The Quality Metric Prolonged Length of Stay Misses Clinically Important Adverse Events

Development and comparison of machine-learning models for predicting prolonged postoperative length of stay in lung cancer patients following video-assisted thoracoscopic surgery

Objective

This study aimed to develop models for predicting prolonged postoperative length of stay (PPOLOS) in lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS) by utilizing machine-learning techniques. These models aim to offer valuable insights for clinical decision-making.

Methods

This retrospective cohort study analyzed a dataset of lung cancer patients who underwent VATS, identifying 25 numerical features and 45 textual features. Three classification machine-learning models were developed: XGBoost, random forest, and neural network. The performance of these models was evaluated based on accuracy (ACC) and area under the receiver operating characteristic curve, whereas the importance of variables was assessed using the feature importance parameter from the random forest model.

Results

Of the 6767 lung cancer patients, 1481 patients (21.9%) experienced a postoperative length of stay of > 4 days. The majority were male (4111, 60.8%), married (6246, 92.3%), and diagnosed with adenocarcinoma (4145, 61.3%). The Random Forest classifier exhibited superior prediction performance with an area under the curve (AUC) of 0.792 and ACC of 0.804. The calibration plot revealed that all three classifiers were in close alignment with the ideal calibration line, indicating high calibration reliability. The five most critical features identified were the following: surgical duration (0.116), age (0.066), creatinine (0.062), hemoglobin (0.058), and total protein (0.054).

Conclusions

This study developed and evaluated three machine-learning models for predicting PPOLOS in lung cancer patients undergoing VATS. The findings revealed that the Random Forest model is most accurately predicting the PPOLOS. Findings of this study enable the identification of crucial determinants and the formulation of targeted interventions to shorten the length of stay among lung cancer patients after VATS, which contribute to optimize the allocation of healthcare resources.

Liposomal Bupivacaine Suspension Can Reduce the Length of Stay of Patients Undergoing Open Reduction and Internal Fixation of Mandibular Fracture

BACKGROUND

Poorly controlled postoperative pain results in prolonged length of stay (LOS). The use of liposome bupivacaine injectable suspension (LB) for postoperative pain control is a relatively recent practice.

PURPOSE

The purpose of this study was to investigate the following. In patients undergoing open reduction and internal fixation of mandibular fracture(s), does the use of LB reduce LOS compared with regular bupivacaine?

STUDY DESIGN, SETTING, SAMPLE

We implemented a retrospective cohort study of consecutive patients with mandibular fracture(s) presented to Grady Memorial Hospital in Atlanta, GA, from January 2021 to January 2022. Adult patients diagnosed with 1 or more isolated mandibular fracture(s) and treated by open reduction and internal fixation were included. We excluded patients with non-isolated mandibular fracture(s), isolated condyle, infected, previously treated fractures, and documented allergy to amide local anesthetics and/or its preservatives.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Primary predictor variable was local anesthetic (regular bupivacaine alone or LB/regular bupivacaine).

MAIN OUTCOME VARIABLE(S)

Primary outcome variable was LOS, defined as the number of days from surgical procedure until discharge. Secondary outcome variables were number of opioid prescription refill(s) and postoperative pain at discharge, determined with visual analogue scale.

COVARIATES

The covariates were Demographics, American Society of Anesthesiologists classification, smoking, alcohol exposure, illicit drug use, etiology, location, laterality, number of fracture(s), surgical approach, and method of maxillomandibular fixation.

ANALYSES

Univariate and bivariate analyses were calculated. Statistical significance was P < .05.

RESULTS

Sixty-two subjects met the inclusion criteria (31 subjects in each group). The mean ages in LB/regular bupivacaine and regular bupivacaine alone groups were 33.3 (±12) and 35.1 (±15.6), respectively (P = .94), the mean LOS in days was 0.23 (±0.44) in LB/regular bupivacaine and 1.48 (±1.77) in regular bupivacaine alone (P= < .001), and the mean VAS pain scores for LB/regular bupivacaine and regular bupivacaine alone groups were 0.53 (±1.07) and 1.87 (±2.66), respectively (P = .02). Mean number of opioid prescription refill(s) was 0 in LB/regular bupivacaine and 1 in regular bupivacaine alone group, respectively (P = .01).

