Socioeconomic Factors Are Associated With Readmission After Lobectomy for Early Stage Lung Cancer

Readmission after enhanced recovery video-assisted thoracoscopic surgery wedge resection

BACKGROUND

Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection.

METHODS

A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0-30 days postoperatively) and late readmission (occurring within 31-90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses.

RESULTS

A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1-2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission.

CONCLUSIONS

Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia.

Identifying the origin of socioeconomic disparities in outcomes of major elective operations

Background

While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences.

Methods

The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest.

Results

Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98).

Conclusion

This study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.

Predictors of Readmission After Pulmonary Resection in Patients With Lung Cancer: A Systematic Review and Meta-analysis

Objective: Postoperative readmissions are considered an indicator of healthcare quality. The purpose of this study was to assess the factors associated with readmission following pulmonary resection for lung cancer. Methods: A comprehensive search was performed in PubMed, Web of science, the Cochrane Library, and databases of CNKI and Wanfang. We collected the factors associated with readmission following pulmonary resection from the included studies, and data analysis was conducted with STATA SE12.0 software. Results: A total of 11 studies (386 012 participants) were included. The meta-analysis results showed that age (standardized mean difference [SMD] = 0.093), male sex (odds ratio [OR] = 1.260), Charlson score (SMD = 1.408), forced expiratory volume in 1 second predicted (SMD = -0.203), congestive heart failure (OR = 1.708), peripheral vascular disease (OR = 1.436), and histology (OR = 0.804) were associated with readmission (P < .05), while hypertension was not. Patients with postoperative empyema, pneumonia, air leak, and arrhythmia (all P < .05) had higher odds of hospital readmission. Conclusion: The predictive factors for readmission can help in establishing individualized discharge and follow-up plans and programs for reducing hospital readmissions after pulmonary resection in patients with lung cancer.

Social disparities in unplanned 30-day readmission rates after hospital discharge in patients with chronic health conditions: A retrospective cohort study using patient level hospital administrative data linked to the population census in Switzerland

Unplanned readmissions shortly after discharge from hospital are common in chronic diseases. The risk of readmission has been shown to be related both to hospital care, e.g., medical complications, and to patients’ resources and abilities to manage the chronic disease at home and to make appropriate use of outpatient medical care. Despite a growing body of evidence on social determinants of health and health behaviour, little is known about the impact of social and contextual factors on readmission rates. The objective of this study was to analyse possible effects of educational, financial and social resources of patients with different chronic health conditions on unplanned 30 day-readmission risks. The study made use of nationwide inpatient hospital data that was linked with Swiss census data. The sample included n = 62,109 patients aged 25 and older, hospitalized between 2012 and 2016 for one of 12 selected chronic conditions. Multivariate logistic regressions analysis was performed. Our results point to a significant association between social factors and readmission rates for patients with chronic conditions. Patients with upper secondary education (OR = 1.26, 95% CI: 1.11, 1.44) and compulsory education (OR = 1.51, 95% CI: 1.31, 1.74) had higher readmission rates than those with tertiary education when taking into account demographic, social and health status factors. Having private or semi-private hospital insurance was associated with a lower risk for 30-day readmission compared to patients with mandatory insurance (OR = 0.81, 95% CI: 0.73, 0.90). We did not find a general effect of social resources, measured by living with others in a household, on readmission rates. The risk of readmission for patients with chronic conditions was also strongly predicted by type of chronic condition and by factors related to health status, such as previous hospitalizations before the index hospitalization (+77%), number of comorbidities (+15% higher probability per additional comorbidity) as well as particularly long hospitalizations (+64%). Stratified analysis by type of chronic condition revealed differential effects of social factors on readmissions risks. Compulsory education was most strongly associated with higher odds for readmission among patients with lung cancer (+142%), congestive heart failure (+63%) and back problems (+53%). We assume that low socioeconomic status among patients with chronic conditions increases the risk of unplanned 30-day readmission after hospitalisation due to factors related to their social situation (e.g., low health literacy, material deprivation, high social burden), which may negatively affect cooperation with care providers and adherence to recommended therapies as well as hamper active participation in the medical process and the development of a shared understanding of the disease and its cure. Higher levels of comorbidity in socially disadvantaged patients can also make appropriate self-management and use of outpatient care more difficult. Our findings suggest a need for increased preventive measures for disadvantaged populations groups to promote early detection of diseases and to remove financial or knowledge-based barriers to medical care. Socially disadvantaged patients should also be strengthened more in their individual and social resources for coping with illness.

Distance of Residence From the Cancer Center Influences Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy?

Introduction

Increased distance of residence from the hospital has been previously associated with worse postoperative outcomes, especially increased hospital length of stay (LOS) after elective surgery in the USA as well as after pulmonary lobectomy in Japan. We sought to determine if the distance from our cancer center affects postoperative outcomes after robotic-assisted pulmonary lobectomy.

