Objective To investigate the modified frailty index (mFI) as a pre-operative predictor of post-operative complications following radical cystectomy in bladder cancer patients. Materials and Methods Patients undergoing radical cystectomy (RC) were identified from the National Surgical Quality Improvement Program (NSQIP) participant use files (2011-2013). The mFI was defined in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to NSQIP comorbidities and activities of daily living (ADL)s. Modified frailty index groups were determined by the number of risk factors per patient (0, 1, 2, ≥3). Univariate, χ2, independent sample t-test, and logistic regression analyses were performed when appropriate. A sensitivity analysis was performed to determine the mFI value at which Clavien 4 and 5 complications would reach significance. Results Of the 2679 cystectomy patients identified, 31% percent of patients had a mFI of 0, 44% had a mFI of 1, 21% had a mFI of 2, and 4% had a mFI ≥ 3. Overall, 59% of patients experienced a Clavien complication. When stratified at a cutoff of mFI >=2, the overall complication rate was not different (61.7% vs. 58.3%, p=0.1319), but the mFI2 or greater group had a significantly higher rate of Clavien grade 4 or 5 complications (14.6% vs. 8.3%, p<0.001) and overall mortality rate (3.5% vs. 1.8%, p=0.0128) in the 30-day post-operative period. The multivariate logistic regression model showed independent predictors of Clavien grade 4 or 5 complications were age >80 years old (OR, 1.58 [1.11-2.27]), mFI2 (odds ratio [OR], 1.84 [1.28-2.64]), and mFI3 (OR, 2.58 [1.47-4.55]). Conclusions Among patients undergoing radical cystectomy, the mFI can identify those patients at greatest risk for severe complications and mortality. Given that bladder cancer is increasing in prevalence particularly among the elderly, pre-operative risk stratification is crucial to inform decision making about surgical candidacy.
Purpose Many patients with small adrenal masses undergo total adrenalectomy. We evaluate the outcomes of partial adrenalectomy by performing a comprehensive literature review. Materials and Methods We performed a Pubmed search of literature published in the English language using the following queries: “partial adrenalectomy” and “adrenal sparing surgery”, and identified 317 and 155 articles, respectively. We excluded case reports or series containing less than 5 patients, articles not focused on surgical management, and those that did not indicate perioperative outcomes. The remaining articles were cross-referenced by author and institution in order to eliminate studies with redundant cases. Demographics, diagnosis, tumor characteristics, perioperative and functional outcomes, as well as recurrence data was collected when available. Results Twenty-two articles from 22 first authors met our inclusion criteria describing outcomes of 417 patients. There is an increasing trend towards utilization of partial adrenalectomy worldwide over the past 20 years. Partial adrenalectomy is most commonly performed for Conn's Syndrome, followed by pheochromocytoma. Most of the procedures are performed laparoscopically with minimal morbidity. The recurrence rate is only at 3% and over 90% of patients remain steroid independent. Conclusions Surgical outcomes and perioperative complications of partial adrenalectomy are similar to those reported for total adrenalectomy. When partial adrenalectomy is performed for small adrenal lesions, the rate of malignancy is negligible, the recurrence rate is low, and the vast majority of patients remain steroid independent at long-term follow up. These data strongly support acceptance of partial adrenalectomy as a first line treatment for small adrenal masses.
Background: Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood. Objective: To quantify the costs of inpatient and outpatient surgery in the Medicare population. Methods: We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008–2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpatient episode payments by surgical specialty. For inpatient episodes, we determined component payments related to the index hospitalization, readmissions, physician services, and postacute care. For outpatient episodes, we differentiated by the site of care (hospital outpatient department versus physician office versus ambulatory surgery center). We used linear regression to evaluate temporal trends in inpatient and outpatient surgical spending. Finally, we estimated the contribution of surgical care to overall Medicare expenditures. Results: Total Medicare payments for surgical care are substantial, representing 51% of Program spending in 2014. They declined modestly over the study period, from $133.1 billion in 2008 to $124.9 billion in 2014 (−6.2%, P = 0.085 for the temporal trend). While spending on inpatient surgery contributed the most to total surgical payments (69.4% in 2014), it declined over the study period, driven by decreases in index hospitalization (−16.7%, P = 0.002) and readmissions payments (−27.0%, P = 0.003). In contrast, spending on outpatient surgery increased by $8.5 billion (28.7%, P < 0.001). This increase was realized across all sites of care (hospital outpatient department: 36.6%, P < 0.001; physician office: 22.1%, P < 0.001; ambulatory surgery center: 36.6%, P < 0.001). Ophthalmology and hand surgery witnessed the greatest growth in surgical spending over the study period. Conclusions and Relevance: Surgical care accounts for half of all Medicare spending. Our findings not only highlight the magnitude of spending on surgery, but also the areas of greatest growth, which could be targeted by future payment reforms.
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