Surgeon Specialty Research Articles

Sartorius Muscle Flaps: Perioperative Outcomes Based on Surgical Specialty

Complicated groin wounds often require repair by sartorius muscle flap (SMF). Operating surgical specialty differs based on SMF indication, hospital, and operating surgeon preference. We aim to assess the effect of operating surgical specialty, indication for SMF, and other patient-level factors on 30-day outcomes. We collected data on all patients undergoing SMF performed at our institution from 2005 to 2015, including age, sex, body mass index, comorbidity index (hypertension, diabetes, dyslipidemia, peripheral arterial disease, coronary artery disease), smoking status, history of malignancy, indication for SMF (infection, noninfectious complication, prophylaxis), and operating surgeon's specialty (vascular, plastic, general, other). Primary outcome was any 30-day complications (wound infection, seroma, dehiscence, or bleeding). Secondary outcome included 30-day surgical reintervention rate. Univariate analysis and multivariate logistic regression modeling were used to evaluate primary outcomes. A total of 170 SMFs were performed during the study period (mean patient age 58years; 49% male). Primary indication for SMF was prophylaxis in 116 cases (68%), followed by infection in 36 cases (21%) and noninfectious complications in 18 cases (11%). General surgeons performed the highest proportion of SMF (45%) followed by vascular surgeons (26%), "other specialties" (15%), and plastic surgeons (14%). Compared with all specialties, vascular surgeons operated on the severely ill patients (77% of vascular patients had ≥3 comorbidities, P<0.001). Surgical reintervention within 30days was required in 7 patients (4.1%): 3 by vascular surgeons (6.8% of total cases by vascular surgery) and 4 by plastic surgeons (17.4% of total cases by plastic surgery, P<0.001). Any 30-day complications occurred in 47 patients (28%): 30 general surgery cases (39%), 7 plastic surgery cases (30%), 7 other specialty cases (27%), and 3 vascular surgery cases (7%) (P<0.001). Of all vascular disease-related cases (56), plastic surgeons performed 21% of SMF, while vascular surgeons performed 79%. On logistic regression correcting for baseline differences between groups, vascular surgeon SMF outcomes were compared favorably with those done by other specialties. Overall, SMFs have low perioperative reintervention rates but high complication rates. Vascular surgeons perform SMF on high-risk patients with more comorbidities compared with other specialties. Although overall morbidity associated with this procedure is high, perioperative outcomes for SMF performed by vascular surgeons are favorable.

Fixed and variable cost of carotid endarterectomy and stenting in the United States: A comparative study

ObjectiveDespite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database. MethodsWe studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar. ResultsA total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively. ConclusionsThe total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS.

