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Coimbra R, Kim M, Allison-Aipa T, Zakhary B, Kwon J, Firek M, Coimbra BC, Costantini TW, Haynes LN, Edwards SB. Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients. Am Surg 2024; 90:2447-2456. [PMID: 38656140 DOI: 10.1177/00031348241248796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR. METHODS A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression. RESULTS Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR. DISCUSSION Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.
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Affiliation(s)
- Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Department of Surgery, University of California Riverside, Moreno Valley, CA, USA
| | - Maru Kim
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- Department of Trauma Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Timothy Allison-Aipa
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Junsik Kwon
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- Department of Trauma Surgery, Ajou University School of Medicine, Seoul, Republic of Korea
| | - Matthew Firek
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
| | - Bruno Cammarota Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Laura N Haynes
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Sara B Edwards
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Department of Surgery, University of California Riverside, Moreno Valley, CA, USA
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Zakhary B, Coimbra BC, Kwon J, Allison-Aipa T, Firek M, Coimbra R. Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis. J Am Coll Surg 2024; 239:211-222. [PMID: 38661145 DOI: 10.1097/xcs.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty. STUDY DESIGN Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes. RESULTS A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty. CONCLUSIONS Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.
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Affiliation(s)
- Bishoy Zakhary
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
| | - Bruno C Coimbra
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
- George Washington University School of Medicine and Health Sciences, Washington, DC (BC Coimbra)
| | - Junsik Kwon
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
- Department of Trauma Surgery, Ajou University School of Medicine, Seoul, Republic of Korea (Kwon)
| | - Timothy Allison-Aipa
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
| | - Matthew Firek
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
| | - Raul Coimbra
- From the Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, CA (Zakhary, BC Coimbra, Kwon, Allison-Aipa, Firek, R Coimbra)
- Division of Trauma and Acute Care Surgery, Riverside University Health System Medical Center, Moreno Valley, CA (R Coimbra)
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA (R Coimbra)
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Schultz KS, Moore MS, Pantel HJ, Mongiu AK, Reddy VB, Schneider EB, Leeds IL. For Whom the Bell Tolls: Assessing the Incremental Costs Associated With Failure-To-Rescue After Elective Colorectal SurgeryRunning Title: Cost of Failure-To-Rescue After Colorectal Surgery. J Gastrointest Surg 2024:S1091-255X(24)00587-0. [PMID: 39181234 DOI: 10.1016/j.gassur.2024.08.019] [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: 07/12/2024] [Revised: 08/07/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Failure-to-rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. The purpose of this study was to assess the incremental costs of failure-to-rescue after elective colorectal surgery. METHODS This was a retrospective study of adult patients identified in the National Inpatient Sample (NIS) from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into four groups: uneventful recovery, successfully rescued, failure-to-rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs. RESULTS Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure-to-rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR $12,611-23,116), for the successfully rescued cohort was $42,295 (IQR $27,959-67,077), for the failure-to-rescue cohort was $53,182 (IQR $30,852-95,615), and for the died without attempted rescue cohort was $29,296 (IQR $19-812-45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs compared to the successfully rescued patients for the last three quantiles (fifth quantile (90th percentile): $163,963 vs. $106,521, p<0.001). DISCUSSION Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision-making and medical futility and highlight opportunities for resource optimization following postoperative complications.
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Affiliation(s)
- Kurt S Schultz
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Miranda S Moore
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Haddon J Pantel
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Anne K Mongiu
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Vikram B Reddy
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Eric B Schneider
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States
| | - Ira L Leeds
- Yale School of Medicine, Department of Surgery, Division of Colon & Rectal Surgery, New Haven, CT, United States.
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Balian J, Cho NY, Vadlakonda A, Kwon OJ, Porter G, Mallick S, Benharash P. Failure to rescue following emergency general surgery: A national analysis. Surg Open Sci 2024; 20:77-81. [PMID: 38973813 PMCID: PMC11225886 DOI: 10.1016/j.sopen.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/24/2024] [Indexed: 07/09/2024] Open
Abstract
Background Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. Methods All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. Results Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. Conclusion Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.
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Affiliation(s)
- Jeffrey Balian
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Oh. Jin Kwon
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Giselle Porter
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Saad Mallick
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Abla H, Collins RA, Dhanasekara CS, Shrestha K, Dissanaike S. Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy. J Surg Res 2024; 296:135-141. [PMID: 38277949 DOI: 10.1016/j.jss.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/27/2023] [Accepted: 12/25/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.
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Affiliation(s)
- Habib Abla
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Reagan A Collins
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas.
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Rangrass G, Obiyo L, Bradley AS, Brooks A, Estime SR. Closing the gap: Perioperative health care disparities and patient safety interventions. Int Anesthesiol Clin 2024; 62:41-47. [PMID: 38385481 DOI: 10.1097/aia.0000000000000439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Govind Rangrass
- Department of Anesthesiology and Critical Care, Saint Louis University Hospital/SSM Health, Saint Louis, Missouri
| | - Leziga Obiyo
- Department of Anesthesia & Critical Care, University of Chicago Medicine, Chicago, Illinois
| | - Anthony S Bradley
- Department of Anesthesiology, University of South Florida Moffitt Cancer Center, Tampa, Florida
| | - Amber Brooks
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stephen R Estime
- Department of Anesthesia & Critical Care, University of Chicago Medicine, Chicago, Illinois
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Strobel RJ, Kaplan EF, Young AM, Rotar EP, Mehaffey JH, Hawkins RB, Joseph M, Quader MA, Yarboro LT, Teman NR. Socioeconomic distress is associated with failure to rescue in cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:1100-1114.e1. [PMID: 36031426 PMCID: PMC9852359 DOI: 10.1016/j.jtcvs.2022.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue. METHODS Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue. RESULTS A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044). CONCLUSIONS Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Emily F Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Robert B Hawkins
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Mark Joseph
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed A Quader
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va.
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Diaz A, Azap L, Moazzam Z, Knight-Davis J, Pawlik TM. Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions. Surgery 2024; 175:899-906. [PMID: 37863693 DOI: 10.1016/j.surg.2023.08.046] [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: 05/10/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs. METHODS Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. RESULTS Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. CONCLUSION International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University, Department of Surgery, Columbus, OH.
| | - Lovette Azap
- The Ohio State University, Department of Surgery, Columbus, OH
| | - Zorays Moazzam
- The Ohio State University, Department of Surgery, Columbus, OH
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Abreu AA, Meier J, Alterio RE, Farah E, Bhat A, Wang SC, Porembka MR, Mansour JC, Yopp AC, Zeh HJ, Polanco PM. Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States. HPB (Oxford) 2024; 26:212-223. [PMID: 37863740 DOI: 10.1016/j.hpb.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/12/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.
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Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Pant K, Haider SF, Turner AL, Merchant AM. The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction. J Surg Res 2023; 291:611-619. [PMID: 37542775 DOI: 10.1016/j.jss.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS). METHODS This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction. RESULTS 20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications. CONCLUSIONS Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.
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Affiliation(s)
- Krittika Pant
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Syed F Haider
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Amber L Turner
- Department of Surgery, RWJBarnabas Health, Livingston, New Jersey
| | - Aziz M Merchant
- Department of Surgery, Hackensack Meridian JFK Medical Center, Edison, New Jersey.
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11
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Roberts SE, Rosen CB, Keele LJ, Kaufman EJ, Wirtalla CJ, Syvyk S, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions. Med Care 2023; 61:587-594. [PMID: 37476848 PMCID: PMC10527290 DOI: 10.1097/mlr.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA USA
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, University of Pennsylvania
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
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12
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Rosen CB, Roberts SE, Syvyk S, Finn C, Tong J, Wirtalla C, Spinks H, Kelz RR. A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial. JMIR Form Res 2023; 7:e42970. [PMID: 37440310 PMCID: PMC10375392 DOI: 10.2196/42970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/14/2023] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Multimorbidity is associated with an increased risk of poor surgical outcomes among older adults; however, identifying multimorbidity in the clinical setting can be a challenge. OBJECTIVE We created the Multimorbid Patient Identifier App (MMApp) to easily identify patients with multimorbidity identified by the presence of a Qualifying Comorbidity Set and tested its feasibility for use in future clinical research, validation, and eventually to guide clinical decision-making. METHODS We adapted the Qualifying Comorbidity Sets' claims-based definition of multimorbidity for clinical use through a modified Delphi approach and developed MMApp. A total of 10 residents input 5 hypothetical emergency general surgery patient scenarios, common among older adults, into the MMApp and examined MMApp test characteristics for a total of 50 trials. For MMApp, comorbidities selected for each scenario were recorded, along with the number of comorbidities correctly chosen, incorrectly chosen, and missed for each scenario. The sensitivity and specificity of identifying a patient as multimorbid using MMApp were calculated using composite data from all scenarios. To assess model feasibility, we compared the mean task completion by scenario to that of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS-NSQIP-SRC) using paired t tests. Usability and satisfaction with MMApp were assessed using an 18-item questionnaire administered immediately after completing all 5 scenarios. RESULTS There was no significant difference in the task completion time between the MMApp and the ACS-NSQIP-SRC for scenarios A (86.3 seconds vs 74.3 seconds, P=.85) or C (58.4 seconds vs 68.9 seconds,P=.064), MMapp took less time for scenarios B (76.1 seconds vs 87.4 seconds, P=.03) and E (20.7 seconds vs 73 seconds, P<.001), and more time for scenario D (78.8 seconds vs 58.5 seconds, P=.02). The MMApp identified multimorbidity with 96.7% (29/30) sensitivity and 95% (19/20) specificity. User feedback was positive regarding MMApp's usability, efficiency, and usefulness. CONCLUSIONS The MMApp identified multimorbidity with high sensitivity and specificity and did not require significantly more time to complete than a commonly used web-based risk-stratification tool for most scenarios. Mean user times were well under 2 minutes. Feedback was overall positive from residents regarding the usability and usefulness of this app, even in the emergency general surgery setting. It would be feasible to use MMApp to identify patients with multimorbidity in the emergency general surgery setting for validation, research, and eventual clinical use. This type of mobile app could serve as a template for other research teams to create a tool to easily screen participants for potential enrollment.
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Affiliation(s)
| | | | - Solomiya Syvyk
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Caitlin Finn
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Tong
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Hunter Spinks
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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13
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Roberts SE, Rosen CB, Wirtalla CJ, Finn CB, Kaufman EJ, Reilly PM, Syvyk S, McHugh MD, Kelz RR. Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries. Am J Surg 2023; 225:1074-1080. [PMID: 36473737 PMCID: PMC10199957 DOI: 10.1016/j.amjsurg.2022.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/26/2022] [Accepted: 11/19/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.
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Affiliation(s)
- Sanford E Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Claire B Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher J Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Caitlin B Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick M Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew D McHugh
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, University of Pennsylvania, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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14
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Diaz JJ, Barnes S, O'Meara L, Sawyer R, May A, Cullinane D, Schroeppel T, Chipman A, Kufera J, Vesselinov R, Zielinski M. Acute Care Surgery and Surgical Rescue: Expanding the Definition. J Am Coll Surg 2023; 236:827-835. [PMID: 36633328 DOI: 10.1097/xcs.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Surgical rescue (SR) is the recovery of patients with surgical complications. Patients transferred (TP) for surgical diagnoses to higher-level care or inpatients (IP) admitted to nonsurgical services may develop intra-abdominal infection (IAI) and require emergency surgery (ES). The aims were to characterize the SR population by the site of ES consultation, open abdomen (OA), and risk of mortality. STUDY DESIGN This was an international, multi-institutional prospective observational study of patients requiring ES for IAI. Laparotomy before the transfer was an exclusion criterion. Patients were divided into groups: clinic/ED (C/ED), IP, or TP. Data collected included demographics, the severity of illness (SOI), procedures, OA, and number of laparotomies. The primary outcome was mortality. Multivariable logistic regression models were constructed. RESULTS There were 752 study patients (C/ED 63.8% vs TP 23.4% and IP 12.8%), with a mean age of 59 years and 43.6% women. IP had worse SOI scores (Charlson Comorbidity Index, American Society of Anesthesiologists Physical Status Classification System, and Sequential Organ Failure Assessment). The most common procedures were small and large bowel (77.3%). IP and TP had similar rates of OA (IP 52.1% and TP 52.3 %) vs C/ED (37.7%, p < 0.001), and IP had more relaparotomies (3 or 4). The unadjusted mortality rate was highest in IP (n = 24, 25.0%) vs TP (n = 29, 16.5%) and C/ED (n = 68, 14.2%, p = 0.03). Adjusting for age and SOI, only SOI had an impact on the risk of mortality (area under the curve 86%). CONCLUSIONS IP had the highest unadjusted mortality after ES for IAI and was followed by the TP; SOI drove the risk of mortality. SR must be extended to IP for timely recognition of the IAI.
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Affiliation(s)
- Jose J Diaz
- From the University of Maryland School of Medicine, Baltimore, MD (Diaz, Chipman, Kufera, Vesselinov)
| | - Stephen Barnes
- Department of Surgery, University of Missouri, Columbia, MO (Barnes)
| | - Lindsay O'Meara
- University of Maryland Medical Center, Baltimore, MD (O'Meara)
| | - Robert Sawyer
- Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI (Sawyer)
| | - Addison May
- Atrium Health/Carolinas Medical Center, Charlotte, NC (May)
| | | | - Thomas Schroeppel
- University of Colorado-Health Memorial Hospital Central, Colorado Springs, CO (Schroeppel)
| | - Amanda Chipman
- From the University of Maryland School of Medicine, Baltimore, MD (Diaz, Chipman, Kufera, Vesselinov)
| | - Joseph Kufera
- From the University of Maryland School of Medicine, Baltimore, MD (Diaz, Chipman, Kufera, Vesselinov)
| | - Roumen Vesselinov
- From the University of Maryland School of Medicine, Baltimore, MD (Diaz, Chipman, Kufera, Vesselinov)
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15
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Lois A, Kohler JE, Monsell SE, Pullar KM, Victory J, Odom SR, Fischkoff K, Kaji AH, Evans HL, Sohn V, Kao LS, Dodwad SJ, Ehlers AP, Alam HB, Park PK, Krishnadasan A, Talan DA, Siparsky N, Price TP, Ayoung-Chee P, Chiang W, Salzberg M, Jones A, Kutcher ME, Liang MK, Thompson CM, Self WH, Bizzell B, Comstock BA, Lavallee DC, Flum DR, Fannon E, Kessler LG, Heagerty PJ, Lawrence SO, Pham TN, Davidson GH. A Video-Based Consent Tool: Development and Effect of Risk-Benefit Framing on Intention to Randomize. J Surg Res 2023; 283:357-367. [PMID: 36427446 DOI: 10.1016/j.jss.2022.10.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/14/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Nearly 75% of clinical trials fail to enroll enough participants, and cohorts often fail to reflect the clinical and demographic diversity of at-risk populations. Effective recruitment strategies are critically important for successful clinical trials. Framing treatment risks are known to affect medical decision-making for both physicians and patients but has not been rigorously studied in surgical trials. We sought to examine the impact of a high-quality video-based consent tool and the effect of risk-benefit framing on patient willingness to participate in a surgical clinical trial. METHODS A standardized video consent was shown to all potential participants in the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, a randomized controlled trial comparing antibiotics and surgery for acute appendicitis. We report (1) differences in recruitment between two versions of a video-based tool that differed in production quality and (2) the impact of risk-benefit framing on participant randomization rates. The reasons for declining randomization were also assessed. RESULTS Of 4697 eligible patients approached to participate in the CODA trial, 1535 (33% [95% confidence interval (CI): 31%-34%]) agreed to randomization; this did not change from video version 1 to version 2. There was no difference in participation between positively framed videos (32% [95% CI: 30%-34%]) versus negatively framed videos (33.0% [95% CI: 30.8-35.2]). The most common reason for declining participation was treatment preference (72% for surgery and 18% for antibiotics). CONCLUSIONS Neither the change from video 1 to video 2 nor the positive versus negative framing affected participant willingness to randomize. The stakeholder-informed video-based consenting tool used in CODA was an effective strategy for the recruitment of a heterogeneous patient population within the proposed study period.
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16
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Karnick AT, Bond AE, Kaufman EJ, Anestis MD, Capron DW. Injury characteristics and circumstances of firearm trauma: Assessing suicide survivors and decedents. Suicide Life Threat Behav 2022; 52:1217-1225. [PMID: 36056539 DOI: 10.1111/sltb.12916] [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: 04/26/2022] [Revised: 07/25/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Despite representing fewer than 5% of suicide attempts, firearms account for over half of deaths. Yet there is little clinical information regarding firearm attempts, particularly survivors. We assessed clinical factors differentiating firearm suicide survivors from decedents, firearm attempters from other methods, and firearm attempters from similarly injured trauma patients. METHODS We used clinical data from the National Trauma Data Bank (2017) to assess firearm suicide attempts using cross-sectional and case-control designs. We used logistic and multinomial regression to compare groups and assess firearm type and discharge destination. RESULTS Older age, being uninsured, and injury location were associated with increased mortality among firearm attempters. Older age, White race, male sex, and being uninsured were associated with firearm attempts. Major psychiatric disorders were associated with firearm attempts and using a rifle or shotgun. Major psychiatric disorders, female sex, and smoking were associated with psychiatric discharge. Black and other race were associated with law enforcement discharge, and Black race was associated with lower odds of psychiatric discharge. Uninsured patients had lower odds of discharge to long-term care, psychiatric, or rehabilitation facilities. CONCLUSIONS This study identifies factors associated with firearm suicide and includes indicators of disparities in health services for patients at high risk of suicide death.
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Affiliation(s)
- Aleksandr T Karnick
- Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi, USA
| | - Allison E Bond
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA.,New Jersey Gun Violence Research Center, Piscataway, New Jersey, USA
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D Anestis
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA.,New Jersey Gun Violence Research Center, Piscataway, New Jersey, USA
| | - Daniel W Capron
- Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi, USA
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17
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Villarreal ME, Jalilvand A, Schubauer K, Kellet W, DiDonato C, Roberts L, Helkin A, Scarlet S, Wisler J. Comorbidities Matter as Distressed Communities Index Fails to Predict Mortality in Necrotizing Soft Tissue Infection. Surg Infect (Larchmt) 2022; 23:801-808. [DOI: 10.1089/sur.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Anahita Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kathryn Schubauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney DiDonato
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luke Roberts
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex Helkin
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sara Scarlet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jonathan Wisler
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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18
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The physiology of failure: Identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record. J Trauma Acute Care Surg 2022; 93:409-417. [PMID: 35998289 DOI: 10.1097/ta.0000000000003618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality. METHODS Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality. RESULTS There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7). CONCLUSION After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Voldby AW, Boolsen AW, Aaen AA, Burcharth J, Ekeløf S, Loprete R, Jønck S, Eskandarani HA, Thygesen LC, Møller AM, Brandstrup B. Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study. J Gastrointest Surg 2022; 26:1930-1941. [PMID: 35606601 DOI: 10.1007/s11605-021-05240-6] [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: 07/05/2021] [Accepted: 12/29/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation. METHODS We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation. RESULTS Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation. CONCLUSION This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.
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Affiliation(s)
- Anders Winther Voldby
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark.
| | - Anders Watt Boolsen
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anne Albers Aaen
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Sarah Ekeløf
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | | | - Simon Jønck
- Department of Emergency Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Hassan Ali Eskandarani
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Lau Caspar Thygesen
- Department of Population Health and Morbidity, University of Southern Denmark, Odense, Denmark
| | - Ann Merete Møller
- Department of Anesthesiology and Intensive Care Medicine, Herlev Hospital, Herlev, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
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20
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Minetos PD, Karamian BA, Kothari P, Jeyamohan H, Canseco JA, Patel PD, Thaete L, Singh A, Campbell D, Kaye ID, Woods BI, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department. Am J Med Qual 2022; 37:207-213. [PMID: 34787591 DOI: 10.1097/jmq.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.
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Affiliation(s)
- Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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21
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Moroni EA, Bustos SS, Mehta M, Munoz-Valencia A, Douglas NKO, Bustos VP, Evans S, Diego EJ, De La Cruz C. Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey? Ann Plast Surg 2022; 88:S279-S283. [PMID: 35513331 DOI: 10.1097/sap.0000000000003195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR). METHODS An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05. RESULTS Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction. CONCLUSIONS While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.
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Affiliation(s)
- Elizabeth A Moroni
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samyd S Bustos
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Meeti Mehta
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nerone K O Douglas
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Steven Evans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emilia J Diego
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carolyn De La Cruz
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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22
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Morisod K, Luta X, Marti J, Spycher J, Malebranche M, Bodenmann P. Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review. Health Equity 2022; 5:801-817. [PMID: 35018313 PMCID: PMC8742300 DOI: 10.1089/heq.2021.0035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care. Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine. Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care. Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.
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Affiliation(s)
- Kevin Morisod
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Xhyljeta Luta
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Joachim Marti
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Jacques Spycher
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Mary Malebranche
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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23
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Disparities in cardiac arrest and failure to rescue after major elective noncardiac operations. Surgery 2022; 171:1358-1364. [DOI: 10.1016/j.surg.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 01/30/2023]
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24
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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25
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Kelleher DC, Lippell R, Lui B, Ma X, Tedore T, Weinberg R, White RS. Hospital safety-net burden is associated with increased inpatient mortality after elective total knee arthroplasty: a retrospective multistate review, 2007-2018. Reg Anesth Pain Med 2021; 46:663-670. [PMID: 33990442 DOI: 10.1136/rapm-2020-101731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is among the most common surgical procedures performed in the USA and comprises an outsized proportion of Medicare expenditures. Previous work-associated higher safety-net burden hospitals with increased morbidity and in-hospital mortality following total hip arthroplasty. Here, we examine the association of safety-net burden on postoperative outcomes after TKA. METHODS We retrospectively analyzed 1 141 587 patients aged ≥18 years undergoing isolated elective TKA using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York and Washington from 2007 through 2018. Hospitals were grouped into tertiles by safety-net burden status, defined by the proportion of inpatient cases billed to Medicaid or unpaid (low: 0%-16.83%, medium: 16.84%-30.45%, high: ≥30.45%). Using generalized estimating equation models, we assessed the association of hospital safety-net burden status on in-hospital mortality, patient complications and length of stay (LOS). We also analyzed outcomes by anesthesia type in New York State (NYS), the only state with this data. RESULTS Most TKA procedures were performed at medium safety-net burden hospitals (n=6 16 915, 54%), while high-burden hospitals performed the fewest (n=2 04 784, 17.9%). Overall in-patient mortality was low (0.056%), however, patients undergoing TKA at medium-burden hospitals were 40% more likely to die when compared with patients at low-burden hospitals (low: 0.043% vs medium: 0.061%, adjusted OR (aOR): 1.40, 95% CI 1.09 to 1.79, p=0.008). Patients who underwent TKA at medium or high safety-net burden hospitals were more likely to experience intraoperative complications (low: 0.2% vs medium: 0.3%, aOR: 1.94, 95% CI 1.34 to 2.83, p<0.001; low: 0.2% vs high: 0.4%, aOR: 1.91, 95% CI 1.35 to 2.72, p<0.001). There were no statistically significant differences in other postoperative complications or LOS between the different safety-net levels. In NYS, TKA performed at high safety-net burden hospitals was more likely to use general rather than regional anesthesia (low: 26.7% vs high: 59.5%, aOR: 4.04, 95% CI 1.05 to 15.5, p=0.042). CONCLUSIONS Patients undergoing TKA at higher safety-net burden hospitals are associated with higher odds of in-patient mortality than those at low safety-net burden hospitals. The source of this mortality differential is unknown but could be related to the increased risk of intraoperative complications at higher burden centers.
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Affiliation(s)
| | - Ryan Lippell
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Xiaoyue Ma
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Tiffany Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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26
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Jimenez MF, Isaza-Restrepo A, Conde D, Arroyo A, Ibánez-Pinilla M, Borda F, Colmenares D, Puyana JC. Surgical Rescue in a High-volume Urban Emergency General Surgery Service at a Middle-income Country. PANAMERICAN JOURNAL OF TRAUMA, CRITICAL CARE & EMERGENCY SURGERY 2021; 10:16-19. [PMID: 36196079 PMCID: PMC9529028 DOI: 10.5005/jp-journals-10030-1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction: The capacity for prompt “rescue” from death in patients with complications has become an important marker of the quality of care since mortality and morbidity have been identified as incongruous indicators. This study aims to describe the incidence of “surgical rescue” failure and the outcomes of emergency general surgery (EGS) patients at a large academic medical center. Materials and methods: In our high-volume surgical hospital, an electronic EGS registry was developed to automatically capture in-hospital information and outcomes from the Electronic Medical Record (EMR). Surgical complications were included in an online application and automatically captured in the electronic EGS registry, and prospectively screened from June to July 2017 for acute EGS surgical patients from operative procedures. Results: A total of 501 patients (average age: 53.9 ± 20.9, 56.5% female) underwent 882 EGS procedures. Thirteen patients (2.6%) of the 501 patients required “surgical rescue”, mainly for uncontrolled sepsis (43%) and anastomotic leakage (30%). The surgical rescue failure rate (inability to prevent death after a surgical complication) was 15.4%. Patients requiring critical care (OR = 3.3, IC 95%: 1.04, 10.5), hospital admission (p = 0.038), and hospital LOS (days) (p = 0.004) were significantly higher for the surgical rescue patients than for those without complications. Conclusion: Surgical failure to rescue rate was similar among high-volume EGS services, as has recently been described in the United States. The latest development and implementation of an electronic automatic captured EGS registry database in our academic medical center will serve to build best practices for “surgical rescue” and drive quality improvement programs.
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Affiliation(s)
- Maria F Jimenez
- Department of Surgery, General Surgeon-Hospital Universitario Mayor, Universidad del Rosario, Bogota, Colombia
| | - Andrés Isaza-Restrepo
- Department of Surgery, General Surgeon-Hospital Universitario Mayor, Universidad del Rosario, Bogota, Colombia
| | - Danny Conde
- Department of Surgery, General Surgeon-Hospital Universitario Mayor, Universidad del Rosario, Bogota, Colombia
| | - Alex Arroyo
- Department of Surgery, Statistics Hospital Universitario Mayor, Bogota, Colombia
| | | | - Felipe Borda
- Department of Surgery, PGY-5 Hospital Universitario Mayor, Bogota, Colombia
| | - Daniel Colmenares
- Department of Surgery, PGY-5 Hospital Universitario Mayor, Bogota, Colombia
| | - Juan C Puyana
- Department of Surgery, University of Pittsburgh, Pennsylvania, USA
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27
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Williams BM, Purcell LN, Varela C, Gallaher J, Charles A. Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue. J Surg Res 2021; 259:320-325. [PMID: 33129505 PMCID: PMC7897218 DOI: 10.1016/j.jss.2020.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi. METHODS We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality. RESULTS We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation. CONCLUSIONS Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.
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Affiliation(s)
- Brittney M Williams
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jared Gallaher
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.
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28
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Oh KJ, Gajdos C, Savulionyte GE, Hennon M, Schwaitzberg SD, Nader ND. Failure to Rescue from Surgical Complications After Trans-thoracic and Trans-hiatal Esophageal Resection: an ACS-NSQIP Study. J Gastrointest Surg 2021; 25:536-538. [PMID: 32948959 DOI: 10.1007/s11605-020-04797-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/06/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Kenny J Oh
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Csaba Gajdos
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Goda E Savulionyte
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Mark Hennon
- Department of Surgery, Roswell Park Cancer Institute, Buffalo, NY, 14203, USA
| | - Steven D Schwaitzberg
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Nader D Nader
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA. .,Department of Anesthesiology, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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29
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Ma LW, Kaufman EJ, Hatchimonji JS, Xiong R, Scantling DR, Stoecker JB, Holena DN. The Impact of Socially Stigmatized Preexisting Conditions on Outcomes After Injury. J Surg Res 2020; 257:511-518. [PMID: 32916504 DOI: 10.1016/j.jss.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/16/2020] [Accepted: 08/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR. MATERIALS AND METHODS We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR. RESULTS We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001). CONCLUSIONS Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted.
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Affiliation(s)
- Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elinore J Kaufman
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruiying Xiong
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dane R Scantling
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan B Stoecker
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Hatchimonji JS, Swendiman RA, Kaufman EJ, Scantling D, Passman JE, Yang W, Kit Delgado M, Holena DN. Multiple Complications in Emergency Surgery : Identifying Risk Factors for Failure-to-Rescue. Am Surg 2020; 86:787-795. [PMID: 32683944 DOI: 10.1177/0003134820934400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND While the use of the failure-to-rescue (FTR) metric, or death after complication, has expanded beyond elective surgery to emergency general surgery (EGS), little is known about the trajectories patients take from index complication to death. METHODS We conducted a retrospective cohort study of EGS operations using the National Surgical Quality Improvement Project (NSQIP) dataset, 2011-2017. 16 major complications were categorized as infectious, respiratory, thrombotic, cardiac, renal, neurologic, or technical. We tabulated common combinations of complications. We then use logistic regression analyses to test the hypotheses that (1) increase in the number and frequency of complications would yield higher FTR rates and (2) secondary complications that span a greater number of organ systems or mechanisms carry a greater associated FTR risk. RESULTS Of 329 183 EGS patients, 69 832 (21.2%) experienced at least 1 complication. Of the 11 195 patients who died following complication (16.0%), 8205 (63.4%) suffered more than 1 complication. Multivariable regression analyses revealed an association between the number of complications and mortality risk (odds ratio [OR] 2.37 for 2 complications vs 1, P < .001). There was a similar increase in mortality with increased complication accrual rate (OR 3.29 for 0.2-0.4 complications/day vs <0.2, P < .001). Increasing the number of types of complication were similarly associated with mortality risk. DISCUSSION While past FTR analyses have focused primarily on index complication, a broader consideration of ensuing trajectory may enable identification of high-risk cohorts. Efforts to reduce mortality in EGS should focus on attention to those who suffer a complication to prevent a cascade of downstream complications culminating in death.
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Affiliation(s)
- Justin S Hatchimonji
- 6572 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Robert A Swendiman
- 6572 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Elinore J Kaufman
- 6572 Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dane Scantling
- 6572 Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse E Passman
- 6572 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Yang
- 6572 Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - M Kit Delgado
- 6572 Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,6572 Department of Emergency Medicine, Center for Emergency Care Policy and Research, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Daniel N Holena
- 6572 Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,6572 Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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31
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Patel R, Patel KS, Alvarez-Downing MM, Merchant AM. Laparoscopy improves failure to rescue compared to open surgery for emergent colectomy. Updates Surg 2020; 72:835-844. [PMID: 32519206 DOI: 10.1007/s13304-020-00803-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/14/2020] [Indexed: 01/02/2023]
Abstract
Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42-2.08), mortality (OR 1.72, 95% CI 1.44-2.07), and morbidity (OR 1.73, 95% CI 1.60-1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08-1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03-2.93), and septic shock (OR 2.34, 95% CI 1.97-2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p < 0.0001). This study demonstrates the safety and efficacy of the laparoscopic approach for emergent colectomy vs open surgery. Laparoscopy was associated with improved complications rates, mortality, and failure to rescue, indicating that it is a promising option to improve patient outcomes during emergent colectomy.
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Affiliation(s)
- Richa Patel
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA
| | - Krishan S Patel
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA
| | - Melissa M Alvarez-Downing
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.,Department of Surgery, Division of Colorectal Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Aziz M Merchant
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA. .,Department of Surgery, Division of General Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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Gupta A, Cadwell JB, Merchant AM. Social determinants of health and outcomes of ventral hernia repair in a safety-net hospital setting. Hernia 2020; 25:287-293. [PMID: 32361947 DOI: 10.1007/s10029-020-02203-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Lower socioeconomic status has been shown to be predictive of poorer surgical outcomes in ventral hernia repair. Recently, safety-net hospitals have been attempting to address these disparities to improve the care of patients of lower socioeconomic status. METHODS A query of all patients undergoing ventral hernia repair at our institution between 2010 and 2019 was completed (n = 580). Patients not from identifiable New Jersey ZIP-codes were excluded (n = 572). ZIP codes were assigned quartiles based off socioeconomic variables including median household income, percent below poverty line, and high school graduation rate. Patients were then assigned to socioeconomic status quartiles based off their residential ZIP-code. Outcomes of ventral hernia surgery were compared across ZIP-code quartiles. Logistic regression was used to analyze predictors of poor outcomes. RESULTS Patients from lower socioeconomic brackets were more likely to be younger (p < 0.001), female (p = 0.014), black (p < 0.001), and/or Hispanic (p = 0.003). Most notably, outcomes of ventral hernia were not significantly different between patients of different socioeconomic status ZIP-code quartiles. The risk of any post-operative morbidity was higher for longer procedures (p < 0.001) and for hernia repairs being done with other procedures (p < 0.001). Risk of prolonged length of stay and related 30-day readmission was higher with longer procedures (p < 0.001 and p = 0.003, respectively). CONCLUSION We found that outcomes of ventral hernia repair at a safety-net hospital were unaffected by socioeconomic status. This supports the important role that safety-net institutions play in providing quality care to their vulnerable populations. Future studies at other safety-net hospitals should be done to further assess the updated impact of socioeconomic status on ventral hernia outcomes.
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Affiliation(s)
- A Gupta
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA
| | - J B Cadwell
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA
| | - A M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA.
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Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care? J Gastrointest Surg 2020; 24:939-948. [PMID: 31823324 DOI: 10.1007/s11605-019-04471-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors. METHODS Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017-2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups. RESULTS The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001). CONCLUSION Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity.
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Ball CG, Murphy P, Verhoeff K, Albusadi O, Patterson M, Widder S, Hameed SM, Parry N, Vogt K, Kortbeek JB, MacLean AR, Engels PT, Rice T, Nenshi R, Khwaja K, Minor S. A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform? Can J Surg 2020; 63:E150-E154. [PMID: 32216251 DOI: 10.1503/cjs.019118] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.
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Affiliation(s)
- Chad G. Ball
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Patrick Murphy
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Kevin Verhoeff
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Omar Albusadi
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Matthew Patterson
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Sandy Widder
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - S. Morad Hameed
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Neil Parry
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Kelly Vogt
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - John B. Kortbeek
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Anthony R. MacLean
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Paul T. Engels
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Timothy Rice
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Rahima Nenshi
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Kosar Khwaja
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
| | - Samuel Minor
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ball, Albusadi, Patterson, Kortbeek, MacLean); Western University, London, Ont. (Murphy, Parry, Vogt); the University of Alberta, Edmonton, Alta. (Verhoeff, Widder); the University of British Columbia, Vancouver, B.C. (Hameed); McMaster University, Hamilton, Ont. (Engels, Rice, Nenshi); McGill University, Montréal, Que. (Khwaja); and Dalhousie University, Halifax, N.S. (Minor)
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Hatchimonji JS, Kaufman EJ, Stoecker JB, Sharoky CE, Holena DN. Failure to Rescue in Emergency Surgery: Is Precedence a Problem? J Surg Res 2020; 250:172-178. [PMID: 32070836 DOI: 10.1016/j.jss.2019.12.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/04/2019] [Accepted: 12/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations. METHODS National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations. RESULTS There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy. CONCLUSIONS Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan B Stoecker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine E Sharoky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Failure to rescue in surgical patients: A review for acute care surgeons. J Trauma Acute Care Surg 2020; 87:699-706. [PMID: 31090684 DOI: 10.1097/ta.0000000000002365] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 87:491-501. [PMID: 31095067 DOI: 10.1097/ta.0000000000002368] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE Review, Economic/Decision, level III.
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Carlock TC, Barrett JR, Kalvelage JP, Young JB, Nunez JM, Colonna AL, Enniss TM, Nirula R, McCrum ML. Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use. J Am Coll Surg 2019; 230:228-236. [PMID: 31654733 DOI: 10.1016/j.jamcollsurg.2019.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. STUDY DESIGN Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. RESULTS Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. CONCLUSIONS Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.
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Affiliation(s)
- Tanner C Carlock
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - James R Barrett
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - James P Kalvelage
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jason B Young
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jade M Nunez
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Alexander L Colonna
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Toby M Enniss
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Raminder Nirula
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Marta L McCrum
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT.
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