Richard Hoehn - Academia.edu (original) (raw)

Papers by Richard Hoehn

Research paper thumbnail of Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery

JAMA Surgery, 2015

Safety-net hospitals provide broad services for a vulnerable population of patients and are finan... more Safety-net hospitals provide broad services for a vulnerable population of patients and are financially at risk owing to impending reimbursement penalties and policy changes. To determine the effect of patient and hospital factors on surgical outcomes and cost at safety-net hospitals. Hospitals in the University HealthSystem Consortium database from January 1, 2009, through December 31, 2012 (n = 231), were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time (n = 12 638 166). Nine cohorts, based on a variety of surgical procedures, were created and examined with regard to preoperative characteristics, postoperative outcomes, and resource utilization. Multiple logistic regression was performed to analyze the effect of patient and center factors on outcomes. Hospital Compare data from the Centers for Medicare & Medicaid Services were linked and used to characterize and compare the groups of hospitals. Postoperative mortality, 30-day readmissions, and total direct cost. For all 9 procedures examined in 231 hospitals comprising 12 638 166 patient encounters, patients at hospitals with high safety-net burden (HBHs) (vs hospitals with low and medium safety-net burdens) were most likely to be young, to be black, to be of the lowest socioeconomic status, and to have the highest severity of illness and the highest cost for surgical care (P < .01 for all). For 7 of 9 procedures, HBHs had the highest proportion of emergent cases and longest length of stay (P < .01 for all). After adjusting for patient characteristics and center volume, HBHs still had higher odds of mortality for 3 procedures (odds ratios [ORs], 1.81-2.08; P < .05), readmission for 2 procedures (ORs, 1.19-1.30; P < .05), and the highest cost of care associated with 7 of 9 procedures (risk ratios, 1.23-1.35; P < .05). Analysis of Hospital Compare data found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency (all P < .05). These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost across 9 elective surgical procedures. These outcomes are likely owing to hospital resources and not necessarily patient factors. In addition, impending changes to reimbursement may have a negative effect on the surgical care at these centers.

Research paper thumbnail of Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2015

Higher-volume centers demonstrate better perioperative outcomes for complex surgical intervention... more Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs. From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable. The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortalit...

Research paper thumbnail of Disparities in care for patients with curable hepatocellular carcinoma

HPB, 2015

The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues ... more The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues to be underutilized. This retrospective review investigates treatment decisions and survival for early stage HCC. The National Cancer Database (NCDB) was queried for all patients with curable HCC (Stage I/II) from 1998 to 2011 (n = 43 859). Patient and tumour characteristics were analysed to determine predictors of having surgery and of long-term survival. Only 39.7% of patients received surgery for early stage HCC. Surgical therapies included resection (34.6%), transplant (28.7%), radiofrequency ablation (27.1%) and other therapies. Surgery correlated with improved median survival (48.3 versus 8.4 months), but was only performed on 42% of stage I patients and 50% of tumours smaller than 2 cm. Patients were more likely to receive surgery if they were Asian or white race, had private insurance, higher income, better education, or treatment at an academic centre (P < 0.05). However, private insurance and treatment at an academic centre were the only variables associated with improved survival (P < 0.05). Fewer than half of patients with curable HCC receive surgery, possibly as a result of multiple socioeconomic variables. Past these barriers to care, survival is related to adequate and reliable treatment. Further efforts should address these disparities in treatment decisions.

Research paper thumbnail of Adjuvant Therapy for Gallbladder Cancer: an Analysis of the National Cancer Data Base

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 21, 2015

The role of adjuvant therapy in patients with resected gallbladder cancer (GBC) is unclear. The A... more The role of adjuvant therapy in patients with resected gallbladder cancer (GBC) is unclear. The American College of Surgeons National Cancer Data Base was used to identify patients with resected GBC (pathologic stage 1-3) from 1998 to 2006 (n = 6690). We compared three groups: surgery only (S, 78.6 %), surgery plus adjuvant chemotherapy (AC, 6.2 %), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, 15.1 %). Univariate and Cox regression analyses were used to determine factors influencing overall survival and the use of adjuvant therapy. ACR was associated with improved survival for all patients (HR 0.77, 95 % CI 0.66-0.90), especially node-positive patients (HR 0.64, 95 % CI 0.53-0.78); AC was not associated with changes in survival. Patients were less likely to have their lymph nodes examined if they had any comorbidities, lower income, or were treated at community cancer centers (all p < 0.05). Among patients with unknown lymph node status, those with T2 or T3 ...

