Background
Recent attention has focused on the ability to rescue patients from postoperative complications and prevent short-term mortality. However, it is unknown whether patients rescued from ...complications after complex cancer resections have long-term survival outcomes similar to those of patients without complications.
Methods
From 2005 to 2009 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the study identified elderly patients who underwent resection for cancers of the esophagus, lung, or pancreas. The association of risk-adjusted long-term survival with serious complications, minor complications, and no complications was analyzed.
Results
The study included 905 patients with esophageal cancer, 12,395 patients with lung cancer, and 1966 patients with pancreatic cancer. The serious complication rates were respectively 17.4, 9.5 and 11.8 %. The patients with serious complications had lower 5-year survival rates than those with no complications even if they were rescued and survived 30 days (20 vs 43 % for esophagus, 29 vs 54 % for lung, and 10 vs 21 % for pancreas cancer). Even after patients who died within 180 days after surgery were excluded from the analysis, a decrement in risk-adjusted long-term survival was observed among the patients with serious complications after all three procedures. The association between complications and long-term survival was not explained by differences in receipt of adjuvant chemotherapy
Conclusion
Patients who undergo complex cancer resection and experience serious complications have diminished long-term survival, even if they are “rescued” from their complications. This finding persists even when deaths within 6 months after surgery are excluded from the analysis. Metrics of surgical success should consider terms beyond 30 and even 90 days as well as the long-term consequences of surgical complications.
Purpose Distal radius fractures (DRFs) are the second most common fracture experienced by elderly individuals. In 2005, 16% of DRFs in the Medicare population were being treated with internal ...fixation, up from 3% in 1997. This shift in treatment strategy can have substantial financial impact on Medicare and the health care system in general. The specific aims of this project were to quantify the current and future Medicare expenditures attributable to DRF and to compare Medicare payments for the 4 treatment options for elderly DRF. Methods We analyzed the 100% 2007 Medicare dataset for annual DRF-attributable spending. Payments were obtained for claims that were identified as attributable to DRF by International Classification of Diseases, 9th Revision, Clinical Modification codes for DRF in conjunction with a Current Procedural Technology code for relevant treatment or service. We projected annual payments based on increasing internal fixation treatment. All payments are reported in 2007 U.S. dollars. Results In 2007, Medicare made $170 million in DRF-attributable payments. If the usage of internal fixation were to reach 50%, DRF-attributable payments could be nearly $240 million. The mean attributable payment made for each patient in 2007 was $1,983. Most of this is due to facility and staffing cost for the treatment procedure. Conclusions This analysis provides an accurate quantification of Medicare DRF-attributable expenditure. Use of 100% Medicare data allows for the summation of actual patient experience rather than modeling or estimation. The burden of DRF is going to grow as the U.S. population ages and as internal fixation becomes more widely used. The Medicare payment data can help in allocating resources nationally to address the increasing disease burden of DRF. Type of study/level of evidence Economic and Decision Analysis I.
Context:
Total thyroidectomy with central lymph node dissection is recommended in patients with medullary thyroid cancer (MTC). However, the relationship between disease severity and extent of ...resection on overall survival remains unknown.
Objective:
The aim of the study was to identify the effect of surgery on overall survival in MTC patients.
Methods:
Using data from 2968 patients with MTC diagnosed between 1998 and 2005 from the National Cancer Database, we determined the relationship between the number of cervical lymph node metastases, tumor size, distant metastases, and extent of surgery on overall survival in patients with MTC.
Results:
Older patient age (5.69 95% CI, 3.34–9.72), larger tumor size (2.89 95% CI, 2.14–3.90), presence of distant metastases (5.68 95% CI, 4.61–6.99), and number of positive regional lymph nodes (for ≥16 lymph nodes, 3.40 95% CI, 2.41–4.79) were independently associated with decreased survival. Overall survival rate for patients with cervical lymph nodes resected and negative, cervical lymph nodes not resected, and 1–5, 6–10, 11–16, and ≥16 cervical lymph node metastases was 90, 76, 74, 61, 69, and 55%, respectively. There was no difference in survival based on surgical intervention in patients with tumor size ≤ 2 cm without distant metastases. In patients with tumor size > 2.0 cm and no distant metastases, all surgical treatments resulted in a significant improvement in survival compared to no surgery (P < .001). In patients with distant metastases, only total thyroidectomy with regional lymph node resection resulted in a significant improvement in survival (P < .001).