Abstract P3-14-02: Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons

Abstract Purpose/Objective In the United States over 40% of incident breast cancer diagnoses are in women over 65 years of age. Effective breast cancer treatments allow elderly patients to live long, healthy lives; questions regarding long-term quality of life are increasingly important. In women over 65, post-mastectomy breast reconstruction (PMBR) is uncommon with reported rates of 6-30%. The goal of this study is to report complication rates in elderly PMBR patients and to evaluate the impact of individual surgeons on PMBR in elderly patients. Material/methods We identified 19,417 Medicare beneficiaries diagnosed with localized breast cancer between 2005 and 2011 who underwent mastectomy. Medicare claims were used to identify PMBR, post-operative complications after PMBR (within 30 days of surgery), and long-term complications related to reconstruction (within three years following surgery). Mastectomy surgeon was identified from Medicare claims with surgeon characteristics identified through linkage to the American Medical Association (AMA) Masterfile. Multi-level, multivariable logistic models clustered by surgeon and geographic area were used to determine the impact of surgeons on the likelihood of reconstruction. The intraclass correlation coefficient (ICC) and median odds ratio (MOR) were used to describe the relative impact of the individual surgeon. The ICC estimates the proportion of variability explained by the surgeon on PMBR rates. The MOR quantifies the likelihood of a patient having a different PMBR outcome if the patient were to change surgeons (or geographic area); it is directly comparable to odds ratios. Odds ratios (OR) were used to describe the impact of fixed demographic and clinical covariates. Results Among the entire cohort, 1,234 (6.4%) patients underwent PMBR. The post-operative complication rate was 8.4% and the long-term complication rate was 19.9%. Eighteen percent of the variability in PMBR use was attributed to the individual surgeon (ICC 0.181). The MOR for surgeon was found to be 1.85 (95% CI [1.70,1.99]), indicating that a patient had an 85% chance of having a different outcome (receiving or not receiving PMBR) if the patient saw a different mastectomy surgeon. The MOR for geographic area indicated that a patient had a 32% chance of having a different outcome if the patient saw a surgeon in a different geographic area (1.32, 95% CI [1.17, 1.47]). Patients who were Asian, single, older, of lower socioeconomic status, and underwent radiation therapy were less likely to undergo PMBR. Patients who had pre-operative MRI or received chemotherapy were more likely to undergo PMBR. Patients who were treated by female surgeons or plastic surgeons were significantly more likely to undergo PMBR. Overall, the individual surgeon was the most predictive of PMBR, except for the use of pre-operative MRI and mastectomy surgeon's specialty being plastic surgery. Conclusion A small minority of older women undergo PMBR despite having low post-operative and long-term complication rates. The individual surgeon and geographic area significantly influences whether older breast cancer patients will undergo PMBR. Future research should focus on surgeon characteristics that may influence a patient's decision to undergo PMBR. Citation Format: Schoenbrunner AR, Fero KE, Boero IJ, Matsuno R, Kronstadt N, Lance S, Reid C, Wallace AM, Gosman AA, Murphy JD. Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-02.

Impact of Surgical Specialty on Outcomes Following Carotid Endarterectomy.

The impact of surgeon specialty on outcomes following carotid endarterectomy (CEA) has been widely debated within the literature. Previous studies on this subject are often limited by small sample sizes, single-intuition designs, variability in patients and procedures, and potential confounding factors such as institution type and volume. To identify similarities and differences between surgeon specialties in postoperative stroke and mortality rates for patients undergoing unilateral CEAs by utilizing a large, multicenter prospective database. We utilized a large national prospective database (National Surgical Quality Inpatient database) and investigated all patients with a 1-sided, surgically naïve CEA, performed by either a general, vascular, cardiothoracic, or neurological surgeon. We employed a logistic regression analysis to control for the most salient variables identified via univariate analysis. Our primary outcomes were all-cause mortality and stroke. There were 42 369 patients included across all specialties. Patients from each specialty were similar in demographics but varied in medical history. Multivariate analysis demonstrated that among the specialties only general surgeons had significantly greater postoperative stroke rates (2.3%) when compared to vascular surgeons (1.5%; P = .003, odds ratio [OR] 1.574, confidence interval [CI]: 1.168-2.121). In contrast, surgical specialty was not a significant risk factor for 30-d postoperative mortality (0% in cardiothoracic surgeons; 0.8% in vascular surgeons; 1.1% in general surgeons; 1.8% in neurosurgeons; Cardiothoracic surgeons: P = .995, OR: 0 [no incidences of mortality]; neurosurgeon: P = .118, OR: 0.2057, CI: 0.833-2.057; general surgeon P = .210, OR: 1.326, CI: 1.853-2.062). Most secondary outcomes (myocardial infarction, infection, reoperation, pneumonia) were similar between specialties (P = .339-.816). However, length of stay (P < .001), operative duration (P < .001), incidence of venous thromboembolism (P < .001), and the postoperative requirement for a ventilator greater than 48 h (P = .004) were all the greatest among neurosurgeons. Multidisciplinary approaches with improved communication among surgical specialties may enhance patient management and improve success after CEA. Though there were differences in postoperative stroke and other secondary outcomes, no differences were observed among specialties in mortality after unilateral CEA in more than 40 000 patients.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence.

Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI. The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location. A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures. InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Description of a risk predictive model of 30-day postoperative mortality after elective abdominal aortic aneurysm repair

ObjectiveDespite vast improvement in the field of vascular surgery, elective abdominal aortic aneurysm (AAA) repair still leads to perioperative death. Patients with asymptomatic AAAs, therefore, would benefit from an individual risk assessment to help with decisions regarding operative intervention. The purpose of this study was to describe such a 30-day postoperative (POD) risk prediction model using American College of Surgeons National Surgical Quality Improvement Project (NSQIP) data. MethodsThe NSQIP database (2005-2011) was queried for patients undergoing elective AAA repair using open or endovascular techniques. Clinical variables and known predictors of mortality were included in a full prediction model. These variables included procedure type, patient's age, functional dependence and comorbidities, and surgeon's specialty. Backward elimination with alpha-level of 0.2 was used to construct a parsimonious model. Model discrimination was evaluated in equally sized risk quintiles. ResultsThe overall mortality rate for 18,917 elective AAA patients was 1.7%. In this model, surgeon's specialty was not predictive of POD. The most significant factors affecting POD included open repair (odds ratio [OR], 2.712; 95% confidence interval [CI], 2.119-3.469; P < .001), age >70 (OR, 2.243; 95% CI, 1.695-3.033; P < .001), functional dependency (OR, 2.290; 95% CI, 1.442-3.637; P < .001), creatinine above 2.0 mg/dL (OR, 2.1; 95% CI, 1.403-3.142; P < .001) and low hematocrit levels (OR, 2.157; 95% CI, 1.365-3.408; P = .001).The discriminating ability of the NSQIP model was reasonable (C-statistic = 0.751) and corrected to 0.736 after internal validation. The NSQIP model performed well predicting mortality among risk-group quintiles. ConclusionsThe NSQIP risk prediction model is a robust vehicle to predict POD among patient undergoing elective AAA repair. This model can be used for risk stratification of patients undergoing elective AAA repair.

Surgical Management of Benign Adnexal Masses in the Pediatric/Adolescent Population: An 11-Year Review

Study ObjectiveThe purpose of this study was to compare ovarian conservation rates and surgical approach in benign adnexal surgeries performed by surgeons vs gynecologists at a tertiary care institution. DesignA retrospective cohort review. SettingChildren's and adult tertiary care university-based hospital. ParticipantsPatients 21 years of age and younger who underwent surgery for an adnexal mass from January 2003 through December 2013. InterventionsPatient age, demographic characteristics, menarchal status, clinical symptoms, radiologic imaging, timing of surgery, surgeon specialty, mode of surgery, rate of ovarian conservation, and pathology were recorded. Patients were excluded if they had a uterine anomaly or pathology-proven malignancy. Main Outcome MeasuresThe primary outcome was the rate of ovarian conservation relative to surgical specialty; secondary outcome was surgical approach relative to surgical specialty. ResultsOf 310 potential cases, 194 met inclusion criteria. Gynecologists were more likely than surgeons to conserve the ovary (80% vs 63%; odds ratio, 2.28; 95% confidence interval, 1.16-4.48). After adjusting for age, body mass index, mass size, and urgency of surgery, the difference was attenuated (adjusted odds ratio, 1.84; 95% confidence interval, 0.88-3.84). Surgeons and gynecologists performed minimally invasive surgery at similar rates (62% vs 50%; P = .11). A patient was more likely to receive surgery by a gynecologist if she was older (P < .001) and postmenarchal (P = .005). ConclusionResults of our study suggest that gynecologists are more likely to perform ovarian-conserving surgery. However, our sample size precluded precise estimates in our multivariable model. Educational efforts among all pediatric and gynecologic surgeons should emphasize ovarian conservation and fertility preservation whenever possible.

