The association of different social vulnerability subthemes (ie, socioeconomic status, household composition and disability, minority status and language, and housing and transportation) with ...surgical outcomes remains poorly defined. The current study aimed to identify distinct profiles of social vulnerability among Medicare beneficiaries and define the association of these profiles with postoperative outcomes.
The Medicare 100% Standard Analytic Files were used to identify patients undergoing lung resection, coronary artery bypass grafting, abdominal aortic aneurysm repair, and colectomy between 2013 and 2017. A cluster analysis was performed based on ranked scores across the 4 subthemes of the Centers for Disease Control and Prevention social vulnerability index. The likelihood of complications, extended length of stay, readmission, and mortality were assessed relative to cluster vulnerability profiles.
Among 852,449 Medicare beneficiaries undergoing surgery, median social vulnerability index among patients in the cohort was 49 (interquartile range: 24–74); cluster analysis revealed 5 vulnerability profiles that had heterogeneity in the vulnerability subthemes, even among patients with similar overall social vulnerability index scores. Postoperative outcomes differed across the 5 vulnerability profiles, with patients in the profiles characterized by higher overall vulnerability having worse postoperative outcomes. In particular, risk of complications (profile 1, 31.9% vs profile 5, 34.0%), extended length of stay (profile 1, 21.7% vs profile 5, 24.3%), 30-day readmission (profile 1, 12.6% vs profile 5, 13.2%), and 30-day mortality (profile 1, 4.0% vs profile 5, 4.7%) was greater among patients with the highest vulnerability (all P < .01). Of note, surgical outcomes varied among patients who resided in communities with similar average social vulnerability index scores (social vulnerability index 49–54). In particular, patients in social vulnerability profile 4 had 26% increased odds of 30-day mortality compared to social vulnerability profile 2 patients (odds ratio 1.26, 95% confidence interval 1.21–1.30). Additionally, profile 3 patients had 15% higher odds of 30-day mortality versus profile 2 patients (odds ratio 1.15, 95% confidence interval 1.10–1.20).
Postoperative outcomes differed across patients based on cluster vulnerability profiles. Despite similar overall aggregate social vulnerability index scores, cluster analysis was able to discriminate various social determinants of health subthemes among patients who resided in “average” vulnerability communities that stratified patients relative to risk of adverse postoperative events.
Textbook outcomes in hepatobiliary and pancreatic surgery Tsilimigras, Diamantis I; Pawlik, Timothy Michael; Moris, Dimitrios
World journal of gastroenterology,
2021-Apr-21, 2021-4-21, 20210421, Volume:
27, Issue:
15
Journal Article
Open access
The concept of textbook outcome (TO) has recently gained popularity in surgical research and has been used to evaluate the quality or success of different surgical procedures, including ...hepatopancreatobiliary (HPB) operations. TO consists of individual outcome parameters that each reflect different domains of care including structure, process, and individual outcomes; in turn, the composite TO metric represents the optimal course after a surgical episode. TO can be used to assess patient-level outcomes, hospital performance, center designation and quality metrics. In addition to being an outcome measurement, TO may also be linked to healthcare costs. Future efforts should be directed towards establishing a universal definition of TO in HPB surgery so that surgeons and hospitals can assess and compare outcomes, identify shortcomings and improve real world patient outcomes.
Background
Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have questioned the prognostic stratification of this ...classification schema, as well as the proposed treatment allocation of patients with a single large tumor.
Methods
Patients who underwent curative-intent hepatectomy for histologically proven hepatocellular carcinoma (HCC) between 1998 and 2017 were identified using an international multi-institutional database. Overall survival (OS) among patients with BCLC stage 0, A, and B was examined. Patients with a single large tumor were classified as BCLC stage A1 and were independently assessed.
