BACKGROUND: Although debate continues on US healthcare and insurance reform, data are lacking on the effect of insurance on community-level cancer outcomes. Therefore, the objective of the present study was to examine the association of insurance and cancer outcomes. MATERIALS AND METHODS: The US Census Bureau Current Population Survey, Small Area Health Insurance Estimates (2000) were used for the rates of uninsurance. Counties were divided into tertiles according to the uninsurance rates. The data were compared with the cancer incidence and survival for patients residing in counties captured by the Surveillance, Epidemiology, and End Results database (2000-2006). Aggregate patient data were collected of US adults (aged >/=18 y) diagnosed with the following cancers: pancreatic, esophageal, liver or bile duct, lung or bronchial, ovarian, colorectal, breast, prostate, melanoma, and thyroid. The outcomes included the stage at diagnosis, surgery, and survival. Univariate tests and proportional hazards were calculated. RESULTS: The US uninsurance rate was 14.2%, and the range for the Surveillance, Epidemiology, and End Results counties was 8.3%-24.1%. Overall, patients from lower uninsurance rate counties demonstrated longer median survival. Adjusting for patient characteristics and cancer stage (for each cancer), the patients in the higher uninsurance rate counties demonstrated greater mortality (8%-15% increased risk on proportional hazards). The county uninsurance rate was associated with the stage at diagnosis for all cancers, except pancreatic and esophageal, and was also associated with the likelihood of being recommended for cancer-directed surgery (for all cancers). CONCLUSIONS: Health insurance coverage at a community level appears to influence survival for patients with cancer. Additional investigations are needed to examine whether individual versus community associations exist and how best to surmount barriers to cancer care.

OBJECTIVE: In the majority of literature concerning age in TBI, specifically in subdural hematomas (SDH), the mean age of patients considered elderly is 55-65. Limited data in SDH patients>75 years suggest an increased mortality rate. The impact of medical decision making on these data is not well-documented. PATIENTS/METHODS: We use the Nationwide Inpatient Sample (NIS) database to compare outcomes between SDH patients 60-79 and >/=80. As administrative databases have some shortcomings, i.e. in-hospital data only, acute and chronic SDHs listed together, we examined institutional data to evaluate the impact of these factors on medical decision making which may falsely elevate mortality rates. RESULTS: In-hospital mortality was increased in NIS patients>80 treated both surgically and non-surgically (P80 with SDHs as a group. However, the SDH patients>80 who underwent surgery at our institution had much lower mortality rates. We found that patients>/=80 made up 87% of all patients with "surgical lesions" that were not operated on. Type of subdural, admission GCS, and baseline cognitive status appeared to have a significant impact on surgical decision making. CONCLUSION: This study examines mortality rates in patients>80 with SDHs who are managed surgically and non-surgically using a large administrative database and institutional data. It provides preliminary insight into medical decision making which make affect mortality rates of the very elderly.

BACKGROUND: Undergoing a pancreatectomy obligates the patient to risks and benefits. For complex operations such as pancreatectomy, the objective assessment of baseline risks may be useful in decision-making. We developed an integer-based risk score estimating in-hospital mortality after pancreatectomy, incorporating institution-specific mortality rates to enhance its use. METHODS: Pancreatic resections were identified from the Nationwide Inpatient Sample (1998-2006), and categorized as proximal, distal, or nonspecified by the International Classification of Diseases, 9th edition. Logistic regression and bootstrap methods were used to estimate in-hospital mortality using demographics, diagnosis, comorbidities (Charlson index), procedure, and hospital volume; 80% of this cohort was selected randomly to create the score and 20% was used for validation. Score assignments were subsequently individually fitted to risk distributions around specific mortality rates. RESULTS: Sixteen thousand one hundred sixteen patient discharges were identified. Nationwide in-hospital mortality was 5.3%. Integers were assigned to predictors (age group, Charlson index, sex, diagnosis, pancreatectomy type, and hospital volume) and applied to an additive score. Three score groups were defined to stratify in-hospital mortality (national mortality, 1.3%, 4.9%, and 14.3%; P < .0001), with sufficient discrimination of derivation and validation sets (C statistics, 0.72 and 0.74). Score groups were shifted algorithmically to calculate risk based on institutional data (eg, with institutional mortality of 2.0%, low-, medium-, and high-risk patient groups had 0.5%, 1.9%, and 5.4% mortality, respectively). A web-based tool was developed and is available online (http://www.umassmed.edu/surgery/panc_mortality_custom.aspx). CONCLUSION: To maximize patient benefit, objective assessment of risk for major procedures is necessary. We developed a Surgical Outcomes Analysis and Research risk score predicting pancreatectomy mortality that combines national and institution-specific data to enhance decision-making. This type of risk stratification tool may identify opportunities to improve care for patients undergoing specific operative procedures.

BACKGROUND:: The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and the care of these patients remains highly specialized and complex. Multiple treatment options are available for HCC but their use and effectiveness remain unknown. METHODS:: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, 8730 patients who were diagnosed with HCC between 1991 and 2005 were identified. Therapy included surgical resection (8.7%), liver transplantation (1.4%), ablation (3.6%), or transarterial chemoembolization (16%). Patients who received no or palliative-only treatment were grouped together (NoTx; 70.3%). Patient, disease, and tumor factors were examined as determinants of therapy. RESULTS:: HCC is increasing in the Medicare population. The median age at diagnosis was 75.1 years and 73.6% of patients were coded as white, 17.2% as Asian, 8.3% as black, and 0.9% as other race. The rate of therapy increased over time, but only 29.7% of patients overall underwent therapy. In patients with early stage HCC, only 43.1% underwent therapy. In the NoTx group, 49.4% did not have cirrhosis, 36.0% had tumors that measured <5 >cm, and 39.8% were diagnosed with stage I or II disease when variables were complete. The use of therapy for all HCC patients increased over time, correlating with a commensurate increase in median survival. In multivariate regression analysis, patients who received any modality of treatment achieved significant benefit compared with the NoTx group (odds ratio, 0.41; 95% confidence interval, 0.39-0.43). CONCLUSIONS:: In the Medicare population, HCC patients who received therapy experienced a substantial survival advantage over their nonoperative peers (NoTx). Despite evidence that many patients had favorable biological characteristics, <30% of patients diagnosed with HCC received any treatment. Cancer 2010. (c) 2010 American Cancer Society.

INTRODUCTION: Distinct outcome measures such as in-hospital and 30-day mortality have been used to evaluate pancreatectomy results. We posited that these measures could be compared using national data, providing more precision for evaluating published outcomes after pancreatectomy. METHODS: Patients undergoing resection for pancreatic cancer were identified from the linked SEER-Medicare databases (1991-2002). Mortality was analyzed and trend tests were utilized to evaluate risk of death within ≤60 days of resection and from 60 days to 2 years post-resection. Univariate analysis assessed patient characteristics such as race, gender, marital status, socioeconomic status, hospital teaching status, and complications. RESULTS: One thousand eight hundred forty-seven resected patients were identified: 7.7% (n = 142) died within the first 30 days, 83.6% of whom died during the same hospitalization. Postoperative in-hospital mortality was 8.1% (n = 150), 79% of which was within 30 days, greater than 90% of which was within 60 days. Risk of death decreased significantly over the first 60 days (P < 0.0001). After 60 days, the risk did not decrease through 2 years (P = 0.8533). Univariate analysis showed no difference between the two groups in terms of race, gender, marital status, and socioeconomic status, but patients dying within 60 days were more likely to have experienced a complication (41.1% vs. 17.0%, P < 0.0001). CONCLUSIONS: In-hospital and 30-day mortality after resection for cancer are similar nationally; thus, comparing mortality utilizing these measures is acceptable. After a 60-day post-resection window of increased mortality, mortality risk then continues at a constant rate over 2 years, suggesting that mortality after pancreatectomy is not limited to early ("complication") and late ("cancer") phases. Determining ways to decrease perioperative mortality in the 60-day interval will be critical to improving overall survival.

BACKGROUND AND AIMS: Alcohol consumption is a well-documented determinant of adverse perioperative outcome. We sought to determine the effect of active alcohol consumption following elective surgery. METHODS: We queried discharge records from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP, 2005-2007) for all elective adult admissions. The 7,631 (2.5%) patients with documented alcohol use (active alcohol use of at least two drinks per day within 2 weeks of surgery; ETOH use) underwent elective surgery; 301,994 (97.5%) patients denied ETOH use. Multivariate analysis was performed with adjustments for demographic and comorbid factors. Primary outcome measures included length of stay (LOS), postoperative complications, and death. RESULTS: ETOH use associated with elective surgery decreased over the course of the study (p < 0.0001). ETOH use was an independent predictor of pneumonia (OR 1.98, 95% CI 1.84-2.13), sepsis (OR 1.19, 95% CI 1.03-1.37), superficial surgical site infection (SSI; OR 1.15, 95% CI 1.02-1.31), wound disruption (OR 1.41, 95% CI 1.11-1.80), and prolonged LOS (OR 1.17, 95% CI 1.08-1.26). Except for SSI, these complications were independent risk factors for postoperative mortality. ETOH use was associated with earlier time to wound disruption (9 vs. 11 days; p = 0.04), longer median hospital stays (5 vs. 3 days; p < 0.0001), and longer LOS after operation (4 vs. 3 days; p < 0.0001). CONCLUSIONS: Active alcohol consumption is a significant determinant of adverse outcomes in elective surgery; patients with ETOH use who are scheduled to undergo elective surgery should be appropriately educated and counseled.

OBJECTIVE: To assess perioperative mortality following resection of biliary tract cancer within the U.S. BACKGROUND: Resection remains the only curative treatment for biliary tract cancer. However, current data on operative mortality after surgical resections for biliary tract cancer are limited to small and single-center studies. METHODS: Using the Nationwide Inpatient Sample 1998-2006, a cohort of patient-discharges was assembled with a diagnosis of biliary tract cancer, including intrahepatic bile duct, extrahepatic bile duct, and gall bladder cancers. Patients undergoing resection, including hepatic resection, bile duct resection, pancreaticoduodenectomy, and cholecystectomy, were retained. The primary outcome measure was in-hospital mortality. Categorical variables were analyzed by chi-square. Multivariable logistic regression was performed to identify independent predictors of in-hospital mortality following resection. RESULTS: 31 870 patient-discharges occurred for the diagnosis of biliary tract cancer, including 36.2% intrahepatic ductal, 26.7% extrahepatic ductal, and 31.1% gall bladder. Of the total, 18.6% underwent resection: mean age was 69.3 years (median 70.0); 60.8% were female; 73.7% were white. Overall inpatient surgical mortality was 5.6%. Independently predictive factors of mortality included patient age >/=50 (vs./= 70 OR 9.03, 95% CI 2.86-28.56), the presence of identified comorbidities (congestive heart failure, OR 3.67, 95% CI 2.61-5.16; renal failure, OR 4.72, 95% CI 2.97-7.49), and admission designated as emergent (vs. elective; OR 1.82, 95% CI 1.39-2.37). CONCLUSION: Increased in-hospital mortality for patients undergoing biliary tract cancer resection corresponded to age, comorbidity, hospital volume, and emergent admission. Further study is warranted to utilize these observations in promoting early detection, diagnosis, and elective resection.