Abstract: Surgeon and Hospital Factors in Open Ventral Hernia Repair

INTRODUCTION: Open ventral hernia repair (OVHR) is performed by surgeons of differing training and with supplemental techniques such as mesh or components separation. Although general surgeons perform most OVHRs, plastic surgeons also participate in ventral hernia repair. The impact of specialty training upon OVHR practices is not well understood. Moreover, there has been significant cross-pollination of repair techniques across specialties. We hypothesized that surgeon specialty, surgeon volume, and hospital volume would be predictors of surgical complications, mortality, extended hospital stay, and total charge. METHODS: Retrospective analysis was performed using data from the National Inpatient Sample (NIS) from 2001 to 2009. Patients undergoing open ventral hernia repair (OVHR) were identified using ICD-9 codes. Physician identifiers in the database were used to quantify surgeon OVHR case volume. Surgeon specialty was identified utilizing specialty specific case examples. Plastic surgeons (PS) and General Surgeons (GS) were selected. Non-elective cases or those involving the repair of an inguinal, umbilical, femoral, or diaphragmatic hernia or any type of GI resection were also excluded. Multivariate regression modeling was used to characterize the association between patient, hospital, and surgeon factors with surgical complications, total charge, length of hospital stay, and in-hospital mortality. Surgical complications were defined using previously described surrogates. Patient age, gender, obesity status, Charlson comorbidity score, payment type, admission source, location, hospital teaching status and region, and total number of concurrent diagnosis and procedure codes were included as covariates in the multivariate models. All tests were two-sided and significance was set at p<0.05. RESULTS: A total of 77,572 open ventral hernia repairs were included in the analysis. 7.1% (n=5,494) of cases were performed by PS and 92.9% (n=72,078) were performed by GS. PS was associated with decreased odds of extended length of stay (OR=0.72, p<0.001), surgical complications (OR=0.71, p<0.01), and death (OR=0.40, p<0.05). PS was also a significant predictor of lower total hospital charge (Beta=-3151.3, p<0.001). High volume hospitals were associated with greater total charge (Beta=1709.7, p<0.001) and increased odds of extended LOS (OR=1.09, p<0.01), but lower risk for complications (OR=0.90, p=0.001). CONCLUSIONS: In this analysis, we found that PS patients had shorter hospital stays, fewer surgical complications or deaths, and lower total charge, despite the fact that GS performs the vast majority of OVHR cases. High volume surgeons and hospitals were both associated with reduced risk for complications of surgery. We identified PS as a predictive factor in the quality and efficiency of OVHR. DISCLOSURE:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: Current Practice Patterns and Predictors of Adoption

Video-assisted thoracoscopic surgery (VATS) lobectomy has been shown to be a safe, minimally invasive approach for the surgical management of lung cancer. Despite evidence supporting oncologic efficacy, recent reports indicate that less than half of lobectomies are performed by VATS. We examined nationwide lobectomy practice patterns to identify specific predictors for VATS adoption. Premier hospital data (2010 to 2014) were used to identify open and VATS lobectomy procedures performed for the treatment of primary lung cancer. Propensity score method was used to match VATS and open operations (1:1) on clinical characteristics. Variables associated with VATS lobectomy were assessed by logistic regression to evaluate independent predictors. Secondary outcomes included postoperative complications, readmission, and mortality. Patients with primary lung cancer (n= 17,304) that underwent VATS (n= 6,670, 38.5%) or open (n= 10,634, 61.5%) lobectomy were identified; 6,670 patients in each group were matched for analysis. VATS performance increased significantly from 2010 to 2014, (39.6% versus 43.8%, p= 0.0004), particularly for thoracic surgeons (50.3% versus 54.7%, p < 0.0001), those performing 15 or more lobectomies per year (53.6% versus 59.8%, p<0.0001), and for surgeons practicing in the Northeast (54.8% versus 59.9%, p= 0.0001). Independent predictors of VATS utilization included surgeon volume and specialty training, hospital type and size, and region. Multivariate analysis demonstrated a significant association between VATS and surgeon volume, independent of specialty. National rates of VATS lobectomy continue to increase, particularly for thoracic surgeons, high-volume surgeons, and surgeons in the Northeast. Surgeon volume and specialty are strong independent predictors of VATS lobectomy. Efforts that support centralization of care may improve VATS lobectomy rates and decrease the regional variability identified in this analysis.