Results
Among 814 patients, 68 (8.4%) were BCLC-0, 310 (38.1%) were BCLC-A, 279 (34.3%) were BCLC-A1, and 157 (19.3%) were BCLC-B. Five-year OS among patients with BCLC stage 0, A, A1, and B HCC was 86.2%, 69.0%, 56.9%, and 49.9%, respectively (
p
< 0.001). Among patients with very early- and early-stage HCC (BCLC 0, A, and A1), patients with BCLC stage A1 had the worst OS (
p
= 0.0016). No difference in survival was noted among patients undergoing surgery for BCLC stage A1 and B HCC (5-year OS: 56.9% vs. 49.9%;
p
= 0.259) even after adjusting for competing factors (hazard ratio 0.83, 95% confidence interval 0.54–1.28;
p
= 0.40).
Conclusion
Prognosis following liver resection among patients with BCLC-A1 HCC was similar to patients presenting with BCLC-B tumors. Surgery provided acceptable long-term outcomes among select patients with BCLC-B HCC. Designation into BCLC stage B should not be considered an a priori contraindication to surgery.
The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in “textbook outcomes” (TO) relative to social vulnerability among ...Medicare beneficiaries who underwent operations for cancer.
Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression.
Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 90.8%). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05).
Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.
IMPORTANCE: Hepatocellular carcinoma (HCC) is the sixth most common malignancy and fourth leading cause of cancer-related death worldwide. Recent advances in systemic and locoregional therapies have ...led to changes in many guidelines regarding systemic therapy, as well as the possibility to downstage patients to undergo resection. This review examines the advances in surgical and medical therapies relative to multidisciplinary treatment strategies for HCC. OBSERVATIONS: HCC is a major health problem worldwide. The obesity epidemic has made nonalcoholic fatty liver disease a major risk factor for the development of HCC. Multiple societies, such as the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, the Asian Pacific Association for the Study of the Liver, and the National Comprehensive Cancer Network, provide guidelines for screening at-risk patients, as well as define staging systems to guide optimal treatment strategies. The Barcelona Clinic Liver Cancer staging system is widely accepted and has recently undergone updates with the introduction of new systemic therapies and stage migration. CONCLUSIONS AND RELEVANCE: The treatment of patients with HCC should involve a multidisciplinary approach with collaboration among surgeons, medical oncologists, radiation oncologists, and interventional radiologists to provide optimal care. Treatment paradigms must consider both tumor and patient-related factors such as extent of liver disease, which is a main driver of morbidity and mortality. The advent of more effective systemic and locoregional therapies has prolonged survival among patients with advanced disease and allowed some patients to undergo surgical intervention who would otherwise have disease considered unresectable.
Prediction of survival after the treatment of hepatocellular carcinoma (HCC) has been widely investigated, yet remains inadequate. The application of artificial intelligence (AI) is emerging as a ...valid adjunct to traditional statistics due to the ability to process vast amounts of data and find hidden interconnections between variables. AI and deep learning are increasingly employed in several topics of liver cancer research, including diagnosis, pathology, and prognosis.
To assess the role of AI in the prediction of survival following HCC treatment.
A web-based literature search was performed according to the Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines using the keywords "artificial intelligence", "deep learning" and "hepatocellular carcinoma" (and synonyms). The specific research question was formulated following the patient (patients with HCC), intervention (evaluation of HCC treatment using AI), comparison (evaluation without using AI), and outcome (patient death and/or tumor recurrence) structure. English language articles were retrieved, screened, and reviewed by the authors. The quality of the papers was assessed using the Risk of Bias In Non-randomized Studies of Interventions tool. Data were extracted and collected in a database.
Among the 598 articles screened, nine papers met the inclusion criteria, six of which had low-risk rates of bias. Eight articles were published in the last decade; all came from eastern countries. Patient sample size was extremely heterogenous (
= 11-22926). AI methodologies employed included artificial neural networks (ANN) in six studies, as well as support vector machine, artificial plant optimization, and peritumoral radiomics in the remaining three studies. All the studies testing the role of ANN compared the performance of ANN with traditional statistics. Training cohorts were used to train the neural networks that were then applied to validation cohorts. In all cases, the AI models demonstrated superior predictive performance compared with traditional statistics with significantly improved areas under the curve.
