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Graham LA, Illarmo S, Gray CP, Harris AHS, Wagner TH, Hawn MT, Iannuzzi JC, Wren SM. Mapping the Discharge Process After Surgery. JAMA Surg 2024; 159:438-444. [PMID: 38381415 PMCID: PMC10882508 DOI: 10.1001/jamasurg.2023.7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/28/2023] [Indexed: 02/22/2024]
Abstract
Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Caroline P. Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H. S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T. Hawn
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - James C. Iannuzzi
- Department of Surgery, San Francisco VA Medical Center, San Francisco, California
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco
| | - Sherry M. Wren
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
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Urie BR, Laskowski T, Richard M, Tihonov N, Katz D, d'Audiffret A, Lim S. Impact of Care Fragmentation after Major Lower Extremity Amputation. Ann Vasc Surg 2024; 100:47-52. [PMID: 38122975 DOI: 10.1016/j.avsg.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/14/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease. METHODS Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges. RESULTS We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4 years old vs. 69.7 years old, P = 0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P < 0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P < 0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P < 0.001 and 54.7% vs. 42.0%, P < 0.001, respectively). On their first postamputation readmission, LOS (16.3 days vs. 14.7 days, P = 0.004) and hospital charge ($48,964 vs. $44,388, P = 0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P < 0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P < 0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P = 0.36). CONCLUSIONS CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.
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Affiliation(s)
- Braedon R Urie
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Taylor Laskowski
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Michele Richard
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Nikita Tihonov
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Daniel Katz
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Alexandre d'Audiffret
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Sungho Lim
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL.
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Tran Z, Lee J, Richardson S, Bakhtiyar SS, Shields L, Benharash P. Clinical and financial outcomes of transplant recipients following emergency general surgery operations. Surg Open Sci 2023; 13:41-47. [PMID: 37131533 PMCID: PMC10149279 DOI: 10.1016/j.sopen.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 05/04/2023] Open
Abstract
Introduction Due to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS. Methods The 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences. Results Of 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types. Conclusion The incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Jonathan Lee
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Lauren Shields
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
- Corresponding author at: UCLA David Geffen School of Medicine, CHS 62-249, 10833 Le Conte Ave, Los Angeles, CA 90095, United States of America.
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Abstract
OBJECTIVE Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. BACKGROUND Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. METHODS The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. CONCLUSION One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE Level III Prognostic. STUDY TYPE Prognostic.
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Rickenbach ON, Tumin D, Mendez LMG, Beng H. Factors associated with follow-up outside a transplant center among pediatric kidney transplant recipients. Pediatr Nephrol 2022; 37:1915-1922. [PMID: 35015122 DOI: 10.1007/s00467-021-05397-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Transfer of follow-up care after pediatric kidney transplantation (KTx) may jeopardize quality of care and patient outcomes. We sought to determine if minority status and socioeconomic factors were associated with increased likelihood of follow-up outside a transplant center, and whether this transition of care was associated with worse long-term graft and patient survival. METHODS We performed an analysis of the United Network for Organ Sharing database, including children age < 18 years who received a kidney transplant between 2003 and 2018. Survival analysis (conditional on survival with functioning graft to 1 year) was performed using a Cox proportional hazards model where transfer of care (place of follow-up recorded as any setting other than a transplant center) was entered as a time-varying covariate. RESULTS The study included 10,293, of whom 2083 received care outside of a transplant center during follow-up. Medicare coverage, but not minority race/ethnicity or socioeconomic status, was associated with increased likelihood of follow-up outside a transplant center. Follow-up outside a transplant center was associated with a 10% increased hazard of death or graft failure (hazard ratio: 1.10; 95% confidence interval: 1.004, 1.21; p = 0.041). CONCLUSION Follow-up outside of a transplant center increased risk of poor outcomes, though the likelihood of receiving care outside a transplant center did not vary by race/ethnicity or socioeconomic status. Our results highlight the need to improve continuity of care after KTx and to further understand the mechanisms leading to poor survival rates among minority populations. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Olivia Nieto Rickenbach
- Department of Pediatrics, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27858, USA.