CONCLUSION AND RELEVANCE

The use of LB/regular bupivacaine for mandibular fracture(s) results in decrease in LOS and number of opioid refills compared to regular bupivacaine alone.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69−94] vs. 85 [73−98]), Forced Expiratory Volume (FEV1) % (92 [79−106] vs. 96 [82−109]), operative time (180 [141−230] vs. 160 [125−195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69–94] vs. 85 [73–98]), Forced Expiratory Volume (FEV1) % (92 [79–106] vs. 96 [82–109]), operative time (180 [141–230] vs. 160 [125–195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty

BACKGROUND

Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay.

METHODS

A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days.

RESULTS

A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking.

CONCLUSIONS

Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

Predicting Prolonged Length of Hospital Stay for Peritoneal Dialysis-Treated Patients Using Stacked Generalization: Model Development and Validation Study

Background

The increasing number of patients treated with peritoneal dialysis (PD) and their consistently high rate of hospital admissions have placed a large burden on the health care system. Early clinical interventions and optimal management of patients at a high risk of prolonged length of stay (pLOS) may help improve the medical efficiency and prognosis of PD-treated patients. If timely clinical interventions are not provided, patients at a high risk of pLOS may face a poor prognosis and high medical expenses, which will also be a burden on hospitals. Therefore, physicians need an effective pLOS prediction model for PD-treated patients.

Objective

This study aimed to develop an optimal data-driven model for predicting the pLOS risk of PD-treated patients using basic admission data.

Methods

Patient data collected using the Hospital Quality Monitoring System (HQMS) in China were used to develop pLOS prediction models. A stacking model was constructed with support vector machine, random forest (RF), and K-nearest neighbor algorithms as its base models and traditional logistic regression (LR) as its meta-model. The meta-model used the outputs of all 3 base models as input and generated the output of the stacking model. Another LR-based pLOS prediction model was built as the benchmark model. The prediction performance of the stacking model was compared with that of its base models and the benchmark model. Five-fold cross-validation was employed to develop and validate the models. Performance measures included the Brier score, area under the receiver operating characteristic curve (AUROC), estimated calibration index (ECI), accuracy, sensitivity, specificity, and geometric mean (Gm). In addition, a calibration plot was employed to visually demonstrate the calibration power of each model.

Results

The final cohort extracted from the HQMS database consisted of 23,992 eligible PD-treated patients, among whom 30.3% had a pLOS (ie, longer than the average LOS, which was 16 days in our study). Among the models, the stacking model achieved the best calibration (ECI 8.691), balanced accuracy (Gm 0.690), accuracy (0.695), and specificity (0.701). Meanwhile, the stacking and RF models had the best overall performance (Brier score 0.174 for both) and discrimination (AUROC 0.757 for the stacking model and 0.756 for the RF model). Compared with the benchmark LR model, the stacking model was superior in all performance measures except sensitivity, but there was no significant difference in sensitivity between the 2 models. The 2-sided t tests revealed significant performance differences between the stacking and LR models in overall performance, discrimination, calibration, balanced accuracy, and accuracy.

Conclusions

This study is the first to develop data-driven pLOS prediction models for PD-treated patients using basic admission data from a national database. The results indicate the feasibility of utilizing a stacking-based pLOS prediction model for PD-treated patients. The pLOS prediction tools developed in this study have the potential to assist clinicians in identifying patients at a high risk of pLOS and to allocate resources optimally for PD-treated patients.

Predictors of Opioid Prescription After Orthognathic Surgery in Opioid Naive Adults From a Large Database

BACKGROUND

Orthognathic surgery often requires postoperative opioid pain management. The goal of this study was to examine opioid prescribing patterns in adults after orthognathic surgery and to analyze factors associated with high-dose postoperative opioid administration and persistent opioid use.

METHODS

We included opioid naive adults in the IBM MarketScan Databases who had undergone orthognathic surgery from 2003 to 2017. Three outcomes were examined: presence of a perioperative outpatient opioid claim; total oral morphine milliequivalents (MMEs) in the perioperative period; and persistent opioid use. Univariate analysis and multiple regression were used to determine associations between the outcomes and independent variables.

RESULTS

Our study yielded a cohort of 8163 opioid naive adults, 45.6% of whom had an opioid claim in the perioperative period. The average prescribed MMEs in the perioperative period was 466 MMEs total, and 66 MMEs daily. Of patients with an opioid claim, 17.9% had persistent opioid use past 90 days. The presence of a complication was a predictor of having an opioid claim (P<0.001). Increasing age (P<0.001) and days hospitalized (P < 0.001) were associated with increased opioid usage. Persistent opioid use was associated with being prescribed more than 600 MMEs in the perioperative period (P < 0.001), as well as increasing age and days hospitalized. Interestingly, patients undergoing double-jaw surgery did not have significantly more opioids prescribed than those undergoing single-jaw surgery.

CONCLUSIONS

Prescription opioids are relatively uncommon after jaw surgery, although 17.9% of patients continue to use opioids beyond 3 months after surgery. Predictors of persistent opioid use in this population include the number of days hospitalized, increasing age, and increasing amount of opioid prescribed postoperatively.

Volume Pledge is Not Associated with Better Short-Term Outcomes After Lung Cancer Resection

PURPOSE

We examined the relationship between short-term outcomes and hospitals and surgeons who met minimum volume thresholds for lung cancer resection based on definitions provided by the Volume Pledge. A secondary aim was to evaluate the volume-outcome relationship to determine alternative thresholds in the event the Volume Pledge was not associated with outcomes.

PATIENTS AND METHODS

We conducted a retrospective study (2015-2017) using the Society of Thoracic Surgeons General Thoracic Surgery Database. We used generalized estimating equations that accounted for confounding and clustering to compare outcomes across hospitals and surgeons who did and did not meet the Volume Pledge criteria: ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons. Our secondary aim was to model volume by using restricted cubic splines to determine the association between volume and short-term outcomes.

RESULTS

Among 32,183 patients, 465 surgeons, and 209 hospitals, 16,630 patients (52%) received care from both a hospital and surgeon meeting the Volume Pledge criteria. After adjustment, there was no relationship with operative mortality, complications, major morbidity, a major morbidity-mortality composite end point, or failure to rescue. The Volume Pledge group had a 0.5 day (95% CI, 0.2 to 0.7 day) shorter length of stay. Our secondary aim revealed a nonlinear relationship between hospital volume and complications in which intermediate-volume hospitals had the highest risk of complications. Surgeon volume was associated with major morbidity, a major morbidity-mortality composite end point, and length of stay in an inverse linear fashion. Only 8% of surgeons had volumes associated with better outcomes.

CONCLUSION

The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A re-examination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.

Hospitalizations and length of stay of cancer patients: A cohort study in the Brazilian Public Health System

The hospitalizations are part of cancer care and has been studied by researchers worldwide. A better understanding about their associated factors may help to achieve improvements on this area. The aims of this study were to investigate the association between demographic and clinical characteristics and hospitalizations, as well as between these characteristics and the length of stay (LOS), within the first year of outpatient treatment, for the most incident cancers in the Brazilian population. In this cohort study, we investigated 417,477 patients aged 19 years or more, who started outpatient cancer treatment, from 2010-2014, for breast, prostate, colorectal, cervix, lung and stomach cancers. The outcomes evaluated were: i) Hospitalizations within the first year of outpatient cancer treatment; and ii) LOS of the hospitalized patients. It was performed a binary logistic regression to evaluate the association between the explanatory variables and the hospitalizations and a negative binomial regression to evaluate their influence on the length of hospital stay. The hospitalizations occurred for 34% of patients, with a median of LOS of 6 days (IQR: 2-15). Female patients were 16% less likely to be hospitalized (OR: 0.84; 95% CI: 0.82-0.86), with lower average of LOS (AR: 0.98; 95% CI: 0.97-0.99), each additional year of age reduced in 2% the hospitalization odds (OR: 0.98; 95% CI: 0.98-0.99) and in 1% the average of LOS (AR: 0.99; 95% CI: 0.98-0.99), patients from South region had twice more chances of hospitalization than from North region (OR: 2.01; 95% CI: 1.93-2.10) and patients with colorectal cancer had greater probability of hospitalization (OR: 4.42; 95% CI: 4.27-4.48), with the highest average of LOS (AR: 1.37; 95% CI: 1.35-1.40). In view of our results, we consider that the government must expand the policies with potential to reduce the number of hospitalizations.

Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors

BACKGROUND

Robot-assisted radical prostatectomy (RARP) can generally be performed with 1-2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day.

METHODS

Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications.

RESULTS

Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0-2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications.

CONCLUSIONS

This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.

Comparative clinical features and short-term outcomes of gastric and small intestinal gastrointestinal stromal tumours: a retrospective study

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. Recent research has shown that small intestinal GISTs exhibit more aggressive features than gastric GISTs. To compare the clinical features of gastric and small intestinal GISTs for the further prediction of different prognoses, we conducted a retrospective study. 43 patients in the small intestine group and 97 in the gastric group were collected between January 2016 and December 2017. Data on demographics, preoperative lab results, clinicopathological results and surgical management were compared between groups. Significant elements were subsequently included in logistic regression analysis for further identification. The Kaplan-Meier method and log-rank test were used to calculate the relapse-free survival (RFS) rate and cumulative survival rate. Univariable analysis demonstrated that underlying disease, gastrointestinal (GI) bleeding, lymphocyte count, haemoglobin (Hb), albumin (ALB), platelet-to-lymphocyte ratio (PLR), thrombin time (TT), National Institutes of Health (NIH) category, Dog1, surgical procedure types and postoperative hospitalization were different between the two groups. Among these factors, logistic regression analysis identified that patients in small intestinal group exhibited significantly higher GI bleeding rate (p = 0.022), NIH category (p = 0.031), longer postoperative hospitalization time (p = 0.001) with lower TT value (p = 0.030) than those in gastric group. The log-rank test indicated that the location of the GIST (p = 0.022), GIST with GI bleeding (p = 0.027) and NIH category (p = 0.031) were independent prognostic predictors for poor outcome regarding RFS. Regarding cumulative survival, only the location of the GIST (p = 0.027) was an independent prognostic predictor for poor outcome. Thus, we concluded that small intestine GISTs were associated with lower TT, recurrent GI bleeding, advanced NIH category and extended postoperative hospitalization. Nevertheless, future multicentre prospective study are expected to validate our results.

Development and validation of nomogram estimating post-surgery hospital stay of lung cancer patients: relevance for predictive, preventive, and personalized healthcare strategies

OBJECTIVE

In the era of fast track surgery, early and accurately estimating whether postoperative length of stay (p-LOS) will be prolonged after lung cancer surgery is very important, both for patient's discharge planning and hospital bed management. Pulmonary function tests (PFTs) are very valuable routine examinations which should not be underutilized before lung cancer surgery. Thus, this study aimed to establish an accurate but simple prediction tool, based on PFTs, for achieving a personalized prediction of prolonged p-LOS in patients following lung resection.

METHODS

The medical information of 1257 patients undergoing lung cancer surgery were retrospectively reviewed and served as the training set. p-LOS exceeding the third quartile value was considered prolonged. Using logistic regression analyses, potential predictors of prolonged p-LOS were identified among various preoperative factors containing PFTs and intraoperative factors. A nomogram was constructed and subjected to internal and external validation.

RESULTS

Five independent risk factors for prolonged p-LOS were identified, including older age, being male, and ratio of residual volume to total lung capacity (RV/TLC) ≥ 45.0% which is the only modifiable risk factor, more invasive surgical approach, and surgical type. The nomogram comprised of these five predictors exhibited sufficient predictive accuracy, with the area under the receiver operating characteristic curve (AUC) of 0.76 [95% confidence interval (CI) 0.73-0.79] in the internal validation. Also its predictive performance remained fine in the external validation, with the AUC of 0.70 (95% CI 0.60-0.79). The calibration curves showed satisfactory agreements between the model predicted probability and the actually observed probability.

CONCLUSIONS

Preoperative amelioration of RV/TLC may prevent lung cancer patients from unnecessary prolonged p-LOS. The integrated nomogram we developed could provide personalized risk prediction of prolonged p-LOS. This prediction tool may help patients perceive expected hospital stays and enable clinicians to achieve better bed management after lung cancer surgery.

Evaluation of adherence to the Commission on Cancer lung cancer quality measures

OBJECTIVE

In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer.

METHODS

The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics.

RESULTS

Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy.

CONCLUSIONS

Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.

All grades of severity of postoperative adverse events are associated with prolonged length of stay after lung cancer resection

OBJECTIVE

To determine whether all grades of severity of postoperative adverse events are associated with prolonged length of stay in patients undergoing pulmonary cancer resection.

