Plan Database Research Articles

Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes

The increased incidence of bile duct injuries (BDIs) after the adoption of laparoscopic cholecystectomy has been well documented. However, the longitudinal impact of bile leaks and BDIs on survival and healthcare use have not been studied adequately. The aims of this analysis were to determine the incidence, long-term outcomes, and costs of bile leaks and ductal injuries in a large population. The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Bile leaks, BDIs, and their management strategy were defined. Survival was calculated by Kaplan-Meier failure estimates with multivariable regression and propensity analyses. Cost analyses used inflation adjustments and institution-specific cost-to-charge ratios. Of 711,454 cholecystecomies, bile leaks occurred in 3,551 patients (0.50%) and were managed almost exclusively by endoscopists. Bile duct injuries occurred in 1,584 patients (0.22%) with 84% managed surgically. Patients with a bile leak were more likely to die at 1 year (2.4% vs 1.4%; odds ratio 1.85; p < 0.001). Similarly, BDI patients had an increased 1-year mortality (7.2% vs 1.3%; odds ratio 2.04; p < 0.0001). Survival of BDI patients was better with an operative approach (odds ratio 0.19; p < 0.001) when compared with endoscopic management. Operatively managed BDIs were also associated with fewer emergency department visits and readmissions, as well as lower cumulative costs at 1 year ($60,539 vs $118,245; p < 0.001). The 0.22% incidence of BDIs observed in California is lower than reported in the first decade after the introduction of laparoscopic cholecystectomy. Bile leaks are 2.3 times more common than BDIs. Patients with a bile leak or BDI have diminished survival. Surgical repair of a BDI leads to enhanced survival and reduced cumulative cost compared with endoscopic management.

Correlation of hospital magnet status with the quality of physicians performing neurosurgical procedures in New York State

Purpose: The quality of physicians practicing in hospitals recognized for nursing excellence by the American Nurses Credentialing Center has not been studied before. We investigated whether Magnet hospital recognition is associated with higher quality of physicians performing neurosurgical procedures.Materials and methods: We performed a cohort study of patients undergoing neurosurgical procedures from 2009–2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Propensity score adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial.Results: During the study period, 185,277 patients underwent neurosurgical procedures, and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions. Instrumental variable analysis demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% CI, 13.2% to 14.1%), and a 4.3% higher chance of being treated by a physician with superior performance in terms of length-of-stay (LOS) (95% CI, 3.8% to 4.7%) in comparison to non-Magnet institutions. The same associations were present in propensity score adjusted mixed effects models.Conclusions: Using a comprehensive all-payer cohort of neurosurgical patients in New York State we identified an association of Magnet hospital recognition with superior physician performance.

Assessment of Urban Physical Seismic Vulnerability Using the Combination of AHP and TOPSIS Models: A Case Study of Residential Neighborhoods of Mymensingh City, Bangladesh

Mymensingh, one of the oldest municipalities of Bangladesh, is at great risk against earthquakes because three major faults viz. Dauki fault, Madhupur fault, and Sylhet-Assam fault are located around it, and possesses liquefaction susceptible soil type. The city has great significance from the economic and administrative point of view and recently declared as the 8th administrative division of Bangladesh which directly stimulates the unplanned future expansion. Considering the potentiality of haphazard development and high seismic risk, it is crucial to assess the seismic vulnerability for taking the judicious decision regarding risk reduction measures for the city. The study combines Technique for Order Preference by Similarity to Ideal Solution method (TOPSIS) and Analytical Hierarchical Process (AHP) models to assess the seismic vulnerability of residential neighborhoods of Mymensingh city as the probability of death and damage is remarkable in residential neighborhoods than other land use types. A combined quantitative methodology of AHP-TOPSIS is used in this study to quantify 13 important qualitative and quantitative factors of earthquake vulnerability, decided on expert opinions. The data of 13 vulnerability factors are collected from the Mymensingh Strategic Development Plan (MSDP, 2011-2031) database, done under Comprehensive Disaster Management Programme (CDMP)-II during 2012-2014. Geographic Information System is used in this study to analyze and mapping of seismic vulnerability. Results indicated that 37 residential neighborhoods are very highly vulnerable, 55 neighborhoods are highly vulnerable, 75 neighborhoods are moderately vulnerable and 74 neighborhoods are in the low vulnerable category.

