BARIATRIC SURGERY OUTCOMES AND VOLUMES DURING THE EARLY COVID 19 PANDEMIC

Background: To address the persistent ethnoracial and socioeconomic disparities in access to quality surgical cancer care, it is imperative to rigorously understand the role of clinician-level factors including clinician-to-clinician connectedness. For patients with gastric cancer, the pathway from primary care (PC) clinicians to gastroenterologists (GI) to cancer specialists (medical oncologists or surgeons) is referral-dependent and requires significant care coordination. However, the impact of clinician-to-clinician connectedness on access to quality gastric cancer surgical care, such as at National Cancer Institute-Designated Cancer Centers (NCI-CC), remains underexplored. This study evaluates how the connectedness between PC clinician or GI with cancer specialists at NCI-CC can influence receipt of gastrectomy for gastric cancer at NCI-CC.

Methods: Maryland’s All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013-2018. Clinician-to-clinician connectedness was measured via referral linkages between clinicians. Two separate referral linkages, defined as ≥9 shared patients between two clinicians, were examined from: 1) PC clinicians to GI at NCI-CC and 2) GI to cancer specialists at NCI-CC. Multiple logistic regression models were used to determine associations between referral linkages and adjusted odds of undergoing gastrectomy at NCI-CC.

Results: Only 15% of gastric cancer surgeries were performed at NCI-CC. Patients treated by GI with stronger referral links to cancer specialists at NCI-CC were more likely to be <65 years of age, male, white, and privately insured (for all, p< 0.05). Every additional referral link between PC clinician and GI at NCI-CC and between GI and cancer specialists at NCI-CC increased the odds of receiving gastric cancer surgery at NCI-CC by 71% and 26%, respectively (Table). Black patients had half the odds as white patients in receiving gastrectomy at NCI-CC (OR: 0.53, CI:[0.30, 0.93]). However, adjusting for covariates including clinician-to-clinician connectedness weakened the observed negative effects of black race on receipt of gastrectomy at NCI-CC (OR: 0.63, CI:[0.10, 3.83]).

Conclusion: Patients of clinicians with low clinician-to-clinician connectedness and black patients are less likely to receive gastrectomy at NCI-CC. Clinician connectedness appears to be an actionable area of intervention to overcome existing disparities in access to quality surgical cancer care. These results are relevant to policy makers, healthcare systems, clinicians, and patient advocates seeking to achieve equitable access to quality cancer care.

Objective
Computed tomography (CT) imaging routinely detects incidental findings, including hiatal hernias. We utilized a natural language processing algorithm to identify incidental hiatal hernias, characterize their natural progression, and evaluate clinical follow-up.

Methods
Imaging of adult trauma patients from 2010-2020 who underwent CT chest and/or abdomen/pelvis was evaluated using an open-source natural language processor query for hiatal hernias. Patients who underwent subsequent imaging, endoscopy, fluoroscopy or operation were retrospectively reviewed.

Results
1,087 of 10,299 patients (10.6%) had incidental hiatal hernias: 812 small (74.7%) and 275 moderate/large (25.3%). 224 patients (20.7%) had subsequent imaging or endoscopic evaluation, with a mean follow up of 2.78 ± 2.79 years. Patients with moderate/large hernias were older (small vs moderate/large: 66.3±19.4 vs 79.6±12.6 years,p<0.001) and predominantly female (small vs moderate/large: 403[49.6%] vs 199[72.4%],p<0.001). Hernia size was not associated with hernia growth (small vs moderate/large: 13[7.6%] vs 8[15.1%],p=0.102) or symptomology (small vs moderate/large 55.6% vs 67.9%,p=0.110) (Table.1). Though patients with moderate/large hernia were more likely to have an intervention/referral (small vs moderate/large 6[3.5%] vs 7[13.2%], p=0.008), more than 80% of symptomatic patients (n=28) with moderate/large hernias had no follow-up. No patients underwent elective or emergent hernia repair. Three patients had surgical referral; however, only one was seen by a surgeon. One patient death was associated with a large hiatal hernia.

Conclusions
We demonstrate a novel utilization of an NLP to identify patients with incidental hiatal hernia in a large population, and found a 10.6% incidence with only 1.2% of these receiving a referral for follow-up. While most incidental hiatal hernias are small, moderate/large hernias have very high risk of loss-to-follow up and need referral pipelines to improve patient outcomes.

Introduction
The early and swift spread of COVID-19 not only significantly impacted access to healthcare for elective, subacute and acute medical conditions across the US, but also resulted in associated worse outcomes in patients with COVID-19 undergoing procedures compared to pre-pandemic estimates. Additionally, hospital understaffing resulted in increased rates of staff burnout, near misses, and other adverse outcomes. The aim of this study was to explore the use and outcomes of inpatients undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in the early months of the COVID-19 pandemic.

Methods
A retrospective observational study was conducted using the National Inpatient Sample for 2020. All patients with RYGB and SG ICD-10 codes were included. The primary outcome was the monthly inpatient odds of RYGB and SG compared to pre-pandemic Jan. Secondary outcomes were monthly inpatient odds of mortality, morbidity and resource utilization comparing these groups. The month of Jan (pre-pandemic) was used as the comparator month for all outcomes. Multivariate regression was used to adjust for gender, age, insurance status, Charlson Comorbidity Index, income in patient zip code, hospital region, location, size and teaching status.

Results
A total of 173,505 patients who underwent bariatric surgery were identified, of which 62,840 (36.22%) were RYGB. Mean age was 45.1 and 79.3% were female. For the primary outcome, there were significantly lower odds of both RYGB and SG in the months of Mar, Apr and May compared to pre-pandemic Jan. This reflects a dramatic drop in monthly procedures from Jan vs Apr of 5,295 to 1,050 (RYGB) and of 9,600 to 275 (SG). Odds for both procedures were significantly increased in the following months from Jun to Dec when compared to Jan. The odds of inpatient mortality for RYGB were not significantly different throughout the year, while they were significantly higher in the month of Apr for SG (N=10 mortalities for April). Increased odds of morbidity and healthcare utilization measures were also evident in both procedures for the month of Apr compared to Jan (pre-pandemic). All results are displayed in Table 1 and 2.

Conclusion
Performance of bariatric surgical procedures in the US was significantly negatively impacted by the COVID-19 pandemic, particularly in the months of March, April and May. Not only did the procedural volumes “recover” in the following months, but a seemingly “compensatory increase” was seen, as reflected by increased procedural volumes from June-December as compared to January (pre-pandemic). Despite the dramatically lower procedural volumes for the month of April, increased odds of post-procedural morbidity measures were noted for patients undergoing both RYGB and SG in that month. This could be due to several reasons, including staffing, patient acuity, and altered work flows.