Research paper thumbnail of Use of Elderly Allografts in Liver Transplantation

Transplantation, 2015

The use of liver allografts from elderly donors (≥70 years) has increased because of organ shorta... more The use of liver allografts from elderly donors (≥70 years) has increased because of organ shortage and increased life expectancy. The aim of this study is to evaluate the current utilization of elderly donors in United States, recipient selection, and their posttransplant outcomes. A linkage between Scientific Registry of Transplant Recipients and University HealthSystem Consortium databases was performed. Between January 2007 and December 2011, 12,445 liver transplant (LT) recipients were identified and divided into 2 cohorts based on donor age: 70 years or older (n = 540) and younger than 60 years (n = 10,473). Elderly donors accounted for 4.3% of all donors used in the 5-year period. When compared to younger donors, elderly donors were more likely to be women, shared regionally or nationally, and used at higher volume centers. Elderly donor allografts were less likely to be used in recipients with model of end-stage liver disease score higher than 27 (13.2% vs 23.0%, P &amp;amp;amp;amp;lt; 0.001), hospitalized (16.8% vs 21.7%, P = 0.03), or on hemodialysis at time of transplant (2.6% vs 8.2%, P &amp;amp;amp;amp;lt; 0.001). Both recipient groups had similar perioperative mortality, 30-day readmission rates, and short-term patient survival. In the multivariate analysis, including recipient, donor, center and regional factors, donor age 70 years or older was associated with slightly increased risk of graft loss (hazard ratio, 1.3; 95% confidence interval, 1.08-1.56; P = 0.005). The current trend toward the use of elderly donors in liver transplant recipients with low model of end-stage liver disease scores (&amp;amp;amp;amp;lt;27), without hepatitis C, not hospitalized and not on dialysis, is associated with acceptable perioperative outcomes, patient survival, and slightly worse graft survival.

Research paper thumbnail of The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery

Surgery, 2015

Background. Although evidence to support the use of laparoscopic and robotic approaches for the t... more Background. Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections. Methods. The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches. Results. We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery.

Research paper thumbnail of Adjuvant Chemotherapy and Radiation Therapy is Associated with Improved Survival for Patients with Extrahepatic Cholangiocarcinoma

Annals of Surgical Oncology, 2015

This study aimed to analyze adjuvant therapy among patients with extrahepatic cholangiocarcinoma ... more This study aimed to analyze adjuvant therapy among patients with extrahepatic cholangiocarcinoma (EHC) at a national level. The American College of Surgeons National Cancer Data Base was used to identify patients with resected EHC (pathologic stages 1-3) between 1998 and 2006 (n = 8741). Three groups were compared: surgery only (S, n = 5766), surgery plus adjuvant chemotherapy (AC, n = 450), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, n = 1918). The study investigated how patient demographics, provider characteristics, and tumor-specific variables were associated with receipt of adjuvant therapy and overall survival. Patients who received adjuvant treatment were more likely to be younger (median age S, 70 years; AC, 65 years; ACR, 63 years), in the highest income quartile (&amp;amp;amp;amp;amp;amp;amp;amp;gt;$46,000: S, 38.3 %; AC, 43.4 %; ACR, 44.7 %), and treated at a community cancer center (S, 43.0 %; AC, 50.7 %; ACR, 52.9 %) (all p &amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). These patients also were more likely to have positive lymph nodes (S, 34.7 %; AC, 69.6 %; ACR, 63.3 %), positive surgical margins (S, 5.9 %; AC, 7.1 %; ACR, 10.7 %), and stage 3 disease (S, 21.4 %; AC, 37.8 %; ACR, 37.9 %) (all p &amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Multivariate analysis of the entire cohort showed improved survival with ACR (hazard ratio [HR] 0.82; 95 % confidence interval [CI] 0.75-0.91). The survival benefit was independent of margin status (R0: HR 0.88; 95 % CI 0.79-0.97; R1: HR 0.49; 95 % CI 0.38-0.62). This national analysis suggests that ACR are associated with improved survival for high-risk EHC patients, such as those with positive lymph nodes. Until randomized clinical trials are conducted, these may be the best available data to guide adjuvant therapy for resected EHC.