Rate of revisions or conversion after bariatric surgery over 10 years in the state of New York

BackgroundA primary measure of the success of a procedure is the whether or not additional surgery may be necessary. Multi-institutional studies regarding the need for reoperation after bariatric surgery are scarce. ObjectivesThe purpose of this study is to evaluate the rate of revisions/conversions (RC) after 3 common bariatric procedures over 10 years in the state of New York. SettingUniversity Hospital, involving a large database in New York State. MethodsThe Statewide Planning and Research Cooperative System database was used to identify all patients undergoing laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) between 2004 and 2010. Patients were followed for RC to other bariatric procedures for at least 4 years (up to 2014). Multivariable cox proportional hazard regression analysis was performed to identify risk factors for additional surgery after each common bariatric procedure. Multivariable logistic regression was used to check the factors associated with having ≥2 follow-up procedures. ResultsThere were 40,994 bariatric procedures with 16,444 LAGB, 22,769 RYGB, and 1781 SG. Rate of RC was 26.0% for LAGB, 9.8% for SG, and 4.9% for RYGB. Multiple RC ( = />2) were more common for LAGB (5.7% for LAGB, .5% for RYGB, and .2% for LSG). Band revision/replacements required further procedures compared with patients who underwent conversion to RYGB/SG (939 compared with 48 procedures). Majority of RC were not performed at initial institution (68.2% of LAGB patients, 75.9% for RYGB, 63.7% of SG). Risk factors for multiple procedures included surgery type, as LAGB was more likely to have multiple RC. ConclusionsReoperation was common for LAGB, but less common for RYGB (4.9%) and SG (9.8%). RC rate are almost twice after SG than after RYGB. LAGB had the highest rate (5.7%) of multiple reoperations. Conversion was the procedure of choice after a failed LAGB.

Serum cholesterol trajectories in the 10 years prior to lymphoma diagnosis.

Many studies suggest a role for cholesterol in cancer development. Serum cholesterol levels have been observed to be low in newly diagnosed lymphoma cases. The objective of these analyses was to examine the time-varying relationship of cholesterol with lymphomagenesis in the 10years prior to diagnosis by lymphoma subtype. Participants were selected from the combined membership of six National Cancer Institute-funded Cancer Research Network health plans from 1998 to 2008, excluding members with human immunodeficiency virus, cancer (except lymphoma), or organ transplants. Incident lymphoma cases within this population were ascertained and matched with up to five controls. Total serum cholesterol, high-density lipoprotein, and low-density lipoprotein were collected from plan databases. Multilevel, multivariable longitudinal models were fit after choosing the best polynomial order by deviance statistics for selected lymphoma histotypes to examine pre-diagnosis cholesterol trajectories: Hodgkin lymphoma (n = 519) and all non-Hodgkin lymphomas combined (n = 12,635) as well as six subtypes of the latter. For all categories, lymphoma cases had statistically significantly lower estimated total serum cholesterol, high-density lipoprotein, and low-density lipoprotein levels than controls in the years prior to diagnosis/index date. Between-group differences were most pronounced 3-4 years prior to diagnosis, when cases' cholesterol levels declined steeply. This analysis is the first to examine changes in serum cholesterol for a decade prior to lymphoma diagnosis. A drop in cholesterol levels was evident several years before diagnosis. Our results suggest that cholesterol-related pathways have an important relationship with lymphomagenesis and low cholesterol could be a preclinical lymphoma marker.

Hospital Centralization Impacts High-Risk Lung and Bladder Cancer Surgical Patients

ABSTRACTWe investigated the effects of hospital centralization on the distribution of the individual surgical patient risk in higher versus lower volume hospitals. Lung (n = 28,471) and bladder (n = 8,160) cancer surgical patients were selected from the New York Statewide Planning and Research Cooperative System database, 1997–2011. Estimated patient risk was consistently lower in the highest compared to the lowest hospital volume-quartiles for lung and bladder cancer mortality, complications, and long length of stay. Although centralization has improved outcomes, lower volume hospitals continue to perform surgery on higher surgical risk patients compared to higher volume hospitals.

Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis.

