Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus
De Jager E, Osman SY, Levine AA, et al. Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus. J Am Coll Surg. 2022, in press.
Available evidence has confirmed that socially at-risk patients in the US are more likely to receive low quality healthcare. These patients are also at risk for high rates of comorbid conditions, resulting in worse outcomes when receiving acceptable quality care. Social factors such as socioeconomic status, rural residence, race, and ethnicity are characteristics that can be used to identify at-risk patients. The authors noted that performance measurement and improvement efforts are underused measures that have potential value for the identification and elimination of healthcare disparities. The article describes outcomes of deliberations of a Delphi consensus panel that was convened as part of a program sponsored by the ACS to identify existing performance measures that could be used in initiatives designed for eliminating healthcare disparities.
The panel compiled a list of 125 performance measures that have potential value for this activity; a list of the measures is provided as supplemental content. The authors concluded that these measures could be used to quantify healthcare quality for at risk patients and provide guidance for performance improvement.
Editorial
Bonner SN, Dimick JB. Towards Better Measurement of Surgical Equity. J Am Coll Surg. 2022, in press.
In the editorial that accompanied this article, Sidra N. Bonner, MD, and Justin B. Dimick, MD, MPH, FACS, emphasized that effective quality measures would need to be specifically designed for individual subpopulations of at-risk patients. They also noted that these efforts would require policy mandates, financial support, and a gathering of risk-adjusted data. This article and the accompanying editorial provide exceptionally valuable information that will help identify pathways that could potentially lead to reduction and, ideally, elimination of healthcare disparities.
Supervised Exercise Therapy and Adjuvant Chemotherapy for Pancreatic Cancer
Okada K, Kouda K, Kawai M, et al. Supervised Exercise Therapy and Adjuvant Chemotherapy for Pancreatic Cancer: A Prospective, Single-Arm, Phase II Open Label, Nonrandomized, Historically Controlled Study. J Am Coll Surg. 2022, in press.
Because of its increasing incidence and lethality, pancreatic ductal adenocarcinoma is on track to become the second-leading cause of cancer-related death. Recognition of the success rates of combination therapies that include surgery, neoadjuvant and/or adjuvant chemotherapy, and radiation therapy has increased usage of these approaches. A significant number of patients, between 30% and 50%, assigned to combination therapy protocols do not complete it because of problems related to treatment side effects, frailty, and poor physical condition. The authors noted that increased physical activity has been associated with decreased cancer mortality in animal studies; their research, reported in this article, was a prospective trial designed to determine whether supervised exercise conducted during combination therapy would be associated with increasing rates of treatment completion.
Patients (N=43) were provided a supervised exercise program, in addition to the combination cancer treatment protocol. The data analysis showed that the rate of completion of the treatment protocol was significantly higher (93%) in patients who underwent supervised exercise compared to the threshold completion rate of 53% documented prior to beginning the study. Of note was the observation that standard frailty indices obtained before and after the exercise program also improved significantly. The authors concluded that addition of supervised exercise to a multimodal support program for patients undergoing combination therapy for pancreatic cancer had a significant benefit.
Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults after Major Surgery
Park CM, Inouye SK, Marcantonio ER, et al. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults after Major Surgery. JAMA Intern Med. Published online September 19, 2022. doi:10.1001/jamainternmed.2022.3680
Opioid use reduction efforts for perioperative pain control have led to increased inclusion of multimodal pain control protocols in enhanced recovery pathways (ERAS). Non-opioid analgesics are preferred options for these protocols, and one of the most often used is gabapentin. The authors noted that the average age of patients undergoing major surgical procedures is increasing and that definitive data on the safety of gabapentin in older patients is lacking. They conducted a retrospective cohort study to determine the types and rates of gabapentin-related adverse events for perioperative analgesia in patients aged 65 years and older and retrieved information from a health system database on 967,547 patients who underwent major surgical procedures. Propensity score matching was used to attempt accurate risk adjusted comparisons of patients who did and did not receive gabapentin.
The data analysis showed that there was a significant increase in rates of delirium, new antipsychotic drug use, and pneumonia in patients who received gabapentin. Risk of delirium was highest in patients with multiple comorbid conditions. Mortality risk was similar in both comparison groups. The authors hypothesized that the increase in pneumonia incidence might be due to gabapentin-associated respiratory depression and/or aspiration.
Editorial
Bongiovanni T, Anderson TS, Marcum ZA. Perioperative Gabapentin Use in Older Adults: Revisiting Multimodal Pain Management. JAMA Intern Med. Published online September 19, 2022. doi:10.1001/jamainternmed.2022.3757
In the editorial that accompanied the article, Tasce Bongiovanni, MD, MPPS, MHS, and coauthors noted that most patients received gabapentin very soon after completion of the surgical procedure, possibly before any complaint of pain. They speculated that this may have contributed to increased rates of delirium. They emphasized that this study highlights risks of gabapentin use that should stimulate revision of perioperative pain control protocols with reduction or possible elimination of this agent for older patients.