Research paper thumbnail of Does race affect management and survival in hepatocellular carcinoma in the United States?

Surgery, 2015

Background. Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its in... more Background. Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its incidence is increasing in the United States. This analysis describes the association between race, treatment decisions, operative outcomes, and survival for patients with HCC. Methods. The National Cancer Database was queried for all patients diagnosed with HCC from 1998 to 2011 (n = 143,692) who were white (76.9%), black (14.7%), or Asian (8.4%). Multivariate logistic regression was performed to determine factors that affected the likelihood of having surgery and postoperative mortality, and a Cox regression was performed to evaluate the effect of these factors on survival.

Research paper thumbnail of 479 Patients With Resected Gallbladder Cancer Demonstrate Improved Survival With Adjuvant Therapy

Research paper thumbnail of Tu1782 Factors Affecting Hospital Cost After Liver Transplantation: Implications of Broader Sharing

Research paper thumbnail of Su1781 Whipples in Octogenarians: Patient Selection Trumps Ageism

Research paper thumbnail of A Systematic Approach to Developing A Global Surgery Elective

Journal of surgical education, Jan 26, 2015

Interest in global health has been increasing for years among American residents and medical stud... more Interest in global health has been increasing for years among American residents and medical students. Many residency programs have developed global health tracks or electives in response to this need. Our goal was to create a global surgery elective based on a synergistic partnership between our institution and a hospital in the developing world. We created a business plan and 1-year schedule for researching potential sites and completing a pilot rotation at our selected hospital. We administered a survey to general surgery residents at the University of Cincinnati and visited medical facilities in Sierra Leone, Cameroon, and Malawi. The survey was given to all general surgery residents. A resident and a faculty member executed the fact-finding trip as well as the pilot rotation. Our general surgery residents view an international elective as integral to residency training and would participate in such an elective. After investigating 6 hospitals in sub-Saharan Africa, we conducted...

Research paper thumbnail of Variation by center and economic burden of readmissions after liver transplantation

Liver Transplantation, 2015

The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unkn... more The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n= 12,445; 43% of all LT) undergoing LT from 2007-2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine incidence and risk factors for 30-day readmissions and utilization metrics at 90-days post-LT. Overall 30-day hospital readmission rate after LT was 37.9% with half of patients admitted in seven days post discharge. Readmitted patients had worse overall graft and patient survival with 2-year follow-up. Multivariable analysis identified risk factors associated with 30-day hospital readmission including higher MELD, diabetes at LT, dialysis dependent, high donor risk index allografts and discharge to rehab facility. After adjusting for donor, recipient and geographic factors in a hierarchical model, there was significant variation in readmission rates among hospitals from 26.3% to 50.8% (OR 0.53 to 1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 added cost compared to patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions were associated with center variation and increased resource utilization. This article is protected by copyright. All rights reserved.

Research paper thumbnail of Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011

Journal of the American College of Surgeons, 2015

Although donation after cardiac death (DCD) liver allografts have been used to expand the donor p... more Although donation after cardiac death (DCD) liver allografts have been used to expand the donor pool, concerns exist regarding primary nonfunction and biliary complications. Our aim was to compare resource use and outcomes of DCD allografts with donation after brain death (DBD) liver allografts. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 11,856 patients who underwent deceased donor liver transplantation (LT) from 2007 to 2011. Patients were divided into 2 cohorts based on type of allograft (DCD vs DBD). Matched pair analysis (n = 613 in each group) was used to compare outcomes of the 2 donor types. Donation after cardiac death allografts comprised 5.2% (n = 613) of all LTs in the studied cohort; DCD allograft recipients were healthier and had lower median Model of End-Stage Liver Disease (MELD) score (17 vs 19; p &amp;amp;amp;amp;lt; 0.0001). Post LT, there was no significant difference in length of stay, perioperative mortality, and discharge to home rates. However, DCD allografts were associated with higher direct cost ($110,414 vs $99,543; p &amp;amp;amp;amp;lt; 0.0001) and 30-day readmission rates (46.4% vs 37.1%; p &amp;amp;amp;amp;lt; 0.0001). Matched analysis revealed that DCD allografts were associated with higher direct cost, readmission rates, and inferior graft survival. While confirming the previous reports of inferior graft survival associated with DCD allografts, this is the first national report to show increased financial and resource use associated with DCD compared with DBD allografts in a matched recipient cohort.

