Tag: Digestive Disorders

Fewer patients sent to hospital rehabilitation facilities for recovery after colorectal operations early in the COVID pandemic
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Key takeaways
- The first months of the COVID pandemic in 2020 caused a discernible change in post-surgery practice; colorectal surgeons discharged more patients direct to home for recovery, thus, bypassing a stay at a rehabilitation facility.
- The rate of patients discharged to rehabilitation facilities dropped 3% but the number of patients who were readmitted to the hospital with complications remained stable, even though patients underwent fewer minimally invasive procedures.
- Telemedicine visits rose among patients discharged home so care providers could check in on their patients. Study findings showing stable hospital readmission rates in pandemic year 2020 highlight the potential for lowering rehabilitation utilization for colorectal patients. 
Newswise — SAN DIEGO: The first months of the COVID pandemic had a profound effect on hospital discharge practices and use patterns for patients with colorectal disease, according to findings presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. A study of more than 100,000 surgical patients who underwent procedures for colorectal cancer found that they had 40% lower odds of being discharged to post-hospital rehabilitation during the pandemic than before.

Despite this significantly lower rate, the hospital readmission rate did not change from pre-pandemic levels, said Marc Mankarious, MD, a surgical resident at Penn State Hershey Medical Center, Hershey, Pennsylvania.

“We found that discharge to a rehabilitation facility pre-pandemic was 10%, which agreed with previous literature, but once the pandemic hit, the discharge-to-rehabilitation rate dropped to about 7%,” Dr. Mankarious said. “We saw a drop of three percentage points, even though we were doing more emergent operations and more open operations, which are typical risk factors for requiring rehabilitation after surgery.”

The authors hypothesized that anecdotally, fear of going into confined spaces, staff and supply shortages, and disease outbreaks contributed to changes in discharge practices.

About the Study

The retrospective cohort study used two databases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®): the Participant Use File and Target Colectomy databases. Researchers analyzed data on 116,677 patients: 90,250 from 2017 through 2019, and 26,427 from 2020. For comparison, the first quarter was excluded from all years because the first COVID restrictions did not go into effect until March 2020. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information.

Key findings
- In comparing the pre- and post-COVID-19 periods, the proportion of emergent cases and open operations—as opposed to minimally invasive procedures—increased in 2020, from 13 to 15% (p<0.001) and 31 to 32% (p<0.001), respectively.
- A multivariable analysis found that patients in 2020 had 40% lower odds of going to a post-discharge facility (odds ratio 0.62, p<0.001), even after the analysis adjusted for reasons for having the operations and other medical conditions the patients had.
- The rates of patients going back to the hospital within 30 days of discharge was 10% in both periods (p=0.4).
Surgeons’ observations

The stability in hospital readmission rates was telling because that may be “one of the factors that goes into deciding whether to offer a rehabilitation stay to a patient,” Dr. Mankarious said.

The study data did not include reasons why patients did or did not choose to go to post-discharge rehabilitation to recover; the authors hypothesized that factors included limited availability of beds and patient concerns about visitor restrictions and contracting COVID-19 Dr. Mankarious said. But the pandemic saw a 63-fold increase in telehealth use in 2020 over 2019.* “This situation may have made patients and physicians more comfortable with the patient going home and following up with each other electronically,” he said.

The data included some information on medical reasons for going to rehabilitation. “We did find that patients that went to rehabilitation in 2020 were more functionally dependent or functionally impaired than patients that went to rehabilitation in previous years, so those factors may also play a part in it.” Dr. Mankarious said.

The study grew out of what surgeons at Penn State Hershey were observing in the early days of the pandemic, said senior author Audrey Kulayat, MD, assistant professor of colorectal surgery. “We wondered if those observations had an impact on a bigger scale other than just at our institution,” she said. “But then we wanted to know, what’s the downside? Was there a downside? Are patients getting readmitted more frequently as a result of going back to their home or whatever institution versus going to a place with a higher level of nursing care? We didn’t find that they were readmitted more often.”