Methods

We retrospectively analyzed 449 patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Two patients were excluded due to incomplete data. Each patient’s residential ZIP code was used to determine the distance of their primary residence from our cancer center. Group 1 consisted of patients living less than 120 miles away while Group 2 consisted of patients living more than 120 miles away. Demographic factors, preoperative comorbidities, the incidence of postoperative complications, chest tube duration, and hospital LOS were compared by the Pearson chi-square or Kruskal-Wallis tests, and Kaplan-Meier survival was compared by Cox regression. Statistical significance was established as p≤0.05.

Results

Group 1 was found to have a higher mean body mass index (BMI) (28.3 kg/m²) than Group 2 (27.0 kg/m²; p=.031). Group 1 also tended to have a higher rate of preoperative hypertension (HTN; 59%) than Group 2 (47%; p=.018). No other preoperative comorbidities were significant. Median hospital LOS was found to differ between Group 1 (4 days) and Group 2 (5 days; p=.048). Postoperative complication rates did not differ between Group 1 (35%) and Group 2 (40%; p=.370). Median chest tube durations for Group 1 (4 days) vs. Group 2 (4 days) did not differ (p=.093). Five-year overall survival (OS) did not differ between the two groups (p=.550).

Conclusions

Longer distance from patient residence to our cancer center was associated with higher BMI, higher rates of preoperative HTN, and longer LOS. Postoperative complication rates, chest tube duration, and five-year OS were not significantly affected by distance. These results supported similar results in a Japanese study that indicated distance extends the LOS, regardless of the type of transportation used by patients. Further research analyzing the effects of socioeconomic status and insurance coverage on perioperative outcomes should be conducted to identify subpopulations in the USA that suffer disparities in access to and delivery of healthcare.

Disparities in surgical outcomes for low socioeconomic status patients in Australia

Background

There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self‐reported unemployment and neighbourhood level socioeconomic status in Australia.

Methods

A retrospective administrative data review was conducted at a tertiary care centre over a 10‐year period (2008–2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed.

Results

106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50–2.82), OR 1.37 (1.15–1.64)), all complications (OR 1.43 (1.31–1.56), OR 1.21 (1.14–1.28)), failure to rescue (OR 2.03 (1.39–2.95), OR 1.38 (1.11–1.72)) and return to theatre (OR 1.42 (1.27–1.59), OR 1.24 (1.14–1.36)) (P < 0.005 for all).

Conclusions

Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

The Impact of Social Determinants of Health on 30 and 90-Day Readmission Rates After Spine Surgery

BACKGROUND

Since its 2012 inception, the U.S. Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP) has espoused cost-effective health-care delivery by financially penalizing hospitals with excessive 30-day readmission rates. In this study, we hypothesized that socioeconomic factors impact readmission rates of patients undergoing spine surgery.

METHODS

In this study, 2,830 patients who underwent a spine surgical procedure between 2012 and 2018 were identified retrospectively from our institutional database, with readmission (postoperative day [POD] 0 to 30 and POD 31 to 90) as the outcome of interest. Patients were linked to U.S. Census Tracts and ZIP codes using the Geographic Information Systems (ArcGIS) mapping program. Social determinants of health (SDOH) were obtained from publicly available databases. Patient income was estimated at the Public Use Microdata Area level based on U.S. Census Bureau American Community Survey data. Univariate and multivariable stepwise regression analyses were conducted. Significance was defined as p < 0.05, with Bonferroni corrections as appropriate.

RESULTS

Race had a significant effect on readmission only among patients whose estimated incomes were <$31,650 (χ2 = 13.4, p < 0.001). Based on a multivariable stepwise regression, patients with estimated incomes of <$31,000 experienced greater odds of readmission by POD 30 compared with patients with incomes of >$62,000; the odds ratio (OR) was 11.06 (95% confidence interval [CI], 6.35 to 15.57). There were higher odds of 30-day readmission for patients living in neighborhoods with higher diabetes prevalence (OR, 3.02 [95% CI, 1.60 to 5.49]) and patients living in neighborhoods with limited access to primary care providers (OR, 1.39 [95% CI, 1.10 to 1.70]). Lastly, each decile increase in the Area Deprivation Index of a patient's Census Tract was associated with higher odds of 30-day readmission (OR, 1.40 [95% CI, 1.30 to 1.51]).

CONCLUSIONS

Socioeconomically disadvantaged patients and patients from areas of high social deprivation have a higher risk of readmission following a spine surgical procedure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Autologous Breast Reconstruction is Associated with Lower 90-day Readmission Rates

Background:

Methods:

Results:

Conclusions:

[Patient outcomes after lung resection. The impact of unplanned readmission]

Unplanned readmissions after lung cancer surgery impair normal postoperative recovery and are associated with increased postoperative mortality. The objective of this review was to compile a detailed and comprehensive dataset on unplanned readmissions after pulmonary resection so as to better understand the associated factors and how they may be attenuated. Based on the identified risk factors, prevention involves improved preoperative preparation of at-risk patients and preoperative discharge planning so as to help prevent unscheduled readmissions, which are predictive of a poorer prognosis.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

BACKGROUND

Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery.

METHODS

Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI.

RESULTS

Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery.

CONCLUSIONS

In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Readmission After Lobectomy for Lung Cancer: Not All Complications Contribute Equally

OBJECTIVE

The aim of this study was to identify independent predictors of hospital readmission for patients undergoing lobectomy for lung cancer.

SUMMARY BACKGROUND DATA

Hospital readmission after lobectomy is associated with increased mortality. Greater than 80% of the variability associated with readmission after surgery is at the patient level. This underscores the importance of using a data source that includes detailed clinical information.

METHODS

Using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), we conducted a retrospective cohort study of patients undergoing elective lobectomy for lung cancer. Three separate multivariable logistic regression models were generated: the first included preoperative variables, the second added intraoperative variables, and the third added postoperative variables. The c statistic was calculated for each model.

RESULTS

There were 39,734 patients from 277 centers. The 30-day readmission rate was 8.2% (n = 3237). In the final model, postoperative complications had the greatest effect on readmission. Pulmonary embolus {odds ratio [OR] 12.34 [95% confidence interval (CI),7.94-19.18]} and empyema, [OR 11.66 (95% CI, 7.31-18.63)] were associated with the greatest odds of readmission, followed by pleural effusion [OR 7.52 (95% CI, 6.01-9.41)], pneumothorax [OR 5.08 (95% CI, 4.16-6.20)], central neurologic event [OR 3.67 (95% CI, 2.23-6.04)], pneumonia [OR 3.13 (95% CI, 2.43-4.05)], and myocardial infarction [OR 3.16 (95% CI, 1.71-5.82)]. The c statistic for the final model was 0.736.

CONCLUSIONS

Complications are the main driver of readmission after lobectomy for lung cancer. The highest risk was related to postoperative events requiring a procedure or medical therapy necessitating inpatient care.

[Readmissions after lung resection in France: The PMSI database]

BACKGROUND

Readmission within 30 days is an indicator of the quality of care, because it often reflects post-discharge care that is not optimal. The objective of this work is to measure over time on the one hand the readmission rate and on the other hand the number of hospitals with a standardized readmission rate beyond the national average.

METHOD

All patients with major pulmonary resection for lung cancer in France were extracted from the PMSI national database. Readmission within 30 days was defined as any new hospitalization either in the same hospital or in another establishment.

RESULTS

From January 1, 2005 to December 31, 2018, 110,603 patients were included. The 30-day all-cause readmissions rate was 24.9% (n=27,540). Patients after pneumonectomy had a readmission rate of 37% (n=4918) and 23% after lobectomy (n=2684) (P<0.0001). For the first period, we counted 10 hospitals with a standardized readmissions rate above the 99.8 limit and 10 hospitals above the 95% limit. For the second period, 8 hospitals had a standardized readmission rate above the 99.8% limit and 11 hospitals above the 95% limit. For the third period, 7 hospitals had a standardized readmission rate above the 99.8% limit and 6 hospitals above the 95% limit.

CONCLUSION

Readmissions to hospital 30 days after major lung resection for cancer in France declined little during these three periods. Measures to prevent readmissions should be introduced.

Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer

Background

To review and discuss the current literature regarding socio-economic and racial disparities in the treatment of early-stage non-small cell lung cancer (NSCLC).

Methods

Narrative review of peer reviewed literature synthesizing findings retrieved from searches of computerized databases, primary article reference lists, authoritative texts and expert options.

Results

The current incidence of lung cancer appears to be similar between White and Black patients. However, Black patients are substantially less likely to receive curative intent surgery. Mitigation strategies do exist to narrow this inequity. Lower socioeconomic status (SES) is associated with a higher incidence of lung cancer, lower utilization of surgery and poorer outcomes after surgery.

Conclusions

Race and SES remain closely linked to outcomes in lung cancer. Outcomes are still worse when controlling for stage and specifically, in early-stage disease, surgical therapy is consistently underused in Black patients and patients of low SES.