Research paper thumbnail of Effect of pretransplant diabetes on short-term outcomes after liver transplantation: A National cohort study

Liver International, 2015

Research paper thumbnail of Is liver transplantation safe and effective in elderly (≥70 years) recipients? A case-controlled analysis

HPB, 2014

Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outc... more Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outcomes in this group have not been well defined. A linkage of the Scientific Registry of Transplant Recipients (SRTR) and the University HealthSystem Consortium (UHC) databases identified 12,445 patients who underwent LT during 2007-2011. Two cohorts were created consisting of, respectively, elderly recipients aged ≥70 years (n = 323) and recipients aged 18-69 years (n = 12,122). A 1:1 case-matched analysis was performed based on propensity scores. Elderly recipients had lower Model for End-stage Liver Disease (MELD) scores at LT (median 15 versus 19; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), more often underwent transplantation at high-volume centres (46% versus 33%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) and more often received grafts from donors aged &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;60 years (24% versus 15%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). The two cohorts had similar hospital lengths of stay, in-hospital mortality, hospital costs and 30-day readmission rates. There were no differences in graft survival between the two cohorts (P = 0.10), but elderly recipients had worse longterm overall survival (P = 0.009). However, a case-controlled analysis confirmed similar perioperative hospital outcomes, graft survival and longterm patient survival in the two matched cohorts. Elderly LT recipients accounted for &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;3% of all LTs performed during 2007-2011. Selected elderly recipients have perioperative outcomes and survival similar to those in younger adults.

Research paper thumbnail of Comparing living donor and deceased donor liver transplantation: A matched national analysis from 2007 to 2012

Liver Transplantation, 2014

A complete evaluation of living donor liver transplantation (LDLT) in the United States has been ... more A complete evaluation of living donor liver transplantation (LDLT) in the United States has been difficult because of the persistent low volume and the lack of adequate comparisons with deceased donor liver transplantation (DDLT). Recent reports have suggested outcomes equivalent to those for DDLT, but these studies did not adjust for differences in recipient selection. From a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 14,282 patients at 62 centers who underwent DDLT from 2007 to 2012 and 715 patients at 35 centers who underwent LDLT during the same period. Then, we performed 1:1 propensity score matching for 708 LDLT recipients based on age, Model for End-Stage Liver Disease (MELD) score, and pretransplant patient status. The median follow-up was 2 years. Compared with DDLT recipients, LDLT recipients were more likely to be white (84.5% versus 72.2%) and female (41.1% versus 31.7%), to have lower MELD scores (15 versus 19), and to be classified preoperatively as independent (65.3% versus 46.7%) and not hospitalized (91.3% versus 78.4%). The posttransplant length of stay (LOS), in-hospital mortality, costs, and survival were similar between the groups, but LDLT recipients were more likely to be readmitted within 30 days (44.9% versus 37.1%, P 5 0.001). After matching, the difference in 30-day readmission rates persisted (45.1% versus 33.8%, P 5 0.001), but there were no differences in the LOS, costs, patient survival, or graft survival. This national report shows that LDLT is associated with higher readmission rates in comparison with DDLT, but the results are comparable for other key patient metrics.

Research paper thumbnail of Readmission After Pancreaticoduodenectomy: An Issue of Survival and Survivorship

Annals of Surgical Oncology, 2009

Background. As increased focus is placed on quality of care in surgery, readmission is an increas... more Background. As increased focus is placed on quality of care in surgery, readmission is an increasingly important metric by which hospital and surgeon quality is measured. For complex pancreatic surgery, we hypothesized that increased pancreaticoduodenectomy (PD) volume may mitigate readmission rates. Methods. The University Healthsystems Consortium database was queried for all patients (n = 9805) undergoing PD from 2009 to 2011. Hospitals were stratified into quintiles based on number of cases performed annually. Univariate and multivariate logistic regression analyses were performed to identify factors associated with 30-day readmission.

Research paper thumbnail of Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation

Surgery, 2015

Background. The desire to provide cost-effective care has lead to an investigation of the costs o... more Background. The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. Methods. The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable.