The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes. We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial. During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals. Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted.

Adaptive synthesis of indoor scenes via activity-associated object relation graphs

We present a system for adaptive synthesis of indoor scenes given an empty room and only a few object categories. Automatically suggesting indoor objects and proper layouts to convert an empty room to a 3D scene is challenging, since it requires interior design knowledge to balance the factors like space, path distance, illumination and object relations, in order to insure the functional plausibility of the synthesized scenes. We exploit a database of 2D floor plans to extract object relations and provide layout examples for scene synthesis. With the labeled human positions and directions in each plan, we detect the activity relations and compute the coexistence frequency of object pairs to construct activity-associated object relation graphs. Given the input room and user-specified object categories, our system first leverages the object relation graphs and the database floor plans to suggest more potential object categories beyond the specified ones to make resulting scenes functionally complete, and then uses the similar plan references to create the layout of synthesized scenes. We show various synthesis results to demonstrate the practicability of our system, and validate its usability via a user study. We also compare our system with the state-of-the-art furniture layout and activity-centric scene representation methods, in terms of functional plausibility and user friendliness.

A Study on Method of Vertical Zoning of Construction Lift for High-rise Building based on Lift Planning & Operation History Database

As the height and size of urban buildings constructed in cities in Korea have recently increased, vertical lift planning and operation is a key factor for the successful project of a tall building. Although many studies have attempted to set up a lift planning system at an early stage, a real-time lift operation control system with respect to the construction stage has yet to be proposed. Therefore, in this study, the sensor module and storage device named the Embedded Lift Information System (ELIS) was used to collect the lift operating data for improvement of lift operation efficiency in order to develop an optimum lift operating analysis system which could perform real-time analysis. Finally, the pattern of operation data of the lift was analyzed and the lift event of the next day was derived. In addition, we verified the efficiency of the proposed optimum vertical zoning simulation system using the expected lift event extracted from the operation history data pattern. In this paper, the proposed system provides more efficient vertical zoning alternatives for the lift manager. This simulation based decision making tool reduces the user’s queuing time compared with the previous system. This system is expected to contribute to high-rise building construction of over 400 m.

Colorectal Surgery Fellowship Improves In-hospital Mortality After Colectomy and Proctectomy Irrespective of Hospital and Surgeon Volume

BackgroundGeneral surgery residents are increasingly pursuing sub-specialty training in colorectal (CR) surgery. However, the majority of operations performed by CR surgeons are also performed by general surgeons. This study aimed to assess in-hospital mortality stratified by CR training status after adjusting for surgeon and hospital volume. MethodsThe Statewide Planning and Research Cooperative system database was used to identify all patients who underwent colectomy/proctectomy from January 1, 2000, to December 31, 2014, in the state of New York. Operations performed by board-certified CR surgeons were identified. The relationships between CR board certification and in-hospital mortality, in-hospital complications, length of stay, and ostomy were assessed using multivariate regression models. ResultsTwo hundred seventy thousand six hundred eighty-four patients underwent colectomy/proctectomy over the study period. Seventy-two thousand two hundred seventy-nine (26.7%) of operations were performed by CR surgeons. Without adjusting for hospital and surgeon volume, in-hospital mortality was lower for those undergoing colectomy/proctectomy by a CR surgeon (OR 0.49, CI 0.44–0.54, p = 0.001). After controlling for hospital and surgeon volume, the odds of inpatient mortality after colectomy/proctectomy for those operated on by CR surgeons weakened to 0.76 (CI 0.68–0.86, p = 0.001). Hospital and surgeon volume accounted for 53% of the reduction in in-hospital mortality when CR surgeons performed colectomy/proctectomy. Patients who underwent surgery by a CR surgeon had a shorter inpatient stay (0.8 days, p = 0.001) and a decreased chance of colostomy (OR 0.86, CI 0.78–0.95, p < 0.001). ConclusionsFor patients undergoing colectomy/proctectomy, in-hospital mortality decreased when the operation was performed by a CR surgeon even after accounting for hospital and surgeon volume.