The role of gender in non-small cell lung cancer: a narrative review

The role of gender in the development, treatment and prognosis of thoracic malignancies has been underappreciated and understudied. While most research has been grounded in tobacco-related malignancies, the incidence of non-smoking related lung cancer is on the rise and disproportionately affecting women. Recent research studies have unveiled critical differences between men and women with regard to risk factors, timeliness of diagnosis, incongruent screening practices, molecular and genetic mechanisms, as well as response to treatment and survival. These studies also highlight the increasingly recognized need for targeted therapies that account for variations in the response and complications as a function of gender. Similarly, screening recommendations continue to evolve as the role of gender is starting to be ellucidated. As women have been underrepresented in clinical trials until recently, the data regarding optimal care and outcomes is still lagging behind. Understanding the underlying similarities and differences between men and women is paramount to providing adequate care and prognostication to patients of either gender. This review provides an overview of the critical role that gender plays in the care of patients with non-small cell lung cancer and other thoracic malignancies, with an emphasis on the need for increased awareness and further research to continue elucidating these disparities.

Adding a Social Risk Adjustment Into the Estimation of Efficiency: The Case of Chilean Hospitals

BACKGROUND AND OBJECTIVES

There is much interest in adding social variables to hospital performance assessments. Many of the existing analyses, however, already include patients' diagnosis data, and it is not clear that adding a social adjustment variable would improve the quality of the results: the growing literature on this issue provides mixed results. The purpose in this study was to add evidence from a developing country into this discussion.

METHODS

We estimate the efficiency of hospitals controlling for casemix, with and without adjusting the hospital's casemix for the patients' sociodemographic variables. The magnitude of the adjustment is based on the observed impact of age, sex, and income on length of stay, conditional on the diagnosis related group (DRG). We use a data envelopment analysis (DEA) to assess the efficiency of 50 Chilean hospitals' discharges, including 780 DRGs and covering about 60% of total discharges in Chile from 2013 to 2015.

RESULTS

We found that the sociodemographic adjustment introduces very small changes in the DEA estimation of efficiency. The underlying reason is the relatively low influence of sociodemographics on hospital costs, conditional on DRG, and the changing pattern of sociodemographics across DRGs for any given hospital.

CONCLUSION

We conclude that the casemix-adjusted estimation of hospital efficiency is robust to the heterogeneity of patients' sociodemographic heterogeneity across hospitals. These results confirm, in a developing country, what has been observed in developed countries. For management purposes, then, the processing costs of adding social variables into hospitals' performance assessments might not be justified.

Lower household income is associated with an increased risk of hospital readmission in patients with decompensated cirrhosis

BACKGROUND AND AIM

The impact of household income, a surrogate of socioeconomic status, on hospital readmission rates for patients with decompensated cirrhosis has not been well characterized.

METHODS

The Nationwide Readmission Database from 2012 to 2014 was used to study the association of lower median household income on 30-, 90-, and 180-day hospital readmission rates for patients with decompensated cirrhosis.

RESULTS

From the 42 679 001 hospital admissions contained in the sample, there were 82 598 patients with decompensated cirrhosis who survived a hospital admission in the first 6 months of the year. During a uniform 6-month follow-up period, 25 914 (31.4%), 39 928 (48.3%), and 47 496 (57.5%) patients were readmitted at 30, 90, and 180 days, respectively. After controlling for demographic and clinical confounders, patients residing in the three lowest income quartiles were significantly more likely to be readmitted at 30 days than those in the fourth quartile (first quartile, odds ratio [OR] 1.32 [95% confidence interval, CI, 1.17-1.47, P < 0.01]; second quartile, OR 1.25 [95% CI 1.13-1.38, P < 0.01]; and third quartile, OR 1.08 [95% CI 0.97-1.20, P = 0.07]). The association between lower socioeconomic status and the higher risk of readmissions persisted at 90 days (first quartile, OR 1.21 [95% CI 1.14-1.30, P < 0.01]) and 180 days (first quartile, OR 1.32 [95% CI 1.20-1.44, P < 0.01]).

CONCLUSION

Patients with decompensated cirrhosis residing in the lowest income quartile had a 32% higher odds of hospital readmissions at 30, 90, and 180 days compared with those in the highest income quartile.

Socioeconomic risk-adjustment with the Area Deprivation Index predicts surgical morbidity and cost

BACKGROUND

There is a strong association between socioeconomic status and surgical outcomes; however, the optimal method for socioeconomic risk-stratification remains elusive. We aimed to compare 2 metrics of socioeconomic ranking by ZIP code, the Distressed Communities Index, and the Area Deprivation Index and their association with surgical outcomes.

METHODS

This retrospective study included all general surgery cases performed at a single institution from 2005 to 2015. Each patient was assigned Distressed Communities Index and Area Deprivation Index scores based on ZIP code. Both indices are normalized composite measures of socioeconomic status derived from census data. Primary outcome was 30-day morbidity; secondary outcomes included long-term mortality and cost, stratified by socioeconomic status. The utility of the addition of each metric to the American College of Surgeons National Surgical Quality Improvement Program risk calculator was assessed.

RESULTS

The 9,843 patients had normally distributed Distressed Communities Index (47.3 ± 22.4) and Area Deprivation Index (35.4 ± 19.0). Patients who experienced any complication or readmission had significantly higher Distressed Communities Index (48.6 vs 47.1, P = .04) and Area Deprivation Index (37.2 vs 35.1, P = .002). Risk-adjusted models demonstrated that only Area Deprivation Index independently predicted postoperative complications (odds ratio 1.11, P = .02), improved the discrimination of risk-stratification when added to the American College of Surgeons National Surgical Quality Improvement Program risk calculator (area under curve 0.758-0.790, P = .02), and was associated with hospitalization cost ($1,811 ± 856/quartile, P = .03).

CONCLUSION

Area Deprivation Index provides improved socioeconomic risk-adjustment in this surgical population. The addition of Area Deprivation Index to risk-stratification tools would allow us to better inform our patients of their expected postoperative courses, more accurately account for the increased cost of providing their care, and identify patients and regions that are most in need of improvements in health and healthcare.

Factors Associated with Unexpected Readmission Following Lung Resection

BACKGROUND

Identification of the predictors of readmission can facilitate appropriate perioperative management. The current study aimed to investigate the potential predictors of unexpected readmission after lung resection for primary lung cancers.

METHODS

This retrospective study enrolled 1000 patients who underwent pulmonary resection for lung cancer at our institution between January 2016 and December 2017. Unexpected readmission was defined as unscheduled readmission to our hospital within 30 days after discharge. Univariate and multivariate analyses were performed for identification of perioperative factors associated with readmission.

RESULTS

Forty-three patients (4.3%) required unexpected readmission, and the median interval between the day of discharge and readmission was 10 days (range 1-29 days). The reasons for readmission included empyema and pleural effusion (n = 11), acute exacerbation of idiopathic pulmonary fibrosis (n = 7), pneumothorax (n = 7), and others (n = 18). The median hospitalization length after readmission was 14 days (range 2-90 days). Four patients (9.3%) died in the hospital because of acute exacerbation of idiopathic pulmonary fibrosis after readmission. In multivariate logistic regression analysis, postoperative refractory air leakage, defined as prolonged air leakage lasting > 5 days or requiring reoperation, was identified as a significant predictor associated with an increased risk of readmission (odds ratio 2.87; 95% confidence interval 1.22-6.72; p = 0.015).

CONCLUSIONS

Unexpected readmission was an inevitable event following lung resection. Patients with readmission had an increased risk of death. Refractory air leakage after lung resection for primary lung cancer was strongly associated with unexpected readmission.

Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery

Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.

Socioeconomic Status and Days Alive and Out of Hospital after Major Elective Noncardiac Surgery: A Population-based Cohort Study

BACKGROUND

Socioeconomic status is an important but understudied determinant of preoperative health status and postoperative outcomes. Previous work has focused on the impact of socioeconomic status on mortality, hospital stay, or complications. However, individuals with low socioeconomic status are also likely to have fewer supports to facilitate them remaining at home after hospital discharge. Thus, such patients may be less likely to return home over the short and intermediate term after major surgery. The newly validated outcome, days alive and out of hospital, may be highly suited to evaluating the impact of socioeconomic status on this postdischarge period. The study aimed to determine the association of socioeconomic status with short and intermediate term postoperative recovery as measured by days alive and out of hospital.

METHODS

The authors evaluated data from 724,459 adult patients who had one of 13 elective major noncardiac surgical procedures between 2006 and 2017. Socioeconomic status was measured by median neighborhood household income (categorized into quintiles). Primary outcome was days alive and out of hospital at 30 days, while secondary outcomes included days alive and out of hospital at 90 and 180 days, and 30-day mortality.

RESULTS

Compared to the highest income quintile, individuals in the lowest quintile had higher unadjusted risks of postoperative complications (6,049 of 121,099 [5%] vs. 6,216 of 160,495 [3.9%]) and 30-day mortality (731 of 121,099 [0.6%] vs. 701 of 160,495 [0.4%]) and longer mean postoperative length of stay (4.9 vs. 4.4 days). From lowest to highest income quintile, the mean adjusted days alive and out of hospital at 30 days after surgery varied between 24.5 to 24.9 days.

CONCLUSIONS

Low socioeconomic status is associated with fewer days alive and out of hospital after surgery. Further research is needed to examine the underlying mechanisms and develop posthospital interventions to improve postoperative recovery in patients with fewer socioeconomic resources.

Household disposable income and long-term survival after pulmonary resections for lung cancer

Introduction

Socioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung cancer surgery should be unrelated to household income. The aim of this study was to investigate the association between household disposable income and survival following surgery for lung cancer in Sweden.

Methods

We conducted a nationwide population-based cohort study including all patients who underwent pulmonary resections for lung cancer in Sweden 2008–2017. Individual-level record linkages between national quality and health-data registers were performed to acquire information regarding socioeconomic status and medical history. Cox regression by quintiles of household disposable income was used to estimate the adjusted risk for all-cause mortality.

Results

We included 5500 patients and the age-adjusted and sex-adjusted incidence rate of death per 100 person-years was 15 and 9.4 in the lowest and highest income quintile, respectively (mean follow-up time 3.2 years). Deprived patients were older, had more comorbidities and were less likely to have preoperative positron emission tomography or minimally invasive surgery, compared with patients with higher income. The adjusted HR for death was 0.77 (95% CI: 0.62 to 0.96) for the highest income quintile compared with the lowest.

Conclusions

We found an association between household disposable income and survival in patients who underwent surgery for lung cancer in Sweden, despite tax-funded universal health coverage. The association remained after adjustment for differences in baseline characteristics.

Evidence-based follow-up in lung cancer?

In 2012 approximately 410,000 patients were diagnosed with lung cancer and about 353,000 lung cancer deaths were registered in the European Union. Although lung cancer is still the leading cause of cancer-related death worldwide, advances in detection and treatment have increased the likelihood of long-term survival. In patients receiving definitive curative treatment for lung cancer guidelines suggest follow-up of patients using clinical and radiological examinations over a certain period of time. However, standards differ and there are no generally accepted follow-up recommendations. Aim of this short review is to summarize the currently available knowledge and guidelines regarding surveillance of patients receiving definitive lung cancer treatment.

Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure

INTRODUCTION

While the number of total hip arthroplasties (THAs) performed increases, so is the number of postoperative readmissions, resulting in costly episodes of care that may disproportionately affect certain hospitals. This study examines the rates of readmission of patients to the same hospital at which they underwent index THA, compared with readmission to a different hospital.

METHODS

Data for all hospital discharges from 1995 to 2010 were obtained from the California Office of Statewide Health Planning and Development database. Patient outcomes, readmission data, demographic information, hospital teaching status, and location were analyzed. Regression modeling was used to evaluate the effect of hospital teaching status, location, and individual complications on the risk of readmission to the same hospital as opposed to a different hospital following the index procedure.

RESULTS

The overall postoperative readmission rate for specific defined complications or all-cause 30-day readmissions was 3.92%, with 75.17% readmitted to the same hospital. Following index THA at a nonacademic or academic hospital, 95.9% and 84.6% of patients were readmitted to the same type of hospital, respectively. Patients who had their index procedure at an academic hospital had lower odds for readmission to the same hospital (odds ratio, 0.734; P < 0.0001) compared with nonacademic centers. Hospitals in midsize towns had higher odds of readmission to the same hospital (odds ratio, 1.735; P = 0.0012) compared with those in large metropolitan areas.

DISCUSSION

Although more than 75% of patients with unplanned readmissions went to the same hospital as their index THA, academic and larger metropolitan hospitals had higher odds of postoperative readmissions to a different hospital.

Reintervention and Survival After Limited Lung Resection for Lung Cancer Treatment in Australia

BACKGROUND

To investigate the risk and predictors of reintervention (surgery or radiotherapy) after limited resection for lung cancer.

METHODS

A population-based, all-inclusive study using linked data from the New South Wales Admitted Patient Data Collection and Death Register included all patients undergoing limited resection for lung cancer between July 1, 2002, and March 31, 2014. Univariate and adjusted competing risk analyses were used to estimate the effect of potential factors for risk of reintervention within 6 months and 24 months of the initial surgery.

RESULTS

The overall 5-year survival for lung cancer patients undergoing limited lung resection was 52% (49% to 54%); for patients aged 70 years or more, the survival rate was 44% (40% to 47%). Reintervention occurred in 6.2% by 6 months and 11.3% by 24 months after the surgery. Younger age, surgery in private hospitals, and fewer comorbidities were independently associated with increased risk of reintervention. Patients who had the surgery performed in high surgical volume hospitals had 49% lower risk of reintervention within the first 6 months (95% confidence interval: 0.30 to 0.85). The effect of hospital surgical volume was attenuated by 24 months (hazard ratio 0.87, 95% confidence interval: 0.60 to 1.28). Patients undergoing reintervention within 6 months or 24 months had a twofold (1.52 to 2.57) and 2.3-fold (1.89 to 2.83) increased risk of death, respectively.

CONCLUSIONS

The reintervention rate within 6 or 24 months of initial limited lung cancer resection was modest, but there was considerable variation among hospitals. Reintervention was not a benign event and was associated with lower survival in an Australian population.

Unplanned readmission after lung resection surgery: A systematic review

Urgent readmissions have a major impact on outcomes in patient health and healthcare costs. The associated risk factors have generally been infrequently studied. The main objective of the present work is to identify pre- and perioperative determinants of readmission; the secondary aim was to determine readmission rate, identification of readmission diagnoses, and impact of readmissions on survival rates in related analytical studies. The review was performed through a systematic search in the main bibliographic databases. In the end, 19 papers met the selection criteria. The main risk factors were: sociodemographic patient variables; comorbidities; type of resection; postoperative complications; long stay. Despite the great variability in the published studies, all highlight the importance of reducing readmission rates because of the significant impact on patients and the healthcare system.

Perioperative Outcomes for Stage I Non-Small Cell Lung Cancer: Differences Between Men and Women

BACKGROUND

Previous studies have highlighted important biologic and survival-related differences among men and women with non-small cell lung cancer (NSCLC). However, differences in perioperative or short-term outcomes have not been as well characterized. In this study, we investigated differences in the perioperative period and postoperative emergency department (ED) visits among men and women after lobectomy for stage I NSCLC.

METHODS

A retrospective review was performed of patients who underwent a lobectomy for clinical stage I NSCLC at a single institution from 2010 to 2015.

RESULTS

We identified 559 patients for inclusion, including 293 women (52%) and 266 men (48%). Women were more likely to present with clinical T1 status (p = 0.005) and to undergo a minimally invasive operation (p = 0.058). To reduce confounding, 206 case-matched pairs were identified. After matching, no differences were found in length of stay (p = 0.551) or pulmonary complications (p = 0.509); however, men experienced more cardiac complications (18% versus 7%, p = 0.001). Of importance, although rates of 30- and 90-day ED visits between sexes were similar (p = 0.531, p = 0.890, respectively) and no sex-related differences were found in presenting symptom on return to the ED (p = 0.478), women were more likely to be readmitted after presenting to the ED within 30 days (p = 0.038).

CONCLUSIONS

Women demonstrated an increased likelihood of being admitted after presenting to the ED within 30 days after discharge, indicating important differences between men and women in the short-term period after lobectomy. Further research will be required to further understand the cause for these differences.

When good operations go bad: The additive effect of comorbidity and postoperative complications on readmission after pulmonary lobectomy

BACKGROUND

Hospital readmission after major thoracic surgery has a marked effect on health care delivery, particularly in the era of value-based reimbursement. We sought to investigate the additive impact of comorbidity and postoperative complications on the risk of readmission after thoracic lobectomy.

METHODS

We queried the Nationwide Readmission Database of the Healthcare Cost and Utilization Project between 2010 and 2014 for discharges after pulmonary lobectomy with a primary diagnosis of lung cancer. We compared 90-day all-cause readmission rates across the presence of Elixhauser comorbidities and postoperative complications. Adjusted logistic and linear regression, accounting for patient and hospital factors were used to calculate the mean change in readmission rate by the number of comorbidities and postoperative complications.

RESULTS

A total of 87,894 patients undergoing pulmonary lobectomies were identified during the study period, of whom 15,858 (18.0%) were readmitted for any cause within 90 days of discharge. After adjusting for other factors, each additional comorbidity and postoperative complication were associated with a 2.0% and 2.7% increased probability of readmission, respectively (both P < .0001). Patients with a low burden of low comorbidities were readmitted more frequently for postoperative complications, while those with a high burden of comorbidities were readmitted more frequently for chronic disease.

CONCLUSION

Among patients with the lowest risk profile, there was an 11.7% readmission rate. Adjusting for other factors, each additional comorbidity and complication increased this rate by approximately 2.0% and 2.7%, respectively. These results demonstrate that the avoidance of postoperative complications may represent an effective mechanism for decreasing readmissions after thoracic surgery.

Impact of major video-assisted thoracoscopic surgery on care quality

Background

The objective of this study was to investigate the impact of a program of major video-assisted surgery on care quality in a Unit of Thoracic Surgery.

Methods

A descriptive comparative study was conducted of 793 major thoracic procedures performed between 2009 and 2012. Quality indicators and hospital performance before [2009-2010] and after (2011 and 2012) the implementation of the program.

Results

The incidence of surgical complications decreased significantly from 6.32%/7.88% (2009/2010, respectively) to 1.87%/1.67% (2011/2012, respectively) [95% CI for 7.08% (4.20-9.96%); 95% CI for 1.76% (0.44-3.08%) P<0.001, respectively]. The mean hospital stay was reduced from 8.5/7.8 days in 2009/2010, respectively, to 6.3/5.8 days in 2011/2012, respectively. Mortality rates were 0.57%, 0.60%, 0.93% and 0.43% in 2009, 2010, 2011, and 2012, respectively (P=0.624, 95% CI: -0.6, 0.7). The percentages of emergency readmissions in 2009/2010 were 1.16%/1.23%, respectively vs. 2.80%/0.84% in 2011/2012.

Conclusions

The implementation of the video-assisted thoracic surgery (VATS) program in the unit of Thoracic Surgery Care resulted in a significant improvement in care quality, with a reduction of length of hospital stay, but without any changes in mortality or the percentage of readmissions at 30 post-operative days.

Risk factors and costs associated with nationwide nonelective readmission after trauma

BACKGROUND

Most prior studies of readmission after trauma have been limited to single institutions, whereas multi-institutional studies have been limited to single states and an inability to distinguish between elective and nonelective readmissions. The purpose of this study was to identify the risk factors and costs associated with nonelective readmission after trauma across the United States.

METHODS

The Nationwide Readmission Database was queried for all patients with nonelective admissions in 2013 and 2014 with a primary diagnosis of trauma. Univariate and multivariate logistic regression identified risk factors for 30-day nonelective same- and different-hospital readmission. The diagnosis groups on readmission were evaluated, and the total cost of readmissions was calculated.

RESULTS

There were 1,180,144 patients admitted for trauma, the 30-day readmission rate was 9.4%, and 26.4% of readmissions occurred at a different hospital. The median readmission cost for patients readmitted to the same hospital was $8,298 (interquartile range, $4,899-$14,911), whereas the median readmission cost for patients readmitted to a different hospital was $8,568 (interquartile range, $4,935-$16,078; p < 0.01). Multivariate regression revealed that patients discharged against medical advice were at increased risk of readmission (odds ratio, 2.79; p < 0.01) and readmission to a different facility (odds ratio, 1.58; p < 0.01). Home health care was associated with a decreased risk of readmission to a different hospital (odds ratio, 0.74; p < 0.01). Septicemia and disseminated infections were the most common diagnoses on readmission (8.4%) and readmission to a different hospital (8.6%).

CONCLUSIONS

A significant portion of US readmissions occur at different hospitals with implications for continuity of care, quality metrics, cost, and resource allocation. Home health care reduces the likelihood of nonelective readmission to a different hospital. Infection was the most common reason for readmission, with ramifications for outcomes research and quality improvement.

LEVEL OF EVIDENCE

Care management/epidimeological, level IV.

Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program

BACKGROUND

Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population.

STUDY DESIGN

An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected.

RESULTS

Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group.

CONCLUSIONS

Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.

Effect of gender on perioperative outcomes after robotic-assisted pulmonary lobectomy

BACKGROUND

Female gender has been associated with worse outcomes after cardiovascular surgery and critical illness. We investigated the effect of gender on perioperative outcomes following robotic-assisted pulmonary lobectomy.

METHODS

We retrospectively analyzed 282 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 53 months. Perioperative outcomes and clinically significant intraoperative and postoperative complications, including respiratory and cardiovascular events, were noted. Chi-Square (χ²), Fisher's exact test, Analysis of Variance (ANOVA), Student's t-test, and Kruskal-Wallis or Mood's median test were used to compare variables, with significance at P≤0.05.

RESULTS

There were 128 men (mean age, 68.8 yr) and 154 women (mean age, 65.9 yr; P=0.02). Women had higher preoperative forced expiratory volume in 1 second as percent of predicted (FEV1%; P=0.001). There were more former smokers in the male cohort (P=0.03) and more nonsmokers in the female cohort (P<0.001). Women had smaller tumors (3.0±0.1 vs. 3.5±0.2 cm, P=0.04), lower estimated blood loss (EBL) (150±34 vs. 250±44 mL, P<0.001), and shorter operative time (168±6 vs. 196±7 min, P=0.01). Rates of intraoperative complications (7.1% vs. 8.6%, P=0.65) and of conversion to open lobectomy (7.8% vs. 8.6%; P=0.81) were similar between genders. Postoperative complications were fewer in women (27.9% vs. 44.5%; P=0.004), the most common of which, in both women and men, were prolonged air leak for ≥7 days (13.0% vs. 22.7%, P=0.03), atrial fibrillation (7.1% vs. 14.8%, P=0.04), and pneumonia (7.8% vs. 10.2%, P=0.49). Hospital length of stay (LOS) (4±0.3 vs. 5±0.5 days) was also shorter for women (P=0.02). Despite the higher postoperative complication rate in men, in-hospital mortality did not differ between genders (P=0.23). Multivariable analyses did not identify female gender as an independent predictor of post-operative complications.

CONCLUSIONS

Female gender was associated with rates of intraoperative complications and of conversion to open lobectomy as low as those for men, but with better perioperative outcomes, lower risk of intraoperative bleeding, and fewer postoperative complications. Thus, robotic-assisted pulmonary lobectomy is feasible and safe for women.