Influence of Specialty Training and Trainee Involvement on Perioperative Outcomes of Esophagectomy

Hospitals' and surgeons' volume-outcome relationship have been reported in several esophagectomy studies with an inverse association of mortality and volume. The purpose of our study was to evaluate the outcomes of esophagectomy in the United States relative to the surgeon's specialty. This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database (2006 to 2013). All patients (18 years of age and older) who underwent esophagectomy were divided into 2 groups according to whether the operation was performed by a general surgeon (GS) or a cardiothoracic surgeon (CTS). A comparison of intraoperative and postoperative outcomes between the groups was conducted. The primary outcome was 30-day mortality. Secondary outcomes included overall and serious morbidity, discharge destination, and length of hospital stay. Of the 5,142 esophagectomies identified, 70.3% were performed by GS and 29.7% by CTS. Overall, CTS patients had significantly higher comorbidities and cancer rates (61% versus 53%). Both specialties preferred the transthoracic approach (59.41% for CTS versus 44.90% for GS). Trainee involvement was higher for CTS. There was no significant difference in mortality or overall morbidity. Patients operated on by GS had higher rates of wound infection, sepsis, shock, prolonged or unplanned intubation, and a longer hospital stay, whereas patients operated on by CTS had higher chance for bleeding and return to the operating room. Trainees' involvement in esophagectomy was not associated with worse outcome. Our study showed that a large number of esophagectomies in the United States are performed by GS, with the transthoracic approach being the most popular among both specialties. Trainees' involvement in esophagectomy did not significantly affect patients' outcomes. However CTS specialty was associated with lower incidence of infection and a shorter hospital stay.

Understanding age and race disparities in the application of sentinel lymph node biopsy in breast cancer

Sentinel lymph node biopsy (SLNB) is the standard of care for surgical evaluation of early-stage breast cancer and is being employed as a quality metric for accreditation of breast centers....

Contemporary Trends in the Management of Renal Trauma in the United States: A National Community Hospital Population-based Analysis

To better define the shift in the management of renal trauma throughout the United States, with a population-based assessment of community hospital practice patterns. To investigate how hospital, patient, and injury-specific factors influence management strategy by both urologists and nonurologists. Using the Premier Hospital database, we performed a retrospective study of all patients with renal trauma between 2003 and 2013. We identified patients using International Classification of Diseases, Ninth Revision diagnosis codes (866.0x, 866.1x), determined management strategy by International Classification of Diseases, Ninth Revision procedure codes, and dichotomized grouping by surgeon specialty. We stratified hospitals by annual renal trauma volume categorized a priori into low, <10 cases per year; intermediate, 10-20 cases per year; and high, >20 cases per year. We performed descriptive statistics and univariate and multivariate regression analyses adjusting for survey weighting and for patient, hospital, and injury-specific characteristics. Our study cohort included a weighted sample size of 21,531 patients. Higher renal trauma hospitals (12.6%) were significantly less likely than low (26.4%) and intermediate (31.3%) volume hospitals to undergo surgical intervention for renal trauma on adjusted models. There was a statistically significant increase in nonoperative management from 65.2% in 2003 to 81.8% in 2013. National rates of surgical intervention for renal trauma are significantly higher than those frequently quoted by the literature, especially among low- and intermediate-volume renal trauma hospitals. Although operative rates are decreasing, further consideration may need to be given to centralization of care in higher-volume teaching hospitals to improve renal salvage.

Predictors of 5-year local, regional, and distant recurrent events in a population-based cohort of breast cancer patients

BackgroundThe study purpose was to identify tumor and surgeon predictors of local recurrence (LR), regional recurrence (RR), and distant metastasis (DM) after breast cancer (BC) surgery in a population-based cohort. MethodsConsecutive BC surgical cases from 12 hospitals in South Central Ontario between May 2006 and October 2006 were included. Data collected on chart review included patient and tumor factors, surgery type, adjuvant treatment, surgeon specialty, surgeon case volume, and practice type. Univariate and multivariable survival analyses were performed. ResultsMedian follow-up was 5.5 years for 402 patients (97% of sample). LR, RR, and DM occurred in 18 (4.5%), 10 (2.5%), and 47 (12%) patients, respectively. Significant predictors of BC recurrence (LR or RR or DM) were tumor size and grade, nodal status, and lymphovascular invasion on multivariable analysis. ConclusionTumor factors such as size, grade, lymphovascular invasion, and nodal status predicted BC recurrence, while practice type, surgeon specialty, and case volume did not.

The Impact of Physician Specialization on Clinical and Hospital Outcomes in Patients Undergoing EVAR and TEVAR

Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR. Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates. A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8-117.8, P<0.05) and cardiac complications (9.4% vs. 2.0%, OR 5.0, 95% CI 1.5-16.6, P<0.01) compared with other specialties. Costs were lowest for vascular surgeons ($32,094), and highest for cardiothoracic surgeons ($41,663, P<0.05). Only vascular surgeons completed more than 10 EVARs per year. A total of 2531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional radiologists had significantly more elective cases (77.8%, P<0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P<0.001) and cardiac events (7.2% vs. 3.6%, P<0.001). Length of stay (LOS, 10.7days) and median costs ($52,156) were similar across specialties. Vascular surgeons have a low stroke rate (1.1%, P<0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P<0.01) despite caring for patients with higher diagnosis-related group mortality scores (3.6 vs. 3.4, P<0.05). Vascular surgeons appear to have a comparative advantage over other specialties for EVAR because not only are their complication and mortality rates comparable but overall LOS and hospital charges are lower. Furthermore, primarily only vascular surgeons are performing the high volume of annual EVARs necessary to ensure optimal patient outcomes. For TEVAR, vascular surgeons have the lowest overall morbidity compared with the other specialties, and lower mortality compared with cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers.

MP12-17 ADRENALECTOMY FOR BENIGN AND MALIGNANT DISEASE: A POPULATION-BASED STUDY ON UTILIZATION AND OUTCOMES FROM 2003-2013

You have accessJournal of UrologyAdrenal1 Apr 2016MP12-17 ADRENALECTOMY FOR BENIGN AND MALIGNANT DISEASE: A POPULATION-BASED STUDY ON UTILIZATION AND OUTCOMES FROM 2003-2013 Izak Faiena, Alexandra Tabakin, Jeffrey Leow, Neal Patel, Parth Modi, Amirali Salmasi, Benjamin Chung, Steven Chang, and Eric Singer Izak FaienaIzak Faiena More articles by this author , Alexandra TabakinAlexandra Tabakin More articles by this author , Jeffrey LeowJeffrey Leow More articles by this author , Neal PatelNeal Patel More articles by this author , Parth ModiParth Modi More articles by this author , Amirali SalmasiAmirali Salmasi More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , Steven ChangSteven Chang More articles by this author , and Eric SingerEric Singer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2457AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES With advances in minimally invasive surgery (MIS), adrenal tumors have become more amenable to laparoscopic or robotic resection. Our aim is to study the national utilization and outcomes of adrenalectomy for benign and malignant disease. METHODS Data on patients who underwent open, laparoscopic, or robotic adrenalectomy for benign or malignant diseases from 2003-2013 were extracted using ICD-9 codes from the Premier Hospital Database. Surgeon specialty, patient demographics, hospital characteristics, intraoperative and perioperative data, and complications were compared. Data were analyzed using univariate and multivariable logistic regression analyses. RESULTS 8,831 adrenalectomies were performed for benign and malignant tumors (4,049 vs 4,781). For both benign and malignant neoplasms, surgery was more commonly performed in patients >50 years of age (74 vs 83%), men (52 vs 64%), and white race (69 vs 80%). There was no significant difference in rate of adrenalectomy with regards to comorbidities, insurance status, teaching vs non-teaching hospital, bed size, or geographic region. Non-urologists performed adrenalectomy more often than urologists for both benign (57 vs 43%; P=0.011) and malignant disease (66 vs 34%; P=0.011). Across all indications, non-urologists performed open surgery most often followed by laparoscopic and robotic approaches (56.3 vs 37.4 vs 6.4%, respectively), compared to urologists (48.8 vs 38.4 vs 12.9%, respectively). Overall, urologists were more likely to use MIS techniques (P=0.001). There was no difference in complication rate or operative time between surgical specialties, or by surgeon volume. On multivariable regression analysis, the best predictor of major complication was a Charlson Comorbidity Index (CCI) >2 (OR 3.9, 95%CI 2.1-7.1; P=<0.001). Compared to open, laparoscopy had significantly reduced odds of major complication (OR 0.6, 95%CI 0.3-0.9; P=0.03). Specialty, urology vs. non-urology, was not a predictor of complications (OR 0.7, 95%CI 0.4-1.1; P=0.1). Patients undergoing robotic procedures had a shorter length of stay than those with laparoscopic and open procedures (2 vs. 3 vs. 5 days, respectively; P=0.01). CONCLUSIONS Adrenalectomy was more commonly performed by non-urologists via an open approach. Urologists were earlier adopters of MIS adrenalectomy, which may explain a shorter length of stay. Patient with CCI >2 were associated with a higher rate of post-operative complications, while surgeon, surgeon volume and surgical approach did not influence complication rate. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e132 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Izak Faiena More articles by this author Alexandra Tabakin More articles by this author Jeffrey Leow More articles by this author Neal Patel More articles by this author Parth Modi More articles by this author Amirali Salmasi More articles by this author Benjamin Chung More articles by this author Steven Chang More articles by this author Eric Singer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of Recombinant Human Bone Morphogenetic Protein-2 in the Treatment of Degenerative Spondylolisthesis.

