Utility of 90-Day Mortality vs 30-Day Mortality as a Quality Metric for Transcatheter and Surgical Aortic Valve Replacement Outcomes

ASA-score is associated with 90-day mortality after complicated mild traumatic brain injury - a retrospective cohort study

PURPOSE

This study explores the association of the American Society of Anesthesiologists (ASA) score with 90-day mortality in complicated mild traumatic brain injury (mTBI) patients, and in trauma patients without a TBI.

METHODS

This retrospective study was conducted using a cohort of trauma patients treated at a level III trauma center in Stockholm, Sweden from January to December 2019. The primary endpoint was 90-day mortality. The population was identified using the Swedish Trauma registry. The Trauma and Injury Severity Score (TRISS) was used to estimate the likelihood of survival. Trauma patients without TBI (NTBI) were used for comparison. Data analysis was conducted using R software, and statistical analysis included univariate and multivariate logistic regression.

RESULTS

A total of 244 TBI patients and 579 NTBI patients were included, with a 90-day mortality of 8.2% (n = 20) and 5.4% (n = 21), respectively. Deceased patients in both cohorts were generally older, with greater comorbidities and higher injury severity. Complicated mTBI constituted 97.5% of the TBI group. Age and an ASA score of 3 or higher were independently associated with increased mortality risk in the TBI group, with odds ratios of 1.04 (95% 1.00-1.09) and 3.44 (95% CI 1.10-13.41), respectively. Among NTBI patients, only age remained a significant mortality predictor. TRISS demonstrated limited predictive utility across both cohorts, yet a significant discrepancy was observed between the outcome groups within the NTBI cohort.

CONCLUSION

This retrospective cohort study highlights a significant association between ASA score and 90-day mortality in elderly patients with complicated mTBI, something that could not be observed in comparative NTBI cohort. These findings suggest the benefit of incorporating ASA score into prognostic models to enhance the accuracy of outcome prediction models in these populations, though further research is warranted.

Postoperative Outcomes Associated with the Timing of Surgery After SARS-CoV-2 Infection

OBJECTIVE

Examine the association between prior SARS-CoV-2 infection, interval from infection to surgery, and adverse surgical outcomes.

SUMMARY BACKGROUND DATA

Earlier series have reported worse outcomes for surgery after COVID-19 illness, and these findings have led to routinely deferring surgery seven weeks after infection.

METHODS

We created a retrospective cohort of patients from the US Veterans Health Administration facilities nationwide, April 2020 to September 2022, undergoing surgical procedures. Primary outcomes were 90-day all-cause mortality and 30-day complications. Within surgical procedure groupings, SARS-CoV-2 infected and uninfected patients were matched in a 1:4 ratio. We categorized patients by 2-week intervals from SARS-CoV-2 positive test to surgery. Hierarchical multilevel multivariable logistic regression models were used to estimate the association between infection to surgery interval versus no infection and primary end points.

RESULTS

We identified 82,815 veterans undergoing eligible operations (33% general, 27% orthopedic, 13% urologic, 9% vascular), of whom 16,563 (20%) had laboratory-confirmed SARS-CoV-2 infection before surgery. The multivariable models demonstrated an association between prior SARS-CoV-2 infection and increased 90-day mortality (odds ratio (OR) 1.42, 95% CI: 1.08, 1.86) and complications (OR 1.32, 95% CI: 1.11, 1.57) only for patients having surgery within 14 days of infection. ASA-stratified multivariable models showed that the associations between increased 90-day mortality (OR 1.40, 95% CI: 1.12, 1.75) and complications (OR 1.73, 95% CI: 1.34, 2.24) for patients having surgery within 14 days of infection were confined to those with ASA 4-5.

CONCLUSIONS

In a contemporary surgical cohort, patients with prior SARS-CoV-2 infection only had increased postoperative mortality or complications when they had surgery within 14 days after the positive test. These findings support revising timing recommendations between surgery and prior SARS-CoV-2 infection.

Association between surgical quality and long-term survival in lung cancer

OBJECTIVES

There are significant variations in both perioperative and long-term outcomes after lung cancer resection. While perioperative outcomes are often used as comparative measures of quality, they are unreliable, and their association with long-term outcomes remain unclear. In this context, we evaluated whether historical perioperative mortality after lung cancer resection is associated with 5-year survival.

PATIENTS AND METHODS

The National Cancer Database (NCDB) was queried to identify patients diagnosed with non-small cell lung cancer (NSCLC) in 2010-2016 who underwent surgical resection (n = 234200). Hospital-level reliability-adjusted 90-day mortality rate quartiles for 2010-2013 was used as the independent variable to analyze 5-year survival for patients diagnosed in 2014-2016 (n = 85396).

RESULTS

There were 85,396 patients in the 2014-2016 cohort across 1,086 hospitals. Overall observed 90-day mortality rate was 3.2% (SD 17.6%) with 2.6% (SD 16.0%) for the historically best performing quartile vs. 3.9% (SD 19.4%) for the worst performing quartile (p < 0.0001). Patients who underwent resection at hospitals with the best historical mortality rate had significantly better 5-year survival across all stages compared to those treated at hospitals in the worst performing quartile in multivariate Cox regression analysis (all stages - HR 1.21 [95% CI 1.15-1.26]; stage I - HR 1.19 [95% CI 1.12-1.25]; stage II - HR 1.20 [95% CI 1.09-1.32]; stage III - HR 1.36 [95% CI 1.20-1.54]) and Kaplan-Meier survival estimates (all stages - p < 0.0001, stage I - p < 0.0001; stage II - p = 0.0004; stage III - p < 0.0001).

CONCLUSION

With expanded lung cancer screening criteria and likely increase in early-stage detection, profiling performance is paramount to ensuring mortality benefits. We found that episodes surrounding surgical resection may be used to profile long-term outcomes that likely reflect quality across a broader context of care. Evaluating lung cancer care quality using perioperative outcomes may be useful in profiling provider performance and guiding value-based payment policies.

Unique Challenges in Diabetic Foot Science

In the past 30 years, there has been a rapid influx of information pertaining to the diabetic foot (DF) coming from numerous directions and sources. This article discusses the current state of the DF literature and challenges it presents to clinicians with its associated increase in knowledge on their derivations, complications, and interventions. Further, we attempt to provide tips on how to navigate and criticize the current literature to encourage and maximize positive outcomes in this challenging patient population.

The relationship between discharge location and cardiac rehabilitation use after cardiac surgery

BACKGROUND

Cardiac rehabilitation (CR) is a guideline-recommended risk-reduction program offered to cardiac surgical patients. Despite CR's association with better outcomes, attendance remains poor. The relationship between discharge location and CR use is poorly understood.

METHODS

This study was a nationwide, retrospective cohort analysis of Medicare fee-for-service claims for beneficiaries undergoing coronary artery bypass grafting and/or surgical aortic valve repair between July 1, 2016, and December 31, 2018. The primary outcome was attendance of any CR session. Discharge location was categorized as home discharge or discharge to extended care facility (ECF) (including skilled nursing facility, inpatient rehabilitation, and long-term acute care). Multivariable logistic regression models evaluated the association between discharge location, CR attendance, and 1-year mortality.

RESULTS

Of the 167,966 patients who met inclusion criteria, 34.1% discharged to an ECF. Overall CR usage rate was 53.9%. Unadjusted and adjusted CR use was lower among patients discharged ECFs versus those discharged home (42.1% vs 60.0%; adjusted odds ratio, 0.66; P < .001). Patients discharged to long-term acute care were less likely to use CR than those discharged to skilled nursing facility or inpatient rehabilitation (reference category: home; adjusted odds ratio for long-term acute care, 0.36, adjusted odds ratio for skilled nursing facility, 0.69, and adjusted odds ratio for inpatient rehabilitation, 0.71; P < .001). CR attendance was associated with a greater reduction in adjusted 1-year mortality in patients discharged to ECFs (9.7% reduction) versus those discharged home (4.3% reduction).

CONCLUSIONS

In this national analysis of Medicare beneficiaries, discharge to ECF was associated with lower CR use, despite a greater association with improved 1-year mortality. Interventions aimed at increasing CR enrollment at ECFs may improve CR use and advance surgical quality.

Sex differences in outcomes after revascularization for acute lower limb ischemia: Propensity score adjusted analysis

BACKGROUND

Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes.

METHODS

A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90-day and 1-year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score.

RESULTS

A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1-year mortality was 0.99 (95% CI 0.67-1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29-0.91).

CONCLUSION

Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively.

Association of risk analysis index with 90-day failure to rescue following major abdominal surgery in geriatric patients

BACKGROUND

Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90).

METHODS

Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression.

RESULTS

A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P = .002), had a greater preoperative American Society of Anesthesiologists classification score (P < .001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P < .001) and mortality (0.067% vs 0.012%, P < .001). The FTR-90 group had a greater median RAI score (23 vs 19; P = .002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P = .028) but not with FTR-30 (P = .13).

CONCLUSION

Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.

Predicting post-discharge complications in cardiothoracic surgery: A clinical decision support system to optimize remote patient monitoring resources

Cardiac surgery patients are highly prone to severe complications post-discharge. Close follow-up through remote patient monitoring can help detect adverse outcomes earlier or prevent them, closing the gap between hospital and home care. However, equipment is limited due to economic and human resource constraints. This issue raises the need for efficient risk estimation to provide clinicians with insights into the potential benefit of remote monitoring for each patient. Standard models, such as the EuroSCORE, predict the mortality risk before the surgery. While these are used and validated in real settings, the models lack information collected during or following the surgery, determinant to predict adverse outcomes occurring further in the future. This paper proposes a Clinical Decision Support System based on Machine Learning to estimate the risk of severe complications within 90 days following cardiothoracic surgery discharge, an innovative objective underexplored in the literature. Health records from a cardiothoracic surgery department regarding 5 045 patients (60.8% male) collected throughout ten years were used to train predictive models. Clinicians' insights contributed to improving data preparation and extending traditional pipeline optimization techniques, addressing medical Artificial Intelligence requirements. Two separate test sets were used to evaluate the generalizability, one derived from a patient-grouped 70/30 split and another including all surgeries from the last available year. The achieved Area Under the Receiver Operating Characteristic curve on these test sets was 69.5% and 65.3%, respectively. Also, additional testing was implemented to simulate a real-world use case considering the weekly distribution of remote patient monitoring resources post-discharge. Compared to the random resource allocation, the selection of patients with respect to the outputs of the proposed model was proven beneficial, as it led to a higher number of high-risk patients receiving remote monitoring equipment.

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform

BACKGROUND

Posterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis.

METHODS

Patients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota's fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test.

RESULTS

A total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant.

CONCLUSION

Perioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

Chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: A meta-analysis

AIM

Chronic Kidney Disease (CKD) is a common comorbidity among acute ischaemic stroke (AIS) patients undergoing reperfusion therapies, including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). Acknowledging CKD's prevalence in this cohort and understanding its influence on outcomes is crucial for prognosis and optimizing care. This study aims to determine the prevalence of CKD among anterior circulation AIS (acAIS) patients undergoing reperfusion therapies and to analyse the role of CKD in mediating outcomes.

METHODS

A random-effects meta-analysis was conducted to pool and examine prevalence data. A total of 263 633 patients were included in the meta-analysis. The study assessed CKD's association with functional outcomes, symptomatic intracranial haemorrhage (sICH) and mortality.

RESULTS

The overall pooled prevalence of CKD among acAIS ranged from 30% to 56% in IVT-treated patients and 16%-42% for EVT-treated patients. CKD was associated with increased odds of unfavourable functional outcome at 90 days in both IVT (OR 1.837; 95% CI: [1.599; 2.110]; p < .001) and EVT (OR 1.804; 95% CI: [1.525; 2.133]; p < .001) groups. In IVT-treated patients, CKD was associated with increased odds of 30-day mortality (OR 6.211; 95% CI: [1.105; 34.909]; p = .038). CKD in IVT-treated patients exhibited increased odds of sICH, albeit statistically non-significant (OR 1.595; 95% CI: [0.567; 3.275]).

CONCLUSIONS

The high prevalence of CKD and its significant impact on outcomes in acAIS patients treated with reperfusion therapies underscore its clinical significance. This insight can guide personalised care strategies and potentially improve the prognosis in the management of acAIS.

Interhospital variability in failure to rescue rates following aortic valve surgery

Objective

This study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement.

Methods

An observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Postoperative complications were defined as major (stroke, renal failure, reoperation, prolonged ventilation, sternal infection) and overall (major plus 14 other morbidities). Hospital terciles of observed to expected (O/E) mortality were compared on crude rates of major and overall complications, operative mortality, and failure to rescue (among major and overall complications). The correlation between hospital observed and expected failure-to-rescue rates was assessed.

Results

Median Society of Thoracic Surgeons Adult Cardiac Surgery Database predicted mortality risk was similar across hospital O:E mortality terciles (P = .10). As expected, mortality rates significantly increased across terciles (low O/E tercile: 1.6%, high O/E tercile: 4.7%; P < .001). Failure-to-rescue rates increased substantially across hospital mortality terciles among patients with major (low tercile, 8.8% and high tercile, 20.8%) and overall (low tercile, 3.0% and high tercile, 8.9%) complications. Hospital-level expected failure to rescue had a higher correlation with observed complications for overall complications (R2 = 0.71) compared with Society of Thoracic Surgeons major complications (R2 = 0.24).

Conclusions

Considerable interhospital variation exists in failure-to-rescue rates following aortic valve replacement. Hospitals in the low O/E mortality tercile experience failure to rescue nearly one-third less than those in the high O/E mortality tercile. Efforts to advance quality will benefit from identifying and disseminating optimal rescue strategies in this patient population.

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care

OBJECTIVES

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation.

DESIGN

Retrospective, Observational cohort study.

SETTING

Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019.

PATIENTS

Adult patients that electively underwent 1 of 19 major procedures.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 ( n = 2,103,836) and PostM: 2016-2019 ( n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts.

CONCLUSIONS

We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Minimally Invasive Versus Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) has arisen as a viable alternative to surgery. Similarly, minimally invasive surgical aortic valve replacement (mini-SAVR), such as ministernotomy and minithoracotomy, have also gained interest. We conducted a pairwise meta-analysis to further investigate the efficacy of TAVR versus mini-SAVR.

METHODS

Medical databases were comprehensively searched for studies comparing TAVR with a mini-SAVR modality, defined as minimally invasive aortic surgery, ministernotomy, minithoracotomy, or rapid-deployment or sutureless SAVR. Random-effects meta-analysis was conducted using the generic inverse variance method. Primary outcomes included 30-day mortality, midterm mortality, 30-day stroke, acute kidney injury (AKI), paravalvular leak (PVL), new permanent pacemaker (PPM), new-onset atrial fibrillation, and postintervention mean and peak valve pressure gradients and were pooled as risk ratio (RR), mean difference (MD), or hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

A total of 5,071 patients (2,505 mini-SAVR vs 2,566 TAVR) from 12 studies were pooled. Compared with TAVR, mini-SAVR showed significantly lower rates of both 30-day (RR = 0.63, 95% CI: 0.42 to 0.96, P = 0.03) and midterm mortality at 4 years of follow-up (HR = 0.76, 95% CI: 0.67 to 0.87, P < 0.001). Furthermore, mini-SAVR was protective against 30-day PVL (RR = 0.07, 95% CI: 0.04 to 0.13, P < 0.001) and new PPM (RR = 0.25, 95% CI: 0.11 to 0.57, P < 0.001). Conversely, TAVR was protective against 30-day AKI (RR = 1.67, 95% CI: 1.20 to 2.32, P = 0.002) and postinterventional mean gradients (MD = 1.65, 95% CI: 0.25 to 3.05, P = 0.02). No difference was observed for 30-day stroke (RR = 0.84, 95% CI: 0.56 to 1.24, P = 0.38), new-onset atrial fibrillation (RR = 1.79, 95% CI: 0.93 to 3.44, P = 0.08), or postinterventional peak gradients (MD = 3.24, 95% CI: -1.10 to 7.59, P = 0.14).

CONCLUSIONS

Compared with TAVR, mini-SAVR was protective against 30-day and midterm mortality, 30-day PVL, and new permanent pacemaker, while TAVR patients had lower 30-day AKI. Future randomized trials comparing the efficacy of mini-SAVR approaches with TAVR are needed.

Using days alive and out of hospital to measure surgical outcomes in New Zealand: a cross-sectional study

OBJECTIVES

To measure differences at various deciles in days alive and out of hospital to 90 days (DAOH₉₀) and explore its utility for identifying outliers of performance among district health boards (DHBs).

METHODS

Days in hospital and mortality within 90 days of surgery were extracted by linking data from the New Zealand National Minimum Data Set and the births and deaths registry between 1 January 2011 and 31 December 2021 for all adults in New Zealand undergoing acute laparotomy (AL-a relatively high-risk group), elective total hip replacement (THR-a medium risk group) or lower segment caesarean section (LSCS-a low-risk group). DAOH₉₀ was calculated without censoring to zero in cases of mortality. For each DHB, direct risk standardisation was used to adjust for potential confounders and presented in deciles according to baseline patient risk. The Mann-Whitney U test assessed overall DAOH₉₀ differences between DHBs, and comparisons are presented between selected deciles of DAOH₉₀ for each operation.

RESULTS

We obtained national data for 35 175, 52 032 and 117 695 patients undergoing AL, THR and LSCS procedures, respectively. We have demonstrated that calculating DAOH without censoring zero allows for differences between procedures and DHBs to be identified. Risk-adjusted national mean DAOH₉₀ Scores were 64.0 days, 79.0 days and 82.0 days at the 0.1 decile and 75.0 days, 82.0 days and 84.0 days at the 0.2 decile for AL, THR and LSCS, respectively, matching to their expected risk profiles. Differences between procedures and DHBs were most marked at lower deciles of the DAOH₉₀ distribution, and outlier DHBs were detectable. Corresponding 90-day mortality rates were 5.45%, 0.78% and 0.01%.

CONCLUSION

In New Zealand after direct risk adjustment, differences in DAOH₉₀ between three types of surgical procedure reflected their respective risk levels and associated mortality rates. Outlier DHBs were identified for each procedure. Thus, our approach to analysing DAOH₉₀ appears to have considerable face validity and potential utility for contributing to the measurement of perioperative outcomes in an audit or quality improvement setting.

Comparison of Postdischarge Outcomes Between Valve-in-Valve Transcatheter Mitral Valve Replacement and Reoperative Surgical Mitral Valve Replacement