Potential change in discharge practice

The study findings raise questions about the potential overuse of posthospital rehabilitation for colorectal patients, Dr. Mankarious said. “Medicare spends about $60 billion per year on patients going to post-acute care facilities or rehab in general and any small reductions, even our 3% reduction, which was significant, could result in considerable cost savings for the healthcare system.

“And it really helps us rethink who should go to post-surgery rehab, maybe raise our thresholds as we become more comfortable sending patients home and have better utilization of the new available modalities to help us follow up with them without having to send them to rehab,” Dr. Mankarious added.

Dr. Mankarious and Dr. Kulayat have no disclosures.

Study co-authors are Austin C. Portolese, MD; Jeffrey S. Scow, MD, FACS; Michael Deutsch, MD, FACS; and Nimalan A. Jeganathan, MD, FACS, all of Penn State Hershey Medical Center.

Citation: Mankarious MM, et al. Changing Disposition Patterns of Colorectal Surgery Patients in the Era of COVID-19. Scientific Forum Presentation, American College of Surgeons Clinical Congress 2022.

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* Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristic and Location. (Issue Brief No. HP-2021-27) Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; Washington, D.C.; December 2021. Available online.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
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American College of Surgeons (ACS)

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October 16, 2022
Study finds less expensive noninvasive test is an effective alternative to a more costly test for colorectal cancer screening
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Key takeaways
- National guidelines suggest a fecal immunochemical test (FIT) can be used as the primary noninvasive screening modality for early-stage colorectal cancer, but a significant proportion of patients still receive a more expensive alternative test called Cologuard®.
- Data used for national screening guidelines has shown no difference between the two tests at detecting adenoma versus colorectal malignancy.
- These results align with previous studies out of Japan and the Netherlands examining FIT as an appropriate screening modality that is more cost effective than other types of noninvasive colorectal screening tests.
Newswise — SAN DIEGO: Commercially available noninvasive screening tests for colorectal cancer—a fecal immunochemical test (FIT) and the multi-target stool DNAtest (mt-sDNA; or Cologuard®)—are equally effective for screening patients with early-stage colorectal cancer. However, a FIT costs about one-fifth of the multi-target DNA test, according to new study results presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022.

Pavan K. Rao, MD, a general surgery resident at Allegheny Health Network in Pittsburgh, Pennsylvania, presented study results looking at 117,519 people in the Highmark claims database who underwent colorectal screening in 2019. Highmark is a Blue Cross Blue Shield Association insurer in four Mid-Atlantic states.

From that group, the researchers identified 91,297 people who had noninvasive screening with either the fecal immunochemical test (FIT, n=45,487) or the DNA test (mt-sDNA, n=46,110) instead of having a routine colonoscopy.

Key findings
- Among the study population that underwent colorectal screening, 45,487 (38.7 percent) had one of two commercially available FIT tests and 46,110 (39.2 percent) had the mt-sDNA test.
- Patients who were screened with either test presented with early disease, staged from 0 to II, at similar rates: 59.5 percent for FIT and 63.2 percent for mt-sDNA test (p=0.77).
- Patients within the Allegheny Health Network Oncology Registry diagnosed with colorectal cancer were matched to their claims data to determine distribution of cancer stage. If the noninvasive test indicated signs of early disease, patients were then referred for additional testing to confirm the findings.
- The total annual costs for the tests were $6.47 million—$1.1 million for a FIT, or about $24 per test, and $5.6 million for mt-sDNA, or about $121 per test. Costs were calculated using Medicare reimbursement rates.
Observations on study results

The study followed guidelines issued by the U.S. Preventive Services Task Force (USPSTF) in 2016 and updated in 2019. Since then, the guidelines were updated again in 2021.¹

“Despite national guidelines suggesting that FIT be used as the primary noninvasive screening modality, we found that on review of our insurer’s claims data, a significant proportion of patients still receive a more expensive alternative test. There is substantial cost savings not only to our patients but to our health system with promoting appropriate use of noninvasive testing,” Dr. Rao said.