A questionnaire survey. To report the current use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar fusion procedures for the treatment of degenerative spondylolisthesis (DS), and identify associated factors including fusion technique, surgeon location, surgeon specialty, or surgeon practice model. The prevalence of rhBMP-2 use in fusions increased dramatically from 0.7% in 2002 to 24.7% in 2006, however more recent studies have identified significant complications with its use. Furthermore, an independent review of the industry-sponsored trial data has demonstrated no significant difference in fusion rates or clinical results with the use of rhBMP-2 compared with iliac-crest autograft. In July 2014, a survey was sent requesting information on the usage of rhBMP-2 in the treatment of DS. Determinants included the fusion technique, geographic location, specialty, and associated practice models. No funding was received for this work. Overall, 7.8% +/- 2.0% of surgeons reported using rhBMP-2 when performing an open L4-L5 posterolateral fusion for DS; 6.2% +/- 1.8% reported using rhBMP-2 for an open L4-L5 interbody fusion, and 12.1% +/- 2.5% reported using rhBMP-2 for a L4-L5 minimally invasive (MIS) interbody fusion. The variables that were statistically associated with the use of rhBMP-2 were North America surgeons (P < 0.0001) and the type of procedure (P = 0.0005). Compared with historical data, there has been a dramatic decrease in the number of surgeons using rhBMP-2 in lumbar fusion procedures for the treatment of DS. Currently, rhBMP-2 is more commonly used by surgeons in North America and those performing MIS interbody fusions. N/A.

The effect of minimally invasive prostatectomy on practice patterns of American urologists

Introduction and objectivesTo determine how robotic prostatectomy affects practice patterns of urologists, we examined the case volume characteristics among certifying urologists for the surgical treatment of prostate cancer. We hypothesized that the utilization of open and robotic prostatectomy as well as lymph node dissection changed dynamically over the last 10 years. MethodsA total of 6-month case log data of certifying urologists from 2003 to 2013 were obtained for the American Board of Urology. Cases were identified using Current Procedural Terminology codes for open radical prostatectomy (ORP) and laparoscopic or robotic-assisted laparoscopic prostatectomy (RALP) with a corresponding diagnosis of prostate cancer as defined by ICD-9 code 185.0. Results obtainedA total of 6,563 urologists submitted case logs, of which 68% (4,470/6,563) reported performing at least one radical prostatectomy (RP), totaling 46,030 RPs logged. There was a 376% increase in the performance of RALP over the study period with robotic volume increasing from 22% of all RP in 2003 to 85% in 2013.Among surgeons performing ORP, the median number performed was 2; of surgeons who performed RALP, the median number performed was 8 (P<0.001). Overall, 39% of surgeons logging ORP performed 2 or fewer RP, whereas 19% of surgeons who performed RALP performed 2 or less RP (P<0.001). The highest volume robotic surgeons (top 10% surgical volume) performed 41% of all RALP with the highest performing robotic surgeon recording 658 prostatectomies over 6 months. Oncologists represented 4.1% of all surgeons performing RP and performed 15.1% of all RP (P<0.001); general urologists performed the majority of RP (57.8%). When performed open, there was no influence of surgeon specialty on the performance of lymph node dissection (LND); if performed robotically, oncologists were significantly more likely to perform LND compared with general surgeons (47% vs. 25.9%, respectively, P<0.001). ConclusionsRobotic prostatectomies are performed 5 times more commonly than open prostatectomy and represent 85% of all RP performed by board-certified urologists in 2013. Compared to RALP, ORP are significantly more likely to be performed by lower volume surgeons. Oncologists perform a higher relative percentage of RPs and are significantly more likely to perform LND if performed robotically when compared with general urologists.