Conclusions:
The number of lymph node metastases should be incorporated into MTC staging. The extent of surgery in patients with MTC should be tailored to tumor size and distant metastases.
Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are ...associated with omission of chemotherapy for colorectal cancer.
We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied.
We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001).
Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.
ESRD is considered an irreversible loss of renal function, yet some patients will recover kidney function sufficiently to come off dialysis. Potentially modifiable predictors of kidney recovery, such ...as dialysis prescription, have not been fully examined.
Retrospective cohort study using United States Renal Data System (USRDS) data to identify incident hemodialysis (HD) patients between 2012 and 2016, the first 4 years for which dialysis treatment data is available. The primary outcome was kidney recovery within 1 year of ESRD and HD initiation, defined by a specific recovery code and survival off dialysis for at least 30 days. Patient and treatment characteristics were compared between those that recovered versus those that remained dialysis-dependent. A time-dependent survival model was used to identify independent predictors of kidney recovery.
During the study period, there were 372,387 incident HD patients with available data, among whom 16,930 (4.5%) recovered to dialysis-independence. Compared to non-recovery, a higher proportion of patients with kidney recovery were of white race, and non-Hispanic ethnicity. Both groups had a similar age distribution. Patients with an acute kidney injury diagnosis as primary cause of ESRD were most likely to recover, but the most common ESRD diagnosis among recovering patients was type 2 diabetes (29.8% of recovery cases). Higher eGFR and lower albumin at ESRD initiation were associated with increased likelihood of recovery. When examining HD ultrafiltration rate (UFR), each quintile above the first quintile was associated with a progressively lower likelihood of recovery (HR 0.45, 95% CI 0.43-0.48 for highest versus lowest quintile, p < 0.001).
We identified non-modifiable and potentially modifiable factors associated with kidney recovery which may assist clinicians in counseling and monitoring incident ESRD patients with a greater chance to gain dialysis-independence. Clinical trials are warranted to examine the impact of dialysis prescription on subsequent kidney function recovery.
Studies have investigated heavy metal (HM) contamination in the Bohai Sea, but primarily in seawater and associated sediments, or in single rivers. For the first time, 31 major rivers discharging ...into the Bohai Sea were analyzed, along with 27 uniformly distributed coastal seawater samples and selected invertebrates. The elements measured were As, Cd, Cr, Cu, Ni, Pb, V, and Zn. We calculated the ‘geo-accumulation index’, the ‘metal enrichment factor’, and the ‘contamination factor’, coupled with the ‘pollution load index’, and our findings suggested low-grade HM pollution, although two conspicuous associations of elements were found to stand out in particular: One is a combination of As, Cu, Cr, and V in seawater samples that may indicate pollution from intensive ship traffic. The other shows a significant pattern of Cr, Pb, and Zn in water samples from rivers discharging between Yantai and Weihai on the Shandong Peninsula at the south edge of the Bohai Sea. This is primarily a farming area, with a moderate share of industrial enterprises. Investigations including fertilizers and pesticides point to agricultural practices and textile printing/chrome tanneries as the causes of contamination. Overall, a significant decline was found in the HM load in the rivers, apart from those discharging into the Yellow Sea section.