Effects of the New York State Concussion Management and Awareness Act (“Lystedt Law”) on Concussion-Related Emergency Health Care Utilization Among Adolescents, 2005-2015

Background: All states have enacted legislation addressing the management of sports-related concussions (SRCs) in adolescent athletes. The effect of these laws on health care utilization is uncertain. Hypothesis/Purpose: The purpose was to evaluate the effects of New York’s 2011 Concussion Management and Awareness Act (“Lystedt Law”) on emergency department (ED) concussion health care visits (EDCHVs) and brain imaging utilization. It was hypothesized that New York concussion legislation would have a significant temporal effect on EDCHVs. Study Design: Descriptive epidemiology study. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database, trends in EDCHVs from 2005 to 2015 were identified among 12- to 18-year-old patients, comprising 5,740,403 total ED visits. Results: Overall, 208,024 EDCHVs, including 54,669 for an SRC, occurred during the study period. EDCHVs increased from 13,664 (2.74% of all ED visits) in 2005 to a peak of 21,374 (4.26%) in 2013, with greatest relative increases from 2008 to 2013. SRCs followed a similar trend: 3213 (0.64%) in 2005 to a peak of 6197 (1.24%) in 2013. Brain imaging utilization decreased by 5.3% for EDCHVs and 15.4% for SRCs (all comparisons year-by-year and for trends; P < .001). Conclusion: The period of greatest increases in EDCHVs and decreases in brain imaging utilization for SRCs preceded New York concussion legislation by several years, suggesting a minimal direct effect on emergency care–seeking behavior for concussions. Instead, increased public awareness of SRCs and imaging guidelines may have driven EDCHV trends and imaging practices.

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty.

For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections. Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. Level III: prognostic study.

Developing a National Patient Transfer Letter for use by both the Nursing Home (NH) &amp; Acute Hospital (AH) Sectors

Background: This project was initially undertaken by the Department of Medicine for Older people in two Academic Teaching Hospitals in Dublin. It is led by two Clinical Nurse Specialists in Gerontology and is supported by geriatricians in both sites. It has recently gained the support of the Irish Hospice Foundation (IHF) Nursing Homes Ireland (NHI) and National Clinical Programme for Older People (NCPOP). Problem: Information sent from local nursing homes to the acute hospital Emergency Department often lacks the information required to provide safe quality care to the older person in an emergency situation. Hence, members of the interdisciplinary team spend inordinate amounts of time contacting these NH’s in order to obtain basic information that will support important care and treatment decisions in the acute setting for this complex, frail patient group. Information on medications, infection status, diet, cognition, functionality, advanced care planning are essential if we are to determine patient need. Assessment of problem and analysis of its causes: A prospective audit was carried out in 2011 to assess the problem outlined above in which 35 transfer letters from 29 different NHs were reviewed. A questionnaire was used to assess 24 aspects of information been received at the point of hospital entry. A template transfer letter was devised from the questionnaire to capture demographic information, baseline medical information, physical information and the cognitive status of the patient being transferred to hospital from each NH. The template was sent at the end of the audit period to all Directors of Nursing in each NH. All were requested to send feedback on the template so it could be modified for phase 2 of the project. Intervention: As a result of the consultative process a new transfer document was developed. Support from the national advisory body Nursing Homes Ireland (NHI) was ascertained. In order to enhance accessibility and promote usage, the document was made available on both hospital websites and a care planning database ‘Epicare’ which is used by 60% of NH’s nationally. Strategy for change: From the outset of the project in 2011, we consulted with Directors of Care from NH’s through NHI; in order to ascertain that: 1) the proposed content of the Transfer letter was appropriate and, 2) that updates on the transfer document were communicated to reflect national standards / guidance. Measurement of improvement: Continuous audit cycles (4) and on-going consultation with NH’s; allowed us measure improvements in the quality of transfer information. In 2015, 62% of NH were using the standardised template document (n=37) a decrease from 73% in 2012. However, baseline demographic & medical information was well documented, as were Functional Scores (90-100%). Other Results show improvements & areas for concern Effects of changes: Improvements in transfer communication meant clinicians in Acute Hospitals (AH)’s and NH’s spent less time looking for information deemed vital to patient care. One of the challenges was that NH’s wanted more information on the document at each stage of the consultation process. Its’ success as a single page document at local level allowed the document to trialled at regional level with funding support from the IHF. 189 NH’s were contacted and 83% (81 replies) used the document and reported it to be useful and comprehensive. Lessons learnt: The document is currently undergoing an integrated consultation process between both the NH & AH Sectors for National application with the support of NCPOP. Other stakeholders challenge its single page status and its’ scope has been be broadened to include other areas of the residential care sector. Quality of transfer information from AH to NH will need to be considered following this phase as requested by NH’s. Messages for others: A single page document with key information that represents patient need is vital during transitions of care. It helps reduce incidences of missed care through the provision of appropriate information between healthcare stakeholders. Consultation with Directors of Care or Clinicians from both NH & AH respectively is essential on behalf of NH patients to ensure that the information been transferred is satisfactory and that patient need is been met through appropriate transfer of information when developing or using a standardised template.