Research paper thumbnail of Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery

JAMA Surgery, 2015

Safety-net hospitals provide broad services for a vulnerable population of patients and are finan... more Safety-net hospitals provide broad services for a vulnerable population of patients and are financially at risk owing to impending reimbursement penalties and policy changes. To determine the effect of patient and hospital factors on surgical outcomes and cost at safety-net hospitals. Hospitals in the University HealthSystem Consortium database from January 1, 2009, through December 31, 2012 (n = 231), were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time (n = 12 638 166). Nine cohorts, based on a variety of surgical procedures, were created and examined with regard to preoperative characteristics, postoperative outcomes, and resource utilization. Multiple logistic regression was performed to analyze the effect of patient and center factors on outcomes. Hospital Compare data from the Centers for Medicare &amp;amp;amp; Medicaid Services were linked and used to characterize and compare the groups of hospitals. Postoperative mortality, 30-day readmissions, and total direct cost. For all 9 procedures examined in 231 hospitals comprising 12 638 166 patient encounters, patients at hospitals with high safety-net burden (HBHs) (vs hospitals with low and medium safety-net burdens) were most likely to be young, to be black, to be of the lowest socioeconomic status, and to have the highest severity of illness and the highest cost for surgical care (P &amp;amp;lt; .01 for all). For 7 of 9 procedures, HBHs had the highest proportion of emergent cases and longest length of stay (P &amp;amp;lt; .01 for all). After adjusting for patient characteristics and center volume, HBHs still had higher odds of mortality for 3 procedures (odds ratios [ORs], 1.81-2.08; P &amp;amp;lt; .05), readmission for 2 procedures (ORs, 1.19-1.30; P &amp;amp;lt; .05), and the highest cost of care associated with 7 of 9 procedures (risk ratios, 1.23-1.35; P &amp;amp;lt; .05). Analysis of Hospital Compare data found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency (all P &amp;amp;lt; .05). These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost across 9 elective surgical procedures. These outcomes are likely owing to hospital resources and not necessarily patient factors. In addition, impending changes to reimbursement may have a negative effect on the surgical care at these centers.

Research paper thumbnail of Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2015

Higher-volume centers demonstrate better perioperative outcomes for complex surgical intervention... more Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs. From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable. The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortalit...

Research paper thumbnail of Disparities in care for patients with curable hepatocellular carcinoma

HPB, 2015

The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues ... more The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues to be underutilized. This retrospective review investigates treatment decisions and survival for early stage HCC. The National Cancer Database (NCDB) was queried for all patients with curable HCC (Stage I/II) from 1998 to 2011 (n = 43 859). Patient and tumour characteristics were analysed to determine predictors of having surgery and of long-term survival. Only 39.7% of patients received surgery for early stage HCC. Surgical therapies included resection (34.6%), transplant (28.7%), radiofrequency ablation (27.1%) and other therapies. Surgery correlated with improved median survival (48.3 versus 8.4 months), but was only performed on 42% of stage I patients and 50% of tumours smaller than 2 cm. Patients were more likely to receive surgery if they were Asian or white race, had private insurance, higher income, better education, or treatment at an academic centre (P &amp;amp;amp;amp;lt; 0.05). However, private insurance and treatment at an academic centre were the only variables associated with improved survival (P &amp;amp;amp;amp;lt; 0.05). Fewer than half of patients with curable HCC receive surgery, possibly as a result of multiple socioeconomic variables. Past these barriers to care, survival is related to adequate and reliable treatment. Further efforts should address these disparities in treatment decisions.

Research paper thumbnail of Adjuvant Therapy for Gallbladder Cancer: an Analysis of the National Cancer Data Base

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 21, 2015

The role of adjuvant therapy in patients with resected gallbladder cancer (GBC) is unclear. The A... more The role of adjuvant therapy in patients with resected gallbladder cancer (GBC) is unclear. The American College of Surgeons National Cancer Data Base was used to identify patients with resected GBC (pathologic stage 1-3) from 1998 to 2006 (n = 6690). We compared three groups: surgery only (S, 78.6 %), surgery plus adjuvant chemotherapy (AC, 6.2 %), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, 15.1 %). Univariate and Cox regression analyses were used to determine factors influencing overall survival and the use of adjuvant therapy. ACR was associated with improved survival for all patients (HR 0.77, 95 % CI 0.66-0.90), especially node-positive patients (HR 0.64, 95 % CI 0.53-0.78); AC was not associated with changes in survival. Patients were less likely to have their lymph nodes examined if they had any comorbidities, lower income, or were treated at community cancer centers (all p < 0.05). Among patients with unknown lymph node status, those with T2 or T3 ...