Abstract P3-08-05: The use of chemoprevention increases significantly with oncology trained providers and with application of a risk assessment model

Abstract BACKGROUND Large clinical trials have proven the efficacy of selective estrogen receptor modulators in reducing the risk of breast cancer in high risk women. However, despite these studies the use of chemoprevention in high risk women remains low. The goal of this study was to determine in a clearly identified high risk population, the utilization rate of chemoprevention and factors that affect its use, notably, surgeon training and the Gail model. METHODS This was a retrospective chart review of all women diagnosed with Atypical Ductal Hyperplasia (ADH) at our institution from 2008 to 2013. We examined the use of chemoprevention and screening recommendations after diagnosis. Other factors evaluated included family history, Gail model, surgeon specialty and menopausal status. RESULTS Ninety-four women with ADH were treated at our facility in the study time frame. The overall use of chemoprevention in our study population was 41.5%. Of those who were not on chemoprevention, 56.4 % were offered chemoprevention and declined. In addition, after the diagnosis of ADH, annual mammography was recommended for 75% of women. However, this was preferentially seen in women on chemoprevention (95% vs. 65%). Menopausal status and use of the Gail model were statistically significant in predicting annual screening after a diagnosis of ADH. The Gail score was calculated preferentially in women who chose chemoprevention. Prior breast biopsy, family history of cancer, first degree relative with cancer, age and menopausal status were not found to be statistically significant in the use of chemoprevention. Oncology training and use of the Gail model were found to be statistically significant in chemoprevention use. CONCLUSION The use of chemoprevention in high risk women is significantly improved with oncology training and the use of the Gail model. Concern regarding side effects continues to result in low utilization of selective estrogen receptor modulators. Education regarding newer agents for chemoprevention with minimal side effects may result in increased utilization of chemoprevention. Table 1: Patient CharacteristicsFactorsChemoprevention n (%)No Chemoprevention n (%)p valueMedian age (range)58 (37-78)52 (30-77)0.07Race 0.790Caucasian18 (46.1 %)33 (60.0 %) Asian/PCI6 (15.4 %)5 (9.1 %) African American2 (5.1 %)2 (3.6 %) Hispanic2 (5.1 %)1 (1.8 %) Family history10 (25.6 %)18 (32.7 %)0.358First degree26 (66.7 %)32 (58.1 %)1.000Gail score calculated29 (74.3 %)20 (36.3 %)&amp;lt;0.001Gail score median (range)3.4 % (0.8-17.7)2.7% (0.2-8.6)0.169Menopausal status17 (43.6 %)19 (34.5 %)0.796Specialty provider37 (94.9 %)38 (69.1 %)0.002Prior breast biopsy13 (33.3 %)16 (29.1 %)0.438 The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Citation Format: Oseni T, Perkins S, Deutsch E, Soballe P. The use of chemoprevention increases significantly with oncology trained providers and with application of a risk assessment model. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-08-05.

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery.

Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p=0.0835) and the most common procedure a sigmoidectomy (p=0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80days, p<0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68%, p<0.0001), complication (32.60 vs. 42.28%, p<0.0001), and mortality rates (0.52 vs. 1.28%, p<0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p<0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p<0.0001), room and board (p<0.0001), recovery room (p=0.0058), ICU (p<0.0001), and laboratory and imaging services (both p<0.0001). Surgical supplies (p<0.0001), surgery (p<0.0001), and anesthesia (p=0.0053) were higher for the laparoscopic group. Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BackgroundThe management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention. MethodsA retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS). ResultsOne hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis. ConclusionsAlthough surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.