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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 2024:31348241248796. [PMID: 38656140 DOI: 10.1177/00031348241248796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 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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Í Soylu L, Kokotovic D, Gögenur I, Ekeloef S, Burcharth J. Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study. Eur J Trauma Emerg Surg 2024; 50:295-304. [PMID: 37646801 PMCID: PMC10923996 DOI: 10.1007/s00068-023-02352-3] [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: 05/04/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.
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Affiliation(s)
- Lív Í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Javed H, Olanrewaju OA, Ansah Owusu F, Saleem A, Pavani P, Tariq H, Vasquez Ortiz BS, Ram R, Varrassi G. Challenges and Solutions in Postoperative Complications: A Narrative Review in General Surgery. Cureus 2023; 15:e50942. [PMID: 38264378 PMCID: PMC10803891 DOI: 10.7759/cureus.50942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024] Open
Abstract
In general surgery, the goal of achieving favorable results following surgical procedures is consistently impeded by the intricate range of postoperative problems. This abstract summarizes a comprehensive narrative study that examines the numerous difficulties associated with postoperative complications and investigates potential remedies. With the progress of surgical practices, the intricacies of complications also increase, requiring a flexible comprehension of the diverse scenarios. This review examines the many factors contributing to postoperative complications, including patient-specific variables and advancing surgical procedures. It also explores the broader consequences of these problems on individual patients and healthcare systems. The economic results, such as extended hospitalizations and increased allocation of resources, highlight the need for specific solutions. This abstract also emphasizes the review's examination of novel methodologies, technology incorporations, and cooperative tactics as potential transformative factors. This abstract provides an overview of the ongoing efforts to change how postoperative complications are understood in general surgery. It highlights the importance of taking preventive measures and adopting a comprehensive approach to patient care.
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Affiliation(s)
- Herra Javed
- General Surgery, Shifa College of Medicine, Islamabad, PAK
| | - Olusegun A Olanrewaju
- Pure and Applied Biology, Ladoke Akintola University of Technology, Ogbomoso, NGA
- General Medicine, Stavropol State Medical University, Stavropol, RUS
| | | | - Ayesha Saleem
- General Surgery, Hayatabad Medical Complex (HMC), Peshawar, PAK
| | - Peddi Pavani
- General Surgery, Kurnool Medical College, Kurnool, IND
| | - Humza Tariq
- Surgery, Lahore General Hospital, Lahore, PAK
| | | | - Raja Ram
- Medicine, MedStar Washington Hospital Center, Washington, USA
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Moneme AN, Wirtalla CJ, Roberts SE, Keele LJ, Kelz RR. Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions. JAMA Surg 2023; 158:1293-1301. [PMID: 37755816 PMCID: PMC10534988 DOI: 10.1001/jamasurg.2023.4534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/01/2023] [Indexed: 09/28/2023]
Abstract
Importance The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. Objective To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. Design, Setting, and Participants This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Exposure Follow-up with a PCP within 30 days after hospital discharge for the index admission. Main Outcomes and Measures The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. Results The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. Conclusions and Relevance In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.
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Affiliation(s)
- Adora N. Moneme
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Christopher J. Wirtalla
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
| | - Sanford E. Roberts
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
| | - Luke J. Keele
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
| | - Rachel R. Kelz
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Blank J, Shiroff AM, Kaplan LJ. Surgical Emergencies in Patients with Significant Comorbid Diseases. Surg Clin North Am 2023; 103:1231-1251. [PMID: 37838465 DOI: 10.1016/j.suc.2023.06.003] [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: 10/16/2023]
Abstract
Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.
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Affiliation(s)
- Jacqueline Blank
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA
| | - Adam M Shiroff
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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Clausen J, Boesen V, Gögenur I, Watt T. A Content Framework of a Novel Patient-Reported Outcome Measure for Detecting Early Adverse Events After Major Abdominal Surgery. World J Surg 2023; 47:2676-2687. [PMID: 37610468 PMCID: PMC10545596 DOI: 10.1007/s00268-023-07143-w] [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] [Accepted: 07/12/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Systematic health monitoring with patient-reported outcome instruments may predict post-discharge complications after major surgery. The objective of this study was to conceptualize a novel patient-reported outcome instrument for detecting early adverse events within two weeks of discharge after major emergency abdominal surgery and colorectal cancer surgery. METHODS This study was conducted in two phases. (1) An exhaustive health concept pool was generated using systematic content analysis of existing patient-reported outcome measures (N = 31) and semi-structured interviews of readmitted patients (N = 49) and health professionals (N = 10). Concepts were categorized into three major domains: 'Symptoms,' 'functional status,' and 'general health perception.' We calculated the frequency of each health concept as the proportion of patients, who experienced the respective concept prior to readmission. (2) Colorectal cancer surgeons (N = 13) and emergency general surgeons (N = 12) rated the relevance of each health concept (1 = irrelevant, 5 = very relevant) in the context of detecting post-discharge adverse events. We selected concepts with either a high mean relevance score (≥ 4) or a combination of moderate mean relevance score and high patient-reported frequency (≥ 3 and ≥ 20% or ≥ 2.5 and ≥ 50%, respectively). RESULTS Content analysis of existing items with additions from patients and experts resulted in 58 health concepts, of which the majority were distinct symptoms (N = 40). The selection procedure resulted in 29 patient-reported health concepts relevant for detecting adverse events after discharge. CONCLUSION The outlined framework provides content validity for future patient-reported outcome instruments detecting adverse events in the early post-discharge period after major emergency abdominal surgery and colorectal cancer surgery.
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Affiliation(s)
- Johan Clausen
- Center for Surgical Science, Surgical Department, Zealand's University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark.
| | - Victor Boesen
- Department of Endocrinology, Gentofte and Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Surgical Department, Zealand's University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Torquil Watt
- Department of Endocrinology, Gentofte and Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Fair L, Squiers JJ, Misenhimer J, Perryman M, Jacinto K, Blair S, Michael-Blackwell J, Moore F, Rodriguez C. In-Person Clinic Visits After Laparoscopic Cholecystectomy: Lessons Learned From COVID-19 Pandemic. J Surg Res 2023; 291:396-402. [PMID: 37517347 DOI: 10.1016/j.jss.2023.06.029] [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: 03/22/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION The utility of routine in-person clinic appointments after laparoscopic cholecystectomy (LC) is uncertain, especially after the increase of telehealth visits during the COVID-19 pandemic. The purpose of this study was to evaluate the utility of routine in-person follow-up for patients undergoing LC prior to changes implemented during the pandemic and to determine whether a return to routine in-person follow-up is warranted. METHODS We retrospectively reviewed follow-up encounters for all patients undergoing LC from April 2018 to February 2020. All patients were routinely scheduled for in-person postoperative clinic follow-up 2-4 wk after discharge. Follow-up was considered nonroutine if new studies or medications were ordered, the patient was referred to the emergency department or readmitted, or malignancy was identified on pathology review. RESULTS Of 661 patients undergoing LC, 449 (68%) attended their scheduled in-person postoperative appointment and 212 (32%) did not. The postoperative appointment was nonroutine for 39 patients (9% of clinic attenders). Readmission occurred in 42 patients, with no differences between clinic attenders and nonattenders (P = 0.12). Furthermore, attending a postoperative clinic visit did not affect odds of readmission (odds ratio: 0.705, 95% confidence interval: 0.368, 1.351; P = 0.29). Readmission occurred on median day 9 after discharge in both groups. CONCLUSIONS The incidence of nonroutine follow-up after LC is low, and attendance at follow-up clinic was not associated with reduced readmissions. A return to routinely scheduling in-person follow-up 2-4 wk after discharge may not be warranted. Telehealth visits within 1 wk of discharge after LC should be considered.
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Affiliation(s)
- Lucas Fair
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas; Department of Surgical Research, Baylor Scott & White Research Institute, Dallas, Texas.
| | - John J Squiers
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Jennifer Misenhimer
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Matthew Perryman
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Kimberly Jacinto
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas; Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Somer Blair
- Office of Clinical Research, John Peter Smith Hospital, Fort Worth, Texas
| | | | - Forrest Moore
- Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas
| | - Carlos Rodriguez
- Department of Surgery, Texas Health Harris Methodist Hospital, Fort Worth, Texas
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Parreco JP, Avila A, Pruett R, Romero DC, Solomon R, Buicko JL, Rosenthal A, Carrillo EH. Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison. J Am Coll Surg 2023; 236:775-780. [PMID: 36728000 DOI: 10.1097/xcs.0000000000000571] [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: 02/03/2023]
Abstract
BACKGROUND Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. STUDY DESIGN The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. RESULTS There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). CONCLUSIONS Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.
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Affiliation(s)
- Joshua P Parreco
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Azalia Avila
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Rachel Pruett
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Dino C Romero
- the General Surgery Residency, Memorial Healthcare System, Hollywood, FL (Avila, Pruett, Romero)
| | - Rachele Solomon
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Jessica L Buicko
- the Endocrine, Breast, and General Surgery, Florida Atlantic University, Boynton Beach, FL (Buicko)
| | - Andrew Rosenthal
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
| | - Eddy H Carrillo
- From the Trauma Critical Care Surgery, Memorial Regional Hospital, Hollywood, FL (Parreco, Solomon, Rosenthal, Carrillo)
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A comprehensive analysis of 30-day readmissions after emergency general surgery procedures: Are risk factors modifiable? J Trauma Acute Care Surg 2023; 94:61-67. [PMID: 36221175 DOI: 10.1097/ta.0000000000003804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Modifiable risk factors associated with procedure-related 30-day readmission after emergency general surgery (EGS) have not been comprehensively studied. We set out to determine risk factors associated with EGS procedure-related 30-day unplanned readmissions. METHODS A retrospective cohort study was conducted using the National Surgical Quality Improvement Project database (2013-2019). It included nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Data on patient characteristics, admission status, procedure risk, hospital length of stay, and discharge disposition were analyzed by multivariate logistic regression. RESULTS A total of 312,862 patients were included (16,306 procedure-related 30-day readmissions [5.2%]). Thirty-day readmission patients were older, had higher American Association of Anesthesiology scores, were more often underweighted or markedly obese, and were more frequently presented with sepsis. Risk factors associated with EGS procedure-related 30-day unplanned readmissions included age older than 40 years (adjusted odds ratio [AOR], 1.15), American Association of Anesthesiology ≥3 (AOR, 1.41), sepsis present at the time of surgery (AOR, 1.84), body mass index <18 kg/m 2 (AOR, 1.16), body mass index ≥40 kg/m 2 (AOR, 1.12), high-risk procedures (AOR, 1.51), LOS ≥4 d (AOR, 2.04), and discharge except to home (AOR, 1.33). Thirty-day readmissions following low-risk procedures occurred at a median of 5 days (interquartile range, 2-11 days) and 6 days (interquartile range, 3-11 days) after high-risk procedures. Surgical site infections, postoperative sepsis, wound disruption, and thromboembolic events were more prevalent in the 30-day readmission group. Mortality rate was fourfold higher in the 30-day readmission group (2.4% vs. 0.6%). CONCLUSION We identified several unmodifiable patients and EGS disease-related factors associated with 30-day unplanned readmissions. Readmissions could be potentially reduced by the implementation of a postdischarge surveillance systems between hospitals and postdischarge destination facilities, leveraging telehealth and outpatient care. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Lai CK, Towe CW, Patel NJ, Brown LR, Claridge JA, Ho VP. Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters. Surg Infect (Larchmt) 2022; 23:866-872. [PMID: 36394462 PMCID: PMC9784599 DOI: 10.1089/sur.2022.243] [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: 11/19/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.
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Affiliation(s)
- Clara K.N. Lai
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W. Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nimitt J. Patel
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, USA
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Turrentine FE, Smolkin ME, McMurry TL, Scott Jones R, Zaydfudim VM, Davis JP. Determining the Association Between Unplanned Reoperation and Readmission in Selected General Surgery Operations. J Surg Res 2021; 267:309-319. [PMID: 34175585 DOI: 10.1016/j.jss.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unplanned reoperations and unplanned readmissions can increase morbidity and mortality. Few studies however, have explored the association of reoperation and readmission among general surgery patients. Our aim was to examine this relationship in selected abdominal operations. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files from 2014 to 2018 were utilized. Six groups of operations, defined by ACS NSQIP procedure codes for ventral hernia repair, colectomy, appendectomy, proctectomy, small bowel resection, and gastrectomy, were assessed. Patients discharged ≤ 14 days after operation were included in the study. This time period was selected to reduce ACS NSQIP 30 day post-surgery follow-up bias. Unplanned reoperations were defined as those occurring during the index hospitalization. The primary outcome was unplanned readmission that occurred ≤ 14 days from the date of discharge. Logistic regression models were used to examine variables associated with unplanned readmission for each procedure group. RESULTS A total of 787,118 patients were included: ventral hernia repair 35.2%, colectomy 30.6%, appendectomy 26.5%, proctectomy 3.7%, small bowel resection 3.2%, and gastrectomy 0.8%. Unplanned reoperation was independently associated with unplanned readmission for ventral hernia repair (OR 2.84, 95% CI 2.28-3.54, P < 0.001), colectomy (OR 1.58, CI 1.42- 1.76, P < 0.001), appendectomy (OR 2.91, CI 2.21-3.84, P < 0.001), and proctectomy (OR 1.41, CI 1.10-1.81, P = 0.006). Other clinically relevant covariates associated with readmission were partially dependent functional status before colectomy (OR 1.34, CI 1.23-1.46, P < 0.001), ventral hernia repair (OR 1.79, CI 1.54-2.09, P < 0.001), and small bowel resection (OR 1.44, CI 1.18-1.77, P < 0.001; and ASA 4/5 classification for colectomy (OR 2.71, CI 2.36-3.11, P < 0.001), proctectomy (OR 2.10, CI 1.48-2.97, P < 0.001), ventral hernia repair (OR 8.19, CI 6.78-9.88, P < 0.001), appendectomy (OR 2.80, CI 2.35-3.34, P < 0.001), and small bowel resection (OR 3.42, CI 2.20-5.32, P < 0.001). ASA 2, ASA 3 classification, age, and sex were also associated with unplanned readmission for most procedures. CONCLUSIONS Unplanned reoperations are associated with an increase in unplanned readmission after selected abdominal operations included in this study. This factor should be considered in discharge and follow-up planning to help reduce unplanned readmissions.
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Affiliation(s)
- Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Mark E Smolkin
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - John P Davis
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia.
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