Limited data are available comparing the postdischarge perioperative outcomes of isolated valve-in-valve transcatheter mitral valve replacement (VIV-TMVR) versus surgical reoperative mitral valve replacement (re-SMVR) on a nationwide scale. The objective of this study was to perform a robust head-to-head assessment of contemporary postdischarge outcomes between isolated VIV-TMVR and re-SMVR using a large national multicenter longitudinal database. Adult patients aged ≥18 years with failed/degenerated bioprosthetic mitral valves who underwent either isolated VIV-TMVR or re-SMVR were identified in the 2015 to 2019 Nationwide Readmissions Database. The risk-adjusted differences in 30-, 90-, and 180-day outcomes were compared using propensity score weighting with overlap weights to mimic the results of a randomized controlled trial. The differences between a transeptal and transapical VIV-TMVR approach were also compared. A total of 687 patients with VIV-TMVR and 2,047 patients with re-SMVR were included. After the overlap weighting to attain balance between treatment groups, VIV-TMVR was associated with significantly lower major morbidity within 30 (odds ratio [95% confidence interval (CI)] 0.0.31 [0.22 to 0.46]), 90 (0.34 [0.23 to 0.50]), and 180 (0.35 [0.24 to 0.51]) days. The differences in major morbidity were primarily driven by less major bleeding (0.20 [0.14 to 0.30]), new onset complete heart block (0.48 [0.28 to 0.84]) and need for permanent pacemaker placement (0.26 [0.12 to 0.55]). The differences in renal failure and stroke were not significant. VIV-TMVR was also associated with shorter index hospital stays (median difference [95% CI] -7.0 [4.9 to 9.1] days) and an increased ability for patients to be discharged home (odds ratio [95% CI] 3.35 [2.37 to 4.72]). There were no significant differences in total hospital costs; in-hospital or 30-, 90-, and 180-day mortality; or readmission. The findings remained similar when stratifying the VIV-TMVR access using a transeptal versus a transapical approach. The changes in outcomes over time suggest marked improvements for patients with VIV-TMVR relative to stagnant results for patients with re-SMVR from 2015 to 2019. In this large nationally representative cohort of patients with failed/degenerated bioprosthetic mitral valves, VIV-TMVR appears to confer a short-term advantage over re-SMVR in terms of morbidity, discharge home, and length of stay. It yielded equivalent outcomes for mortality and readmission. Longer-term studies are needed to assess further follow-up beyond 180 days.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Multimorbidity, 30-Day Readmissions, and Postdischarge Mortality Among Medicare Beneficiaries Using a New ICD-Coded Multimorbidity-Weighted Index

BACKGROUND

Medically complex, disabled adults have high 30-day readmission rates. However, physical functioning is not routinely included in risk-adjustment models. We examined the association between multimorbidity with readmissions and mortality using a physical functioning weighted International Classification of Diseases (ICD)-coded multimorbidity-weighted index (MWI-ICD) representing 84 conditions.

METHODS

We included Medicare beneficiaries with ≥1 hospitalization 2000-2015 who participated in a Health and Retirement Study interview before admission. We computed MWI-ICD by summing physical functioning weighted conditions from Medicare claims. We examined 30-, 90-, and 365-day postdischarge mortality using multivariable logistic regression and length of stay through zero-inflated negative binomials. Models adjusted for age, sex, race/ethnicity, body mass index, smoking status, physical activity, education, net worth, and marital status/living arrangement.

RESULTS

The final sample of 10 737 participants had mean ± standard deviation (SD) age 75.9 ± 8.7 years, MWI-ICD 14.9 ± 9.0, and 20% had a 30-day readmission. Adults in the highest versus lowest quartile MWI-ICD had 92% increased odds of 30-day readmission (odds ratio [OR] = 1.92, 95% confidence interval [CI]: 1.65-2.22). A 1-point increase in MWI-ICD was associated with 24% increased odds of 30-day readmission (OR = 1.24, 95% CI: 1.18-1.31). A 1-point increase in MWI-ICD was associated with 32% increased odds of death within 365-day postdischarge (OR = 1.32, 95% CI: 1.25-1.40). Readmitted participants with the highest versus lowest quartile MWI-ICD had 37% increased number of expected hospitalized days (incidence rate ratio = 1.37, 95% CI: 1.17-1.59).

CONCLUSION

Among Medicare beneficiaries, multimorbidity using MWI-ICD is associated with an increased risk of readmissions, mortality, and longer length of stay. MWI-ICD appears to be a valid measure of multimorbidity that embeds physical functioning and presents an opportunity to incorporate functional status into claims-based risk-adjustment models.

Risk factors and effect of postoperative delirium on adverse surgical outcomes in older adults after elective abdominal cancer surgery in Taiwan

BACKGROUND

Postoperative delirium (POD) is a common complication in older adults, with unknown epidemiology and effects on surgical outcomes in Asian geriatric cancer patients. This study evaluated incidence, risk factors, and association between adverse surgical outcomes and POD after intra-abdominal cancer surgery in Taiwan.

METHODS

Overall, 345 patients aged ≥65 years who underwent elective abdominal cancer surgery at a medical center in Taiwan were prospectively enrolled. Delirium was assessed daily using the Confusion Assessment Method. Univariate and multivariate logistic regression analyses investigated risk factors for POD occurrence and estimated the association with adverse surgical outcomes.

RESULTS

POD occurred in 19 (5.5%) of the 345 patients. Age ≥73 years, Charlson comorbidity index ≥3, and operative time >428 min were independent predictors for POD occurrence. Patients presenting with one, two, and three risk factors had 4.1-fold (95% confidence interval [CI], 0.4-35.8, p = 0.20), 17.4-fold (95% CI, 2.2-138, p = 0.007), and 30.8-fold likelihood (95% CI, 2.9-321, p = 0.004) for POD occurrence, respectively. Patients with POD had a higher probability of prolonged hospital stay (adjusted odds ratio [OR] 2.8; 95% CI, 1.0-8.1; p = 0.037), intensive care stay (adjusted OR: 3.9; 95% CI, 1.5-10.5; p = 0.008), 30-day readmission (adjusted OR 3.1; 95% CI, 1.1-9.7; p = 0.039), and 90-day postoperative death (adjusted OR: 4.2; 95% CI, 1.0-17.7; p = 0.041).

CONCLUSION

POD occurrence was significantly associated with adverse surgical outcomes in geriatric patients undergoing elective abdominal cancer surgery, highlighting the importance of early POD identification in geriatric patients to improve postoperative care quality.

Association of APACHE-II Scores With 30-Day Mortality After Tracheostomy: A Retrospective Study

OBJECTIVE

The objective of this study was to assess whether the Acute Physiology, Age, Chronic Health Evaluation II (APACHE-II) score is a reliable predictor of 30-day mortality in the setting of adult patients with ventilator-dependent respiratory failure (VDRF) who undergo tracheostomy.

METHODS

This is a retrospective, single-institution study. Potential subjects were identified using the current procedural terminology codes for the tracheostomy procedure and International Classification of Diseases, 10th Revision, codes for VDRF. APACHE-II scores were retrospectively calculated. Tracheostomies were performed in our population over an 18-month period (November 2018 through April 2020). Our study population did not include patients with novel coronavirus. The primary outcome was mortality at 30 days after tracheostomy.

RESULTS

A total of 238 patients with VDRF who had a tracheostomy were included in this study. Twenty-eight (11.8%) patients died within 30 days of tracheostomy. The mean (standard deviation) APACHE-II score was 22.5 (10.2) for patients who died within 30 days of tracheostomy and 19.8 (7.4) for patients living within 30 days of tracheostomy (p = 0.30). Patients with APACHE-II scores greater than or equal to 30 showed higher odds of death within 30 days of tracheostomy (odds ratio, 3.0; 95% CI, 1.14-7.89, p = 0.03).

CONCLUSION

An APACHE-II score of 30 and above is associated with mortality within 30 days of tracheostomy in patients with VDRF. APACHE-II scores may be a promising tool for assessing risk of mortality in patients with VDRF after tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:273-278, 2023.

No short-term mortality from benzodiazepine use post-acute ischemic stroke after accounting for bias

BACKGROUND AND OBJECTIVES

Older adults receive benzodiazepines for agitation, anxiety, and insomnia after acute ischemic stroke (AIS). No trials have been conducted to determine if benzodiazepine use affects poststroke mortality in the elderly.

METHODS

We examined the association between initiating benzodiazepines within 1 week after AIS and 30-day mortality. We included patients ≥65 years, admitted for new nonsevere AIS (NIH-Stroke-Severity[NIHSS]≤ 20), 2014-2020, with no recorded benzodiazepine use in the previous 3 months and no contraindication for use. We linked a stroke registry to electronic health records, used inverse-probability weighting to address confounding, and estimated the risk difference (RD). A process of cloning, weighting, and censoring was used to avoid immortal time bias.

RESULTS

Among 2,584 patients, 389 received benzodiazepines. The crude 30-day mortality risk from treatment initiation was 212/1,000 among patients who received benzodiazepines, while the 30-day mortality was 34/1,000 among those who did not. When follow-up was aligned on day of AIS admission and immortal time was assigned to the two groups, the estimated risks were 27/1,000 and 22/1,000, respectively. Upon further adjustment for confounders, the RD was 5 (-12 to 19) deaths/1,000 patients.

CONCLUSION

The observed higher 30-day mortality associated with benzodiazepine initiation within 7 days was largely due to bias.

Pre-procedural serum albumin concentration is associated with length of stay, discharge destination, and 90-day mortality in patients after transcatheter aortic valve replacement

Background

As visceral protein expression may influence outcomes in patients with cardiovascular disease, we investigated whether pre-procedural albumin concentration is associated with length of stay (LOS) and 90-day mortality after transcatheter aortic valve repair (TAVR).

Methods

We retrospectively analyzed data from TAVR patients at our institution between January 2013 and December 2017. For all patients, baseline albumin concentration was assessed between one and four weeks before the procedure. To investigate the association between albumin concentration and outcomes, we performed regression analyses, controlling for Society of Thoracic Surgeons, New York Heart Association classification, and Kansas City Cardiomyopathy Questionnaire 12 scores.

Results

Three hundred eighty patients were included in the analyses. Cox-proportional hazards regression showed that patients with albumin concentrations <3.5 g/dL were 80% more likely to have prolonged ICU LOS (HR 1.79; 95%CI 1.04-2.57, P = 0.03) and 70% more likely to have prolonged hospital LOS (HR 1.68; 95%CI 1.01-2.46, P = 0.04) compared to patients with albumin concentrations >3.5 g/dL. Logistic regression showed that patients with albumin concentrations <3.5 g/dL were four times more likely to not survive to 90 days (OR 3.94; 1.13-12.63, P = 0.03) after their TAVR compared to patients with albumin concentrations >3.5 g/dL.

Conclusion

Our data suggest that patients with pre-procedural albumin concentrations <3.5 g/dL are at an increased risk of adverse outcomes after TAVR compared to patients with albumin concentrations ≥3.5 g/dL. Prospective studies are needed to determine whether risk stratification based on pre-procedural albumin can improve outcomes and whether targeted interventions can improve pre-procedural albumin concentrations in potential TAVR candidates.

Neoadjuvant Chemotherapy vs Chemoradiation Therapy Followed by Sleeve Resection for Resectable Lung Cancer

BACKGROUND

Traditionally, neoadjuvant chemoradiation therapy is followed by resection in patients with locally advanced non-small cell lung cancer (NSCLC). The risks and benefits of this approach are not well defined in patients requiring a sleeve lung resection. In this context, we compare the short- and long-term outcomes of neoadjuvant chemotherapy alone vs chemoradiation therapy followed by sleeve lung resection.

METHODS

We used the National Cancer Database to identify locally advanced NSCLC patients who received chemotherapy-alone or chemoradiation therapy in the neoadjuvant setting, followed by a sleeve lung resection, between 2006 and 2017. Our outcomes of interest were 30-day mortality, 90-day mortality, and overall survival. To minimize confounding by indication, we used propensity score adjustment, logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazards models to identify associations.

RESULTS

Of 176 patients undergoing sleeve lung resection, 92 (52.3%) received neoadjuvant chemotherapy-alone, and 84 (47.7%) received neoadjuvant chemoradiation therapy. Patients in both groups were well balanced in age, sex, race, Charlson-Deyo comorbidity index, insurance status, median income, and education (all P > .05). Similarly, the groups were well balanced in histology, tumor location, and stage (all P > .05). Patients receiving neoadjuvant chemoradiation therapy had higher 90-day mortality (11.96% vs 2.38%, P = .015), and there was no difference in overall survival between the neoadjuvant chemotherapy-alone vs chemoradiation therapy cohorts (P = .621).

CONCLUSIONS

In this national study of patients with locally advanced resectable NSCLC requiring a sleeve lung resection, neoadjuvant chemoradiation therapy was associated with a 5-fold increase in 90-day mortality without an overall survival benefit over neoadjuvant chemotherapy-alone.

Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease

Importance

For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown.

Objective

To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis.

Design, Setting, and Participants

Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018.

Exposures

One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure.

Main Outcomes and Measures

The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model.

Results

Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction).

Conclusions and Relevance

Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.

Ninety-Day Risk-Standardized Home Time as a Performance Metric for Cardiac Surgery Hospitals in the United States

BACKGROUND

Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously.

METHODS

The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed.

RESULTS

Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (r=0.31; P<0.001) and inverse correlation with 90-day risk-standardized readmission rate (r=-0.40; P <0.001) and 90-day risk-standardized mortality rate (r=-0.60; P <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics.

CONCLUSIONS

Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.

Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement

OBJECTIVE

Monitored anesthesia care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a Veterans Affairs Medical Center.

METHODS

A single-center retrospective review was performed of 349 patients who underwent transfemoral TAVR (MAC, n = 244 vs GA, n = 105) from January 2014 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs.

RESULTS

In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs 198 min, P < 0.001), ICU LOS (1.4 vs 1.8 days, P < 0.001), total hospital LOS (3.4 vs 5.4 days, P < 0.001), and lower index total cost ($81,300 vs $85,400, P = 0.010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs 196 min, P < 0.05), ICU LOS (1.2 vs 1.7 days, P = 0.006), total LOS (3.5 vs 5.1 days, P = 0.001), and 180-day mortality (2.4% vs 12%, P < 0.03). There was no difference in total hospitalization cost or total cost.

CONCLUSIONS

In propensity-matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality but no significant difference in cost.

Five-meter walk test before transcatheter aortic valve replacement and 1-year noncardiac mortality

Objective

The purpose of this study is to assess whether the 5-m walk test is associated with 1-year mortality after transcatheter aortic valve replacement.

Methods

Included in the analysis were 304 patients who received the 5-m walk test and underwent transcatheter aortic valve replacement from September 2012 to March 2019. They were classified into 3 groups based on their test score: ≤7, >7, and unable to walk. Preprocedure characteristics, postprocedure outcomes, and follow-up outcomes were compared between the groups.

Results

For the 5-m walk test, 145 had a score ≤7 (Group N), 111 had a score >7 (Group S), and 48 were unable to walk (Group I). Average age in years was 80.2 ± 8.7 years in Group N, 81.2 ± 9.4 years in Group S, and 79.4 ± 9.2 in Group I (P = .23). The aortic valve mean gradient at discharge was 9.5 ± 4.1 mm Hg in Group N, 10.4 ± 5.5 mm Hg in Group S, and 8.2 ± 4.2 mm Hg in Group I (P = .05). The discharge survival was 97.2% in Group N, 96.4% in Group S, and 95.8% in Group I (P = .76). One-year survival was 92.8% in Group N, 84.1% in Group S, and 75% in Group I (P < .01) after adjusting for preprocedure characteristics. Noncardiac death was 5.1% in Group N, 13.1% in Group S, and 22.7% in Group I (P = .03). This indicates that the 5-m walk test was a risk factor for 1-year mortality. More specifically, a poor 5-m walk test score was associated with 1-year noncardiac mortality.

Conclusions

The 5-m walk test score before transcatheter aortic valve replacement was associated with 1-year mortality, especially noncardiac mortality. It may help identify patients at high risk for 1-year mortality.

Development and internal validation of a clinical prediction model using machine learning algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above

Purpose

Preoperative prediction of mortality in femoral neck fracture patients aged 65 years or above may be valuable in the treatment decision-making. A preoperative clinical prediction model can aid surgeons and patients in the shared decision-making process, and optimize care for elderly femoral neck fracture patients. This study aimed to develop and internally validate a clinical prediction model using machine learning (ML) algorithms for 90 day and 2 year mortality in femoral neck fracture patients aged 65 years or above.

Methods

A retrospective cohort study at two trauma level I centers and three (non-level I) community hospitals was conducted to identify patients undergoing surgical fixation for a femoral neck fracture. Five different ML algorithms were developed and internally validated and assessed by discrimination, calibration, Brier score and decision curve analysis.

Results

In total, 2478 patients were included with 90 day and 2 year mortality rates of 9.1% (n = 225) and 23.5% (n = 582) respectively. The models included patient characteristics, comorbidities and laboratory values. The stochastic gradient boosting algorithm had the best performance for 90 day mortality prediction, with good discrimination (c-statistic = 0.74), calibration (intercept = − 0.05, slope = 1.11) and Brier score (0.078). The elastic-net penalized logistic regression algorithm had the best performance for 2 year mortality prediction, with good discrimination (c-statistic = 0.70), calibration (intercept = − 0.03, slope = 0.89) and Brier score (0.16). The models were incorporated into a freely available web-based application, including individual patient explanations for interpretation of the model to understand the reasoning how the model made a certain prediction: https://sorg-apps.shinyapps.io/hipfracturemortality/

Conclusions

The clinical prediction models show promise in estimating mortality prediction in elderly femoral neck fracture patients. External and prospective validation of the models may improve surgeon ability when faced with the treatment decision-making.

Level of evidence

Prognostic Level II.

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

STUDY OBJECTIVE

To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.

DESIGN

A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.

SETTING

Preoperative assessment.

PATIENTS

Older patients (≥ 60 years) undergoing non-cardiac surgery.

MEASUREMENTS

Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.

RESULTS

Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).

CONCLUSIONS

Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.

Clinical outcomes following one-, two-, three-, and four-level anterior cervical discectomy and fusion: a national database study

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure. There is markedly less data on outcomes after three- and four-level cases than one- and two-level cases.

PURPOSE

To compare perioperative 90-day adverse events and 5-year reoperation rates between isolated one-, two-, three-, and four-level ACDF cases.

STUDY DESIGN/SETTING

Retrospective review of a large national database.

PATIENT SAMPLE

Overall, 97,081 patients undergoing ACDF were identified, of which one-level cases were 42,382 (43.7%), two-level cases were 24,055 (24.8%), three-level cases were 28,293 (29.1%), and four-level cases were 2,361 (2.4%).

OUTCOME MEASURES

Ninety-day adverse events and 5-year reoperation rates.

METHODS

The 2010 to Q1 2020 PearlDiver database was queried to identify patients who underwent elective ACDF for degenerative pathology without corpectomy or concomitant posterior procedures. Univariate and multivariate analyses were performed to compare outcomes of subcohorts with varying number of levels addressed by ACDF.

RESULTS

Of the 97,081 cases identified, patient characteristics and complication rates differed between the cohorts defined by levels treated. Univariate analyses revealed statistically different rates of 90-day any, serious, and minor adverse event rates between the groups, but the differences were all less than 2.5%. Readmission rates were statistically different by 2.9%, dysphagia by 3.2%, and prolonged length of stay by 6.3%.By multivariate analyses, three-level ACDF cases were not found to have greater 90-day adverse outcomes than two-level cases. Four-level ACDF cases were found to have significantly greater odds ratios of readmission, dysphagia, and prolonged length of stay (relative to one-level cases, OR 1.28, 1.63, and 1.97, respectively) but not other 90-day adverse events. Reoperation rates at five years for one-, two-, three-, and four-level cases were 13.0%, 13.5%, 15.0%, and 22.1%, respectively (log-rank p<.001).

CONCLUSIONS

The current study represents one of the largest comparative studies of patients undergoing one-, two-, three-, and four-level ACDF. While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.

Use of 90-day mortality does not change assessment of hospital quality after coronary artery bypass grafting in New York State

OBJECTIVES

Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass grafting. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture postdischarge mortality, are a better determinant of hospital performance.

METHODS

We performed a retrospective cohort analysis of 30- versus 90-day risk-standardized mortality rates at adult cardiac surgical centers in New York State from 2008 to 2014. Hospitals were classified as good or poor performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital's predicted risk-standardized mortality rates determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days.

RESULTS

During the study period, 72,398 adults underwent a coronary artery bypass grafting procedure at 1 of 42 institutions. The risk-standardized mortality rates increased from 30 to 90 days at all institutions, with a median 30-day risk-standardized mortality rate of 2.16% (interquartile range, 0.69%) and median 90-day risk-standardized mortality rate of 3.69% (interquartile range, 1.00%). In using a 90-day instead of a 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer, and 2 worsened to as expected from good performers.

CONCLUSIONS

In a cohort of patients who underwent coronary artery bypass grafting surgery from 2008 to 2014 in New York State, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.

Risk-Adjusted, 30-Day Home Time After Transcatheter Aortic Valve Replacement as a Hospital-Level Performance Metric

BACKGROUND

Patient-centric measures of hospital performance for transcatheter aortic valve replacement (TAVR) are needed.

OBJECTIVES

This study evaluated 30-day, risk-adjusted home time as a hospital performance metric for patients who underwent TAVR.

METHODS

This study identified 160,792 Medicare beneficiaries who underwent elective TAVR from 2015 to 2019. Home time was calculated for each patient as the number of days alive and spent outside the hospital, skilled nursing facility (SNF), and long-term acute care facility for 30 days after the TAVR procedure date. Correlations between risk-adjusted, 30-day home time and other metrics (30-day, risk-adjusted readmission rate [RSRR], 30-day, risk-adjusted mortality rate [RSMR], and annual TAVR volume) were estimated using Pearson's correlation. Meaningful upward or downward reclassification (≥2 quartile ranks) in hospital performance based on quartiles of risk-adjusted, 30-day home time compared with quartiles of other measures were assessed.

RESULTS

Median risk-adjusted, 30-day home time was 27.4 days (interquartile range [IQR]: 26.3-28.5 days). The largest proportion of days lost from 30-day home time was hospital stay after TAVR and SNF stay. An inverse correlation was observed between hospital-level, risk-adjusted, 30-day home time and 30-day RSRR (r = -0.465; P < 0.001) and 30-day RSMR (r = -0.3996; P < 0.001). The use of the 30-day, risk-adjusted home time was associated with reclassification in hospital performance rank hospitals compared with other metrics (9.1% up-classified, 11.2% down-classified vs RSRR; 9.1% up-classified, 10.3% down-classified vs RSMR; and 20.1% up-classified, 19.3% down-classified vs annual TAVR volume).

CONCLUSIONS

Risk-adjusted, 30-day home time represents a novel patient-centered performance metric for TAVR hospitals that may provide a complimentary assessment to currently used metrics.

Impact of the COVID-19 pandemic on non-COVID-19 hospital mortality in patients with schizophrenia: a nationwide population-based cohort study

It remains unknown to what degree resource prioritization toward SARS-CoV-2 (2019-nCoV) coronavirus (COVID-19) cases had disrupted usual acute care for non-COVID-19 patients, especially in the most vulnerable populations such as patients with schizophrenia. The objective was to establish whether the impact of the COVID-19 pandemic on non-COVID-19 hospital mortality and access to hospital care differed between patients with schizophrenia versus without severe mental disorder. We conducted a nationwide population-based cohort study of all non-COVID-19 acute hospitalizations in the pre-COVID-19 (March 1, 2019 through December 31, 2019) and COVID-19 (March 1, 2020 through December 31, 2020) periods in France. We divided the population into patients with schizophrenia and age/sex-matched patients without severe mental disorder (1:10). Using a difference-in-differences approach, we performed multivariate patient-level logistic regression models (adjusted odds ratio, aOR) with adjustment for complementary health insurance, smoking, alcohol and substance addiction, Charlson comorbidity score, origin of the patient, category of care, intensive care unit (ICU) care, major diagnosis groups and hospital characteristics. A total of 198,186 patients with schizophrenia were matched with 1,981,860 controls. The 90-day hospital mortality in patients with schizophrenia increased significantly more versus controls (aOR = 1.18; p < 0.001). This increased mortality was found for poisoning and injury (aOR = 1.26; p = 0.033), respiratory diseases (aOR = 1.19; p = 0.008) and for both surgery (aOR = 1.26; p = 0.008) and medical care settings (aOR = 1.16; p = 0.001). Significant changes in the case mix were noted with reduced admission in the ICU and for several somatic diseases including cancer, circulatory and digestive diseases and stroke for patients with schizophrenia compared to controls. These results suggest a greater deterioration in access to, effectiveness and safety of non-COVID-19 acute care in patients with schizophrenia compared to patients without severe mental disorders. These findings question hospitals' resilience pertaining to patient safety and underline the importance of developing specific strategies for vulnerable patients in anticipation of future public health emergencies.

Operative mortality in adult cardiac surgery: is the currently utilized definition justified?

Background

This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era.

Methods

This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications.

Results

A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common.

Conclusions

Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.

Predictors of 90-Day All-Cause Morbidity, Mortality and Poor Functional Outcome Scores Following Elective Total Knee Arthroplasty in a High-Volume Setting: A Prospective Cohort Study

BACKGROUND

The primary objective was to ascertain the predictors of 90-day all-cause morbidity, mortality and poor functional outcome scores following primary total knee arthroplasty (TKA).

MATERIAL AND METHOD

The study population comprised 3645 patients who underwent elective primary unilateral TKA at our institution. Demographic variables, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) grade and the Deyo-Charlson comorbidity scores were ascertained. The Functional outcomes, perioperative complications, mortality and readmission rates were monitored prospectively for 90 days and analysed. Patients were assessed twice: at baseline and at 90 days postoperatively. Odds ratio and the corresponding 95% confidence intervals were calculated to quantify the risk. A p < 0.05 for two-tailed tests were considered significant.

RESULT

The 90-day mortality rate was 0.08% (all males) and 3.95% of the patients experienced one or the other complications. The majority of patients reported excellent-to-poor scores at 90-day follow-up VAS (8.85 ± 1.02 vs. 2.65 ± 1.15; p < 0.0001) and KSS scores (42.96 ± 5.90 vs. 80.52 ± 4.15; p < 0.0001). The early readmission rate was 0.96%. Infection was being the primary reason. Age > 70 years; Deyo-Charlson co-morbidity score ≥ 4, ASA grade-III, Diabetes Mellitus, BMI > 35, Cardiac Issues and Male gender were significant predictors of early morbidity and mortality. Female, Deyo-Charlson comorbidity score ≥ 4, ASA grade-III, BMI > 35, Age > 75 years and poor preoperative scores were significantly associated with poor functional outcome.

CONCLUSION

The present study explicates the relative importance of predictors on morbidity, mortality and functional outcome. Efforts to minimize morbidity and mortality should concentrate more on elderly male patients, and those with high Deyo-Charlson comorbidity score, BMI and ASA grade.

The Association Between Institutional Mortality After Coronary Artery Bypass Grafting at One Year and Mortality Rates at 30 Days

OBJECTIVE

To assess the association between the common quality metric of 30-day mortality and mortality at 60 days, 90 days, and one year after coronary artery bypass grafting.

DESIGN

A retrospective cohort study, with multivariate logistic regression to assess association among mortality outcomes.

SETTING

Hospitals participating in Medicare and reporting data within the Centers for Medicare and Medicaid Services Limited Data Set between April 1, 2016, and March 31, 2017.

PARTICIPANTS

A total of 37,036 patients undergoing surgery at 394 hospitals.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Mortality rates were 1.0%-to-3.1% for the top and bottom quartile of hospitals at 30 days. At one year, the top 25th percentile of hospitals had mortality rates averaging 3.9%; while hospitals below the 75th percentile had mortality rates averaging 7.6%. Twenty-three percent of hospitals in the top quartile at 30 days were no longer in the top quartile at 60 days. At one year, only 48% of hospitals that were in the top quartile at 30 days remained in the top quartile. The correlation between mortality rates at 30 days and the reported points was assessed using Spearman's rho. The R value between mortality at 30 days and mortality at one year was 0.53, which improved to 0.7 and 0.76 at 60 and 90 days.

CONCLUSIONS

Mortality at 30 days correlated poorly with mortality at one year. Hospitals that were high- or low-performing at 30 days frequently were no longer within the same performance group at one year.

Center-level CABG and valve operative outcomes and volume-outcome relationships in New York State

BACKGROUND

We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types.

METHODS

We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures.

RESULTS

Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R²  = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase.

CONCLUSION

In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Current Surgical Risk Scores Overestimate Risk in Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary.

METHODS

We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient's European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores' accuracy in predicting mini-AVR 30-day mortality by computing each score's observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer-Lemeshow goodness-of-fit tested calibration.

RESULTS

Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores.

CONCLUSIONS

In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.

Widening volume and persistent outcome disparity in valve operations: New York statewide analysis, 2005-2016

OBJECTIVES

Volume concentration of complex noncardiac operations to high-volume centers has been observed, but whether this is also occurring in cardiac surgery is unknown. We examined the relationship between volume concentration and mortality rates for valve surgery and coronary artery bypass grafting (CABG) between 2005 and 2016 in New York State.

METHODS

We analyzed publicly available, hospital-level case volume and risk-adjusted mortality rates (RAMRs) from 2005 to 2016 for isolated CABG and isolated or concomitant valve operations performed in New York. We identified hospitals in the top- and bottom-volume quartiles for each procedure type and compared changes in percent market share and outcomes. Bivariate and univariate longitudinal analysis was used to evaluate the statistical significance of the temporal trend.

RESULTS

Among 36 centers, percent market share of the top-volume quartile increased for valve cases from 54.4% to 59.4%, whereas CABG share increased from 41.4% to 44.3%. No significant changes were noted in market share for the bottom quartile. The top-volume quartile demonstrated significant trends in improving outcomes over the study period for both valve procedures (RAMR: -0.261%/year, P < .001) and CABG (RAMR: -0.071%/year, P = .018). No significant trends were noted in the bottom quartile for either procedure.

CONCLUSIONS

In New York, over the last decade, highest-volume hospitals increased their market share for valve operations while maintaining lower mortality rates than lowest-volume hospitals. Valve volume is regionalizing in the setting of a persistent outcome gap between the highest- and lowest-volume hospitals, suggesting that volume-based referrals for specialized cardiac procedures may improve surgical mortality.

Transcatheter Aortic Valve Implantation Readmissions in the Current Era (from the National Readmission Database)

Transcatheter aortic valve implantation (TAVI) has become the mainstream treatment for severe aortic stenosis. Despite improvement in device iteration and operator experience rigorous outcome data outside the scope of clinical trials is lacking. Nationwide readmission database 2016 and 2017 was utilized to identify the study population. International Classification of Disease,10th edition codes were used to identify TAVI admissions. Outcomes of interest were the 90-day readmission pattern and in hospital complications of the TAVI procedure. A total of 73,784 TAVI related index admissions were identified in the Nationwide Readmission Database in 2016 to 2017. Forty four percent of patients undergoing TAVI in that timeframe were discharged within 48 hours of their procedure. 16,343 patients (22.2%) were readmitted within 90 days after discharge. Major cardiac co-morbidities like heart failure were prevalent more often in the group of patients that were readmitted within 90 days. Noncardiac causes however accounted for two thirds of these readmissions. The median time to 90-day readmission was 31 days. Multivariate analysis showed that nonagenarians, patients undergoing transapical TAVI, and patients with a higher comorbidity burden were more likely to be readmitted within 90 days. In conclusion, almost half of TAVI patients in the US are discharged within 48 hours after their procedure and 20% of all TAVI patients are readmitted within 90 days. Most readmissions are due to noncardiac causes.

Late Outcome after Surgery for Type-A Aortic Dissection

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.

Development of a Risk Score to Predict 90-Day Readmission After Coronary Artery Bypass Graft

BACKGROUND

Readmission after coronary artery bypass grafting (CABG) is used for quality metrics and may negatively affect hospital reimbursement. Our objective was to develop a risk score system from a national cohort that can predict 90-day readmission risk for CABG patients.

METHODS

Using the National Readmission Database between 2013 and 2014, we identified 104,930 patients discharged after CABG, for a total of 234,483 patients after weighted analysis. Using structured random sampling, patients were divided into a training set (60%) and test data set (40%). In the training data set, we used multivariable analysis to identify risk factors. A point system risk score was developed based on the odds ratios. Variables with odds ratio less than 1.3 were excluded from the final model to reduce noise. Performance was assessed in the test data set using receiver operator characteristics and accuracy.

RESULTS

In the United States, overall 90-day readmission rate after CABG was 19% (n = 44,559 of 234,483). Nine demographic and clinical variables were identified as important in the training data set. The final risk score ranged from 0 to 52; the 2 largest risks were associated with length of stay greater than 10 days (score = +10) and Medicaid insurance (score = +7). The final model's C-statistic was 0.67. Using an optimal cutoff of 18 points, the accuracy of the risk score was 77%.

CONCLUSIONS

Ninety-day readmission after CABG surgery is frequent. A readmission risk score higher than 18 points predicts readmission in 77% of patients. Based on 9 demographic and clinical factors, this risk score can be used to target high-risk patients for additional postdischarge resources to reduce readmission.