METHODS

This was a retrospective cohort study of all patients who underwent pulmonary resection with curative intent for malignancy at The Ottawa Hospital, Division of Thoracic Surgery (January 2008 to July 2015). Postoperative adverse events were collected prospectively with the Thoracic Morbidity & Mortality System, based on the Clavien-Dindo severity classification. Patient demographics, comorbidities, preoperative investigations, cardiopulmonary assessment, pathologic staging, operative characteristics, and length of stay were retrospectively reviewed. Prolonged hospital stay was defined as >75th percentile for each procedure performed (wedge resection 6 days, segmentectomy 6 days, lobectomy 7 days, extended lobectomy 8 days, pneumonectomy 10 days). Univariable and multivariable logistic regression analyses were conducted to identify factors associated with prolonged hospital stay.

RESULTS

Of 1041 patients, 579 (55.6%) were female, 610 (58.1%) were >65 years old, 232 (22.3%) experienced prolonged hospital stay, and 416 (40.0%) patients had ≥1 postoperative adverse event. Multivariable analyses identified significant (P < .05) factors associated with prolonged hospital stay to be (odds ratio; 95% confidence interval): lower diffusion capacity of the lung for carbon monoxide (0.99; 0.98-0.99), surgical approach: open thoracotomy (1.8; 1.3-2.5), and presence of any postoperative adverse event: Grade I (5.8; 3.3-10.2), Grade II (6.0; 4.0-8.9), Grade III (11.4; 7.0-18.7), and Grade IV (19.40; 7.1-55.18).

CONCLUSIONS

Lower diffusion capacity of the lung for carbon monoxide, open thoracotomy approach, and the development of any postoperative adverse event, including minor events that required no additional therapy, were factors associated with prolonged hospital stay.

Effects of immediate post-operative pain medication on length of hospital stay: does it make a difference?

BACKGROUND

Patient reported outcomes and length of hospital stay (LOS) are being used as a proxy for hospital care. An extra day of hospitalization costs thousands of health care dollars. The choice of intraoperative pain medications has been associated with decreased pain scores in other surgical subspecialties. However, the effects of immediate post-operative patient-controlled analgesics (PCA)/intravenous (IV) pain medication on patient care are not well understood in spine surgery. The aim of this study is to determine the effects of different immediate post-operative pain medications on post-operative complications profile, LOS, and patient reported outcomes (PROs) after elective spine surgery.

METHODS

The medical records of 230 patients (morphine: n=98, fentanyl: n=61, hydromorphone: n=71) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized by the immediate post-operative pain medication they were on, with the most common medications being PCA/IV morphine, fentanyl, and hydromorphone. Patient demographics, comorbidities, and post-operative complication rates were collected. All patients had retrospectively collected outcomes measures and a minimum of 6-month follow up. Patient reported outcomes instruments [Oswestry Disability Index (ODI), SF-36 and Neck/Back/Leg-Pain Visual Analog Scale (VAS-NP/BP/LP)] were completed before surgery, then at 3- and 6-month after surgery.

RESULTS

Baseline characteristics were similar in all cohorts. Operative variables were also similar in all cohorts, with no difference in operative time, estimated blood loss (EBL), or fusion levels. Complication rates were similar between cohorts, with the fentanyl-cohort having an increased percentage of urinary tract infection (UTI) than the morphine and hydromorphone cohorts (16.39% vs. 5.15% vs. 5.63%, P=0.0277). The morphine-cohort had a decreased LOS than the fentanyl and hydromorphone cohorts (4.18 vs. 5.56 vs. 5.69 days, P=0.0376). There was a significant difference in the number of feet first ambulated by the patient post-operatively for the morphine and hydromorphone cohorts than the fentanyl-cohort (morphine: 118.44±18.15 vs. fentanyl: 59.26±20.78 vs. hydromorphone: 125.91±19.85, P=0.0420). There was no significant differences in 30-day hospital readmission rates between the cohorts, morphine-cohort did trend lower than the other cohorts (morphine: 5.10 vs. fentanyl: 11.48 vs. hydromorphone: 11.27, P=0.2492). There were no significant differences in PROs between the two cohorts in ODI, SF-36, and VAS-NP/BP/LP at baseline, 3- and 6-month.

CONCLUSIONS

Our study demonstrates that the choice of immediate post-operative pain medication can make a difference in the hospital course for patients. Identifying these types of factors might help increase patient care and reduce health care costs.

Variability in length of stay after uncomplicated pulmonary lobectomy: is length of stay a quality metric or a patient metric?†

OBJECTIVES

Previous studies have identified predictors of prolonged length of stay (LOS) following pulmonary lobectomy. LOS is typically described to have a direct relationship to postoperative complications. We sought to determine the LOS and factors associated with variability after uncomplicated pulmonary lobectomy.

METHODS

Analysing the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality database, we reviewed lobectomies performed (2009-11) on patients in California, Florida and New York. LOS and comorbidities were identified. Multivariable regression analysis (MVA) was used to determine factors associated with LOS greater than the median. Patients with postoperative complications or death were excluded.

RESULTS

Among 22 647 lobectomies performed, we identified 13 099 patients (58%) with uncomplicated postoperative courses (mean age = 66 years; 56% female; 76% white, 57% Medicare; median DEYO comorbidity score = 3, 55% thoracotomy, 45% thoracoscopy/robotic). There was a wide distribution in LOS [median LOS = 5 days; interquartile range (IQR) 4-7]. By MVA, predictors of prolonged LOS included, age ≥ 75 years [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.4-2.0], male gender (OR 1.2, 95% CI 1.1-1.2), chronic obstructive pulmonary disease (OR 1.6, 95% CI 1.5-1.7) and other comorbidities, Medicaid payer (OR 1.7, 95% CI 1.4-2.1) versus private insurance, thoracotomy (OR 3.0, 95% CI 2.8-3.3) versus video-assisted thoracoscopic surgery/robotic approach and low hospital volume (OR 2.4, 95% CI 2.1-2.6).

CONCLUSIONS

Variability exists in LOS following even uncomplicated pulmonary lobectomy. Variability is driven by clinical factors such as age, gender, payer and comorbidities, but also by surgical approach and volume. All of these factors should be taken into account when designing clinical care pathways or when allocating payment resources. Attempts to define an optimal LOS depend heavily upon the patient population studied.

Ninety-day postdischarge outcomes of inpatient elective laparoscopic cholecystectomy

BACKGROUND

Little information is available about postdischarge adverse events after laparoscopic cholecystectomy.

METHODS

Inpatient and 90-day postdischarge adverse events were identified for Medicare patients discharged in 2009-2010 after undergoing elective laparoscopic cholecystectomy on day 0, 1, or 2 of hospitalization at facilities that performed 20 or more laparoscopic cholecystectomies during the study period. A predictive length of stay (LOS) linear regression model was derived and used to identify patients with prolonged LOS (prLOS) whose risk-adjusted LOS exceeded a 3σ upper limit on a moving average control chart. Rates of inpatient and 90-day fatal and nonfatal adverse events and interrelationships among different outcomes and alternative outcome measures were explored.

RESULTS

Of 89,639 study cases, 0.7% died during their index hospitalization, and 1.3% died within 90 days of discharge. Of live discharges, 8.0% had prLOS, and 42.1% had coded complication. In the 90 days after discharge, 9,416 (10.6%) were readmitted. Patients who were prLOS outliers were more likely to die or be readmitted than nonoutliers (P < .0001; χ(2)).

CONCLUSION

More than 18% of Medicare patients undergoing presumably low-risk elective inpatient laparoscopic cholecystectomy died, had a severe inpatient complication, or were readmitted within 90 days of discharge.

Extended length of stay after surgery: complications, inefficient practice, or sick patients?

IMPORTANCE

With the health policy focus on shifting risk to hospitals and physicians, hospital leaders are increasing efforts to reduce excessive resource use, such as patients with extended length of stay (LOS) after surgery. However, the degree to which extended LOS represents complications, patient illness, or inefficient practice style is unclear.

OBJECTIVE

To examine the influence of complications on the variance in hospitals' extended LOS rates after colorectal resections.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study performed from January 1 through December 31, 2009, we analyzed data from the 2009 American College of Surgeons National Surgical Quality Improvement Program. Study participants were 22 664 adults undergoing colorectal resections in 199 hospitals.

EXPOSURES

Inpatient complications recorded in the American College of Surgeons National Surgical Quality Improvement Program registry. Inpatient complications were identified by the association of the complication's postoperative date with the patient's surgical discharge date.

MAIN OUTCOME AND MEASURE

Hospitals' risk-adjusted extended LOS rates, defined as the proportion of patients with a hospital stay greater than the 75th percentile for the entire cohort.