Research paper thumbnail of Use of Elderly Allografts in Liver Transplantation

Transplantation, 2015

The use of liver allografts from elderly donors (≥70 years) has increased because of organ shorta... more The use of liver allografts from elderly donors (≥70 years) has increased because of organ shortage and increased life expectancy. The aim of this study is to evaluate the current utilization of elderly donors in United States, recipient selection, and their posttransplant outcomes. A linkage between Scientific Registry of Transplant Recipients and University HealthSystem Consortium databases was performed. Between January 2007 and December 2011, 12,445 liver transplant (LT) recipients were identified and divided into 2 cohorts based on donor age: 70 years or older (n = 540) and younger than 60 years (n = 10,473). Elderly donors accounted for 4.3% of all donors used in the 5-year period. When compared to younger donors, elderly donors were more likely to be women, shared regionally or nationally, and used at higher volume centers. Elderly donor allografts were less likely to be used in recipients with model of end-stage liver disease score higher than 27 (13.2% vs 23.0%, P &amp;amp;amp;amp;lt; 0.001), hospitalized (16.8% vs 21.7%, P = 0.03), or on hemodialysis at time of transplant (2.6% vs 8.2%, P &amp;amp;amp;amp;lt; 0.001). Both recipient groups had similar perioperative mortality, 30-day readmission rates, and short-term patient survival. In the multivariate analysis, including recipient, donor, center and regional factors, donor age 70 years or older was associated with slightly increased risk of graft loss (hazard ratio, 1.3; 95% confidence interval, 1.08-1.56; P = 0.005). The current trend toward the use of elderly donors in liver transplant recipients with low model of end-stage liver disease scores (&amp;amp;amp;amp;lt;27), without hepatitis C, not hospitalized and not on dialysis, is associated with acceptable perioperative outcomes, patient survival, and slightly worse graft survival.

Research paper thumbnail of The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery

Surgery, 2015

Background. Although evidence to support the use of laparoscopic and robotic approaches for the t... more Background. Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections. Methods. The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches. Results. We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery.

Research paper thumbnail of Adjuvant Chemotherapy and Radiation Therapy is Associated with Improved Survival for Patients with Extrahepatic Cholangiocarcinoma

Annals of Surgical Oncology, 2015

This study aimed to analyze adjuvant therapy among patients with extrahepatic cholangiocarcinoma ... more This study aimed to analyze adjuvant therapy among patients with extrahepatic cholangiocarcinoma (EHC) at a national level. The American College of Surgeons National Cancer Data Base was used to identify patients with resected EHC (pathologic stages 1-3) between 1998 and 2006 (n = 8741). Three groups were compared: surgery only (S, n = 5766), surgery plus adjuvant chemotherapy (AC, n = 450), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, n = 1918). The study investigated how patient demographics, provider characteristics, and tumor-specific variables were associated with receipt of adjuvant therapy and overall survival. Patients who received adjuvant treatment were more likely to be younger (median age S, 70 years; AC, 65 years; ACR, 63 years), in the highest income quartile (&amp;amp;amp;amp;amp;amp;amp;amp;gt;$46,000: S, 38.3 %; AC, 43.4 %; ACR, 44.7 %), and treated at a community cancer center (S, 43.0 %; AC, 50.7 %; ACR, 52.9 %) (all p &amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). These patients also were more likely to have positive lymph nodes (S, 34.7 %; AC, 69.6 %; ACR, 63.3 %), positive surgical margins (S, 5.9 %; AC, 7.1 %; ACR, 10.7 %), and stage 3 disease (S, 21.4 %; AC, 37.8 %; ACR, 37.9 %) (all p &amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Multivariate analysis of the entire cohort showed improved survival with ACR (hazard ratio [HR] 0.82; 95 % confidence interval [CI] 0.75-0.91). The survival benefit was independent of margin status (R0: HR 0.88; 95 % CI 0.79-0.97; R1: HR 0.49; 95 % CI 0.38-0.62). This national analysis suggests that ACR are associated with improved survival for high-risk EHC patients, such as those with positive lymph nodes. Until randomized clinical trials are conducted, these may be the best available data to guide adjuvant therapy for resected EHC.