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27858, USA
| | - Liliana Michelle Gomez Mendez
- Department of Pediatrics, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27858, USA
| | - Hostensia Beng
- Department of Pediatrics, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27858, USA
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Madrigal J, Richardson S, Hadaya J, Verma A, Tran Z, Sanaiha Y, Benharash P. Perioperative outcomes and readmissions following cardiac operations in kidney transplant recipients. Heart 2022; 108:heartjnl-2022-321030. [PMID: 35589379 DOI: 10.1136/heartjnl-2022-321030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/02/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Although kidney transplant (KTx) recipients are at significant risk for cardiovascular disease, outcomes following cardiac operations have been examined in limited series. The present study thus aimed to assess the impact of KTx on in-hospital perioperative outcomes and readmissions in a nationally representative cohort. METHODS All adults undergoing elective coronary artery bypass grafting, valve repair/replacement or a combination thereof were identified from the 2010-2018 Nationwide Readmissions Database. Patients were stratified by history of KTx. Transplant-capable centres were defined as hospitals performing at least one KTx annually. To perform risk-adjustment in assessing outcomes, multivariable regression models were developed. RESULTS Of an estimated 1 407 351 patients included for analysis, 0.2% (n=2849) were KTx recipients. Compared with the general cardiac surgical population, patients with prior KTx experienced higher adjusted odds of in-hospital mortality (adjusted OR (AOR) 2.44, 95% CI 1.72 to 3.47, p<0.001) and perioperative complication (AOR 1.67, 95% CI 1.44 to 1.94, p<0.001). Additionally, KTx was independently associated with greater readmission rates within 30 days (AOR 1.96, 95% CI 1.65 to 2.34, p<0.001) with kidney injury contributing significantly to the burden of rehospitalisation (4.6 vs 1.8%, p=0.005). In a subpopulation comprised of only KTx recipients, treatment at a transplant-capable centre reduced odds of kidney injury with non-transplant hospitals as reference (AOR 0.65, 95% CI 0.43 to 0.98, p=0.037). CONCLUSIONS Kidney transplant recipients undergoing cardiac operations encounter significant risks compared with the general surgical population. Referral to transplant-capable centres should be explored to improve outcomes and to preserve allograft function in this population.
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Affiliation(s)
- Josef Madrigal
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
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Rogers MP, Kuo PC. Identifying and mitigating factors contributing to 30-day hospital readmission in high risk patient populations. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1610. [PMID: 34926654 PMCID: PMC8640920 DOI: 10.21037/atm-2021-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/26/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Michael P Rogers
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Rosenblatt R, Atteberry P, Tafesh Z, Ravikumar A, Crawford CV, Lucero C, Jesudian AB, Brown RS, Kumar S, Fortune BE. Uncontrolled diabetes mellitus increases risk of infection in patients with advanced cirrhosis. Dig Liver Dis 2021; 53:445-451. [PMID: 33153928 DOI: 10.1016/j.dld.2020.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/24/2020] [Accepted: 10/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is common in patients with cirrhosis and is associated with increased risk of infection. AIM To analyze the impact of uncontrolled DM on infection and mortality among inpatients with advanced cirrhosis. METHODS This study utilized the Nationwide Inpatient Sample from 1998 to 2014. We defined advanced cirrhosis using a validated ICD-9-CM algorithm requiring a diagnosis of cirrhosis and clinically significant portal hypertension or decompensation. The primary outcome was bacterial infection. Secondary outcomes included inpatient mortality stratified by elderly age (age≥70). Multivariable logistic regression analyzed outcomes. RESULTS 906,559 (29.2%) patients had DM and 109,694 (12.1%) were uncontrolled. Patients who had uncontrolled DM were younger, had less ascites, but more encephalopathy. Bacterial infection prevalence was more common in uncontrolled DM (34.2% vs. 28.4%, OR 1.33, 95% CI 1.29-1.37, p<0.001). Although uncontrolled DM was not associated with mortality, when stratified by age, elderly patients with uncontrolled DM had a significantly higher risk of inpatient mortality (OR 1.62, 95% CI 1.46-1.81). CONCLUSIONS Uncontrolled DM is associated with increased risk of infection, and when combined with elderly age is associated with increased risk of inpatient mortality. Glycemic control is a modifiable target to improve morbidity and mortality in patients with advanced cirrhosis.