Experience-Based Quality Control in Radiation Therapy Treatment Planning of High Risk Post-prostatectomy Prostate Cancer with RapidPlan: NRG Oncology RTOG 0621

To develop a knowledge based planning (KBP) model with RapidPlan (Varian Medical Systems, Palo Alto, USA) for the treatment of high risk post-prostatectomy prostate cancer using a knowledge database of high quality treatment plans from the national clinical trial RTOG 0621. To test the model as a quality assurance (QA) tool and use it to establish the feasibility of the compliance criteria for NRG GU003. :An initial dosimetric analysis was carried out to identify high quality treatment plans from RTOG 0621. Treatment plans for patients enrolled in the trial were scored according to the system used by the Imaging and Radiation Oncology Core (IROC) of the National Clinical Trials Network (NCTN) of the NCI to assess adherence to the trial protocol. Of the 80 treatment plans enrolled in the trial a knowledge database of 40 high quality plans was used to train the model. Another subset of plans, orthogonal to the training set, was chosen for the validation set to ensure that the model accurately predicts dose volume histograms (DVHs) for all critical structures. The remaining plans were re-optimized with the model in order to test its effectiveness as a QA tool. The re-optimized plans were analyzed to determine what percentage pass each of the compliance criteria for NRG GU003. The RapidPlan prostate model has been successfully trained and used to re-optimize plans selected from RTOG 0621. Plans re-optimized with the model show increased dose sparing to the bladder and rectum without loss of target coverage. These re-optimized plans show a reduction of V50 of up to 45% for the bladder and 24% for the rectum when compared with the original clinical plans submitted to the trial. The RapidPlan prostate model developed in this study is an effective tool for IMRT treatment planning QA.

Is Annual Volume Enough? The Role of Experience and Specialization on Inpatient Mortality After Hepatectomy.

To investigate the effect of subspecialty practice and experience on the relationship between annual volume and inpatient mortality after hepatic resection. The impact of annual surgical volume on postoperative outcomes has been extensively examined. However, the impact of cumulative surgeon experience and specialty training on this relationship warrants investigation. The New York Statewide Planning and Research Cooperative System inpatient database was queried for patients' ≥18 years who underwent wedge hepatectomy or lobectomy from 2000 to 2014. Primary exposures included annual surgeon volume, surgeon experience (early vs late career), and surgical specialization-categorized as general surgery (GS), surgical oncology (SO), and transplant (TS). Primary endpoint was inpatient mortality. Hierarchical logistic regression was performed accounting for correlation at the level of the surgeon and the hospital, and adjusting for patient demographics, comorbidities, presence of cirrhosis, and annual surgical hospital volume. A total of 13,467 cases were analyzed. Overall inpatient mortality was 2.35%. On unadjusted analysis, late career surgeons had a mortality rate of 2.62% versus 1.97% for early career surgeons. GS had a mortality rate of 2.98% compared with 1.68% for SO and 2.67% for TS. Once risk-adjusted, annual volume was associated with reduced mortality only among early-career surgeons (odds ratio 0.82, P = 0.001) and general surgeons (odds ratio 0.65, P = 0.002). No volume effect was seen among late-career or specialty-trained surgeons. Annual volume alone likely contributes only a partial assessment of the volume-outcome relationship. In patients undergoing hepatic resection, increased annual volume did not confer a mortality benefit on subspecialty surgeons or late career surgeons.

Disparities in the Intensity of End-of-Life Care for Children With Cancer.

Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer. By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death. The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ≥1 intensity indicator, 23% ≥2, and 22% ≥1 intense medical intervention. There was a bimodal association between age and intensity: ages <5 years and 15 to 21 years was associated with intense care. Patients with hematologic malignancies were more likely to have high-intensity end-of-life care, as were patients from underrepresented minorities, those who lived closer to the hospital, those who received care at a nonspecialty center (neither Children's Oncology Group nor National Cancer Institute Designated Cancer Center), and those receiving care after 2008. Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.

Predicting the benefits of proton therapy in lung cancer patients from patient-specific anatomic and pathologic geometry

The magnitude of OAR dose sparing feasible with radiation therapy depends upon the patient-specific arrangement of the target volumes in relation to the OARs. When comparing proton beam therapy (PBT) and photon therapy, the evaluation of PBT benefits is currently achieved via resource-intensive treatment planning, which requires specialized software and clinical expertise typically only available at PBT centers. The purpose of this study is to train and validate knowledge-based plan prediction (KPP) models to estimate these benefits for lung cancer patients, requiring fewer resources and no PBT expertise. Our study used a cohort of locally advanced NSCLC patients, enrolled in a trial that randomized treatment between PBT (36 pts) and IMRT (68 pts). KPP models learn geometric patterns from a database of pre-existing treatment plans, and can then predict the feasible OAR DVHs of a new patient. By training independent KPP models for both PBT and IMRT, the feasible benefits of PBT can be predicted for the new patient. Our KPP methodology split each OAR into subvolumes that characterize the dose falloff and coplanar beams. Models were validated by 5-fold cross-validation, by comparing the predicted OAR DVHs to those of the actual treatment plan. DVHs were predicted for the lung (combined lungs excluding GTV), heart and esophagus. For each predicted and planned DVH, the equivalent uniform dose (EUD) and normal tissue complication probability (NTCP) were computed. The table shows the root-mean-square error of the EUD and NTCP predictions, for both the PBT and IMRT models. It also shows the estimated uncertainty in the predicted benefit. Model accuracy depends upon the OAR type and treatment modality, but no significant signs of bias were observed. Pearson’s correlation coefficient was 84% – 98% for PBT and 81% – 96% for IMRT, demonstrating that the KPP models successfully captured the interpatient variation. We developed KPP models for lung cancer patients treated with PBT and an alternative treatment modality (IMRT). By comparing the two predicted plans for a new patient, the patient-specific benefits of PBT can quickly be estimated with high accuracy. This methodology could enable better-informed referral decisions, improving the cost-effectiveness of this expensive therapy and elevating PBT in the era of precision medicine. It could also estimate the expected benefits at an earlier stage in the clinical workflow, or provide a high-throughput patient pre-selection for model-based trials aiming to measure the higher efficacy of PBT.Abstract 3592Prediction Error in EUD [Gy]Prediction Error in NTCP [%]PBTIMRTBenefitsPBTIMRTBenefitsLung2.02.23.02.94.45.3Heart1.93.54.02.14.24.7Esophagus4.35.16.76.87.810.3 Open table in a new tab

Leveraging an Expert Knowledge-Based Plan Matching System Enables Meeting More Clinical Objectives for Prostate External Beam Radiation Therapy