Research paper thumbnail of Does race affect management and survival in hepatocellular carcinoma in the United States?

Surgery, 2015

Background. Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its in... more Background. Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its incidence is increasing in the United States. This analysis describes the association between race, treatment decisions, operative outcomes, and survival for patients with HCC. Methods. The National Cancer Database was queried for all patients diagnosed with HCC from 1998 to 2011 (n = 143,692) who were white (76.9%), black (14.7%), or Asian (8.4%). Multivariate logistic regression was performed to determine factors that affected the likelihood of having surgery and postoperative mortality, and a Cox regression was performed to evaluate the effect of these factors on survival.

Research paper thumbnail of 479 Patients With Resected Gallbladder Cancer Demonstrate Improved Survival With Adjuvant Therapy

Research paper thumbnail of Tu1782 Factors Affecting Hospital Cost After Liver Transplantation: Implications of Broader Sharing

Research paper thumbnail of Su1781 Whipples in Octogenarians: Patient Selection Trumps Ageism

Research paper thumbnail of A Systematic Approach to Developing A Global Surgery Elective

Journal of surgical education, Jan 26, 2015

Interest in global health has been increasing for years among American residents and medical stud... more Interest in global health has been increasing for years among American residents and medical students. Many residency programs have developed global health tracks or electives in response to this need. Our goal was to create a global surgery elective based on a synergistic partnership between our institution and a hospital in the developing world. We created a business plan and 1-year schedule for researching potential sites and completing a pilot rotation at our selected hospital. We administered a survey to general surgery residents at the University of Cincinnati and visited medical facilities in Sierra Leone, Cameroon, and Malawi. The survey was given to all general surgery residents. A resident and a faculty member executed the fact-finding trip as well as the pilot rotation. Our general surgery residents view an international elective as integral to residency training and would participate in such an elective. After investigating 6 hospitals in sub-Saharan Africa, we conducted...

Research paper thumbnail of Variation by center and economic burden of readmissions after liver transplantation

Liver Transplantation, 2015

The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unkn... more The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n= 12,445; 43% of all LT) undergoing LT from 2007-2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine incidence and risk factors for 30-day readmissions and utilization metrics at 90-days post-LT. Overall 30-day hospital readmission rate after LT was 37.9% with half of patients admitted in seven days post discharge. Readmitted patients had worse overall graft and patient survival with 2-year follow-up. Multivariable analysis identified risk factors associated with 30-day hospital readmission including higher MELD, diabetes at LT, dialysis dependent, high donor risk index allografts and discharge to rehab facility. After adjusting for donor, recipient and geographic factors in a hierarchical model, there was significant variation in readmission rates among hospitals from 26.3% to 50.8% (OR 0.53 to 1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 added cost compared to patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions were associated with center variation and increased resource utilization. This article is protected by copyright. All rights reserved.

Research paper thumbnail of Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011

Journal of the American College of Surgeons, 2015

Although donation after cardiac death (DCD) liver allografts have been used to expand the donor p... more Although donation after cardiac death (DCD) liver allografts have been used to expand the donor pool, concerns exist regarding primary nonfunction and biliary complications. Our aim was to compare resource use and outcomes of DCD allografts with donation after brain death (DBD) liver allografts. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 11,856 patients who underwent deceased donor liver transplantation (LT) from 2007 to 2011. Patients were divided into 2 cohorts based on type of allograft (DCD vs DBD). Matched pair analysis (n = 613 in each group) was used to compare outcomes of the 2 donor types. Donation after cardiac death allografts comprised 5.2% (n = 613) of all LTs in the studied cohort; DCD allograft recipients were healthier and had lower median Model of End-Stage Liver Disease (MELD) score (17 vs 19; p &amp;amp;amp;amp;lt; 0.0001). Post LT, there was no significant difference in length of stay, perioperative mortality, and discharge to home rates. However, DCD allografts were associated with higher direct cost ($110,414 vs $99,543; p &amp;amp;amp;amp;lt; 0.0001) and 30-day readmission rates (46.4% vs 37.1%; p &amp;amp;amp;amp;lt; 0.0001). Matched analysis revealed that DCD allografts were associated with higher direct cost, readmission rates, and inferior graft survival. While confirming the previous reports of inferior graft survival associated with DCD allografts, this is the first national report to show increased financial and resource use associated with DCD compared with DBD allografts in a matched recipient cohort.

