Tracking early readmission after pancreatectomy to index and nonindex institutions: a more accurate assessment of readmission

IMPORTANCE

Readmission after pancreatectomy is common, but few data compare patterns of readmission to index and nonindex hospitals.

OBJECTIVES

To evaluate the rate of readmission to index and nonindex institutions following pancreatectomy at a tertiary high-volume institution and to identify patient-level factors predictive of those readmissions.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of a prospectively collected institutional database linked to statewide data of patients who underwent pancreatectomy at a tertiary care referral center between January 1, 2005, and December 2, 2010.

EXPOSURE

Pancreatectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome was unplanned 30-day readmission to index or nonindex hospitals. Risk factors and reasons for readmission were measured and compared by site using univariable and multivariable analyses.

RESULTS

Among all 623 patients who underwent pancreatectomy during the study period, 134 (21.5%) were readmitted to our institution (105 [78.4%]) or to an outside institution (29 [21.6%]). Fifty-six patients (41.8%) were readmitted because of a gastrointestinal or nutritional problem related to surgery and 42 patients (31.3%) because of a postoperative infection. On multivariable analysis, factors independently associated with readmission included age 65 years or older (odds ratio [OR], 1.80; 95% CI, 1.19-2.71), preexisting liver disease (OR, 2.28; 95% CI, 1.23-4.24), distal pancreatectomy (OR, 1.77; 95% CI, 1.11-2.84), and postoperative drain placement (OR, 2.81; 95% CI, 1.00-7.14).

CONCLUSIONS AND RELEVANCE

In total, 21.5% of patients required early readmission after pancreatectomy. Even in the setting of a tertiary care referral center, 21.6% of these readmissions were to nonindex institutions. Specific patient-level factors were associated with an increased risk of readmission.

Hypothalamic-pituitary-adrenal axis in lethal canine Staphylococcus aureus pneumonia

The clinical significance and even existence of critical illness-related corticosteroid insufficiency is controversial. Here, hypothalamic-pituitary-adrenal (HPA) function was characterized in severe canine Staphylococcus aureus pneumonia. Animals received antibiotics and titrated life-supportive measures. Treatment with dexamethasone, a glucocorticoid, but not desoxycorticosterone, a mineralocorticoid, improves outcome in this model. Total and free cortisol, adrenocorticotropic hormone (ACTH). and aldosterone levels, as well as responses to exogenous ACTH were measured serially. At 10 h after the onset of infection, the acute HPA axis stress response, as measured by cortisol levels, exceeded that seen with high-dose ACTH stimulation but was not predictive of outcome. In contrast to cortisol, aldosterone was largely autonomous from HPA axis control, elevated longer, and more closely associated with survival in early septic shock. Importantly, dexamethasone suppressed cortisol and ACTH levels and restored ACTH responsiveness in survivors. Differing strikingly, nonsurvivors, sepsis-induced hypercortisolemia, and high ACTH levels as well as ACTH hyporesponsiveness were not influenced by dexamethasone. During septic shock, only serial measurements and provocative testing over a well-defined timeline were able to demonstrate a strong relationship between HPA axis function and prognosis. HPA axis unresponsiveness and high aldosterone levels identify a septic shock subpopulation with poor outcomes that may have the greatest potential to benefit from new therapies.

Improving safety and quality of care with enhanced teamwork through operating room briefings

OBJECTIVES

To describe the current state of the science for operating room (OR) briefings and debriefings, including an overview of key definitions, a review of the evidence of effectiveness, and a summary of our experiences as part of a comprehensive unit-based safety program.

OVERVIEW

Use of preoperative briefings has been shown to improve team communication, decrease disruptions to surgical workflow, improve compliance with antibiotic and deep vein thrombosis prophylaxis, and improve overall perceptions about the safety climate in the OR. Studies have demonstrated that an effective briefing can be performed in less than 2 minutes and reduce delays by more than 80%. Effective implementation involves changing workflows and expectations of interaction among OR team members, including participation from leaders at all levels. Briefings and debriefings are a strategy for revealing defects and facilitating adaptive change in the OR.

CONCLUSIONS AND RELEVANCE

Briefings and debriefings are a good method for improving teamwork and communication in the OR. Effective implementation may be associated with improved patient outcomes. Commitment by the participating providers is essential for effective briefings, which include discussion of relevant information pertaining to the procedure.

Readmissions after complex aneurysm repair are frequent, costly, and primarily at nonindex hospitals

OBJECTIVE

Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission.

METHODS

Using a prospectively collected institutional database in conjunction with a Maryland statewide database, we reviewed index admissions and early readmissions for all patients who underwent TAA/TAAAR between 2002 and 2013 at the Johns Hopkins Hospital. Only Maryland residents were included to capture readmissions to any Maryland hospital.

RESULTS

We identified 115 Maryland residents (58% men; mean age, 65 ± 1.2 years) undergoing TAA/TAAAR (57% open repair). Early readmissions were frequent and occurred in 29% of patients. Of the readmitted patients, 79% (P < .001) were not readmitted to the index hospital where their operation was performed. Readmitted patients were not significantly different from nonreadmitted patients in age, gender, race, aneurysm type, and index length of stay. They were not different in preoperative comorbidities (including coronary artery disease, diabetes mellitus, smoking, renal insufficiency, and pulmonary disease), postoperative neurologic, renal, and cardiovascular complications, or 30-day or 5-year mortality. Multivariable analysis showed that significant risk factors for readmission were open repair (odds ratio, 3.12; 95% confidence interval, 1.12-9.54; P = .03) and postoperative pneumonia (odds ratio, 4.31; 95% confidence interval, 1.28-15.4; P = .02). Readmitted patients had significantly lower average income compared with the nonreadmitted cohort (U.S. $62,000 ± $4000 vs $73,000 ± $3000; P = .04). Striking differences were seen between patients readmitted to the index hospital where the operation was performed, and those who were readmitted to a nonindex hospital: patients readmitted to the index hospital were readmitted mainly for aneurysm-related surgical issues, whereas patients readmitted to the nonindex hospital were readmitted for medical morbidities. An aneurysm-related intervention was required in 75% of patients readmitted to the index hospital vs in 9% of patients readmitted to the nonindex hospital. Readmissions to a nonindex hospital cost significantly less than to the index hospital (U.S. $20,000 ± $4400 vs $42,000 ± $8800; P = .03) and were not associated with increased overall mortality.

CONCLUSIONS

Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.

Development of a duplex-derived velocity risk prediction model of disease progression in patients with moderate asymptomatic carotid artery stenosis

OBJECTIVE

Previously, we described risk factors for disease progression in moderate asymptomatic carotid artery stenosis (ASCAS). The aim of the current study was to develop a risk prediction model for disease progression in this group.

METHODS

All patients presenting between January 2005 and May 2012 with moderate (50%-69%) ASCAS, as determined by carotid artery duplex imaging, were included. Cox proportional hazard regression models accounting for measured duplex peak systolic velocity and end-diastolic velocity, and the internal carotid artery (ICA)/common carotid artery (CCA) ratio, with and without previously identified risk factors for progression (age, smoking, dual antiplatelet therapy), were used to develop receiver operating characteristic curves for predicting disease progression.

RESULTS

The study analyzed 282 patients (52% male), aged 71 ± 9 years, with 2.6 ± 0.1 years follow-up and 25% disease progression at a mean time of 2.02 ± 0.18 years. Initial peak systolic velocity, end-diastolic velocity, and the ICA/CCA ratio were all significant independent predictors of progression. Receiver operating characteristic curve analyses suggested that a prediction model based on ICA/CCA ratio alone had optimal prediction efficacy (hazard ratio, 2.01; Harrell's C, 0.74; P < .001). Patients with ICA/CCA >2.5, 3.3, and 3.8 were found to have >10%, >20%, and >30% risk of disease progression over 2 years, respectively. Model sensitivity and specificity for predicting 10% risk of disease progression at 2 years was 80.7% and 64.0%, respectively (positive predictive value, 22.9%; negative predictive value, 96.1%).

CONCLUSIONS

We propose a clinical prediction model for moderate ASCAS disease progression that can be used to risk-stratify patients with >10% risk of progression at 2 years using ICA/CCA ratios. Implementation of this model may be useful for identifying high-risk patients who would benefit from routine carotid disease surveillance follow-up.

Association between race and age in survival after trauma

IMPORTANCE

Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.

OBJECTIVE

To determine whether racial disparities in trauma survival persist in patients 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.

MAIN OUTCOMES AND MEASURES

In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.

RESULTS

A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.

CONCLUSIONS AND RELEVANCE

Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.

Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers

OBJECTIVE

The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs.

METHODS

The Nationwide Inpatient Sample (2005-2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Comorbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay.

RESULTS

Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9 ± 0.1 years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P < .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P < .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P < .001). The proportion of nonelective admissions remained stable (25% vs 23%; P = .32) and there were no differences in mean hospital length of stay (7.0 ± 0.1 days vs 6.8 ± 0.1 days; P = .22). Minor (17.9% vs 20.6%; P < .001), but not major amputations (3.9% vs 4.2%; P = .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P < .001, all).

CONCLUSIONS

Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.

Mesenteric calcification following abdominal stab wound

INTRODUCTION

Heterotopic ossification (HO) refers to the formation of bone in non-ossifying tissue. Heterotopic mesenteric ossification is a rare form of HO that is characterized by the formation of an ossifying pseudotumour at the base of the mesentery, usually following abdominal surgery.

PRESENTATION OF CASE

We describe a case of mesenteric HO in a young male who presented for elective ventral incisional hernia repair following a stab wound to the abdomen requiring exploratory laparotomy 21 months earlier. Preoperative workup was unremarkable, but a hard, bone-like lesion was noted to encircle the base of the mesentery upon entering the abdomen, consistent with HO. The lesion was excised with close margins, and his hernia was repaired without incident.

DISCUSSION

Traumatic HO describes the ossification of extra-skeletal tissue that specifically follows a traumatic event. It usually occurs adjacent to skeletal tissue, but has been occasionally described in the abdomen as well, usually in patients who suffer abdominal trauma. Overall the prognosis of HO is good, as it is considered a benign lesion with no malignant potential. However, the major morbidity associated with mesenteric HO is bowel obstruction.

CONCLUSION

The size, location, and symptoms related to our patient's mesenteric HO put him risk for obstruction in the future. As a result, the mass was surgically excised during his ventral hernia repair with good outcomes.

Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies

Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent or may be incarcerated and poses a risk of strangulation. There are multiple surgical options to treat rectal prolapse, and thus care should be taken to understand each patient's symptoms, bowel habits, anatomy, and pre-operative expectations. Preoperative workup includes physical exam, colonoscopy, anoscopy, and, in some patients, anal manometry and defecography. With this information, a tailored surgical approach (abdominal versus perineal, minimally invasive versus open) and technique (posterior versus ventral rectopexy +/- sigmoidectomy, for example) can then be chosen. We propose an algorithm based on available outcomes data in the literature, an understanding of anorectal physiology, and expert opinion that can serve as a guide to determining the rectal prolapse operation that will achieve the best possible postoperative outcomes for individual patients.

Application of a Penrose drain guide for vascular stapling during hepatic surgery: how I do it

The use of stapling devices to manage vascular pedicles during hepatic surgery has been a significant advance in the field. However, insertion and application of the stapler in vascular dissection planes can be associated with injury to adjacent structures. We describe a five-step technique using a silicone Penrose drain to aid in the positioning of an endovascular stapling device to obtain vascular control during hepatectomy. The use is described here for hepatic vein management during right hepatectomy. The technique can be also used for other applications when transecting major vessels during major liver surgery. The use of this silicone Penrose-guided endovascular stapler technique is a simple, cost-effective maneuver that can be used to improve control and prevent vascular injury during the division of major vascular structures when performing hepatic surgery.