite measures like “textbook outcome” (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer. Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time. Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p

Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients.Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy.Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p 0.05). The odds of achieving a TOO improved over time (p-trend 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45).Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.

The impact of metabolic syndrome (MetS) on postoperative outcomes following liver surgery is not well studied. The objective of the current study was to examine the association of MetS with individual perioperative outcomes, as well as the composite “textbook outcome” (TO) following liver resection for both benign and malignant indications. The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent hepatectomy between 2013 and 2017. The impact of MetS on complications, length of stay (LOS), 90-day readmission, 90-day mortality, and TO following hepatectomy was investigated. Among 13,898 patients who underwent hepatectomy, 2491 (17.9%) had MetS while 11,407 (82.1%) did not. Patients with MetS were more often male (59.1% vs 48.5%), Black (8.5% vs 6.6%), and had a diagnosis of cancer (69.9% vs 65.1%) (all p