CONTEXT Health care reform calls for increasing physician accountability and transparency of outcomes. Partial mastectomy is the most commonly performed procedure for invasive breast cancer and often ...requires reexcision. Variability in reexcision might be reflective of the quality of care. OBJECTIVE To assess hospital and surgeon-specific variation in reexcision rates following partial mastectomy. DESIGN, SETTING, AND PATIENTS An observational study of breast surgery performed between 2003 and 2008 intended to evaluate variability in breast cancer surgical care outcomes and evaluate potential quality measures of breast cancer surgery. Women with invasive breast cancer undergoing partial mastectomy from 4 institutions were studied (1 university hospital University of Vermont and 3 large health plans Kaiser Permanente Colorado, Group Health, and Marshfield Clinic). Data were obtained from electronic medical records and chart abstraction of surgical, pathology, radiology, and outpatient records, including detailed surgical margin status. Logistic regression including surgeon-level random effects was used to identify predictors of reexcision. MAIN OUTCOME MEASURE Incidence of reexcision. RESULTS A total of 2206 women with 2220 invasive breast cancers underwent partial mastectomy and 509 patients (22.9%; 95% CI, 21.2%-24.7%) underwent reexcision (454 patients 89.2%; 95% CI, 86.5%-91.9% had 1 reexcision, 48 9.4%; 95% CI, 6.9%-12.0% had 2 reexcisions, and 7 1.4%; 95% CI, 0.4%-2.4% had 3 reexcisions). Among all patients undergoing initial partial mastectomy, total mastectomy was performed in 190 patients (8.5%; 95% CI, 7.2%-9.5%). Reexcision rates for margin status following initial surgery were 85.9% (95% CI, 82.0%-89.8%) for initial positive margins, 47.9% (95% CI, 42.0%-53.9%) for less than 1.0 mm margins, 20.2% (95% CI, 15.3%-25.0%) for 1.0 to 1.9 mm margins, and 6.3% (95% CI, 3.2%-9.3%) for 2.0 to 2.9 mm margins. For patients with negative margins, reexcision rates varied widely among surgeons (range, 0%-70%; P = .003) and institutions (range, 1.7%-20.9%; P < .001). Reexcision rates were not associated with surgeon procedure volume after adjusting for case mix (P = .92). CONCLUSION Substantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.
Reoperation is associated with unfavorable outcomes and increased healthcare utilization. This study seeks to investigate the incidence and factors related to reoperation in patients undergoing ...urgent/emergent colectomies.
The Michigan Surgical Quality Collaborative (MSQC) database was used to identify patients undergoing urgent/emergent colectomies. Outcomes and risk factors of patients who underwent reoperation within 30 days were compared to those who did not.
16,004 patients undergoing urgent/emergent colon resection were identified. Reoperation occurred in 12.4% and was associated with increased 30-day mortality (16.7% vs. 9.6%, p < .0001), median hospital length of stay (17 vs. 10 days, p < .0001), readmission rate (21.0% vs. 12.1%, p < .001), and discharge to a location other than home (62.3% vs. 36.8%, p < .0001). Reoperation rate was highest for vascular-related indications (23.5%), and was associated with several clinical factors (male gender, low albumin, ASA classification, and presence of pre-operative sepsis, dialysis or ventilator dependence)
Reoperation following urgent/emergent colectomy occurs frequently. Additional study into strategies to reduce reoperations in this population is warranted.
Display omitted
•Reoperation following emergent/urgent colectomy is associated with increased mortality and pronounced healthcare utilization.
Major concerns surround combining chemotherapy with bevacizumab in patients with colon cancer presenting with an asymptomatic intact primary tumor (IPT) and synchronous yet unresectable metastatic ...disease. Surgical resection of asymptomatic IPT is controversial.
Eligibility for this prospective, multicenter phase II trial included Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1, asymptomatic IPT, and unresectable metastases. All received infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) combined with bevacizumab. The primary end point was major morbidity events, defined as surgical resection because of symptoms at or death related to the IPT. A 25% major morbidity rate was considered acceptable. Secondary end points included overall survival (OS) and minor morbidity related to IPT requiring hospitalization, transfusion, or nonsurgical intervention.
Ninety patients registered between March 2006 and June 2009: 86 were eligible with follow-up, median age was 58 years, and 52% were female. Median follow-up was 20.7 months. There were 12 patients (14%) with major morbidity related to IPT: 10 required surgery (eight, obstruction; one, perforation; and one, abdominal pain), and two patients died. The 24-month cumulative incidence of major morbidity was 16.3% (95% CI, 7.6% to 25.1%). Eleven IPTs were resected without a morbidity event: eight for attempted cure and three for other reasons. Two patients had minor morbidity events only: one hospitalization and one nonsurgical intervention. Median OS was 19.9 months (95% CI, 15.0 to 27.2 months).
This trial met its primary end point. Combining mFOLFOX6 with bevacizumab did not result in an unacceptable rate of obstruction, perforation, bleeding, or death related to IPT. Survival was not compromised. These patients can be spared initial noncurative resection of their asymptomatic IPT.