To overcome the multiple challenges of water scarcity, agricultural land conversion, food security, and carbon emissions, an optimal collaborative management scheme for food production is urgently ...needed, especially in high food-production and food-consumption countries such as China. The water–land–food–carbon (WLFC) nexus provides a new perspective, but its interactions are complex, dynamic, and spatially heterogeneous; the coupling mechanism is not fully understood; and the driving forces and regulation strategies remain uncertain. Therefore, in this study, the WLFC nexus centered on low-carbon and high-quality agricultural development was systematically reviewed. The main contributions are as follows: (1) A framework of the regional agricultural WLFC nexus was proposed based on bibliographic analysis. (2) The main internal and external factors influencing the WLFC nexus in agriculture were identified by reevaluating meta-analysis review studies. The results showed that changes in the amount and type of irrigation water, the amount and planting activities of agricultural land, and climate change (temperature, precipitation, and CO2 concentration) affected food (rice, wheat, and maize) yields and carbon emissions to varying degrees. Moreover, population, technological innovation, trade, and polices were important external factors impacting food production and carbon emissions. (3) The common methods and tools for assessing, simulating, and optimizing the WLFC nexus in agriculture were summarized from the perspectives of its status, physical links, and embodied links. Integrated indices, complex system thinking, and process-based and data-driven methods were applied in the studies of the WLFC nexus. (4) Strategies and programs for collaborative WLFC management in agriculture within 10 global river basins were compiled. These findings could help us better understand the WLFC nexus in agriculture and identify the optimal cooperative management scheme, thereby realizing low-carbon and high-quality agricultural development.
Distal radial fractures affect an estimated 80,000 elderly Americans each year. Although the use of internal fixation for the treatment of distal radial fractures is becoming increasingly common, ...there have been no population-based studies to explore the dissemination of this technique. The aims of our study were to determine the current use of internal fixation for the treatment of distal radial fractures in the Medicare population and to examine regional variations and other factors that influence use of this treatment. We hypothesized that internal fixation of distal radial fractures would be used less commonly in male and black populations compared with other populations because the prevalence of osteoporosis is lower in these populations, and that use of internal fixation would be correlated with the percentage of the patients who were treated by a hand surgeon in a particular region.
We performed an analysis of complete 2007 Medicare data to determine the percentage of distal radial fractures that were treated with internal fixation in each hospital referral region. We then analyzed the association of patient and physician factors with the type of fracture treatment received, both nationally and within each hospital referral region.
We identified 85,924 Medicare beneficiaries with a closed distal radial fracture who met the inclusion criteria, and 17.0% of these patients were treated with internal fixation. Fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio, 0.84; 95% confidence interval, 0.80 to 0.89) and in black patients than in white patients (odds ratio, 0.74; 95% confidence interval, 0.65 to 0.85). Patients were more likely to be treated with internal fixation rather than with another treatment if they were treated by a hand surgeon than if they were treated by an orthopaedic surgeon who was not a hand surgeon (odds ratio, 2.49; 95% confidence interval, 2.29 to 2.70). Use of internal fixation ranged from 4.6% to 42.1% (nearly a ten-fold difference) among hospital referral regions. The percentage of patients treated with internal fixation within a hospital referral region was positively correlated with the percentage of patients in that region who were treated by a hand surgeon (correlation coefficient, 0.34; p < 0.0001).
The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture.
Purpose Internal fixation for distal radius fractures (DRFs) in the elderly has increased from 3% in 1997 to 17% in 2007. This increase has been uneven across regions of the United States. There is ...some evidence that patients treated by hand surgeons receive internal fixation at an increased rate and that hand surgeons might be driving the increased usage in regions where their presence is greatest. The specific aim of this study was to explore this relationship by analyzing Medicare beneficiaries treated by members of the American Society for Surgery of the Hand (ASSH). Methods Surgeons who were members of ASSH in 2007 were matched with surgeons treating Medicare beneficiaries for DRFs in the same year. We then fit a series of multilevel models to estimate the proportion of total variance in internal fixation usage explained by ASSH membership status, patient demographic data, patient comorbidity, and/or type of fracture diagnosed. Results Beneficiaries treated by ASSH members received internal fixation significantly more often than beneficiaries who were treated by surgeons who were not ASSH members. ASSH member status accounts for 12% of the total variance in internal fixation utilization. Conclusions Medicare beneficiaries who were treated by ASSH member surgeons receive internal fixation at a significantly higher rate than do patients of other physicians. When there is uncertainty about the optimal treatment for a condition, there is the possibility for specialty-related disparities. This specialty effect contributes to the national variations in the treatment of DRFs in the Medicare population. Type of study/level of evidence Therapeutic II.
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