“There was no difference in the clinical stage at the time of diagnosis between the two tests, which again demonstrates the clinical equipoise maintained by switching to FIT,” Dr. Rao said of the variation between the two tests.

He added, “When you look at the national data for which the guidelines put forward, they found no difference between the two tests at detecting adenoma versus colorectal malignancy.”²

Cost savings without compromising care

The researchers determined that transitioning all noninvasive colorectal cancer screening to FIT would result in a $3.9 million savings annually in the study population.

“In the current state of healthcare, we are thinking ever more about efficiency and reduction in costs while maintaining patient outcomes, and not compromising the quality of care we provide,” Dr. Rao said. “I think a colorectal surgeon or any specialist who sees appropriate patients for colorectal cancer screening can use this data to provide recommendations of alternative screening tests to patients who primarily do not want to undergo colonoscopy. We cannot only say it is appropriate from a guideline standpoint, but we’re also reducing wasteful spending in health care by appropriately using the FIT.”

What makes this study unique is the methodology used to analyze the claims data, said study coauthor Casey J. Allen, MD, a surgical oncologist at Allegheny Health Network and an assistant professor at Drexel University College of Medicine, Pittsburgh. The researchers analyzed outcomes in the local health registry and then applied those outcomes to the claims database. “It’s not just the cost of the mt-sDNA test kit or the cost of the FIT kit multiplied by the number of members in the healthcare system,” Dr. Allen said. “It’s the full downstream costs depending on the rates of false-positive and false-negative tests and how much it costs to obtain a colonoscopy when that occurs. The cost of a screening colonoscopy in the database the researchers used was $635.

These results support previous studies out of Japan³ and the Netherlands⁴ that found FIT was more cost-effective than other types of noninvasive colorectal screening tests.

Study coauthors are Samantha Falls, DO, Stacey Shipley, BA, and Katie Farah, MD, of Allegheny Health Network, Wexford, Pennsylvania; and Patrick L. Wagner, MD, FACS, David L. Bartlett, MD, FACS, and Sricharan Chalikonda, MD, MHA, FACS, of Allegheny Health Network, Pittsburgh.

Dr. Rao and Dr. Allen have no disclosures to report.

Citation: Rao, PK et al. Comprehensive Cost Implications of Commercially Available Non-invasive Colorectal Cancer Screening Modalities: Results of A Large National Insurer Claims Database Analysis, Scientific Forum, American College of Surgeons Clinical Congress 2022.

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¹U.S. Preventive Services Taskforce. Final Recommendation Statement, Colorectal Cancer: Screening. Updated May 18, 2021. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening (.)

²Rex DK, Boland CR, Dominitz et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017;112(7):1016-1030.

³Sekiguchi M, Igarashi A, Sakamoto T, Saito Y, Esaki M, Matsuda T. Cost-effectiveness analysis of colorectal cancer screening using colonoscopy, fecal immunochemical test, and risk score. J Gastroenterol Hepatol. 2020 ;35(9):1555-1561.

⁴Lansdorp-Vogelaar I, Goede SL, Bosch LJW, et al. Cost-effectiveness of high-performance biomarker tests vs fecal immunochemical test for noninvasive colorectal cancer screening. Clin Gastroenterol Hepatol. 2018;16(4):504-512.e11.

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About the American College of Surgeons 

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
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American College of Surgeons (ACS)

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October 16, 2022
Operations for diverticulitis decreased in 2020, but the degree of disease severity increased
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Key takeaways
- Overutilization of intubation respirators early in the pandemic may have masked signs and symptoms of diverticulitis in COVID-19 patients.
- Restricted access to computed tomography scanning and a preference for antibiotics may have been factors in postponing surgery until patients were sicker.
- Future research will look at 2021 data to see if care patterns returned to pre-pandemic levels.
Newswise — SAN DIEGO: The first year of the COVID pandemic significantly altered how patients and providers treated diverticulitis, causing a significant drop in operations to manage the disease but a corresponding increase in the proportion of more severe cases and the need for emergency surgery, according to results of a nationwide study presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022.