Basal cell carcinoma (BCC) is the most common skin malignancy in the world. While most lesions are treated using surgical methods, others may present as locally advanced or metastatic disease and are ...not amenable to surgical therapy alone. Treatment with sonic hedgehog pathway inhibitors (vismodegib, sonidegib) is designed to inhibit key signaling proteins and gene pathways involved with BCC to reduce the uncontrolled proliferation of basal cells in complicated disease and can be invaluable in treating patients with advanced disease.
We describe the course of a 68-year-old man who presented with a 7.2 × 6 cm exophytic and ulcerated locally invasive BCC of his upper back. The patient was started on daily vismodegib treatment with the goal of eventual surgical resection. After 11 weeks of therapy, he had significant improvement in both wound size and appearance. After 18 weeks of therapy, he had achieved a near complete clinical response of the central aspect of lesion with three remaining small peripheral lesions. These lesions were biopsied, and two were found to be negative for malignancy, while a small inferior nodule was positive for squamous cell carcinoma (SCC). Vismodegib therapy was discontinued after a total of 26 weeks of therapy. Excision of the SCC was performed, and the patient remains disease free at 2 years.
This case report shows the efficacy of hedgehog pathway inhibitor therapy in the treatment of a locally advanced BCC with complete pathologic response, not requiring surgical intervention.
Surgical resection of the primary tumor for patients who present with incurable stage IV colorectal cancer is controversial. National practice patterns have not been described. We evaluated the use ...of primary tumor resection in patients presenting with stage IV colorectal cancer.
Patients with stage IV colorectal cancer diagnosed between 1988 and 2000 were selected from the Surveillance, Epidemiology, and End Results database. Patients undergoing primary tumor resection were analyzed on the basis of sex, race, year of diagnosis, and the anatomical site of the primary tumor. We compared the survival of resected and nonresected patients.
A total of 17,658 (66%) of the 26,754 patients presenting with stage IV colorectal cancer underwent primary tumor resection. Patients with resected disease were more likely to be young (mean age of 67.1 vs. 70.3 years) and to have right-sided tumors (75.3%, 73.0%, and 45.6%, respectively, for right, left, and rectal; P < .001). In all age groups, patients undergoing resection had higher median and 1-year survival rates (colon: 11 vs. 2 months, 45% vs. 12%, P < .001; rectum: 16 vs. 6 months, 59% vs. 25%, P < .001) when compared with patients who did not undergo resection.
Most patients who present with stage IV colorectal cancer undergo resection of the primary tumor. The proportion of patients undergoing resection depends on patient age and race and the anatomical location of the primary tumor. The degree to which case selection explains the treatment and survival differences observed is not known. Further investigation of the role of surgery in the management of incurable stage IV colorectal cancer is warranted.
Enhancing Quality of Life (QOL) has long been an explicit or implicit goal for individuals, communities, nations, and the world. But defining QOL and measuring progress toward meeting this goal have ...been elusive. Diverse “objective” and “subjective” indicators across a range of disciplines and scales, and recent work on subjective well-being (SWB) surveys and the psychology of happiness have spurred interest. Drawing from multiple disciplines, we present an integrative definition of QOL that combines measures of human needs with subjective well-being or happiness. QOL is proposed as a multi-scale, multi-dimensional concept that contains interacting objective and subjective elements. We relate QOL to the opportunities that are provided to meet human needs in the forms of built, human, social and natural capital (in addition to time) and the policy options that are available to enhance these opportunities. Issues related to defining, measuring, and scaling these concepts are discussed, and a research agenda is elaborated. Policy implications include strategies for investing in
opportunities to maximize QOL enhancement at the individual, community, and national scales.
Abstract Background We sought to decrease organ space infection (OSI) following appendectomy for perforated acute appendicitis (PAA) by minimizing variation in clinical management. Objective A ...postoperative treatment pathway was developed and four recommendations were implemented: 1) clear documentation of post-operative diagnosis, 2) patients with unknown perforation status to be treated as perforated pending definitive diagnosis, 3) antibiotic therapy to be continued post operatively for 4-7 days after SIRS resolution, and 4) judicious use of abdominal computed tomography (CT) scanning prior to post-operative day 5. Patient demographics and potential clinical predictors of OSI were captured. The primary end point was development of OSI within 30 days of discharge. Secondary endpoints included length of stay (LOS), readmission rate, other complications and secondary procedures performed. Results A total of 1246 appendectomies were performed and we excluded patients <18 years (n=205), interval appendectomies (n=51) or appendectomies for other diagnosis (n=37). Among the remaining 953 patients, 133 (14.0%) were perforated and 21 of these (15.8%) developed OSI. Comparing pre (n=91) to post (n=42) protocol patients, we saw similar rates of OSI (16.5 vs 14.3%, p=0.75) with a peak in OSI development immediately prior to protocol implementation which dropped to baseline levels 1 year later based on CUSUM analysis. Readmission rates fell by 49.7% (14.3 vs 7.1%, p=0.39) without increase in LOS (5.3 vs 5.7 days, p=0.55) comparing patients pre and post protocol, although these results did not reach clinical significance. Conclusions The implementation of and compliance with a post-operative protocol status post appendectomy for PAA demonstrated a trend towards diminishing readmission rates and decreased utilization of CT imaging, but did not affect OSI rates. Additional approaches to diminishing OSI following management of perforated appendicitis need to be evaluated.