The creation of an ideal IMRT plan is a challenging and complex process utilizing a team of expert physicians, dosimetrists, medical physicists, and computer algorithms. Due to challenges with simultaneously optimizing multiple dosimetric indices, the full extent of achievable plan results (including plan trade-offs) are not known with high precision. Knowledge based treatment-planning (KBTP) aims to leverage past plan expertise to optimize new plans. The commercial software (QuickMatch™, Siris Medical Inc.) guides the dosimetrist through a library of previously approved plans to identify multiple achievable treatment plans for new patients. In general, the larger the database, the more insights that can be drawn from it. We report on treatment planning results from the largest known (to the best of our knowledge) plan database for treatment plan guidance of prostate plans. QuickMatch (QM) built a library with 1168 prostate patients (over 3,500 plans), spanning the years 2010-2016. These plans included pelvic node & non-pelvic node cases, with dose escalation to the Planning Target Volume (PTV) from 8100 to 8640 cGy using IMRT. We randomly identified 16 consecutive patients and planned them prospectively with QM. For each plan, a clinical dosimetrist using the same treatment planning system compared final dosimetry with respect to PTV coverages, bladder doses, rectal doses, and femur doses using standard planning techniques (SPT) compared to QM. We also retrospectively analyzed 1168 plans to identify those that did not meet either rectal, bladder, or femoral dose constraints using STP to determine if adding QM would result in improved dosimetry. Compared to STP alone, the addition of QM to STP improved overall dosimetry in the final prostate plans. In the 16 prospectively analyzed plans, nearly one more constraint per plan (mean difference = 0.8 constraints, matched pair t-test p=0.0044) was met without sacrificing other constraints or PTV coverage in every case (matched pair t-test p=0.86 that the means are different). QM guidance reduced rectal avoidance D10 in 85% of these patients. There were 561 instances where a clinical dose constraint was not met with STP. In these cases, QuickMatch improved the ability to meet clinical constraints, including PTV constraints, in 58% (323/561), in Rectal D10 in 67% (110/164), Rectal D50 in 59% (33/56), Bladder D10 in 54% (66/122), Bladder D50 in 25% (3/12), and femur D50 in 54% (111/207). We demonstrate the ability for an expert-trained knowledge based system to guide planning and to meet significantly more clinical dose constraints than standard planning for prostate RT.

Redefining the Stone Belt: Precipitation Is Associated with Increased Risk of Urinary Stone Disease.

The American Southeast has been labeled the "Stone Belt" due to its relatively high burden of urinary stone disease, presumed to be related to its higher temperatures. However, other regions with high temperatures (e.g., the Southwest) do not have the same disease prevalence as the southeast. We seek to explore the association of stone disease to other climate-associated factors beyond temperature, including precipitation and temperature variation. We identified all patients who underwent a surgical procedure for urinary stone disease from the California Office of Statewide Health Planning and Development (OSHPD) databases (2010-2012). Climate data obtained from the National Oceanic and Atmospheric Administration (NOAA) were compared to population adjusted county operative stone burden, controlling for patient and county demographic data as potential confounders. A total of 63,994 unique patients underwent stone procedures in California between 2010 and 2012. Multivariate modeling revealed that higher precipitation (0.019 average increase in surgeries per 1000 persons per inch, p < 0.01) and higher mean temperature (0.029 average increase in surgeries per 1000 persons per degree, p < 0.01) were both independently associated with an increased operative stone disease burden. Controlling for county-level patient factors did not change these observed effects. In the state of California, higher precipitation and higher mean temperature are associated with increased rates of stone surgery. Our results appear to agree with the larger trends seen throughout the United States where the areas of highest stone prevalence have warm wet climates and not warm arid climates.

Superior 3-Year Value of Open and Endovascular Repair of Abdominal Aortic Aneurysm with High-Volume Providers

Conflicting literature exists regarding resource utilization for cardiovascular care when stratified by provider volume. This study investigates the differences in value of abdominal aortic aneurysm (AAA) repair by high- and low-volume providers. The hypothesis of this study is that high-volume providers will provide superior value AAA repairs when compared to low-volume providers. Using the New York Statewide Planning and Research Cooperative System database and its linked death database, patients undergoing intact open and endovascular aneurysm repair (EVAR) were identified over a 10-year period. Charge data were normalized to year 2016 dollars and the data stratified by repair modality and annual surgeon volume. Univariate technique was used to compare the 2 groups over a 3-year follow-up period. Nine hundred eleven surgeons performed open AAA repairs and 615 performed EVAR. For both repair modalities, and despite a patient population with more vascular risk factors, the cumulative adjusted charge for all aneurysm-related care was significantly less for high-volume providers than low-volume providers. The calculated 3-year value-patient life years per cumulative charge-was also superior for high-volume providers compared to low-volume providers. This difference in charge and value persisted after propensity score matching for race, sex, insurance status, and common vascular comorbidities including hypertension, dyslipidemia, and a history of smoking. High-volume surgeons performing repair of aortic aneurysms provide superior value when compared to low-volume providers. The improved value margin is driven by both lower charge and improved survival, despite an increased incidence of cardiovascular comorbidities. This study adds support for the regionalization of care for patients with aortic aneurysm.