Etzioni, David A.

BACKGROUNDSurgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood.METHODSWe used data from the Surveillance, Epidemiology, and End Results–Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board‐certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute–designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long‐term survival.RESULTSOur data source yielded 6432 patients. Initial analysis demonstrated improved long‐term survival in patients treated by higher‐volume colorectal surgeons, higher‐volume hospitals, teaching hospitals, and National Cancer Institute (NCI)–designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long‐term survival.CONCLUSIONSPatients treated for rectal cancer by board‐certified colorectal surgeons in centers that are higher volume and/or NCI‐designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable. Cancer 2014;120:2472–2481. © 2014 American Cancer Society.

AbstractAimCurrent recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient.MethodA retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤ 3 days and no readmission for diverticulitis within 30 days after discharge.ResultsOf 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess < 3 cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient‐level predictors, the model did not identify patients likely to need only minimal hospitalization.ConclusionMost patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.