Treatment with neoadjuvant chemotherapy (NAC) has made it possible for some women to be successfully treated with breast conservation therapy (BCT ) who were initially considered ineligible. Factors ...related to current practice patterns of NAC use are important to understand particularly as the surgical treatment of invasive breast cancer has changed. The goal of this study was to determine variations in neoadjuvant chemotherapy use in a large multi-center national database of patients with breast cancer.
We evaluated NAC use in patients with initially operable invasive breast cancer and potential impact on breast conservation rates. Records of 2871 women ages 18-years and older diagnosed with 2907 invasive breast cancers from January 2003 to December 2008 at four institutions across the United States were examined using the Breast Cancer Surgical Outcomes (BRCASO) database. Main outcome measures included NAC use and association with pre-operatively identified clinical factors, surgical approach (partial mastectomy PM or total mastectomy TM), and BCT failure (initial PM followed by subsequent TM).
Overall, NAC utilization was 3.8%l. Factors associated with NAC use included younger age, pre-operatively known positive nodal status, and increasing clinical tumor size. NAC use and BCT failure rates increased with clinical tumor size, and there was significant variation in NAC use across institutions. Initial TM frequency approached initial PM frequency for tumors >30-40 mm; BCT failure rate was 22.7% for tumors >40 mm. Only 2.7% of patients undergoing initial PM and 7.2% undergoing initial TM received NAC.
NAC use in this study was infrequent and varied among institutions. Infrequent NAC use in patients suggests that NAC may be underutilized in eligible patients desiring breast conservation.
Adherence to guideline-based care for melanoma remains suboptimal. This study describes the development of a quality monitoring program and compares the quality of care before and after its ...implementation.
Thirty quality metrics were adopted. An abstraction tool, manual and electronic database were developed. Metrics were analyzed from 1/1/2008-8/31/2013 (Group A) and compared to melanoma care from 9/1/2013-12/31/2017 (Group B).
A total of 311 patients were treated from 2008 to 2017. Demographic data were similar between the groups.
21.7% of patients in Group A had clinical stage (TNM) documented before surgery compared to 100% in Group B. 86.9% of patients in Group A had surgical margins documented in the operative report compared to 100% of Group B. Appropriate surgical margins were obtained in 85.7% of Group A compared to 99.5% in Group B. Pathology reporting of margin status, satellitosis, regression and mitotic rates improved from ∼60% Group A to >92% in Group B. Multidisciplinary process and structural metrics were unchanged.
A comprehensive melanoma quality program has produced significantly improved guideline-based multidisciplinary care.
•Multidisciplinary melanoma care remains inadequate despite published guidelines.•Analysis of care before and after guideline-based quality program development.•Significant improvement identified with implementation of quality improvement program.•Stage specific management and outcomes reported at unprecedented levels.•Program expansion required in order to assess long term outcomes including recurrence and survival.
This retrospective quality improvement project compares melanoma care provided in a community teaching hospital before and after construction and implementation of a comprehensive guideline-based melanoma quality program. Improvement in guideline-based care is identified in the study group compared to care provided prior to its development. Data is substantiated through comparison with previously published outcomes data as well as statistical analysis.
Background Several previous studies have reported conflicting data on recent trends in use of initial total mastectomy (TM); the factors that contribute to TM variation are not entirely clear. Using ...a multi-institution database, we analyzed how practice, patient, and tumor characteristics contributed to variation in TM for invasive breast cancer. Study Design We collected detailed clinical and pathologic data about breast cancer diagnosis, initial, and subsequent breast cancer operations performed on all female patients from 4 participating institutions from 2003 to 2008. We limited this analysis to 2,384 incident cases of invasive breast cancer, stages I to III, and excluded patients with clinical indications for mastectomy. Predictors of initial TM were identified with univariate analyses and random effects multivariable logistic regression models. Results Initial TM was performed on 397 (16.7%) eligible patients. Use of preoperative MRI more than doubled the rate of TM (odds ratio OR = 2.44; 95% CI, 1.58–3.77; p < 0.0001). Increasing tumor size, high nuclear grade, and age were also associated with increased rates of initial TM. Differences by age and ethnicity were observed, and significant variation in the frequency of TM was seen at the individual surgeon level (p < 0.001). Our results were similar when restricted to tumors <20 mm. Conclusions We identified factors associated with initial TM, including preoperative MRI and individual surgeon, that contribute to the current debate about variation in use of TM for the management of breast cancer. Additional evaluation of patient understanding of surgical options and outcomes in breast cancer and the impact of the surgeon provider is warranted.
PDF
