Objective:To investigate how different surgeons' subspecialties comply with treatment guidelines for early stage melanoma. Background:The National Comprehensive Cancer Network developed evidence-based guidelines for surgical margins, depth of excision, and performance of sentinel lymph node biopsy (SLNB) for cutaneous melanoma care. It is unknown how surgeons of varying subspecialties follow these guidelines. Methods:We included patients with primary cutaneous melanoma who underwent wide excision (WE) in 2022 across our healthcare system. We collected patients' clinicopathological characteristics, margin size, and depth of the WE, those who underwent SLNB and the treating surgeon's subspecialty. Results:Among 838 patients, 58.8% had T1 melanoma, 22.2% T2, and 18.9% T3-T4. Surgical oncologists (SO) performed most procedures (56.4%) followed by general surgeons (GS, 20.1%), dermatologists (Derm, 13.5%), otolaryngologists (ENT, 5.4%), and plastic surgeons (PS, 4.7%). Compliance with the recommended surgical margin size was highest for T1 (81.7%) and T2 (92.6%) compared to T3-T4 stages (64.2%; P < 0.0001). By subspecialty, Derm had the highest compliance rate with the margin size recommendations (93.3%) followed by SO (86.9%), PS (70%), GS (64%), and ENT (56.5%; P < 0.0001). Excision depth compliance increased with increasing T stage (P < 0.0001): 79.9%, 91.6%, and 92% for T1, T2, and T3-T4, respectively. 93% of eligible patients (T1b-T4) underwent SLNB. Conclusions:Overall compliance with surgical margin size and excision depth was 80.8% and 84.8%, respectively. In our study, 93% of eligible patients underwent SLNB. Despite overall high compliance rates, we noted large differences in guideline compliance among the surgeons' subspecialty.

BACKGROUND:Symptomatic cholelithiasis is a common surgical problem, with many patients requiring multiple gallstone-related emergency department (ED) visits before cholecystectomy. The Social Vulnerability Index (SVI) identifies vulnerable patient populations. This study aimed to assess the association between social vulnerability and outpatient management of symptomatic cholelithiasis. METHODS:Patients with symptomatic cholelithiasis-related ED visits were identified within our health system from 2016 to 2022. Clinical outcomes data were merged with SVI census track data, which consist of 4 SVI subthemes (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation). Multivariate analysis was used for statistical analysis. RESULTS:A total of 47,292 patients presented to the ED with symptomatic cholelithiasis, of which 6103 patients (13.3 %) resided in vulnerable census tract regions. Of these patients, 13,795 (29.2 %) underwent immediate cholecystectomy with a mean time to surgery of 35.1 h, 8250 (17.4 %) underwent elective cholecystectomy at a mean of 40.6 days from the initial ED visit, and 2924 (6.2 %) failed outpatient management and returned 1.26 times (range, 1-11) to the ED with recurrent biliary-related pain. Multivariate analysis found social vulnerability subthemes of socioeconomic status (odds ratio [OR], 1.29; 95 % CI, 1.09-1.52) and racial and ethnic minority status (OR, 2.41; 95 % CI, 2.05-2.83) to be associated with failure of outpatient management of symptomatic cholelithiasis. CONCLUSION:Socially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis. Policies to support this vulnerable population in the outpatient setting with timely follow-up and elective cholecystectomy can help reduce delays in care and overutilization of ED resources.

Background: Male breast cancer remains relatively underexplored in the medical literature. At present, male patients with breast cancer follow the same treatment guidelines as female patients with breast cancer, principally because of similar outcomes with treatment. However, this practice should not preclude generating evidence for male breast cancer surveillance, diagnosis, and management. BRCA2 gene mutations are associated with an increased risk of male breast cancer, along with lesser-known gene mutations that could also increase this risk, such as mutations of the BRIP1 gene. This case report presents a male patient with dual BRCA2 and BRIP1 deleterious gene mutations. To our knowledge, this combination has not been reported in the medical literature to date. Case Report: A 53-year-old male presented with a palpable symptomatic mass underneath the right nipple-areolar complex. Biopsies confirmed a poorly differentiated, infiltrating ductal carcinoma that was estrogen and progesterone receptor positive and human epidermal growth factor receptor-2 negative. The patient underwent a left modified radical mastectomy, with a right prophylactic simple mastectomy. Postoperatively, he underwent adjuvant chemotherapy and endocrine therapy. Conclusion: This novel case of genetically based male breast cancer with dual deleterious gene mutations provides insight into current treatment recommendations and the subtle differences between male breast cancer and female breast cancer. Engaging in discussions surrounding such rare cases not only raises awareness of male breast cancer but also indicates the need for further research aimed at establishing evidence-based management strategies for male patients with breast cancer.

Background: Medicare expenditures have steadily increased over the decades, and yet Medicare Physician Fee Schedule payments for individual services have declined. We examine trends in Medicare Physician Fee Schedule payments for office visits, inpatient visits, and surgical procedures. Methods: The Medicare Physician Fee Schedule Look-Up Tool was queried for payment data for office visits, inpatient visits, and surgical procedures between 2013 and 2023. All data were adjusted for inflation using the Consumer Price Index. Trends in payments were calculated for 5 common procedures in each surgical specialty. Trends in aggregate national health expenditures were compared to Medicare Physician Fee Schedule payments for physician services from 2013 to 2021. Results: The Consumer Price Index increased by 29.3% from 2013 to 2023. Inflation-adjusted per-visit Medicare Physician Fee Schedule payments decreased by 12.2% for outpatient office visits, 19.1% for inpatient visits, and 22.8% for surgical procedures from 2013 to 2023. This varied by surgical specialty: vascular (-25.8%), endocrine (-22.0%), general surgery (-27.0%), thoracic (-19.2%), surgical oncology (-22.1%), breast (-22.4%), urology (-2.2%), neurosurgery (-22.8%), obstetrics/gynecology (-19.9%), and orthopedics (-24.7%). Adjusted for inflation, national health expenditures increased by 33.9% for physician services from 2013 to 2021. In comparison, Medicare Physician Fee Schedule payments over the same time period 2013 to 2021 increased by 1.3% for outpatient office visits but decreased by 10.6% for inpatient visits and 9.8% for surgical procedures. Conclusion: Controlling rising national health expenditures is important and necessary, but 10 years of declining Medicare Physician Fee Schedule payments on a per-procedure basis in surgery would suggest that this strategy alone may not achieve those goals and could ultimately threaten access to quality surgical care. Surgeons must advocate for permanent payment reforms. (c) 2023 Elsevier Inc. All rights reserved.

BACKGROUND:Bundled Payment (BP) models are becoming more common in surgery. We share our early experiences with Bundled Payments for Care Improvement for major bowel surgery.METHODS:Patients undergoing major bowel surgery between January and October 2021 were identified using Medicare Severity-Diagnosis Related Group (MS-DRG) codes. Major drivers of cost in a BP model are reported and compared to the Fee-For-Service (FFS) payment model.RESULTS:A total of 202 cases (173 FFS vs 29 BP) were analyzed. The mean BP cost per Clinical Episode was $28,340. Eleven patients (38%) in the BP model had costs greater than the Target Price. The drivers of cost in the BP model were 59% acute care facility, 17% physician services, 9% post-acute care facilities, 8% other, and 7% readmissions. Clinical Episode of care costs varied considerably by MS-DRG case complexity. Robotic surgery increased costs by 35% (mean increase $3724, P < .01). The 90-day readmission rate was 17% for a mean cost of $11,332 per readmission. Three patients (10%) were discharged to a skilled nursing facility at an average cost of $11,009, while fifteen patients (52%) received home health services at a mean cost of $2947. Acute care facility costs were similar in the BP vs FFS groups (mean difference $1333, P = .22).CONCLUSIONS:Patients undergoing major bowel surgery are a heterogeneous population. Physicians are ideally positioned to deliver high-value, patient-centered care and are crucial to the success of a BP model. The post-acute care setting is a key component of improving efficiency and quality of care.

BACKGROUND & OBJECTIVES:We previously described a predictive AAMC model that identifies patients (grade 1, hormonepositive) who would not benefit from OncotypeDX testing. The purpose of this study was to validate the AAMC model by assessing distant recurrence-free interval (DRFI) and invasive disease-free survival (IDFS) using TAILORx clinical trial data.MATERIALS & METHODS:We retrospectively analyzed TAILORx trial data and categorized patients based on the AAMC model. AAMC low-risk patients are those with grade 1 and hormone-positive tumors. Kaplan-Meier curves examined DRFI and IDFS.RESULTS:Of the 9195 cases, 2246 (24.4%) were identified by AAMC as low-risk. Among these AAMC low-risk patients, 55.2% had Recurrence Score (RS) 0-15, 42.3% had RS 15-25, and 2.4% had RS > 25. The 10-year DRFI did not differ for those who received adjuvant chemotherapy versus those who did not (98% vs. 96%, log-rank p = 0.46). Similarly, IDFS was comparable between those who received adjuvant chemotherapy and those that did not (86% vs. 86%, log-rank p = 0.66). Only 2.4% of AAMC low-risk patients were categorized as high-risk (RS > 25). A sensitivity analysis of this discordant group, wherein those with RS > 25 were re-classified into the no-chemotherapy group and assumed to have experienced recurrences at the rate expected without chemotherapy, did not find any difference in DRFI between those who received adjuvant chemotherapy and those who did not (log-rank p = 0.16).CONCLUSION:OncotypeDX testing does not benefit AAMC low-risk patients with hormone-positive grade 1 tumors. Based on these data, 1 in 4 TAILORx participants would not need OncotypeDX testing.

Background: Enhanced Recovery after Surgery for mastectomy has resulted in increased use of outpatient same-day mastectomy (SDM). Whether SDM leads to increased readmissions or reoperations is not well documented. This study examines national data to compare outcomes of SDM to an overnight stay. Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File from 2016 to 2018 for all mastectomy cases. Cases with a length of stay (LOS) >1 day were excluded. Cases were then categorized into 2 LOS cohorts: SDM vs 1-day LOS. Results: A total of 22,642 cases (80.8% 1-day LOS vs 19.2% SDM) were identified for the final analysis. Patients in the 1-day LOS group were more likely to be older (57.9 vs 54.0 years, P<0.01), be female (98.0% vs 79.8%, P<0.01), and have greater comorbidity (38.1% vs 30.7% American Society of Anesthesiologists classification 3 or 4, P<0.01) compared to the SDM group. Multivariate analysis demonstrated no difference in risk for 30-day wound complications between the SDM and 1-day LOS groups. The risks for 30-day medical complications (1.60 odds ratio [OR], 95% CI 1.06-2.42, P=0.02), reoperations (1.46 OR, 95% CI 1.17-1.81, P<0.01), and readmissions (1.60 OR, 95% CI 1.25-2.05, P<0.01) were higher in the 1-day LOS group. Even after excluding patients undergoing reoperation on the day of surgery, the risk for reoperations (2.3% vs 3.3%, P<0.01) remained higher in the 1-day LOS group. Characteristics associated with 1-day LOS were hypertension, steroid use, diabetes, dyspnea, dependent functional status, bilateral procedures, and breast reconstruction. Conclusion: We demonstrate that SDM is a safe procedure, with no increase in risk for 30-day postoperative complications. Appropriate patients should be offered SDM.

Gallbladder adenocarcinoma is a rare gastrointestinal malignancy and is associated with a poor prognosis. These malignancies are most often discovered incidentally in similar to 1% of all cholecystectomy procedures. We report an 80-year-old male patient with iron deficiency anemia, who underwent an unremarkable endoscopy and colonoscopy, and was subsequently found to have hemobilia discovered on capsule endoscopy. Magnetic resonance cholangiopancreatography revealed a space-occupying process involving the posterior wall of the gallbladder. The patient underwent an unremarkable laparoscopic cholecystectomy with final pathology revealing a well-differentiated, 8 cm intracystic papillary neoplasm with high-grade dysplasia involving the majority of the gallbladder, with focally invasive adenocarcinoma invading the muscular layer of the gallbladder wall. Postoperative staging work-up revealed no evidence of metastatic disease. Patient then underwent a radical resection of segments 4B/5 of the gallbladder fossa and lymph node resection of the porta hepatis. Final pathology revealed Stage I adenocarcinoma of the gallbladder (T1bNxM0).

BACKGROUND:We previously described a risk prediction model (Anne Arundel Medical Center [AAMC] model) based on pathology which may eliminate the need for recurrence score (RS) testing in select early-stage breast cancers. There is a concern that patients in discordant risk prediction groups (AAMC vs. RS) may be overtreated or undertreated if RS testing were omitted. METHODS:We queried the Surveillance, Epidemiology, and End Results (SEER) database for all breast cancer patients between 2004 and 2015. AAMC low-risk was defined as Grade 1 and progesterone receptor-positive (PR + ) tumors, while AAMC high-risk was defined as Grade 3 or estrogen-negative tumors. RS low-risk group was defined as RS < 16 and age ≤ 50 years, or RS ≤ 25 and age > 50 years. RS high-risk group was defined as RS > 25. RESULTS:A total of 71,212 cases were analyzed. Of these, 590 were AAMC low-risk/RS high-risk discordant, while 5,596 were AAMC high-risk/RS low-risk discordant. For AAMC low-risk/RS high-risk discordant, 10-year breast cancer-specific survival (BCSS) did not differ for patients who received adjuvant chemotherapy versus those who did not (93% chemotherapy vs. 99% unknown/no chemotherapy, p = .12). Overall survival (OS) was also comparable (92% chemotherapy vs. 91% unknown/no chemotherapy, p = .42). In the AAMC high-risk/RS low-risk discordant group, 10-year BCSS (92% chemotherapy vs. 96% unknown/no chemotherapy, p = .06) and OS (87% chemotherapy vs. 90% unknown/no chemotherapy, p = .52) did not differ between adjuvant chemotherapy and unknown/no chemotherapy groups. CONCLUSIONS:Adjuvant chemotherapy in the AAMC low-risk/RS high-risk and AAMC high-risk/RS low-risk discordant groups did not improve survival. This supports consideration of omission of RS testing in Grade 1, PR + tumors. Patients with Grade 3 tumors do benefit from RS testing.

Background: Frailty is characterized by reduced physiologic reserve, and for patients with colon cancer, frailty is associated with increased morbidity after resection. One commonly cited reason for performing an end colostomy vs a primary anastomosis in left-sided colon cancer is the belief that frail patients do not have the physiologic reserve to withstand the morbidity associated with an anastomotic leak. We explored the impact of frailty on the type of operation performed in patients with left-sided colon cancer. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program for patients with colon cancer who underwent a left-sided colectomy from 2016 to 2018. Patients were categorized using the modified 5-item frailty index. Multivariate regression was used to identify independent predictors of complications and type of operation performed. Results: Of 17,461 patients, 20.7% were considered frail. Frail patients received an end colostomy more often than nonfrail patients (11.3% vs 9.6%, P=0.01). On multivariate analysis, frailty was a significant predictor for total medical complications (odds ratio [OR] 1.45, 95% CI 1.29-1.63) and readmission (OR 1.53, 95% CI 1.32-1.77) but was not independently associated with organ space surgical site infections or reoperation. Frailty was independently associated with receiving an end colostomy vs a primary anastomosis (OR 1.23, 95% CI 1.06-1.44), but an end colostomy did not decrease the risk of reoperation or organ space surgical site infections. Conclusion: Frail patients with left-sided colon cancer are more likely to receive an end colostomy, but an end colostomy does not lower the risk of reoperation or organ space surgical site infections. Based on these results, frailty alone should not prompt the decision to perform an end colostomy, but further studies are needed to guide surgical decision-making in this understudied population.

Background: We previously described a validated (AAMC) risk prediction model, based on pathology, which may eliminate the need for OncotypeDX testing in AAMC low-risk (grade 1, progesterone (PR) positive) tumors. Our previous study used the SEER database and examined breast cancer specific survival (BCSS) and overall survival (OS), but was limited by our inability to assess distant recurrence-free interval (DRFI) and invasive disease-free survival (IDFS) with the available data. The purpose of this study was to validate the AAMC model using the TAILORx database, specifically with regard to DRFI and IDFS. Methods: We retrospectively analyzed TAILORx trial data and categorized patients into groups based on the AAMC model (Table). AAMC low-risk were defined as tumors that were both grade 1 and PR positive, while high-risk tumors were grade 3 or estrogen (ER) negative/PR positive. Intermediate-risk were those not categorized as low- or high-risk. The AAMC model recommends against OncotypeDX testing in low-risk tumors, but recommends testing in intermediate- or high-risk tumors. Kaplan-Meier curves were used to examine DRFI and IDFS. Results: A total of 9143 patients with grade and ER/PR information were categorized into AAMC low-risk (24.6%), intermediate-risk (57.9%), and high-risk (17.5%) groups. In the AAMC low-risk cohort, 22.3% had Recurrence Score (RS) 0-10 and did not receive chemotherapy per the TAILORx protocol, while 75.3% had RS 11-25 and were randomized to chemotherapy versus no-chemotherapy, and 2.4% had RS > 25 and received adjuvant chemotherapy. In these AAMC low-risk patients, DRFI did not differ for patients who received adjuvant chemotherapy versus those that did not (log-rank p=.96). Similarly, IDFS was comparable between the chemotherapy and no-chemotherapy groups (log-rank p=.66). Only 2.4% of AAMC low-risk patients were categorized as high-risk per OncotypeDX testing (RS > 25). To account for the fact that all patients in this small group received chemotherapy per protocol, a sensitivity analysis was performed in which AAMC low-risk patients with RS > 25 were re-classified into the no-chemotherapy group and assumed to have experienced recurrences at rates expected without chemotherapy. Under these assumptions, there still was no difference in DRFI (log-rank p=.16) between chemotherapy and no-chemotherapy groups. Conclusion: This study validates our previous recommendations that OncotypeDX testing may be omitted in early-stage breast cancers with grade 1 and PR positive tumors (AAMC low-risk), as adjuvant chemotherapy does not improve distant recurrence-free interval in this group of patients. Based on our recommendations, 1 in 4 TAILORx participants would not need OncotypeDX testing. This would result in substantial cost savings to the healthcare system. Percent of TAILORx trial participants and treatment recommendations based on OncotypeDX testing versus AAMC model.ModelAAMC ModelLow-risk (n=2246, 24.6%)Intermediate-risk (n=5298, 57.9%)High-risk (n=1599, 17.5%)Treatment recommendation*No chemotherapy/No OncotypeDX testingProceed with OncotypeDX testProceed with OncotypeDX testOncotypeDX testing*RS 0 to 15No chemotherapy1240 (55.2%)2224 (42.0%)306 (19.1%)RS 16 to 20, age ≤50Chemotherapy and/or OFS/AI258 (11.5%)492 (9.3%)108 (6.8%)RS 21 to 25, age ≤50Chemotherapy and/or OFS/AI93 (4.1%)274 (5.2%)101 (6.3%)RS 16 to 25, age >50No chemotherapy600 (26.7%)1719 (32.4%)450 (288.1%)RS >25Chemotherapy55 (2.4%)589 (11.1%)634 (39.6%)Ovarian function suppression (OFS); Aromatase inhibitor (AI)*Based on TAILORx results Citation Format: Young Lee, W. Charles Mylander, Tasha Martin, Martin Rosman, Thomas J Sanders, Udai S Sibia, Lorraine Tafra, Rubie S Jackson. OncotypeDX testing does not appear to benefit patients with grade 1, progesterone receptor positive breast cancers: A TAILORx validated study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-06-01.

Background: Closed-incision and surrounding soft tissue negative pressure therapy (cistNPT) is theorized to decrease infection, reduce tissue edema, and promote healing of the mastectomy skin flap. We report our early experience with this dressing in pre-pectoral direct-to-implant (pDTI) breast reconstruction. Methods: We retrospectively reviewed all patients who underwent post-mastectomy pDTI breast reconstruction with cistNPT between July 2019 and February 2020. All reconstructions utilized smooth round silicone gel implants and human acellular dermal matrix. Results: Thirty-five female patients underwent 58 mastectomies. Mean age and body mass index were 49.9 years and 28.9 kg/m2, respectively. Eleven (31.4%) patients had neoadjuvant chemotherapy. The mean sternal notch-to-nipple distance was 27.0 cm. The median specimen weight was 483 g, while the median implant volume was 495 cc. The mean implant-to-specimen ratio was 1.4 for nipple-sparing, 1.1 for skin-sparing, and 0.7 for skin-reducing mastectomy. Total drain volume was 483.1 cc from each breast. Post-operative complications included seroma (5.2%), peri-incisional necrosis (8.6%), and superficial skin epidermolysis (13.8%). There were no cases of surgical site infection, dehiscence, or hematoma. Rate of return to the operative room was 3.4%. Mean follow-up was 90 days. Conclusions: In our series of pDTI breast reconstructions with cistNPT, no patients experienced hematoma, dehiscence, or infection complications. Rates of seroma, skin necrosis requiring operative debridement, and total drain volumes were lower than those reported in literature.

Bundled payments are increasingly becoming common in surgery, yet little is known regarding their potential impact on reimbursements for patients presenting with acute appendicitis. This study examines the financial impact of bundled payments for acute appendicitis.

OBJECTIVE: The general surgery workforce deficit is projected to grow to 15% to 21% by 2050. An estimated 6.6% increase to existing general surgery residency (GSR) programs is needed to meet this shortfall. The purpose of this study was to examine the impact of a new GSR program on efficiency and productivity at a regional healthcare center. STUDY DESIGN: An institutional database was retrospectively queried for all GSR related procedures between July 2015 and June 2018. Procedures done prior to GSR initiation (pre-GSR) were compared to those done after (post-GSR). Univariate and multivariate analyses were performed. RESULTS: We reviewed 10,617 procedures (6365 pre-GSR vs. 4252 post-GSR). Patients had lower preoperative Hierarchical Condition Category scores in the post-GSR group (0.71 vs. 0.58, p < 0.01). Operative times increased post-GSR (101.7 vs. 109.1 minutes, p < 0.01), but length of stay decreased (6.4 vs. 5.5 days, p = 0.01). Thirty-day readmissions (4.0% vs. 3.4%, p = 0.11) were comparable, but reoperations significantly decreased post-GSR (10.1% vs. 8.6%, p = 0.01). Average hospital costs remained unchanged ($10,765 vs. $10,140, p = 0.12). Multivariate analysis revealed no statistical difference in operative times, length of stay, 30-day readmissions and reoperations, and hospital costs between the 2 groups. Subset analysis based on surgical service also showed no statistical difference. Productivity increased on the general surgery service post-GSR (7.1 vs. 7.8 cases per day, p = 0.02). Patient satisfaction increased post-GSR (76% vs. 81%, p = 0.31), but without statistical significance. CONCLUSION: The initiation of a new GSR program did not negatively impact operative times, length of stay, 30-day readmissions and reoperations, hospital costs, case volume, or patient satisfaction. (C) 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The Centers for Medicare & Medicaid Services (CMS) recently announced a new voluntary episode payment model for major bowel surgery. The purpose of this study was to examine the financial impact of bundled payments for major bowel surgery. An institutional database was retrospectively queried for all patients who underwent major bowel surgery between July 2016 and June 2018. Procedures were categorized using MS-DRG coding: MS-DRG 329 (with MCC, major complications and comorbidity), MS-DRG 330 (with CC, complications and comorbidity), and MS-DRG 331 (without CC/MCC). A total of 745 patients underwent 798 procedures, with mean age 62.1 years and BMI 29.2 kg/m2. The median LOS was 4.0 days, with 12.5% of patients being discharged to a post-acute care facility for an average of 38.5 days. The mean hospital cost was $18,525. The mean payment to a post-acute care facility was $423 per day. The 90-day readmission rate was 8.6% at an average cost of $12,859 per readmission. Patients with major complications and comorbidity (MS-DRG 329) had higher CMS Hierarchical Condition Categories scores, longer LOS, higher costs, more required home health services or post-acute care facilities, and had higher 90-day readmissions. In a fee-for-service model, hospital reimbursements resulted in a negative margin of − 8.2% for MS-DRG 329, − 2.6% for MS-DRG 330, but a positive margin of 2.8% for MS-DRG 331. In a bundled payment model, the hospital would incur a loss of − 13.1%, − 11.1%, and − 1.9% for MS-DRG 329, 330, and 331, respectively. Patients undergoing major bowel surgery are often a heterogeneous population with varied pre-existing comorbid conditions who require a high level of complex care and utilize greater hospital resources. Further study is needed to identify areas of cost containment without compromising the overall quality of care.

Sibia, Udai S. MD, MBA; Turcotte, Justin J. MBA; Klune, John R. MD, MBA; Feather, Cristina B. MD, MHS Author Information

Broda, Andrew BS; Sanford, Zachary MD; Weltz, Adam S. MD; Sibia, Udai S. MD; Park, Adrian MD, FACS Author Information