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Affiliation(s)
- Russell Rosenblatt
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States.
| | - Preston Atteberry
- NewYork Presbyterian Hospital, Department of Medicine, New York, NY, United States
| | - Zaid Tafesh
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | | | - Carl V Crawford
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Catherine Lucero
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Arun B Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Robert S Brown
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Sonal Kumar
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Brett E Fortune
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
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Ross-Driscoll K, Kramer M, Lynch R, Plantinga L, Wedd J, Patzer R. Variation in Racial Disparities in Liver Transplant Outcomes Across Transplant Centers in the United States. Liver Transpl 2021; 27:558-567. [PMID: 37160041 PMCID: PMC8201428 DOI: 10.1002/lt.25918] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Little is known about the role that transplant centers may play in perpetuating racial disparities after liver transplantation, which are unexplained by patient-level factors. We examined variation in between-center and within-center disparities among 34,114 Black and White liver transplant recipients in the United States from 2010 to 2017 using Scientific Registry of Transplant Recipient (SRTR) data. We used Cox proportional hazards models to calculate transplant center-specific Black-White hazard ratios and hierarchical survival analysis to examine potential effect modification of the race-survival association by transplant center characteristics, including transplant volume, proportion of Black patients, SRTR quality rating, and region. Models were sequentially adjusted for clinical, socioeconomic, and center characteristics. After adjustment, Black patients experienced 1.11 excess deaths after liver transplant per 100 person-years compared with White patients (95% confidence interval [CI], 0.65-1.56), corresponding to a 21% increased mortality risk (95% CI, 1.12-1.31). Although there was substantial variation in this disparity across transplant centers, there was no evidence of effect modification by transplant center volume, proportion of minority patients seen, quality rating, or region. We found significant racial disparities in survival after transplant, with substantial variation in this disparity across transplant centers that was not explained by selected center characteristics. This is the first study to directly evaluate the role transplant centers play in racial disparities in transplant outcomes. Further assessment of the qualitative factors that may drive disparities, such as selection processes and follow-up care, is needed to create effective center-level interventions to address health inequity.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Joel Wedd
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Rachel Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Atlanta, GA,Department of Medicine, Emory University School of Medicine, Atlanta, GA
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McCrum ML, Cannon AR, Allen CM, Presson AP, Huang LC, Brooke BS. Contributors to Increased Mortality Associated With Care Fragmentation After Emergency General Surgery. JAMA Surg 2021; 155:841-848. [PMID: 32697290 DOI: 10.1001/jamasurg.2020.2348] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear. Objective To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital. Design, Setting, and Participants Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019. Exposures Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission. Main Outcomes and Measures Ninety-day inpatient mortality. Results In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission. Conclusions and Relevance In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.
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Affiliation(s)
- Marta L McCrum
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Austin R Cannon
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Chelsea M Allen
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lyen C Huang
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
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11
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Biju K, Zhang GQ, Stem M, Sahyoun R, Safar B, Atallah C, Efron JE, Rajput A. Impact of Treatment Coordination on Overall Survival in Rectal Cancer. Clin Colorectal Cancer 2021; 20:187-196. [PMID: 33618972 DOI: 10.1016/j.clcc.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer. METHODS A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models. RESULTS A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P< .001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P< .001) but not for stage IV (P= .474). CONCLUSION Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.
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Affiliation(s)
- Kevin Biju
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca Sahyoun
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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12
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Abstract
OBJECTIVES Although acute pancreatitis (AP) is associated with recurrent hospitalizations, the impact of different hospital readmissions (DHR) versus same hospital readmissions (SHR) on outcomes is unknown. We study the burden of DHR among readmissions after survival from AP hospitalizations. METHODS Among adult AP patients (Nationwide Readmissions Database), we calculated the prevalence, trends, and predictors of DHR, and its impact on mortality, hospital stay, and charges during 30- and 90-day readmissions. RESULTS From 2010 to 2014, 15% and 26% of AP hospitalizations (422,950) were readmitted in 30 and 90 days, respectively. The DHR rates were similar (26.3%, 30 days; 26.4%, 90 days) and unchanged from 2010 to 2014 (Ptrends > 0.10). The predictors of DHR were similar during both readmissions and included younger age category (18-45 years), hospital characteristics (nonteaching, small bed size, nonmicropolitan/metropolitan areas), substance abuse, comorbidities, and nonreception of cholecystectomy and pancreatectomy during index hospitalizations.During readmissions (30 and 90 days), DHR was associated with adjusted odds ratio (95% confidence interval), higher mortality (1.40 [1.19-1.64] and 1.50 [1.32-1.71]), longer hospital stay (1.3 days [1.1-1.7 days] and 1.1 days [0.9-1.3 days]), and higher charges (US $16,779 [US $13,898-US $20,254] and US $14,299 [US $12,299-US $16,623]). CONCLUSIONS Targeted measures are needed toward patients at risk for DHR to curb the poor outcomes.
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13
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Snow K, Galaviz K, Turbow S. Patient Outcomes Following Interhospital Care Fragmentation: A Systematic Review. J Gen Intern Med 2020; 35:1550-1558. [PMID: 31625038 PMCID: PMC7210367 DOI: 10.1007/s11606-019-05366-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Interhospital fragmentation of care occurs when patients are admitted to different, disconnected hospitals. It has been hypothesized that this type of care fragmentation decreases the quality of care received and increases hospital costs and healthcare utilization. This systematic review aims to synthesize the existing literature exploring the association between interhospital fragmentation of care and patient outcomes. METHODS MEDLINE, the Cochrane Library, EMBASE, and the Science Citation Index were systematically searched for studies published up to April 30, 2018 reporting the association between interhospital fragmentation of care and patient outcomes. We included peer-reviewed observational studies conducted in adults that reported measures of association between interhospital care fragmentation and one or more of the following patient outcomes: mortality, hospital length of stay, cost, and subsequent hospital readmission. RESULTS Seventy-nine full texts were reviewed and 22 met inclusion criteria. Nearly all studies defined fragmentation of care as a readmission to a different hospital than the patient was previously discharged from. The strongest association reported was that between a fragmented readmission and in-hospital or short-term mortality (adjusted odds ratio range 0.95-3.62). Over half of the studies reporting length-of-stay showed longer length of stay in fragmented readmissions. All three studies that investigated healthcare utilization suggested an association between fragmented care and odds of subsequent readmission. The study populations and exposures were too heterogenous to perform a meta-analysis. DISCUSSION Our review suggests that fragmented hospital readmissions contribute to increased mortality, longer length-of-stay, and increased risk of readmission to the hospital.
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Affiliation(s)
- Katelin Snow
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Karla Galaviz
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sara Turbow
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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14
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Telemedicine Based Remote Home Monitoring After Liver Transplantation: Results of a Randomized Prospective Trial. Ann Surg 2020; 270:564-572. [PMID: 31356267 DOI: 10.1097/sla.0000000000003425] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study assesses the impact of a telemedicine-based home management program (THMP) on patient adherence, hospital readmissions, and quality of life (QOL) after liver transplantation (LT). SUMMARY OF BACKGROUND DATA Telemedicine interventions represent an opportunity to personalize care and can lead to improved adherence and patient satisfaction. However, there is limited data on impact of these interventions on outcomes after LT. Therefore, we conducted the first randomized controlled trial (RCT) of a THMP compared to standard of care (SOC) after LT. METHODS One hundred six consecutive LT recipients were randomized (1:1) to 1 of 2 posttransplant care strategies: SOC or THMP. The THMP included an electronic tablet and bluetooth devices to support daily text messages, education videos, and video FaceTime capability; data was cyber-delivered into our electronic medical record daily. Endpoints were THMP participation, 90-day hospital readmission rate, and QOL. RESULTS One hundred patients completed the study with 50 enrolled in each arm. Participation and adherence with telemedicine was 86% for basic health sessions (vital sign recording), but only 45% for using messaging or FaceTime. The THMP group had a lower 90-day readmission rate compared to SOC (28% vs 58%; P = 0.004). The THMP cohort also showed improved QOL in regards to physical function (P = 0.02) and general health (P = 0.05) at 90 days. CONCLUSIONS To our knowledge, this is the first RCT demonstrating the impact of THMP after LT. The magnitude of effect on LT outcomes, hospital readmissions, and QOL suggests that the adoption of telemedicine has great potential for other major operations.
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15
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Hirji SA, Percy ED, Zogg CK, Vaduganathan M, Kiehm S, Pelletier M, Kaneko T. Thirty-Day Nonindex Readmissions and Clinical Outcomes After Cardiac Surgery. Ann Thorac Surg 2020; 110:484-491. [PMID: 31972128 DOI: 10.1016/j.athoracsur.2019.11.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/08/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND With increasing emphasis on readmissions as an important quality metric, there is an interest in regionalization of care to high-volume centers. As a result, care of readmitted cardiac surgery patients may be fragmented if readmission occurs at a nonindex hospital. This study characterizes the frequency, risk factors, and outcomes of nonindex hospital readmission after cardiac surgery. METHODS In this multicenter, population-based, nationally representative sample, we used weighted 2010-2015 National Readmission Database claims to identify all US adult patients who underwent 2 of the major cardiac surgeries, isolated coronary artery bypass grafting (CABG) or isolated surgical aortic valve replacement (SAVR), during their initial hospitalization. We examined characteristics, predictors, and outcomes after nonindex readmission. RESULTS Overall, 1,070,073 procedures were included (844,206 CABG and 225,866 SAVR). Readmission at 30 days was 12.8% for CABG and 14.5% for SAVR. Nonindex readmissions accounted for 23% and 26% at 30 days; these were primarily noncardiac in etiology. The proportion of nonindex readmissions did not change significantly from 2010 to 2015. For CABG and SAVR, in-hospital mortality (adjusted odds ratios of 1.26 and 1.37, respectively) and major complications (odds ratios of 1.17 and 1.25, respectively) were significantly higher during nonindex versus index readmission, even after adjusting for patient risk profile, case mix, and hospital characteristics. Older age, higher income, and increased comorbidity burden were all independent predictors of nonindex readmission. CONCLUSIONS A considerable proportion of patients readmitted after cardiac surgery are readmitted to nonindex hospitals. This fragmentation of care may account for worse outcomes associated with nonindex readmissions in this complex population.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Muthiah Vaduganathan
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Spencer Kiehm
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Juo YY, Sanaiha Y, Khrucharoen U, Tillou A, Dutson E, Benharash P. Complete Impact of Care Fragmentation on Readmissions Following Urgent Abdominal Operations. J Gastrointest Surg 2019; 23:1643-1651. [PMID: 30623376 DOI: 10.1007/s11605-018-4033-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Urgent abdominal operations commonly occurred in low-volume hospitals with high failure-to-rescue rates. Recent studies have demonstrated a survival benefit associated with readmission to the original hospital after operation, presumably due to improved continuity of care. It is unclear if this survival benefit persists in low-volume hospitals. We seek to evaluate differences in mortality between readmission to the original hospital and a higher-volume hospital after urgent abdominal operations. METHODS A retrospective cohort study using the National Readmissions Database from 2010 to 2014 was performed. Propensity score-weighted multilevel regression analysis was used to examine the association between readmission destination and mortality after accounting for hospital volume. RESULTS A total of 71,551 adult patients who experienced 30-day readmission following urgent abdominal operations were identified, among whom 10,368 (14.5%) were readmitted to a different hospital. Patients with higher baseline comorbidity scores, lower income, less comprehensive insurance coverage, systemic complications, prolonged length of stay, or non-home disposition were more likely to experience readmission to a different hospital. Following stratification by readmission hospital volume and propensity score weighting to adjust for baseline mortality risk differences, readmission to a different hospital is still associated with higher mortality rates than the original hospital. CONCLUSIONS The adverse outcomes associated with case fragmentation are present even after adjusting for readmission hospital volume. Patients who received urgent abdominal operations at low-volume hospitals should return to the original hospital for concern of care fragmentation.
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Affiliation(s)
- Yen-Yi Juo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.,Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Usah Khrucharoen
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Areti Tillou
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Erik Dutson
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA. .,Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA. .,UCLA Division of Cardiac Surgery, UCLA Center for Health Sciences, 10833 Le Conte Avenue, Room 62-249, Los Angeles, CA, 90095, USA.
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17
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Fragmentation in Cirrhosis: The Excluded May Reveal the Full Story. Am J Gastroenterol 2019; 114:1356-1357. [PMID: 31082881 DOI: 10.14309/ajg.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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18
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Incidence of and risk factors associated with care fragmentation following bariatric surgery. Surg Obes Relat Dis 2019; 15:1170-1181. [DOI: 10.1016/j.soard.2019.03.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/20/2019] [Indexed: 11/23/2022]
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19
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Beal EW, Bagante F, Paredes A, Chen Q, Akgul O, Merath K, Dillhoff ME, Cloyd JM, Pawlik TM. Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted? J Gastrointest Surg 2019; 23:702-711. [PMID: 30039444 DOI: 10.1007/s11605-018-3882-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission. METHODS The National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90 days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals. RESULTS A total of 49,080 patients underwent HPB surgery (liver n = 27,081, 55%; pancreas n = 14,787, 30%; biliary n = 7212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90 days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90 days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥ 3 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay > 7 days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all p < 0.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, p = 0.010). CONCLUSIONS Roughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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20
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Abstract
INTRODUCTION There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients. METHODS We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality. RESULTS In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ≥4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay. CONCLUSIONS Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.
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21
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Juo YY, Sanaiha Y, Khrucharoen U, Chang BH, Dutson E, Benharash P. Care fragmentation is associated with increased short-term mortality during postoperative readmissions: A systematic review and meta-analysis. Surgery 2019; 165:501-509. [DOI: 10.1016/j.surg.2018.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/18/2018] [Accepted: 08/21/2018] [Indexed: 01/14/2023]
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22
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Cohen-Mekelburg S, Rosenblatt R, Gold S, Shen N, Fortune B, Waljee AK, Saini S, Scherl E, Burakoff R, Unruh M. Fragmented Care is Prevalent Among Inflammatory Bowel Disease Readmissions and is Associated With Worse Outcomes. Am J Gastroenterol 2019; 114:276-290. [PMID: 30420634 DOI: 10.1038/s41395-018-0417-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Inflammatory bowel disease (IBD) is a complex chronic disease that often requires a multispeciality approach; thus, IBD patients are prone to care fragmentation. We aim to determine the prevalence of fragmentation among hospitalized IBD patients and identify associated predictors and visit-level outcomes. METHODS The State Inpatient Databases for New York and Florida were used to identify 90-day readmissions among IBD inpatients from 2009 to 2013. The prevalence of fragmentation, defined as a readmission to a non-index hospital, was reported. Characteristics associated with fragmented care were identified using multivariable logistic regression. Multivariable models were utilized to determine the association between fragmentation and outcomes (in-hospital mortality, readmission length of stay, and inpatient colonoscopy). RESULTS Among IBD inpatients, 25,241 and 29,033 90-day readmission visits were identified, in New York and Florida, respectively. The prevalence of fragmentation was 26.4% in New York and 32.5% in Florida. Younger age, a non-emergent admission type, public payer or uninsured status, mood disorder, and substance abuse were associated with fragmented care, while female gender and a primary diagnosis of an IBD-related complication had an inverse association. Fragmented inpatient care is associated with a higher likelihood of in-hospital death, higher rates of inpatient colonoscopy, and a longer readmission length of stay. CONCLUSIONS Over one in four IBD inpatient readmissions are fragmented. Disparities and differences in fragmentation exist and contribute to poor patient outcomes. Additional efforts targeting fragmentation should be made to better coordinate IBD management, reduce healthcare gaps, and promote high-value care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Russell Rosenblatt
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Stephanie Gold
- Department of Medicine, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Nicole Shen
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Brett Fortune
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Akbar K Waljee
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, 48109, USA
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, 48109, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA
| | - Ellen Scherl
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Robert Burakoff
- Division of Gastroenterology & Hepatology, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
| | - Mark Unruh
- Department of Healthcare Policy & Research, New York Presbyterian Weill Cornell Medicine, New York, NY, 10021, USA
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Zerillo J, Smith NK, Sakai T. Noteworthy Literature published in 2017 for Abdominal Organ Transplantation. Semin Cardiothorac Vasc Anesth 2018; 22:67-80. [PMID: 29400258 DOI: 10.1177/1089253217753399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In 2017, we identified more than 400 peer reviewed publications on the topic of pancreas transplantation, more than 500 on intestinal transplantation, more than 4000 on renal transplantation, and more than 4700 on liver transplantation. This annual review highlights the most pertinent literature for anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a wide range of topics, including risk for and prediction of perioperative complications, recommendations on perioperative management, economic analyses, and education of the trainees in abdominal transplantation anesthesia and critical care.
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Affiliation(s)
| | | | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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24
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Avery LM, Fominaya CE, Crawford RC, Pleasants KP, Taber DJ. Characterization of Potentially Unsafe Ambulatory Antibiotic Use and Associated Outcomes in an Adult Kidney Transplant Population. Ann Pharmacother 2018; 52:974-982. [PMID: 29770702 DOI: 10.1177/1060028018776606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed to kidney transplant (KTX) recipients in the outpatient setting, but there are limited data assessing the safety and outcomes associated with this practice. OBJECTIVE The primary objective of this study was to describe ambulatory antibiotic prescribing in a large cohort of adult KTX recipients. The secondary objective was to assess the outcomes associated with potentially unsafe antibiotic use in this population. METHODS National Veterans Health Administration data compiled between 2001 and 2010 were used to conduct a pharmacovigilance assessment of antibiotic prescribing, excluding intravenous agents, antifungals, antivirals, and prophylactic regimens. Multivariable Cox proportional hazard regression was used to determine the impact of safe and potentially unsafe antibiotic use on time to event for graft loss. RESULTS Among 5130 KTX recipients and 30 127 patient-years of follow-up, 14 259 antibiotic courses were prescribed at a rate of 0.47 courses per patient-year. Transplant or nephrology providers prescribed 24.8% of courses. Overall, 608 courses (4.3%) in 311 patients (6.1%) were considered potentially unsafe for dosages in disagreement with recommended adjustments for renal function, interaction with immunosuppressive regimens, and other pertinent safety concerns. After adjusting for baseline characteristics, unsafe antibiotic use was associated with a 40% higher risk of graft loss (adjusted hazard ratio = 1.40; 95% CI = 1.03-1.89; P = 0.030) compared with safe use. CONCLUSIONS AND RELEVANCE Although unsafe antibiotic prescribing was uncommon, it was associated with increased risk of graft loss. Prospective research is needed to elucidate whether the driver of poor outcomes is the safety of the antibiotic prescription or fragmented care.
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Affiliation(s)
| | | | - Rena C Crawford
- 1 Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
| | | | - David J Taber
- 1 Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
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