Research paper thumbnail of Effect of pretransplant diabetes on short-term outcomes after liver transplantation: A National cohort study

Liver International, 2015

Research paper thumbnail of Is liver transplantation safe and effective in elderly (≥70 years) recipients? A case-controlled analysis

HPB, 2014

Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outc... more Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outcomes in this group have not been well defined. A linkage of the Scientific Registry of Transplant Recipients (SRTR) and the University HealthSystem Consortium (UHC) databases identified 12,445 patients who underwent LT during 2007-2011. Two cohorts were created consisting of, respectively, elderly recipients aged ≥70 years (n = 323) and recipients aged 18-69 years (n = 12,122). A 1:1 case-matched analysis was performed based on propensity scores. Elderly recipients had lower Model for End-stage Liver Disease (MELD) scores at LT (median 15 versus 19; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), more often underwent transplantation at high-volume centres (46% versus 33%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) and more often received grafts from donors aged &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;60 years (24% versus 15%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). The two cohorts had similar hospital lengths of stay, in-hospital mortality, hospital costs and 30-day readmission rates. There were no differences in graft survival between the two cohorts (P = 0.10), but elderly recipients had worse longterm overall survival (P = 0.009). However, a case-controlled analysis confirmed similar perioperative hospital outcomes, graft survival and longterm patient survival in the two matched cohorts. Elderly LT recipients accounted for &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;3% of all LTs performed during 2007-2011. Selected elderly recipients have perioperative outcomes and survival similar to those in younger adults.

Research paper thumbnail of Comparing living donor and deceased donor liver transplantation: A matched national analysis from 2007 to 2012

Liver Transplantation, 2014

A complete evaluation of living donor liver transplantation (LDLT) in the United States has been ... more A complete evaluation of living donor liver transplantation (LDLT) in the United States has been difficult because of the persistent low volume and the lack of adequate comparisons with deceased donor liver transplantation (DDLT). Recent reports have suggested outcomes equivalent to those for DDLT, but these studies did not adjust for differences in recipient selection. From a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 14,282 patients at 62 centers who underwent DDLT from 2007 to 2012 and 715 patients at 35 centers who underwent LDLT during the same period. Then, we performed 1:1 propensity score matching for 708 LDLT recipients based on age, Model for End-Stage Liver Disease (MELD) score, and pretransplant patient status. The median follow-up was 2 years. Compared with DDLT recipients, LDLT recipients were more likely to be white (84.5% versus 72.2%) and female (41.1% versus 31.7%), to have lower MELD scores (15 versus 19), and to be classified preoperatively as independent (65.3% versus 46.7%) and not hospitalized (91.3% versus 78.4%). The posttransplant length of stay (LOS), in-hospital mortality, costs, and survival were similar between the groups, but LDLT recipients were more likely to be readmitted within 30 days (44.9% versus 37.1%, P 5 0.001). After matching, the difference in 30-day readmission rates persisted (45.1% versus 33.8%, P 5 0.001), but there were no differences in the LOS, costs, patient survival, or graft survival. This national report shows that LDLT is associated with higher readmission rates in comparison with DDLT, but the results are comparable for other key patient metrics.

Research paper thumbnail of Readmission After Pancreaticoduodenectomy: An Issue of Survival and Survivorship

Annals of Surgical Oncology, 2009

Background. As increased focus is placed on quality of care in surgery, readmission is an increas... more Background. As increased focus is placed on quality of care in surgery, readmission is an increasingly important metric by which hospital and surgeon quality is measured. For complex pancreatic surgery, we hypothesized that increased pancreaticoduodenectomy (PD) volume may mitigate readmission rates. Methods. The University Healthsystems Consortium database was queried for all patients (n = 9805) undergoing PD from 2009 to 2011. Hospitals were stratified into quintiles based on number of cases performed annually. Univariate and multivariate logistic regression analyses were performed to identify factors associated with 30-day readmission.

Research paper thumbnail of Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation

Surgery, 2015

Background. The desire to provide cost-effective care has lead to an investigation of the costs o... more Background. The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. Methods. The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable.