Intraaortic Balloon Pump vs Peripheral Ventricular Assist Device Use in the United States

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study

BACKGROUND

Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

METHODS

Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

RESULTS

Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

CONCLUSIONS

Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.

Trends and Outcomes of Surgical Re-exploration Following Cardiac Operations in the United States

BACKGROUND

Surgical re-exploration following cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and its impact on clinical outcomes and resource use in a nationally-representative cohort. We sought to determine patient and hospital factors associated with re-exploration and reoperative mortality, defined as failure-to-rescue-surgical (FTR-S).

METHODS

Adult hospitalizations entailing cardiac operations (coronary artery bypass and/or valve) were identified using the 2005-2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high-performing. Multivariable regression models examined factors associated with re-exploration as well as clinical outcomes including FTR-S and resource utilization.

RESULTS

Of an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required re-exploration with decreasing incidence over time. Valvular procedures, preoperative intra-aortic balloon pump and liver disease were associated with greater likelihood of re-exploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio (AOR): 3.86, 95%CI: 3.61-4.12), perioperative complications and resource utilization. Increasing time from index operation to re-exploration was associated with higher odds of mortality (AOR:1.10/day, 95%CI: 1.07-1.12). High-performing hospitals were associated with lower odds of re-exploration (AOR: 0.88, 95%CI: 0.82-0.95) and FTR-S (AOR: 0.29, 95%CI: 0.23-0.35).

CONCLUSIONS

Surgical re-exploration following cardiac surgery has declined over time. High performing hospitals demonstrated lower rates of re-exploration and subsequent failure-to-rescue. Although unable to identify specific practices, our study highlights the presence of significant variation in takeback rates and further study of underlying factors is warranted.