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Claps F, Rossin G, van Rhijn BWG, Mir MC, Mertens LS, Ongaro L, Traunero F, Iachimovsky AI, Piasentin A, Vedovo F, Perotti A, Tulone G, Zucchi A, Liguori G, Simonato A, Bartoletti R, Trombetta C, Pavan N. The Utility of Inflammatory Serum Markers in the Assessment of Perioperative Morbidity after Radical Cystectomy for Bladder Cancer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050926. [PMID: 37241158 DOI: 10.3390/medicina59050926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: To date, sparse evidence exists about the impact of inflammatory serum markers in predicting perioperative complications after radical cystectomy (RC) for bladder cancer (BC). Here, we evaluated the role of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), C-reactive protein (CRP), and plasma fibrinogen in predicting perioperative morbidity and unplanned 30-days readmission after RC for BC. Materials and methods: We relied on a collaborative database of 271 patients who underwent open RC for cT1-4a N0 M0 BC between January 2012 and December 2022. Univariable and multivariable binomial logistic regression analyses were performed to assess the odds ratio (OR) with 95% confidence intervals (CI) testing the ability of each serum marker to predict postoperative complications (any-grade and major complications), and 30-days unplanned readmission. Results: The median age at RC was 73 yr (IQR 67-79). A total of 182 (67.2%) patients were male and the median BMI was 25.2 (IQR 23.2-28.4). Overall, 172 (63.5%) patients had a Charlson Comorbidity Index (CCI) greater than 2 points and 98 (36.2%) were current smokers at the time of RC. Overall, 233 (86.0%) patients experienced at least one complication after RC. Of these, 171 (63.1%) patients had minor complications (Clavien-Dindo grade 1-2) while 100 (36.9%) experienced major complications (Clavien-Dindo grade ≥ 3). According to multivariable analysis, current smoking status, high plasma fibrinogen, and preoperative anemia were independently associated with major complications (OR 2.10, 95%CI 1.15-4.90, p = 0.02), (OR 1.51, 95%CI 1.26-1.98, p = 0.09), and (OR 1.35, 95%CI 1.17-2.57, p = 0.03), respectively. Overall, 56 (20.7%) patients experienced a 30-days unplanned readmission. According to univariable analysis, high preoperative CRP and hyperfibrinogenemia were significantly associated with an increased risk of unplanned readmission (OR 2.15, 95%CI 1.15-4.16, p = 0.02; OR 2.18, 95%CI 1.13-4.44, p = 0.02, respectively). Conclusions: In our study, the preoperative immune-inflammation signature described by NLR, PLR, LMR, SII, and CRP showed a low reliability in predicting perioperative course after RC. Preoperative anemia and hyperfibrinogenemia were independent predictors of major complications. Further studies are pending in order to draw definitive conclusions.
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Affiliation(s)
- Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Giulio Rossin
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Bas W G van Rhijn
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, 46600 Valencia, Spain
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands
| | - Luca Ongaro
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Fabio Traunero
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Alexandra I Iachimovsky
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Andrea Piasentin
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Francesca Vedovo
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Alessandro Perotti
- Department of Translational Research and New Technologies, University of Pisa, 56126 Pisa, Italy
| | - Gabriele Tulone
- Urology Clinic, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, 90133 Palermo, Italy
| | - Alessandro Zucchi
- Department of Translational Research and New Technologies, University of Pisa, 56126 Pisa, Italy
| | - Giovanni Liguori
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Alchiede Simonato
- Urology Clinic, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, 90133 Palermo, Italy
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, 56126 Pisa, Italy
| | - Carlo Trombetta
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Nicola Pavan
- Urology Clinic, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, 90133 Palermo, Italy
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Radical prostatectomy readmissions: Causes, risk factors, national rates, & costs. Urol Oncol 2023; 41:106.e1-106.e8. [PMID: 36402714 DOI: 10.1016/j.urolonc.2022.10.022] [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: 06/28/2022] [Revised: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Readmissions have substantial clinical and financial impacts on the healthcare system. Radical prostatectomy (RP) is considered a standard treatment in the management of clinically localized prostate cancer. Yet, there is a paucity of research evaluating readmissions for RP in a national dataset. PATIENTS AND METHODS Patients with histologically confirmed prostate cancer managed with RP were identified within the 2016 to 2018 Nationwide Readmissions Database. Patient factors, facility factors, and surgical characteristics were evaluated for associations with readmission using univariable and multivariable analyses. RESULTS A total of 133,727 patients receiving RP were identified. Early (30-day) and late (31-90-day) readmission rates were 4.2% and 1.8% respectively. The most common cause of early readmission was postoperative digestive system complication (10%) and the most common cause of late readmission was septicemia (13%). On multivariable logistic regression, factors associated with both early and late readmission include nonroutine discharge at index (early: OR 1.877, 95% CI 1.667-2.113; late: OR 1.801, 95% CI 1.490-2.183), and circulatory system comorbidity (early: OR 1.29, 95% CI 1.082-1.538); late: OR 1.515, 95% CI 1.157-1.984). CONCLUSIONS Our findings regarding factors associated with readmission provide insight for RP counseling and may inform postoperative care pathways. Elucidation of readmission trends may allow the identification and proactive management of patients at higher risk for readmission.
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Michel J, Jivanji D, Goel AN, Lec PM, Lenis AT, Litwin MS, Chamie K. Readmissions after radical nephrectomy in a national cohort. Scand J Urol 2023; 57:75-80. [PMID: 36644811 DOI: 10.1080/21681805.2023.2166579] [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: 01/17/2023]
Abstract
OBJECTIVE To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy. MATERIALS AND METHODS We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression. RESULTS Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03-1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN - OR: 1.85; 95%CI: 1.33-2.56; Lap RN - OR: 1.99; 95%CI 1.10-3.59; Robotic RN - OR: 2.18; 95%CI: 1.23-3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost. CONCLUSION One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.
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Affiliation(s)
- Joaquin Michel
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dhaval Jivanji
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alexander N Goel
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick M Lec
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Andrew T Lenis
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark S Litwin
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,UCLA Fielding School of Public Health, Los Angeles, CA, USA.,UCLA School of Nursing, Los Angeles, CA, USA
| | - Karim Chamie
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Impact of Hospital volume on postoperative outcomes after radical prostatectomy: A 5-Year nationwide database analysis. Eur Urol Focus 2022; 8:1169-1175. [PMID: 34147406 DOI: 10.1016/j.euf.2021.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital volume is considered to be a quality measure for outcomes after major oncological surgery. However, countrywide data are lacking for radical prostatectomy (RP). OBJECTIVE To assess the impact of hospital volume on postoperative outcomes after RP performed using an open (ORP) versus a minimally invasive surgery (MIS, including pure and robot-assisted RP) approach. DESIGN, SETTING, AND PARTICIPANTS Data for patients undergoing RP in France from 2014 to 2019 were extracted from the central database of the national health care system. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary endpoints were length of hospital stay (LOS), complications (measured as severity index [SI] scores), and hospital readmission rates at 30 and 90 d. RESULTS AND LIMITATIONS The median annual hospital volume was 19 RPs (interquartile range 1-40) in the overall cohort. MIS was associated with better outcomes than ORP. Greater hospital volume was correlated with shorter LOS (p < 0.001), high SI scores (SI3: p < 0.001; SI4: p < 0.001), and 30-d (p < 0.001) and 90-d readmission rates (p < 0.001). Incidence rates for SI3 and SI4 scores, and 30-d and 90-d readmission were 12.8 %, 5.8 %, 29.8 %, and 35.4 % in very low-volume centres (<10 annual cases) compared with 8.1 %, 1.9 %, 18.1 %, and 23.9 %, respectively, in other centres (all p < 0.001). Hospital volume was an independent risk factor for all outcomes after taking into account age, lymph node dissection, year of surgery, and surgical approach (ORP vs MIS). The main limitation is the lack of post-RP oncological and functional data. CONCLUSIONS This nationwide analysis of RP procedures shows a significant correlation between hospital volume and postoperative outcomes irrespective of the surgical approach. Very low case volume (<10 annual procedures per centre) is associated with the highest risk of complications, readmission, and prolonged LOS. Greater hospital volume is directly correlated with shorter LOS even beyond this threshold. PATIENT SUMMARY In this study we analysed the French nationwide database for removal of the prostate for prostate cancer. We found that the number of these cases that a hospital carries out per year was associated with outcomes after surgery, with better outcomes for higher annual case numbers.
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Mallick S, Aiken T, Varley P, Abbott D, Tzeng CW, Weber S, Wasif N, Zafar SN. Readmissions From Venous Thromboembolism After Complex Cancer Surgery. JAMA Surg 2022; 157:312-320. [PMID: 35080619 PMCID: PMC8792793 DOI: 10.1001/jamasurg.2021.7126] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Venous thromboembolism (VTE) is a major cause of preventable morbidity and mortality after cancer surgery. Venous thromboembolism events that are significant enough to require hospital readmission are potentially life threatening, yet data regarding the frequency of these events beyond the 30-day postoperative period remain limited. OBJECTIVE To determine the rates, outcomes, and predictive factors of readmissions owing to VTE up to 180 days after complex cancer operations, using a national data set. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of the 2016 Nationwide Readmissions Database was performed to study adult patients readmitted with a primary VTE diagnosis. Data obtained from 197 510 visits for 126 104 patients were analyzed. This was a multicenter, population-based, nationally representative study of patients who underwent a complex cancer operation (defined as cystectomy, colectomy, esophagectomy, gastrectomy, liver/biliary resection, lung/bronchus resection, pancreatectomy, proctectomy, prostatectomy, or hysterectomy) from January 1 through September 30, 2016, for a corresponding cancer diagnosis. EXPOSURES Readmission with a primary diagnosis of VTE. MAIN OUTCOMES AND MEASURES Proportion of 30-, 90-, and 180-day VTE readmissions after complex cancer surgery, factors associated with readmissions, and outcomes observed during readmission visit, including mortality, length of stay, hospital cost, and readmission to index vs nonindex hospital. RESULTS For the 126 104 patients included in the study, 30-, 90-, and 180-day VTE-associated readmission rates were 0.6% (767 patients), 1.1% (1331 patients), and 1.7% (1449 of 83 337 patients), respectively. A majority of patients were men (58.7%), and the mean age was 65 years (SD, 11.5 years). For the 1331 patients readmitted for VTE within 90 days, 456 initial readmissions (34.3%) were to a different hospital than the index surgery hospital, median length of stay was 5 days (IQR, 3-7 days), median cost was $8102 (IQR, $5311-$10 982), and 122 patients died (9.2%). Independent factors associated with readmission included type of operation, scores for severity and risk of mortality, age of 75 to 84 years (odds ratio [OR], 1.30; 95% CI, 1.02-1.78), female sex (OR, 1.23; 95% CI, 1.11-1.37), nonelective index admission (OR, 1.31; 95% CI, 1.03-1.68), higher number of comorbidities (OR, 1.30; 95% CI, 1.06-1.60), and experiencing a major postoperative complication during the index admission (OR, 2.08; 95% CI, 1.85-2.33). CONCLUSIONS AND RELEVANCE In this cohort study, VTE-related readmissions after complex cancer surgery continued to increase well beyond 30 days after surgery. Quality improvement efforts to decrease the burden of VTE in postoperative patients should measure and account for these late VTE-related readmissions.
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Affiliation(s)
- Saad Mallick
- School of Medicine, Aga Khan University, Karachi, Pakistan
| | - Taylor Aiken
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Patrick Varley
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Daniel Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ching-Wei Tzeng
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Sharon Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic Arizona, Phoenix
| | - Syed Nabeel Zafar
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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Razdan S, Okhawere K, Wilson M, Nkemdirim W, Korn T, Meilika K, Badani K. Conversion to Open Radical or Partial Nephrectomy Associated with Unplanned Hospital Readmission After Attempted Minimally Invasive Approach. J Laparoendosc Adv Surg Tech A 2021; 32:823-831. [PMID: 34962141 DOI: 10.1089/lap.2021.0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction/Objectives: We endeavored to explore the rates of unplanned hospital readmission (UHR) in patients who underwent minimally invasive radical or partial nephrectomy who were subsequently converted to open surgery. Patients and Methods: The National Cancer Database (NCDB) was used for this study. Patients diagnosed with renal cancer and who had minimally invasive partial or radical nephrectomy from 2004 to 2016 were included in the study. Patients were categorized as converted or not converted to open surgery. UHR was the outcome of the study and was defined as UHR within 30 days of discharge. We conducted a one-to-one nearest-neighbor propensity-score matching using baseline clinical, tumor, and facility characteristics. To evaluate the relationship between conversion to open surgery and UHR, we conducted a multivariable logistic regression on the propensity-matched cohort, a propensity score-matched model without controlling for any covariate, and a propensity score-adjusted model, controlling for only the propensity score. Results: A total of 142,040 patients were identified, with a 2.98% conversion rate. There was an overall decrease in the rate of conversion to open surgery from 2010 (4.11%) to 2016 (2.43%). Laparoscopic radical nephrectomy remained a significant contributor to the rate of conversion (at least 50% per year). In the unmatched cohort, the UHR rate was higher among those who had a conversion to open surgery (n = 710, 0.52% versus n = 44, 1.04%; P < .001). Similarly, in the propensity score-matched cohort, the UHR rate was higher among those who had a conversion to open (n = 22, 0.52% versus n = 44, 1.04%; P = .007). After controlling for other factors, conversion to open remained independently associated with UHF. Conclusion: Conversion to open radical or partial nephrectomy from a minimally invasive approach is independently associated with an increased risk of 30-day UHR.
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Affiliation(s)
- Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Kennedy Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Michael Wilson
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - William Nkemdirim
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Talia Korn
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Kirolos Meilika
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Ketan Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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Glauser G, Winter E, Caplan IF, Haldar D, Goodrich S, McClintock SD, Guzzo TJ, Malhotra NR. The LACE + index as a predictor of 90-day urologic surgery outcomes. World J Urol 2020; 38:2783-2790. [DOI: 10.1007/s00345-019-03064-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/21/2019] [Indexed: 12/16/2022] Open
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Chiang HA, Cheng PJ, Speed JM, Steinberg J, Najjar PA, Steele GS, Trinh QD, Eswara JR, Chang SL, Kibel AS, Stopfkuchen-Evans MF, Preston MA. Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol. Eur Urol Focus 2020; 6:74-80. [DOI: 10.1016/j.euf.2018.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/13/2018] [Accepted: 08/28/2018] [Indexed: 01/16/2023]
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Glauser G, Winter E, Caplan IF, Goodrich S, McClintock SD, Guzzo TJ, Malhotra NR. The LACE+ Index as a Predictor of 30-Day Patient Outcomes in a Urologic Surgery Population: A Coarsened Exact Match Study. Urology 2019; 134:109-115. [DOI: 10.1016/j.urology.2019.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/31/2019] [Accepted: 08/21/2019] [Indexed: 10/26/2022]
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Harsfalvi J, Molnar Z, Csanyi MC, Domjan I, Flasko T, Kaposi A, Benyo M. Long-lasting prothrombotic state implied by changes of plasma von Willebrand factor parameters after radical prostatectomy for prostate malignancy. Urol Oncol 2019; 38:191-197. [PMID: 31711834 DOI: 10.1016/j.urolonc.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/27/2019] [Accepted: 10/07/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Thromboembolic complications are present in 0.8%-16.8% of the cases after radical prostatectomy (RP). Association between elevated plasma von Willebrand factor (VWF) levels-as an endothelial activation marker-and increased risk of thrombotic events has been evidenced. We aimed to elicit new data on the VWF after RP in prostate cancer patients and explore the role of it as a thrombotic risk factor. Upon perioperative plasma VWF levels (VWF:Ag) its collagen-binding (CB) activity (VWF:CB), multimerization, and cleaving enzyme (ADAMTS13 [a disintegrin and metalloprotease with thrombospondin type repeats, motif 1, type 13]) of the VWF multimers were quantitated along with Factor VIII and routine laboratory parameters in this observational pilot study. METHODS Plasma samples of 24 prostate cancer patients were collected before (-1 day; D-1) and after RP (1 hour, 6 days, 1 month, and 10 months; H1, D6, M1, and M10). VWF:Ag, VWF:CB, ADAMTS13:Ag were measured by ELISA, and the multimer distribution by electrophoresis and quantitative densitometry. Factor VIII, fibrinogen, D-dimer, and other routine laboratory parameters were determined as well. Preoperative values served as baselines which were compared to controls (24 healthy individuals). RESULTS VWF:Ag and CB elevated by 122% and 143% respectively at H1 after RP then plateaued at D6 compared to baseline values. ADAMTS13/VWF:Ag ratio reduced by 41% at H1, and by 46% at D6, meanwhile the ratio of high molecular weight multimers increased as well. Values returned to baseline at M1 and further reduced to the levels of the controls at M10. All of the 24 patients at H1 and D6 and 14 at M10 were in potential prothombotic state according ROC analysis of the VWF parameters as indicators. CONCLUSIONS Prostate malignancy and then surgical stress, and inflammatory reactions induced release of VWF from the endothelial cells, along with an increasing amount of large multimers and relative reduction of ADAMTS13 level. Because these changes mark a prothrombotic state even at M1 after RP, more than 1 month follow-up and prophylactic targeting through the thrombotic and inflammatory activity of the VWF is proposed. Evaluation of VWF parameters provides new information about the long-term disturbances of primary hemostasis after radical pelvic oncologic surgery like RP and might improve the understanding the physiological and pathological recovery.
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Affiliation(s)
- Jolan Harsfalvi
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary.
| | - Zsuzsanna Molnar
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Department of Laboratory, Grof Tisza Istvan Hospital, Berettyoujfalu, Hungary
| | - Maria Cs Csanyi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Istvan Domjan
- Department of Urology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Department of Urology, Josa Andras Hospital, Hospitals of Szabolcs-Szatmar-Bereg County, Nyiregyhaza, Hungary
| | - Tibor Flasko
- Department of Urology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Andras Kaposi
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Matyas Benyo
- Department of Laboratory, Grof Tisza Istvan Hospital, Berettyoujfalu, Hungary; Department of Urology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Chong JT, Paulucci D, Lubin M, Beksac AT, Gin G, Sfakianos JP, Badani KK. Comparison of overall survival and unplanned hospital readmissions between partial and radical nephrectomy for cT1a and cT1b renal masses. Ther Adv Urol 2018; 10:383-391. [PMID: 30574198 PMCID: PMC6295788 DOI: 10.1177/1756287218810313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/11/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of the study was to compare overall survival (OS) and unplanned hospital readmissions (UHRs) within 30 days between partial nephrectomy (PN) and radical nephrectomy (RN) for clinically localized T1 renal tumors. Methods: The National Cancer Database was queried to identify 51,018 patients who had undergone RN (n = 23,904; 46.9%) or PN (n = 27,114; 53.1%) for a cT1N0M0 renal mass from 2004 to 2013. OS and UHRs were compared using inverse probability of treatment weighted (IPTW)-adjusted Cox proportional hazards regression models. Results: For patients with a cT1a tumor, IPTW-adjusted analysis showed PN compared with RN was associated with improved OS (hazard ratio [HR] = 0.62; 95% confidence interval [CI] = 0.56, 0.67; p < 0.001) with a 5-year and 10-year IPTW-adjusted OS of 93.0% versus 88.2% and 78.1% versus 71.7%, respectively with no difference in UHR (odds ratio [OR] = 1.02; 95% CI = 0.90, 1.16; p = 0.727). For patients with a cT1b tumor, IPTW-adjusted analysis showed PN compared with RN to be associated with marginally improved OS (HR = 0.89; 95% CI = 0.82, 0.99; p = 0.025) with a 5-year and 10-year IPTW-adjusted OS of 85.3% versus 84.3% and 70.8% versus 63.6%, respectively, with more UHRs for PN (OR = 1.43; 95% CI = 1.19, 1.72; p < 0.001). Conclusions: PN compared with RN was associated with a significant survival benefit for patients with a cT1a renal mass and a modest survival benefit for patients with a cT1b renal mass. PN should be offered over RN when feasible despite a marginal increase in UHRs for PN of cT1b tumors. Randomized controlled trials are necessary to confirm these findings.
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Affiliation(s)
- Julio T Chong
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - David Paulucci
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Marc Lubin
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Alp Tuna Beksac
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Greg Gin
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA, and Department of Urology, Veterans Affairs Long Beach Health System, Long Beach, CA, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, 5 E 98th Street, New York, NY 10029, USA
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Arpey NC, Sloan MJ, Hahn AE, Polgreen PM, Erickson BA. Unscheduled Clinical Encounters in the Postoperative Period After Adult and Pediatric Urologic Surgery. Urology 2018; 124:113-119. [PMID: 30385259 DOI: 10.1016/j.urology.2018.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To qualify and quantify unscheduled clinical encounters (UCEs) in postoperative urologic patients and to identify patient and procedural risk factors for UCEs. MATERIALS AND METHODS All UCEs, including phone calls, emails, patient portal messages, clinic visits, ER visits, and hospital readmissions, were analyzed, including the reason for the interaction (eg, pain, infection, etc) were assessed retrospectively for consecutive surgical patients over a 3-month period. Demographic and perioperative data for each patient and surgery was recorded and risk factors for UCE were determined using uni- and multivariate analyses. RESULTS Approximately 40% of adult and pediatric patients experienced a UCE, the most common being phone calls (adult-68.2%, pediatric-90.0%) for new medical concerns (adult-67.7%, pediatric-58.1%). Risk factors for UCE in the adult population included lower BMI, living closer to the surgical hospital, discharge with catheter/wound packing, higher discharge pain, and open (vs endoscopic) surgery. In the pediatric population, surgery on the urethra/ureter and discharge with catheters predicted for UCE. UCEs led to changes in clinical management (17%, 21%), unplanned clinic visits (12%, 20%), and hospital readmissions (6%, 3%) for both adult and pediatric patients, respectively. CONCLUSION Nearly 40% of both adult and pediatric patients experienced an unplanned need for the healthcare system in the postoperative period. The effect that UCEs have on overall costs and patient satisfaction, as well as ways to decrease UCEs, require further study.
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Affiliation(s)
| | - Matthew J Sloan
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Amy E Hahn
- Carver College of Medicine, University of Iowa, Iowa City, IA
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13
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Saluk JL, Blackwell RH, Gange WS, Zapf MAC, Kothari AN, Kuo PC, Quek ML, Flanigan RC, Gupta GN. The LACE Score as a Tool to Identify Radical Cystectomy Patients at Increased Risk of 90-Day Readmission and Mortality. Curr Urol 2018; 12:20-26. [PMID: 30374276 DOI: 10.1159/000447226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/21/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Radical cystectomy for bladder cancer is associated with high rates of readmission. We investigated the LACE score, a validated prediction tool for readmission and mortality, in the radical cystectomy population. Materials & Methods Patients who underwent radical cystectomy for bladder cancer were identified by ICD-9 codes from the Healthcare Cost and Utilization Project State Inpatient Database for California years 2007-2010. The LACE score was calculated as previously described, with components of L: length of stay, A: acuity of admission, C: comorbidity, and E: number of emergency department visits within 6 months preceding surgery. Results Of 3,470 radical cystectomy patients, 638 (18.4%) experienced 90-day readmission, and 160 (4.6%) 90-day mortality. At a previously validated "high-risk" LACE score ≥ 10, patients experienced an increased risk of 90-day readmission (22.8 vs. 17.7%, p = 0.002) and mortality (9.1 vs. 3.5%, p < 0.001). On adjusted multivariable analysis, "high risk" patients by LACE score had increased 90-day odds of readmission (adjusted OR = 1.24, 95% CI: 0.99-1.54, p = 0.050) and mortality (adjusted OR = 2.09, 95% CI: 1.47-2.99, p < 0.001). Conclusion The LACE score reasonably identifies patients at risk for 90-day mortality following radical cystectomy, but only poorly predicts readmission. Providers may use the LACE score to target high-risk patients for closer follow-up or intervention.
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Affiliation(s)
- Jennifer L Saluk
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA.,Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - William S Gange
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Matthew A C Zapf
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA.,Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Anai N Kothari
- Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA.,Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Paul C Kuo
- Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA.,Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA.,Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA.,Department of One: MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL, USA
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14
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Brennan K, Karim S, Doiron RC, Siemens DR, Booth CM. Venous Thromboembolism and Peri-Operative Chemotherapy for Muscle-Invasive Bladder Cancer: A Population-based Study. Bladder Cancer 2018; 4:419-428. [PMID: 30417053 PMCID: PMC6218104 DOI: 10.3233/blc-180184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background: Chemotherapy and major pelvic surgery are established risk factors for venous thromboembolism (VTE). We evaluate the incidence rate, timing, and factors associated with VTE in patients with bladder cancer who underwent radical cystectomy and peri-operative chemotherapy in routine clinical practice. Methods: Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy for bladder cancer in Ontario 1994–2013. VTE events within 6 months of before or after cystectomy were identified using diagnostic codes recorded on hospital admissions and emergency department visits. Multivariable logistic regression was used to analyze factors associated with VTE prior to surgery, within 90-days of cystectomy, and 120-days after the start of adjuvant chemotherapy. Results: 4205 patients had cystectomy and 26% (1084/4205) received peri-operative chemotherapy. The overall incidence rate of VTE within 6 months of cystectomy was 9% (363/4205). VTE rate was highest among those patients treated with neoadjuvant chemotherapy (NACT) compared to patients treated with no chemotherapy or only adjuvant chemotherapy (ACT) (12% vs 8% vs 9%, p = 0.002). Among all VTE events, 10%, 28%, and 61% occurred before, during, and after hospitalization for cystectomy. Pre-operative VTE rate was highest among cases treated with NACT (4%) compared to patients with no chemotherapy (<1%) or ACT (<1%) (p < 0.001). VTE within 90 days of surgery was associated with greater length of hospital admission (p < 0.001) across all treatment groups. Conclusions: A substantial proportion of patients treated with peri-operative chemotherapy will develop VTE. The majority of these occur after discharge from hospital following cystectomy. Extended thromboprophylaxis treatment in high-risk patients including those who receive peri-operative chemotherapy should be considered.
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Affiliation(s)
- Kelly Brennan
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Safiya Karim
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, ON, Canada.,Department of Oncology, Queen's University, Kingston, ON, Canada
| | | | - D Robert Siemens
- Department of Oncology, Queen's University, Kingston, ON, Canada.,Department of Urology, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, ON, Canada.,Department of Oncology, Queen's University, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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15
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Kaczmarek K, Lemiński A, Bańcarz A, Zakrzewska A, Słojewski M. Post-Operative Infections among Patients Undergoing Radical Cystectomy at a Tertiary Center. Surg Infect (Larchmt) 2018; 19:451-458. [PMID: 29768132 DOI: 10.1089/sur.2017.291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Post-operative infection after radical cystectomy is a common complication. It is essential to identify modifiable risk factors that can predict post-operative infection to reduce the incidence of infection after radical cystectomy. We investigated the incidence of post-operative infection, associated pathogens, and risk factors for post-operative infection after radical cystectomy. PATIENTS AND METHODS Patients who underwent radical cystectomy for bladder cancer in a single urologic department from 2014 to 2016 were included. Age, gender, length of stay, body mass index (BMI), diabetes mellitus, hypertension, pre-operative estimated glomerular filtration rate, hydronephrosis, smoking status, neoadjuvant chemotherapy, pathologic tumor stage, pathologic nodal stage, types of urinary diversion, laparoscopic approach, operative time, and receipt of peri-operative blood transfusion were assessed to determine the association of these factors with the risk of infection within 30 days of radical cystectomy. Risk factors were assessed for correlation with any kind of infection and separately for urinary tract infection (UTI), blood infection/septic shock (BI), and surgical site infection (SSI). Pathogens were identified in all cases of infection. RESULTS A total of 134 patients were included in the analysis. Post-operative infection was diagnosed in 10.45%. Urinary tract infection, BI, and SSI were diagnosed in 3.73%, 4.48%, and 7.46%, respectively. Co-infections and mixed infection were diagnosed in 50% of patients with infection. Enterococcus was the most common pathogen. On multivariable analysis, age, BMI ≥30 kg/m2, and laparoscopic approach were associated with the risk of infection; odds ratios (ORs) were 1.27 (95% confidence interval [CI] 1.01-1.59), 13.07 (1.39-122.88), and 0.07 (0.01-0.78), respectively. CONCLUSION One-tenth of patients undergoing radical cystectomy developed an infection within 30 days of surgery. Fifty percent of patients had co-infection with UTI, SSI, and/or BI and 50% of infections were polymicrobial. Increased BMI is the strongest factor associated independently with all types of infection. Therefore, obese patients should be encouraged to lose weight pre-operatively.
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Affiliation(s)
- Krystian Kaczmarek
- Department of Urology and Urological Oncology, Pomeranian Medical University , Szczecin, Poland
| | - Artur Lemiński
- Department of Urology and Urological Oncology, Pomeranian Medical University , Szczecin, Poland
| | - Aleksandra Bańcarz
- Department of Urology and Urological Oncology, Pomeranian Medical University , Szczecin, Poland
| | - Alicja Zakrzewska
- Department of Urology and Urological Oncology, Pomeranian Medical University , Szczecin, Poland
| | - Marcin Słojewski
- Department of Urology and Urological Oncology, Pomeranian Medical University , Szczecin, Poland
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16
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Goldberg H, Shenhar C, Tamir H, Mano R, Baniel J, Margel D, Kedar D, Lifshitz D, Yossepowitch O. Predictors of surgical site infection after radical cystectomy: should we enhance surgical antibiotic prophylaxis? World J Urol 2018; 37:1137-1143. [PMID: 30220044 DOI: 10.1007/s00345-018-2482-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/08/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To compare surgical site infections (SSI) rate after radical cystectomy (RC) over time and ascertain whether antibiotic prophylaxis should be enhanced. METHODS All medical records of RC patients in a single tertiary uro-oncology center between 2007 and 2017 were analyzed. SSI was defined using the criteria of the US Centers for Disease Control and Prevention. All bacterial culture results and antimicrobial resistance rates were recorded. Lastly, multivariable logistic regression analysis was performed to ascertain SSI predictors. RESULTS RC was performed in 405 patients, of which 96 (23.7%) developed SSI. No differences were demonstrated in the mean age, gender, NIDDM prevalence, neoadjuvant chemotherapy, positive preoperative urine culture, bowel preparation, and surgery time between both groups. However, statistically significant higher median BMI, age-adjusted Charlson Comorbidity score, usage of ceftriaxone preoperatively, and intensive care unit (ICU) hospitalization were noted in SSI patients. Overall, 62/96 (63.5%) SSI patients had a positive wound culture, with only 16.7% of the pathogens being sensitive to their perioperative antibiotics. Lastly, on multivariable analysis rising BMI, preoperative ceftriaxone and ICU hospitalization were associated with a higher SSI rate. CONCLUSIONS Preoperative BMI reduction, and maximal preoperative medical optimization in an attempt to lower ICU admittance rates, should be part of the ideal strategy for lowering SSI rates. Additionally, preoperative antibiotics should be enhanced to harbor-wide spectrum coverage, based on local resistance rates.
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Affiliation(s)
- Hanan Goldberg
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel.
| | - Chen Shenhar
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Hadar Tamir
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Roy Mano
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Jack Baniel
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - David Margel
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Daniel Kedar
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - David Lifshitz
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Ofer Yossepowitch
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
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17
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Boon M, Martini C, Yang HK, Sen SS, Bevers R, Warlé M, Aarts L, Niesters M, Dahan A. Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery. PLoS One 2018; 13:e0197036. [PMID: 29791482 PMCID: PMC5965817 DOI: 10.1371/journal.pone.0197036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 04/25/2018] [Indexed: 02/06/2023] Open
Abstract
Recent data shows that a neuromuscular block (NMB) induced by administration of high doses of rocuronium improves surgical conditions in certain procedures. However, there are limited data on the effect such practices on postoperative outcomes. We performed a retrospective analysis to compare unplanned 30-day readmissions in patients that received high-dose versus low-dose rocuronium administration during general anesthesia for laparoscopic retroperitoneal surgery. This retrospective cohort study was performed in the Netherlands in an academic hospital where routine high-dose rocuronium NMB has been practiced since July 2015. Charts of patients receiving anesthesia between January 2014 and December 2016 were searched for surgical cases receiving high-dose rocuronium and matched with respect to procedure, age, sex and ASA classification to patients receiving low-dose rocuronium. The primary post-operative outcome was unplanned 30-day readmission rate. There were 130 patients in each cohort. Patients in the high- and low-dose rocuronium cohorts received 217 ± 49 versus 37 ± 5 mg rocuronium, respectively. In the high-dose rocuronium group neuromuscular activity was consistently monitored; matched patients were unreliably monitored. All patients receiving high-dose rocuronium were reversed with sugammadex, while just 33% of matched patients were reversed with sugammadex and 20% with neostigmine; the remaining patients were not reversed. Unplanned 30-day readmission rate was significantly lower in the high-dose compared to the low-dose rocuronium cohort (3.8% vs. 12.7%; p = 0.03; odds ratio = 0.33, 95% C.I. 0.12–0.95). This small retrospective study demonstrates a lower incidence of unplanned readmissions within 30-days following laparoscopic retroperitoneal surgery with high-dose relaxant anesthesia and sugammadex reversal in comparison to low-dose relaxant anesthesia. Further prospective studies are needed in larger samples to corroborate our findings and additionally assess the pharmacoeconomics of high-dose relaxant anesthesia taking into account the benefits (reduced readmissions) and harm (cost of relaxants and reversal agents) of such practice.
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Affiliation(s)
- Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Chris Martini
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - H. Keri Yang
- Merck & Co., Center for Observational and Real World Evidence, Merck & Co, Inc., Kenilworth, NJ, United States of America
| | - Shuvayu S. Sen
- Merck & Co., Center for Observational and Real World Evidence, Merck & Co, Inc., Kenilworth, NJ, United States of America
| | - Rob Bevers
- Department of Urology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Michiel Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
- * E-mail:
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18
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Perioperative venous thromboembolism in urologic oncology procedures, risk factors, and prevention. Curr Opin Urol 2018; 28:227-232. [PMID: 29465471 DOI: 10.1097/mou.0000000000000491] [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
PURPOSE OF REVIEW Venous thromboembolism (VTE) is a common complication during the perioperative period for major urologic oncology operations. The present review focuses on the risk factors, the mechanisms of hypercoagulability in this patient population, and the timing and prevention of VTE. RECENT FINDINGS Although the vast majority of patients undergoing major urologic oncology operations do not develop VTEs, when they do develop they can be fatal. The risk factors for VTEs are important to identify in this patient population. The timing of VTE events are also essential to understanding their prevention. Prevention focused around the perioperative period is the best way to reduce fatal complications secondary to a VTE event. SUMMARY VTEs are common and can potentially be fatal. Prevention in high-risk patients during the most vulnerable perioperative time period should be the focus of clinical efforts to reduce VTE complications and the associated morbidity and mortality.
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19
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Comparison of readmission and short-term mortality rates between different types of urinary diversion in patients undergoing radical cystectomy. World J Urol 2017; 36:393-399. [PMID: 29230495 DOI: 10.1007/s00345-017-2140-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To analyze the impact of urinary diversion type following radical cystectomy (RC) on readmission and short-term mortality rates. METHODS Patients who underwent RC for bladder cancer in the National Cancer Data Base were grouped based on the type of urinary diversion performed: non-continent [ileal conduit (IC)] or two continent techniques [continent pouch (CP) and orthotopic neobladder (NB)]. We used propensity score matching and multivariable logistic regression models to compare 30-day readmission and 30- and 90-day mortality between the different types of urinary diversion. RESULTS Among 11,933 patients who underwent RC, we identified 10,197 (85.5%) IC, 1044 (8.7%) CP, and 692 (5.8%) NB. Patients who received IC were significantly older and had more comorbidities (p < 0.0001). Continent diversions were more likely to be performed at an academic center (p < 0.0001). Surgery performed at a non-academic center was an independent predictor of 30-day readmission (OR 1.19, p = 0.010) and 30-day mortality (OR 1.27, p = 0.043). Patients undergoing NB had an increased likelihood of being readmitted (OR 1.41, p = 0.010). There was no significant difference in short-term mortality between groups. CONCLUSIONS Patients undergoing NB had marginally increased rates of readmission compared to IC. Surgery performed at a non-academic center was associated with higher readmission and 30-day mortality. Similar short-term mortality rates were observed among the different types of urinary diversion.
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20
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Kaye DR, Syrjamaki J, Ellimoottil C, Schervish EW, Solomon MH, Linsell S, Montie JE, Miller DC, Dupree JM. Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy. Urology 2017; 112:74-79. [PMID: 29155190 DOI: 10.1016/j.urology.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. METHODS We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. RESULTS We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. CONCLUSION Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.
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Affiliation(s)
- Deborah R Kaye
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI.
| | - John Syrjamaki
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Edward W Schervish
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Michigan Institute of Urology, Detroit, MI
| | - M Hugh Solomon
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - James M Dupree
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
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21
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Ellimoottil C, Li J, Ye Z, Dupree JM, Min HS, Kaye D, Herrel LA, Miller DC. Episode-based Payment Variation for Urologic Cancer Surgery. Urology 2017; 111:78-85. [PMID: 29051001 DOI: 10.1016/j.urology.2017.08.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/07/2017] [Accepted: 08/29/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures. METHODS Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation. RESULTS Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals. CONCLUSION Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care.
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Affiliation(s)
- Chad Ellimoottil
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan.
| | - Jonathan Li
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - Zaojun Ye
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - James M Dupree
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - Hye Sung Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - Deborah Kaye
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
| | - David C Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Dow Division of Health Services Research, Department of Urology, Ann Arbor, Michigan
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22
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Rieken M, Bachmann A. Risk of Bleeding Versus Venous Thromboembolism in Urological Surgery-Finding the Right Balance Is Not Always Easy! Eur Urol 2017; 73:252-253. [PMID: 28890251 DOI: 10.1016/j.eururo.2017.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/23/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Malte Rieken
- alta uro AG, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Alexander Bachmann
- alta uro AG, Basel, Switzerland; University of Basel, Basel, Switzerland
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Hospital admission for treatment of complications after extracorporeal shock wave lithotripsy for renal stones: a study of risk factors. Urolithiasis 2017; 46:291-296. [PMID: 28555349 DOI: 10.1007/s00240-017-0983-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/24/2017] [Indexed: 12/23/2022]
Abstract
The objective of this study was to determine risk factors of hospital admission for treatment of complications after extracorporeal shock wave lithotripsy (SWL). The electronic files and images of all patients who underwent SWL for treatment of renal stones between January 2011 and December 2015 were retrospectively reviewed. All patients underwent SWL with the same electromagnetic lithotripter (Dornier Lithotripot S). The data of those who needed hospital admission for treatment of complications within 30 days after SWL were compared with patients who did not require hospital admission. Compared data included patients' demographics (age, gender, BMI, ASA score, and pre-SWL stenting), renal characters (side, hydronephrosis, and solitary kidney), and stone characters (site, length, density, and previous treatment). Univariate and multivariate statistical analyses were used to identify risk factors. The study included 1179 patients. Complications that required hospital admission were observed in 108 patients (9.2%). They included obstructing steinstrasse in 91 (7.7%), peri-renal hematoma in 3 (0.25%), and fever (>38.0 °C) in 14 (1.2%). Independent risk factors on multivariate analysis were solitary kidney (OR 2.855, P = 0.017), pre-SWL stenting (RR 2.03, P = 0.044), ASA II (OR 1.965, P = 0.007), hydronephrosis (RR 1.639, P = 0.024), and stone length (RR 1.083, P < 0.001). Patients with medical co-morbidities, pre-SWL ureteral stents, large stones and those with obstructed and/or solitary renal unit are more liable to post-SWL complications that need hospital admission. The probability of hospital admission has to be explained to patients with these risk factors.
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Jordan BJ, Matulewicz RS, Trihn B, Kundu S. Venous thromboembolism after nephrectomy: incidence, timing and associated risk factors from a national multi-institutional database. World J Urol 2017; 35:1713-1719. [PMID: 28516316 DOI: 10.1007/s00345-017-2046-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To evaluate the rate of venous thromboembolism (VTE) after nephrectomy with specific focus on event timing and location (before or after hospital discharge) in order to identify modifiable risk factors and establish benchmarks for preventive interventions. METHODS Using the ACS-NSQIP database, we identified patients undergoing nephrectomy from 2006 to 2012. Patients were analyzed in two cohorts: collectively and by surgical approach [open vs. lap/robotic (MIS)]. Rates of deep vein thrombosis (DVT) and pulmonary embolus (PE) were assessed and time to each event was established in relation to discharge status. Logistic regression analysis was performed to assess association between preoperative risk factors, surgical variables, and VTE. RESULTS In total, 13,208 patients met inclusion criteria. The overall rate of VTE was 1.2% (PE = 0.5% and DVT = 0.8, 0.1% DVT and PE). Using regression analysis, diabetes, dependent functional status, and longer operative time were associated with higher odds of DVT. For PE, dyspnea, disseminated cancer, and longer operative time were significant associations. The rate of VTE was higher in open surgery compared to MIS (2 vs. 0.8%, p < 0.001). Median times to DVT and PE were 8.5 and 6 days, respectively, with 53.3% of DVTs and 63.1% of PEs occurring prior to discharge. CONCLUSIONS The overall rate of VTE after nephrectomy is low, occurs roughly one week after surgery, and is associated with longer hospital stays. Certain patient factors, open surgical approach, and longer operative times were associated with higher odds of post-operative VTE; these patients may benefit from more aggressive prophylaxis.
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Affiliation(s)
- Brian J Jordan
- Department of Urology, Northwestern Feinberg School of Medicine, 303 E Chicago Ave, Tarry 16-703, Chicago, IL, 60611, USA.
| | - Richard S Matulewicz
- Department of Urology, Northwestern Feinberg School of Medicine, 303 E Chicago Ave, Tarry 16-703, Chicago, IL, 60611, USA
| | - Brian Trihn
- Department of Urology, Northwestern Feinberg School of Medicine, 303 E Chicago Ave, Tarry 16-703, Chicago, IL, 60611, USA
| | - Shilajit Kundu
- Department of Urology, Northwestern Feinberg School of Medicine, 303 E Chicago Ave, Tarry 16-703, Chicago, IL, 60611, USA
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Fry DE, Pine M, Nedza SM, Locke DG, Reband AM, Pine G. Risk-adjusted outcomes in Medicare inpatient nephrectomy patients. Medicine (Baltimore) 2016; 95:e4784. [PMID: 27603382 PMCID: PMC5023905 DOI: 10.1097/md.0000000000004784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 11/25/2022] Open
Abstract
Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions. From the 4 prediction models, total predicted adverse outcomes were determined for each hospital in the dataset that met a minimum of 25 evaluable cases for the study period. Standard deviations (SDs) for each hospital were used to identify specific z-scores. Risk-adjusted adverse outcomes rates were computed to permit benchmarking each hospital's performance against the national standard. Differences between best and suboptimal performing hospitals defined the potential margin of preventable adverse outcomes for this operation.A total of 449 hospitals with 23,477 patients were evaluated. Overall AO rate was 20.8%; 17 hospitals had risk-adjusted AO rates that were 2 SDs poorer than predicted and 8 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 10.2% while the lowest performing decile had 32.1%. With a minimum of 25 cases for each study hospital, no statistically valid improvement in outcomes was seen with increased case volume.Inpatient and 90-day postdischarge risk-adjusted adverse outcomes demonstrated marked variability among study hospitals and illustrate the opportunities for care improvement. This analytic design is applicable for comparing provider performance across a wide array of different inpatient episodes.
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Affiliation(s)
- Donald E. Fry
- MPA Healthcare Solutions
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- University of New Mexico School of Medicine, Albuquerque, NM
| | | | - Susan M. Nedza
- MPA Healthcare Solutions
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Chappidi MR, Kates M, Stimson CJ, Bivalacqua TJ, Pierorazio PM. Quantifying Nonindex Hospital Readmissions and Care Fragmentation after Major Urological Oncology Surgeries in a Nationally Representative Sample. J Urol 2016; 197:235-240. [PMID: 27460756 DOI: 10.1016/j.juro.2016.07.078] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE We quantified the underestimation of hospital readmission rates that can occur with institutional databases and the incidence of care fragmentation among patients undergoing urological oncology procedures in a nationally representative database. MATERIALS AND METHODS The 2013 Nationwide Readmissions Database was queried for patients undergoing prostatectomy, cystectomy, nephroureterectomy, nephrectomy, partial nephrectomy and retroperitoneal lymph node dissection for urological malignancies. Nationally representative 30 and 90-day readmission and care fragmentation rates were calculated for all procedures. Readmission rates with and without nonindex hospital readmissions were compared with Pearson's chi-square test. Multivariable logistic regression models were used to identify predictors of care fragmentation at 90-day followup. RESULTS For all surgical procedures readmission rates were consistently underestimated by 17% to 29% at 90-day followup. The rates of care fragmentation among readmitted patients were similar for all procedures, ranging from 24% to 34% at 90-day followup. Overall 1 in 4 readmitted patients would not be captured in institutional databases and 1 in 3 readmitted patients experienced care fragmentation. Multivariable models did not identify a predictor of care fragmentation that was consistent across all procedures. CONCLUSIONS The high rate of underestimation of readmission rates across all urological oncology procedures highlights the importance of linking institutional and payer claims databases to provide more accurate estimates of perioperative outcomes and health care utilization. The high rate of care fragmentation across all procedures emphasizes the need for future efforts to understand the clinical relevance of care fragmentation in patients with urological malignancies, and to identify patients at risk along with potentially modifiable risk factors for care fragmentation.
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Affiliation(s)
- Meera R Chappidi
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C J Stimson
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
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[Causes of hospital readmission after urologic cancer surgery]. Urologe A 2016; 55:1237. [PMID: 27364821 DOI: 10.1007/s00120-016-0167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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