AI applied to survival prediction after HCC treatment provided enhanced accuracy compared with conventional linear systems of analysis. Improved transferability and reproducibility will facilitate the widespread use of AI methodologies.
Introduction
The objective of the current study was to comprehensively assess the change of practice in hepatobiliary surgery by determining the rates and the trends of textbook outcomes (TO) among ...patients undergoing surgery for primary liver cancer over time.
Methods
Patients undergoing curative-intent resection for primary liver malignancies, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) between 2005 and 2017 were analyzed using a large, international multi-institutional dataset. Rates of TO were assessed over time. Factors associated with achieving a TO and the impact of TO on long-term survival were examined.
Results
Among 1829 patients, 944 (51.6%) and 885 (48.4%) individuals underwent curative-intent resection for HCC and ICC, respectively. Over time, patients were older, more frequently had ASA class > 2, albumin-bilirubin grade 2/3, major vascular invasion and more frequently underwent major liver resection (all
p
< 0.05). Overall, a total of 1126 (62.0%) patients achieved a TO. No increasing trends in TO rates were noted over the years (
p
trend
= 0.90). In addition, there was no increasing trend in the TO rates among patients undergoing either major (
p
trend
= 0.39) or minor liver resection (
p
trend
= 0.63) over the study period. Achieving a TO was independently associated with 26% and 37% decreased hazards of death among ICC (HR 0.74, 95%CI 0.56–0.97) and HCC patients (HR 0.63, 95%CI 0.46–0.85), respectively.
Conclusion
Approximately 6 in 10 patients undergoing surgery for primary liver tumors achieved a TO. While TO rates did not increase over time, TO was associated with better long-term outcomes following liver resection for both HCC and ICC.
Background
Patients can experience barriers and disparities to access high-quality cancer care. This study sought to characterize receipt of surgery and chemotherapy among Medicare beneficiaries with ...a diagnosis of early-stage pancreatic adenocarcinoma cancer (PDAC) relative to race/ethnicity and social vulnerability.
Methods
The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients with a diagnosis of early-stage (stage 1 or 2) PDAC between 2004 and 2016. Data were merged with the CDC’s Social Vulnerability Index (SVI) at the beneficiary’s county of residence. Multivariable, mixed-effects logistic regression was used to assess the association of SVI with resection.
Results
Among 15,931 older Medicare beneficiaries with early-stage PDAC (median age, 77 years; interquartile range IQR, 71–82 years), the majority was White (
n
= 12,737, 80.0 %), whereas a smaller subset was Black or Latino (
n
= 3194, 20.0 %) A minority of patients was more likely to live in highly vulnerable communities (low SVI: white 90.5 % vs minority 9.5 % vs high SVI: white 71.9 % vs minority 28.1 %;
p
< 0.001). Use of resection for early-stage PDAC was lowest among the patients who resided in high-SVI areas (low 38.0 % vs average 34.3 % vs high 31.9 %;
p
< 0.001). The minority patients were less likely to undergo resection than the White patients (no resection: white 64.1 % vs minority 70.7 %;
p
< 0.001). The median SVI was higher among the patients who underwent resection (57.6; IQR, 36.0–81.0) than among those who did not (60.4; IQR, 41.9–84.3), and increased SVI resulted in a decline in the likelihood of resection (SVI trend: OR, 0.98; 95 % confidence interval CI, 0.97–1.00), especially among the minority patients. Minority patients from high-SVI counties had markedly lower odds of preoperative chemotherapy than minority patients from a low-SVI neighborhood (OR, 0.62; 95 % CI, 0.52–0.73).
Conclusions
Older Medicare beneficiaries with early-stage PDAC residing in counties with higher social vulnerability had lower odds of undergoing pancreatic resection, which was more pronounced among minority versus older White Medicare beneficiaries.
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