Rolando H. Rolandelli, MD, FACS, chair of surgery at Morristown Medical Center in Morristown, New Jersey, and professor of surgery at Rutgers New Jersey Medical School, presented a study of 12,514 patients who had a colectomy for diverticulitis in 2018 and 10,869 who had the same procedure in 2020 using the ACS National Surgical Quality Improvement (ACS NSQIP®) database. That decline in 2020 represents a 13.14% decrease in operations for diverticulitis, which is an outpouching of the digestive tract causing painful inflammation or infection. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information.

“In the first year of the pandemic, 2020, we saw that patients were accessing the healthcare system less frequently for diverticulitis, but those who did were sicker on presentation. As a result, their postoperative outcomes were not as good,” Dr. Rolandelli said.

Key findings
- Patients were more likely to have emergency surgery for diverticulitis in 2020, with the proportion increasing to 20% of operations from 17.3% (p<0.001).
- The proportion of patients with a known abscess or perforation of the gastrointestinal tract also increased, from 50.1 to 54.55% (p<0.001).
- The proportion of Black patients increased in 2020, from 7 to 7.7% (p=0.032), which was offset by a decline in the proportion of white patients, from 82.4 to 77.7% (p<0.001).
Dr. Rolandelli said the study findings provide two lessons learned.

“One, when we limit access to health care, we do it by setting a priority for patients that are potentially at higher risk of progression of their disease, and in the early phase of the COVID pandemic, the priority was cancer patients,” he said. “This situation may have led to physicians prescribing antibiotics as an alternative to surgery for diverticulitis, which may have caused patients’ disease to progress. By the time of surgery, they were much sicker.”

The second lesson learned: A possible overuse of intubation respirators early in the pandemic. “We had patients who basically had been in a coma for weeks and could not express their symptoms of diverticulitis,” he said, which typically include pain in the lower left quadrant of the abdomen and, less frequently, fever and constipation. “We probably saw patients who were developing diverticulitis and we were not realizing it.”

Surgeons’ observations

Precautions put into place early in the pandemic may have also contributed to the greater severity of diverticulitis cases at that time, Dr. Rolandelli said. Surgeons were informed that the COVID-19 virus could concentrate in the wall of the gastrointestinal tract, including the colon, and that they should exercise caution when using electrocautery to operate on patients with diverticulitis because it could vaporize the virus and cause it to spread. Also, restricted access to computed tomography scans—an important imaging technique for monitoring the growth of diverticular lesions—may have delayed medical treatment or even surgery.

Study coauthor Zoltan H. Nemeth, MD, PhD, a research scientist at the department of surgery at Morristown Medical Center and an adjunct assistant professor at Columbia University, New York, explained that a strength of the study was its size and the large population in the ACS NSQIP database. The limitation of such databases is that they do not provide granular data on how individual patients were treated.

Next steps

Future research will include analyzing 2021 data to see how they compare to 2018 and 2020, according to Dr. Nemeth.

“I think it’s clear that, at the beginning of the pandemic in 2020, we were not sure how to approach these patients; it was a learning experience,” Dr. Rolandelli said. “So, when we compare it with 2021, when we had a year of experience and we did not place patients on the respirator as often, we’re going to be able to sort out the differences in terms of how we’re managing the patients and the actual severity of diverticulitis.”

Study coauthors are Sara Soliman, BS; Grace C. Chang, DO; and Amanda K. Nemecz, MD, all from Morristown Medical Center.

Dr. Rolandelli and Dr. Nemeth have no disclosures to report.

Citation: Rolandelli, RH et al. How the Covid-19 Pandemic Affected the Severity and Clinical Presentation of Diverticulitis, Scientific Forum, American College of Surgeons Clinical Congress 2022.

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About the American College of Surgeons 

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
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American College of Surgeons (ACS)

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October 16, 2022