RESULTS

A total of 2177 patients (42.8%) with extended LOSs did not have a documented inpatient complication. Although there was wide variation in risk-adjusted extended LOS (14.5%-35.3%) and risk-adjusted inpatient complication (12.1%-28.5%) rates, there was only a weak correlation (Spearman ρ = 0.56, P < .001) between the two. Only 52.0% of the variation in hospitals' extended LOS rates was attributable to hospitals' inpatient complication rates.

CONCLUSIONS AND RELEVANCE

Much of the variation in hospitals' risk-adjusted extended LOS rates is not attributable to patient illness or complications and therefore most likely represents differences in practice style. Efforts to reduce excess resource use should focus on efficiency of care, such as increased adoption of enhanced recovery pathways.

Ninety-day costs of video-assisted thoracic surgery versus open lobectomy for lung cancer

BACKGROUND

Complications after pulmonary resection lead to higher costs of care. Video-assisted thoracoscopic surgery (VATS) for lobectomy is associated with fewer complications, but lower inpatient costs for VATS have not been uniformly demonstrated. Because some complications occur after discharge, we compared 90-day costs of VATS lobectomy versus open lobectomy and explored whether differential health care use after discharge might account for any observed differences in costs.

METHODS

A cohort study (2007-2011) of patients with lung cancer who had undergone resection was conducted using MarketScan-a nationally representative sample of persons with employer-provided health insurance. Total costs reflect payments made for inpatient, outpatient, and pharmacy claims up to 90 days after discharge.

RESULTS

Among 9,962 patients, 31% underwent VATS lobectomy. Compared with thoracotomy, VATS was associated with lower rates of prolonged length of stay (PLOS) (3.0% versus 7.2%; p<0.001), 90-day emergency department (ED) use (22% versus 24%; p=0.005), and 90-day readmission (10% versus 12%; p=0.026). Risk-adjusted 90-day costs were $3,476 lower for VATS lobectomy (p=0.001). Differential rates of PLOS appeared to explain this cost difference. After adjustment for PLOS, costs were $1,276 lower for VATS, but this difference was not significant (p=0.125). In the fully adjusted model, PLOS was associated with the highest cost differential (+$50,820; p<0.001).

CONCLUSIONS

VATS lobectomy is associated with lower 90-day costs--a relationship that appears to be mediated by lower rates of PLOS. Although VATS may lead to lower rates of PLOS among patients undergoing lobectomy, observational studies cannot verify this assertion. Strategies that reduce PLOS will likely result in cost-savings that can increase the value of thoracic surgical care.

Surgical lung biopsy in transplant patients with diffuse lung disease: how much worse when the lung is the graft?

BACKGROUND

There are no data that compare the clinical presentation and results of surgical lung biopsy (SLB) for diffuse lung disease (DLD) in lung transplant patients, in contrast to individuals with other type of solid organ grafts. Our objective was to compare the clinical picture, radiologic pattern, pathology results, and outcomes of SLB for DLD in these two subsets of patients.

METHODS

We retrospectively reviewed the clinical records of transplant patients undergoing SLB for DLD at our institution between 2004 and 2011. Patients with lung transplants and those with other transplants were compared.

RESULTS

During the study period, 1,232 solid organ transplants were done at our institution. Of these, 49 patients (4%) had DLD that needed SLB for diagnosis, and 24 of these patients had a lung transplant. Dyspnea and a radiologic reticular pattern were more frequent in lung transplant patients, 21 of 24 vs 11 of 25 (p = 0.001) and 14 of 24 vs 7 of 25 (p = 0.03), respectively. Although postoperative complications and in-hospital deaths were more common in lung transplant patients, the differences were not statistically significant. Having the SLB performed for diagnosis, as opposed to being conducted for DLD that did not improve on medical treatment, had a protective effect on multivariate analysis (hazard ratio, 0.39; 95% confidence interval, 0.16 to 0.96; p = 0.042). A prior lung transplant was the only independent predictor of survival (hazard ratio, 4.62; 95% confidence interval, 1.53 to 13.92, p = 0.006).

CONCLUSIONS

It is relatively uncommon for a solid organ transplant patient with DLD to require a SLB. Clinical and radiologic presentation differ in patients with lung transplants compared with other transplants. Postoperative outcomes are not significantly different between the groups. SLB performed early in the course of the disease might be beneficial. Having a lung transplant is a significant negative predictor of survival.