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In This Issue of JAMA Surgery
March 2014


JAMA Surg. 2014;149(3):217-219. doi:10.1001/jamasurg.2013.3469


The effect of hospital quality on surgical outcomes between white and nonwhite patients undergoing coronary artery bypass graft (CABG) surgery is largely unexplained. Rangrass et al use National Medicare Claims data to measure the risk-adjusted mortality rate for each hospital. Although a significant fraction of racial disparity remains unexplained, hospital quality contributes significantly to the racial disparities in outcomes after CABG surgery.

Invited Commentary

Failure to rescue (FTR) is an emerging quality indicator. Safety-net hospitals may lack the clinical resources that have been shown to affect FTR. Using the Nationwide Inpatient Sample, Wakeam et al performed an observational study of 45 519 patients who underwent high-risk inpatient surgery between 2007 and 2010. They found that safety-net hospitals had similar and, in some cases, greater access to clinical resources, yet despite access to resources that can improve patient rescue rates, high-burden hospitals had higher odds of FTR, suggesting that availability of hospital clinical resources alone does not explain increased FTR rates.

Invited Commentary

Continuing Medical Education

Minimally invasive approaches to distal pancreatectomy have become popular in recent years, yet currently available data are limited. Tran Cao et al turned to the Nationwide Inpatient Sample, a stratified sample of US hospitals, to compare the short-term outcomes of minimally invasive distal pancreatectomy with those of open distal pancreatectomy. They report the benefits of fewer perioperative complications and shorter hospital lengths of stay with the minimally invasive approach, with no difference in total charges.

Balentine and coauthors test the hypothesis that patients having colorectal surgery at high-volume hospitals would more likely be discharged to home rather than discharged to skilled rehabilitation facilities to complete recovery. They used the Nationwide Inpatient Sample to evaluate colorectal resections and found that patients having colorectal surgery at high-volume hospitals are significantly more likely to recover and return home after surgery than individuals having operations at low-volume hospitals.

Invited Commentary

Given the aggressive nature of triple-negative breast cancer (TNBC), there is controversy as to whether breast-conserving therapy (BCT) is an appropriate treatment. In a prospective database review, Gangi et al compared the outcomes of BCT for patients with TNBC with those of patients with non-TNBC subtypes. It was found that BCT for TNBC is not associated with increased local recurrence compared with non-TNBC subtypes and is an appropriate treatment option.

Cigarette smoking increases complication risk in surgical patients, but the potential effects of smoking status on perioperative health care costs are unclear. Warner and coauthors performed a population-based, propensity-matched cohort study, using a claims-based database to assess costs in the first year after hospital discharge. Health care costs during the first year after hospital discharge for an inpatient surgical procedure are higher for both former and current smokers, compared with never smokers, although the cost of the index hospitalization is not affected by smoking status.

Although breast conservation therapy (BCT) is considered standard of care for early-stage breast cancer, there are no recent studies that directly compare survival after BCT vs mastectomy. Agarwal and coauthors use the Surveillance, Epidemiology, and End Results database to compare the breast cancer–specific survival rates of patients undergoing BCT, mastectomy alone, or mastectomy with radiation using a contemporary cohort of patients during the period from 1998 to 2008. Patients who underwent BCT were found to have a higher breast cancer–specific survival rate compared with those treated with mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma when accounting for other oncologic and demographic characteristics.

Continuing Medical Education

Chang and coauthors examine the effectiveness and risks of bariatric surgery using up-to-date, comprehensive data and appropriate meta-analytic techniques. A total of 164 studies were included (37 randomized clinical trials and 127 observational studies). They found that bariatric surgery provides substantial and sustained effects on weight loss and ameliorates obesity-attributable comorbidities in the majority of bariatric patients, although risks of complication, reoperation, and death exist. Death rates were lower than those reported in previous meta-analyses.

Clinical Review & Education

Current studies of complications following donor hepatectomy may not be generalizable to all hospitals performing this procedure. Hall and colleagues identified live liver donors in the Nationwide Inpatient Sample to determine generalizable estimates for postoperative complications following donor hepatectomy and to explore patient- and hospital-level factors associated with complications. Approximately 25% of liver donors have complications immediately postoperatively but most are minor, lending support to current practices in live liver donation and donor selection.