Deborah S. Keller M.D.

Little, A., K. Brower, D. Keller, B. Ramshaw and J. E. Janis (2019). “A Cost-Minimization Analysis Evaluating the Use of Liposomal Bupivacaine in Reconstructive Plastic Surgery Procedures.” Plast Reconstr Surg 143(4): 1269-1274.

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BACKGROUND: Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures. METHODS: The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed. RESULTS: During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups. CONCLUSIONS: The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.

Augestad, K. M., D. S. Keller, P. M. Bakaki, J. Rose, S. M. Koroukian, T. Oresland and C. P. Delaney (2018). “The impact of rectal cancer tumor height on recurrence rates and metastatic location: A competing risk analysis of a national database.” Cancer Epidemiol 53: 56-64.

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BACKGROUND: The impact of rectal cancer tumor height on local recurrence and metastatic spread is unknown. The objective was to evaluate the impact of rectal cancer tumor height from the anal verge on metastatic spread and local recurrence patterns. METHODS: The Norwegian nationwide surgical quality registry was reviewed for curative rectal cancer resections from 1/1/1996-12/15/2006. Cancers were stratified into five height groups: 0-3cm, >3-5cm, >5-9cm, >9-12cm, 12cm-HI. Competing risk and proportional hazards models assessed the relationship between tumor height and patterns of metastasis and survival. RESULTS: 6859 patients were analyzed. After median follow-up of 52 months (IQR 20-96), 26.7% (n=1835) experienced recurrence. With tumors >12cm, the risk of liver metastases increased (crude HR 1.49, p=0.03), while lung metastases decreased (crude HR 0.66, p=0.03), and risk of death decreased (crude HR 0.81, p=0.001) The cumulative incidence of pelvic recurrence were highest for the low tumors (p=0.01). Median time to liver metastases was 14months (IQR 7-24), lung metastases 25months (IQR 13-39), pelvic recurrence 19months (IQR10-32), (p<0.0001). Time to metastases in liver and lungs were significantly associated with tumor height (p<0.001) CONCLUSION: There are distinct differences in metastatic recurrence patterns and time to recurrence from different anatomic areas of the rectum. In crude analyses, tumor height impacted metastatic spread to the liver and lungs. However, when adjusting for treatment variables, the hazard of metastatic spread to the liver and lungs are limited. Nevertheless, time to metastases in liver and lungs is significantly impacted by tumor height. Venous drainage of the rectal cancer may be a significant contributor of rectal cancer metastatic spread, but further research is warranted.

Lee, L., J. Kelly, G. J. Nassif, D. Keller, T. C. Debeche-Adams, P. A. Mancuso, J. R. Monson, M. R. Albert and S. B. Atallah (2018). “Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms.” Surg Endosc 32(3): 1368-1376.

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INTRODUCTION: Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency. METHODS AND PROCEDURES: All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed. RESULTS: A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain. CONCLUSIONS: TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.

Keller, D. S., J. Qiu and A. J. Senagore (2018). “Predicting opportunities to increase utilization of laparoscopy for rectal cancer.” Surg Endosc 32(3): 1556-1563.

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BACKGROUND: Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer. METHODS: The Premier Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy. RESULTS: 3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use. CONCLUSIONS: Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.

Althans, A. R., J. T. Brady, M. L. Times, D. S. Keller, A. R. Harvey, M. E. Kelly, N. D. Patel and S. R. Steele (2018). “Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?” Dis Colon Rectum 61(1): 115-123.

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BACKGROUND: Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE: The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN: Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS: The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS: A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES: Overall survival across hospital systems was measured. RESULTS: The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS: This was a retrospective review, reporting from medical charts. CONCLUSIONS: Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues.