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Kang D, Lei C, Zhang Y, Wei X, Dai W, Xu W, Zhang J, Yu Q, Su X, Huang Y, Shi Q. Shortness of breath on the day of discharge: an early alert for post-discharge complications in patients undergoing lung cancer surgery. J Cardiothorac Surg 2024; 19:398. [PMID: 38937786 PMCID: PMC11210099 DOI: 10.1186/s13019-024-02845-1] [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: 01/30/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
PURPOSE Symptom assessment based on patient-reported outcome (PRO) can correlate with disease severity, making it a potential tool for threshold alerts of postoperative complications. This study aimed to determine whether shortness of breath (SOB) scores on the day of discharge could predict the development of post-discharge complications in patients who underwent lung cancer surgery. METHODS Patients were from a study of a dynamic perioperative rehabilitation cohort of lung cancer patients focusing on patient-reported outcomes. Patients were assessed using the Perioperative Symptom Assessment Scale for Lung surgery (PSA-Lung). Logistic regression model was used to examine the potential association between SOB on the day of discharge and complications within 3 months after discharge. The post-discharge complications were taken as the anchor variable to determine the optimal cutpoint for SOB on the day of discharge. RESULTS Complications within 3 months post-discharge occurred in 71 (10.84%) of 655 patients. Logistic regression analysis revealed that being female (OR 1.764, 95% CI 1.006-3.092, P < 0.05) and having two chest tubes (OR 2.026, 95% CI 1.107-3.710, P < 0.05) were significantly associated with post-discharge complications. Additionally, the SOB score on the day of discharge (OR 1.125, 95% CI 1.012-1.250, P < 0.05) was a significant predictor. The optimal SOB cutpoint was 5 (on a scale of 0-10). Patients with an SOB score ≥ 5 at discharge experienced a lower quality of life 1 month later compared to those with SOB score<5 at discharge (73 [50-86] vs. 81 [65-91], P < 0.05). CONCLUSION SOB on the day of discharge may serve as an early warning sign for the timely detection of 3 month post-discharge complications.
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Affiliation(s)
- Dan Kang
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Cheng Lei
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Yong Zhang
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Xing Wei
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Dai
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Xu
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Jingyu Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People's Republic of China
| | - Qingsong Yu
- Chengdu Center for Disease Control and Prevention, Chengdu, 610041, Sichuan, China
| | - Xueyao Su
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Yanyan Huang
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China
| | - Qiuling Shi
- School of Public Health, Chongqing Medical University, Chongqing, People's Republic of China.
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China.
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People's Republic of China.
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Nogueira LM, Boffa DJ, Jemal A, Han X, Yabroff KR. Medicaid Expansion Under the Affordable Care Act and Early Mortality Following Lung Cancer Surgery. JAMA Netw Open 2024; 7:e2351529. [PMID: 38214932 PMCID: PMC10787311 DOI: 10.1001/jamanetworkopen.2023.51529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
Importance Medicaid expansion under the Patient Protection and Affordable Care Act is associated with gains in health insurance coverage, earlier stage diagnosis, and improved survival among patients with cancer. Objective To examine the association of Medicaid expansion with changes in early mortality among adults undergoing surgical resection of non-small cell lung cancer (NSCLC), a setting in which access to care is a major determinant of survival. Design, Setting, and Participants This cohort study used the National Cancer Database to identify 14 984 adults 45 to 64 years of age who underwent surgical resection of NSCLC between 2008 and 2019. Analysis was conducted between March 28, 2021, and September 1, 2023. Exposure State of residence Medicaid expansion status. Main Outcomes and Measures Descriptive statistics were used to compare study population characteristics by Medicaid expansion status of patients' state of residence. Difference-in-differences analyses were used to evaluate the association between Medicaid expansion and postoperative mortality before implementation of the ACA (2008-2013) vs after (2014-2019). Results Among 14 984 adults included, the mean (SD) age was 56.3 (5.1) years, 54.6% were women, and 62.1% lived in Medicaid expansion states. Both 30-day (from 0.97% to 0.26%) and 90-day (from 2.63% to 1.32%) postoperative mortality decreased from before the ACA to after among patients residing in Medicaid expansion states (both P < .001) but not in nonexpansion states (30-day mortality before the ACA, 0.75% vs after the ACA, 0.68%; P = .74; and 90-day mortality before the ACA, 2.43% vs after the ACA, 2.20%; P = .57), leading to a difference-in-differences of -0.64 percentage points (95% CI, -1.19 to -0.08; P = .03) for 30-day mortality and -1.08 percentage points (95% CI, -2.08 to -0.08; P = .03) for 90-day mortality. The difference-in-differences for in-hospital mortality was not significant (P = .34) between expansion states (1.41% before the ACA to 0.77% after the ACA; 0.63 percentage point decrease; P = .004) and nonexpansion states (1.49% before the ACA to 1.20% after the ACA; 0.30 percentage point decrease; P = .29). Conclusions and Relevance In this cohort study of patients with NSCLC, Medicaid expansion was associated with declines in 30- and 90-day postoperative mortality following hospital discharge. These findings suggest that Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes in this population.
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Affiliation(s)
- Leticia M. Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Daniel J. Boffa
- Division of Thoracic Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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Iroz CB, Johnson JK, Ager MS, Joung RHS, Brajcich BC, Cella D, Franklin PD, Holl JL, Bilimoria KY, Merkow RP. Barriers and Facilitators to Implementing Patient-Reported Outcome Monitoring in Gastrointestinal Surgery. J Surg Res 2023; 288:341-349. [PMID: 37060860 PMCID: PMC11187775 DOI: 10.1016/j.jss.2023.03.011] [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: 12/01/2022] [Revised: 02/13/2023] [Accepted: 03/09/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION More than 30% of patients experience complications after major gastrointestinal (GI) surgery, many of which occur after discharge when patients and families must assume responsibility for monitoring. Patient-reported outcomes (PROs) have been proposed as a tool for remote monitoring to identify deviations in recovery, and recognize and manage complications earlier. This study's objective was to characterize barriers and facilitators to the use of PROs as a patient monitoring tool following GI surgery. METHODS We conducted semistructured interviews with GI surgery patients and clinicians (surgeons, nurses, and advanced practitioners). Patients and clinicians were asked to describe their experience using a PRO monitoring system in three surgical oncology clinics. Using a phenomenological approach, research team dyads independently coded the transcripts using an inductively developed codebook and the constant comparative approach with differences reconciled by consensus. RESULTS Ten patients and five clinicians participated in the interviews. We identified four overarching themes related to functionality, workflow, meaningfulness, and actionability. Functionality refers to barriers faced by clinicians and patients in using the PRO technology. Workflow represents problematic integration of PROs into the clinical workflow and need for setting expectations with patients. Meaningfulness refers to lack of patient and clinician understanding of the impact of PROs on patient care. Finally, actionability reflects barriers to follow-up and practical use of PRO data. CONCLUSIONS While use of PRO systems for postoperative patient monitoring have expanded, significant barriers persist for both patients and clinicians. Implementation enhancements are needed to optimize functionality, workflow, meaningfulness, and actionability.
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Affiliation(s)
- Cassandra B Iroz
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Hae-Soo Joung
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian C Brajcich
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan P Merkow
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Biological Sciences Division, The University of Chicago, Chicago, Illinois; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
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Borja AJ, Ahmad HS, Tomlinson SB, Na J, McClintock SD, Welch WC, Marcotte PJ, Ozturk AK, Malhotra NR. "July Effect" in Spinal Fusions: A Coarsened Exact-Matched Analysis. Neurosurgery 2023; 92:623-631. [PMID: 36700756 DOI: 10.1227/neu.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/21/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Few neurosurgical studies examine the July Effect within elective spinal procedures, and none uses an exact-matched protocol to rigorously account for confounders. OBJECTIVE To evaluate the July Effect in single-level spinal fusions, after coarsened exact matching of the patient cohort on key patient characteristics (including race and comorbid status) known to independently affect neurosurgical outcomes. METHODS Two thousand three hundred thirty-eight adult patients who underwent single-level, posterior-only lumbar fusion at a single, multicenter university hospital system were retrospectively enrolled. Primary outcomes included readmissions, emergency department visits, reoperation, surgical complications, and mortality within 30 days of surgery. Logistic regression was used to analyze month as an ordinal variable. Subsequently, outcomes were compared between patients with surgery at the beginning vs end of the academic year (ie, July vs April-June), before and after coarsened exact matching on key characteristics. After exact matching, 99 exactly matched pairs of patients (total n = 198) were included for analysis. RESULTS Among all patients, operative month was not associated with adverse postoperative events within 30 days of the index operation. Furthermore, patients with surgeries in July had no significant difference in adverse outcomes. Similarly, between exact-matched cohorts, patients in July were observed to have noninferior adverse postoperative events. CONCLUSION There was no evidence suggestive of a July Effect after single-level, posterior approach spinal fusions in our cohort. These findings align with the previous literature to imply that teaching hospitals provide adequate patient care throughout the academic year, regardless of how long individual resident physician assistants have been in their particular role.
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Affiliation(s)
- Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hasan S Ahmad
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel B Tomlinson
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jianbo Na
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Na S, Mazzaferro N, Xia W, Greenberg P, Beckerman W. Risk Factors for Surgical Site Infections After Lower Extremity Open Revascularization. Ann Vasc Surg 2023; 89:251-260. [PMID: 36404450 DOI: 10.1016/j.avsg.2022.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a serious complication of lower extremity open revascularization and is associated with increased morbidity, increased healthcare costs, and decreased postoperative quality of life. The objective of this study was to determine factors associated with an increased risk of developing postoperative SSI in patients undergoing lower extremity revascularization. Associations between SSI and postoperative complications were also identified. METHODS Patients who underwent lower extremity open revascularization from 2014-2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). A multivariate logistic regression analysis was used to determine risk factors associated with SSIs within 30 days of the operation and postoperative complications. Odds ratios (ORs) were adjusted for demographics, preoperative comorbidities, procedure type, and intraoperative variables. RESULTS Ten thousand nine hundred ten patients who underwent lower extremity open revascularization were identified, with a mean age of 67.24 years and of whom 7,318 (67%) were male. Of the 10,910 patients, 922 (8.45%) had an SSI within 30 days of the operation. Risk factors associated with developing SSI included body mass index 25-29.9 (OR, 1.34; 95% confidence interval [CI], 1.08-1.67), body mass index ≥ 30 (OR, 2.12; 95% CI, 1.71-2.62), history of severe chronic obstructive pulmonary disease (OR, 1.47; 95% CI, 1.18-1.84), preprocedural beta-blocker use (OR, 1.25; CI 95%, 1.05-1.49), procedure time > 214 minutes (OR, 1.44; 95% CI, 1.22-1.70), and creatinine > 1.2 (OR 1.03; 95% CI, 0.87-1.21). One factor associated with a decreased risk of developing SSI was male gender (OR, 0.71; 95% CI, 0.60-0.84). Patients who developed an SSI were more likely to have adverse outcomes such as myocardial infarction/stroke, major amputation, bleeding requiring transfusion or secondary procedure, or require a reintervention in the treated segment. CONCLUSIONS There are various patient-related and operative factors that increase the likelihood of developing an SSI after lower extremity open revascularization. These findings indicate that addressing modifiable perioperative SSI risk factors may be beneficial in decreasing rates of SSI and improving postoperative outcomes.
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Affiliation(s)
- Sungshin Na
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
| | - Natale Mazzaferro
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Weiyi Xia
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Patricia Greenberg
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - William Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
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Amini N, D'Adamo CR, Khashchuk D, Dodson R, Katlic M, Wolf J, Mavanur A. Accuracy of National Surgical Quality Improvement Program Risk Calculator Among Elderly Patients Undergoing Pancreas Resection. J Surg Res 2022; 279:567-574. [DOI: 10.1016/j.jss.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/12/2022] [Accepted: 06/28/2022] [Indexed: 10/31/2022]
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Awan MU, Schwartz G, Shifchik A, Harmon S, Malisetyan T. Elective Hand Surgery in Patients With History of Axillary Node Dissection: Risks and Patient Education. Cureus 2022; 14:e27461. [PMID: 36051709 PMCID: PMC9420452 DOI: 10.7759/cureus.27461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/27/2022] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine if patients with a prior history of axillary lymph node dissection (ALND) secondary to breast cancer surgery and other procedures are at an increased risk of postoperative complications including lymphedema and infection following elective upper extremity surgery. Furthermore, the study aimed to evaluate the extent of patient education regarding lymphedema as a possible complication of upper extremity surgery. Methods: A review of 312 patients presenting to the clinic with upper extremity pathologies was performed of which 15 patients had a history of surgeries secondary to breast cancer and 297 had no prior history of breast cancer. Nine out of 15 patients with prior breast procedures and 66 out of 297 patients with no such history underwent elective hand surgeries, with 22 out of the 75 patients having a history of ALND. Incidences of postoperative complications including lymphedema and infection were recorded. Afterward, a survey inquiring about patient education was conducted to assess whether the patients were educated regarding lymphedema and if so, when and from whom they received the counseling. Results: No patients with a prior history of ALND secondary to breast cancer or other surgeries developed a postoperative infection or onset of lymphedema, and no patients with preoperative lymphedema had any worsening of lymphedema or infection postoperatively. The survey conducted afterward revealed that 61% of the patients with a prior history of breast cancer-related procedures including lymph node dissection were never counseled regarding lymphedema as a possible complication of hand surgery. Furthermore, 75% of the survey participants wished they were given more information about possible causes and complications of, and ways to prevent or minimize the possibility of lymphedema developing postoperatively. Conclusion: Prior history of ALND did not make patients more susceptible to postoperative complications, thus a history of isolated ALND or breast cancer surgery including ALND should not preclude elective hand surgical procedures from being performed ipsilaterally. Additionally, improvements in the degree of patient counseling regarding postoperative complications following hand surgery are needed as increased patient education is shown to be associated with a lower rate of complications and faster recovery times.
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Abraham J, Meng A, Tripathy S, Kitsiou S, Kannampallil T. Effect of health information technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: a systematic review. J Am Med Inform Assoc 2022; 29:735-748. [PMID: 35167689 PMCID: PMC8922181 DOI: 10.1093/jamia/ocac013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/12/2022] [Accepted: 01/25/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To systematically synthesize and appraise the evidence on the effectiveness of health information technology (HIT)-based discharge care transition interventions (CTIs) on readmissions and emergency room visits. MATERIALS AND METHODS We conducted a systematic search on multiple databases (MEDLINE, CINAHL, EMBASE, and CENTRAL) on June 29, 2020, targeting readmissions and emergency room visits. Prospective studies evaluating HIT-based CTIs published as original research articles in English language peer-reviewed journals were eligible for inclusion. Outcomes were pooled for narrative analysis. RESULTS Eleven studies were included for review. Most studies (n = 6) were non-RCTs. Several studies (n = 9) assessed bridging interventions comprised of at least 1 pre- and 1 post-discharge component. The narrative analysis found improvements in patient experience and perceptions of discharge care. DISCUSSION Given the statistical and clinical heterogeneity among studies, we could not ascertain the cumulative effect of CTIs on clinical outcomes. Nevertheless, we found gaps in current research and its implications for future work, including the need for a HIT-based care transition model for guiding theory-driven design and evaluation of HIT-based discharge CTIs. CONCLUSIONS We appraised and aggregated empirical evidence on the cumulative effectiveness of HIT-based interventions to support discharge transitions from hospital to home, and we highlighted the implications for evidence-based practice and informatics research.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Institute for Informatics, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alicia Meng
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sanjna Tripathy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Spyros Kitsiou
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Institute for Informatics, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Brajcich BC, Shallcross ML, Johnson JK, Joung RHS, Iroz CB, Holl JL, Bilimoria KY, Merkow RP. Barriers to Post-Discharge Monitoring and Patient-Clinician Communication: A Qualitative Study. J Surg Res 2021; 268:1-8. [PMID: 34274626 PMCID: PMC8822471 DOI: 10.1016/j.jss.2021.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION As postoperative length of stay has decreased for many operations, the proportion of complications occurring post-discharge is increasing. Early identification and management of these complications requires overcoming barriers to effective post-discharge monitoring and communication. The aim of this study was to identify barriers to post-discharge monitoring and patient-clinician communication through a qualitative study of surgical patients and clinicians. MATERIALS AND METHODS Semi-structured interviews and focus groups were held with gastrointestinal surgery patients and clinicians. Participants were asked about barriers to post-discharge monitoring and communication. Each transcript was coded by 2 of 4 researchers, and recurring themes related to communication and care barriers were identified. RESULTS A total of 15 patients and 17 clinicians participated in interviews and focus groups. Four themes which encompassed barriers to post-discharge monitoring and communication were identified from patient interviews, and 4 barriers were identified from clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences, while clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency. CONCLUSIONS Multiple barriers exist to effective post-discharge monitoring and patient-clinician communication among surgical patients. These barriers must be addressed to develop an effective system for post-discharge care after surgery.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Meagan L Shallcross
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Julie K Johnson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Rachel Hae-Soo Joung
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Cassandra B Iroz
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.
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Minervini F, Kocher GJ, Bertoglio P, Kestenholz PB, Gálvez Muñoz C, Patrini D, Ceulemans LJ, Begum H, Lutz J, Shojai M, Shargall Y, Scarci M. Pneumonectomy for lung cancer in the elderly: lessons learned from a multicenter study. J Thorac Dis 2021; 13:5835-5842. [PMID: 34795932 PMCID: PMC8575851 DOI: 10.21037/jtd-21-869] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/08/2021] [Indexed: 12/25/2022]
Abstract
Background 60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described. Methods We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis. Results A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2–39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9–46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863). Conclusions Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance.
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Affiliation(s)
- Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Gregor J Kocher
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pietro Bertoglio
- Division of Thoracic Surgery, IRCSS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Peter B Kestenholz
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Carlos Gálvez Muñoz
- Department of Thoracic Surgery, University Hospital Alicante, Alicante, Spain
| | - Davide Patrini
- Department of Thoracic Surgery, University College London Hospitals, London, UK
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory BREATHE, KULeuven, Leuven, Belgium
| | - Housne Begum
- Department of Thoracic Surgery, McMaster University, Hamilton, Canada
| | - Jon Lutz
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Max Shojai
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yaron Shargall
- Department of Thoracic Surgery, McMaster University, Hamilton, Canada
| | - Marco Scarci
- Department of Thoracic surgery, San Gerardo Hospital, Monza, Italy
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11
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Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis. Dis Colon Rectum 2021; 64:1426-1434. [PMID: 34623350 PMCID: PMC8502230 DOI: 10.1097/dcr.0000000000001966] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications. OBJECTIVE The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a comprehensive cancer center. PATIENTS Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study. MAIN OUTCOME MEASURES Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d). RESULTS Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories. LIMITATIONS The study was limited by its retrospective design and generalizability. CONCLUSIONS The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521. EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.
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12
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Regenbogen SE, Cain-Nielsen AH, Syrjamaki JD, Norton EC. Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals. Ann Surg 2021; 274:199-205. [PMID: 33351489 PMCID: PMC8211908 DOI: 10.1097/sla.0000000000004726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John D Syrjamaki
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
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Impact of the Implementation of the EAU Guidelines Recommendation on Reporting and Grading of Complications in Patients Undergoing Robot-assisted Radical Cystectomy: A Systematic Review. Eur Urol 2021; 80:129-133. [PMID: 34020829 DOI: 10.1016/j.eururo.2021.04.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Abstract
In 2012, the European Association of Urology (EAU) Ad Hoc Panel proposed a standardised methodology on reporting and grading complications after urological surgical procedures. The aim of the current study was to assess the impact of this implementation on complications reporting for patients undergoing robot-assisted radical cystectomy (RARC). A systematic review of all English-language original articles published on RARC until March 2020 was performed using PubMed, Scopus, and Web of Science databases. The study selection process followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) criteria. The quality of reporting and grading complication was evaluated according to the EAU recommendations. Our analysis failed to observe a statistically significant improvement in reporting outcomes after the EAU guidelines recommendations except for three of the 14 criteria proposed (ie, follow-up duration, utilisation of a severity grade system, and risk factors included in the analyses). A lower statistically significant adherence to outcome reporting in terms of inclusion of readmissions and causes (p = 0.02), was observed. PATIENT SUMMARY: In this study, we evaluated the impact of the proposed European Association of Urology (EAU) standardised reporting tool for urological complications, in patients treated with robot-assisted radical cystectomy. A low adherence to EAU guidelines recommendations for complications reporting was observed.
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Preoperative Dependent Functional Status Is Associated With Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients. Ann Vasc Surg 2021; 76:114-127. [PMID: 34004321 DOI: 10.1016/j.avsg.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/17/2021] [Accepted: 04/28/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Both Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most common procedures to treat patients with symptomatic, and asymptomatic high-grade carotid stenosis. Poor preoperative functional status (FS) is increasingly being recognized as predictor for postoperative outcomes. The purpose of this study is to determine the impact of preoperative functional status on the outcomes of patients who undergo CEA or CAS. METHODS Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2011-2018. All patients in the database who underwent CEA or CAS during this time period were identified. Patients were then further divided into 2 subgroups: FS-Independent and FS-dependent. Bivariate and multivariate analyses was performed for pre, intra and post-operative variables with functional status. Outcomes for treatment of symptomatic carotid disease were compared to those with asymptomatic disease among the cohort of functionally dependent patients. RESULTS A total of 27,163 patients (61.2% Males, 38.8% Females) underwent CEA (n = 26,043) or CAS (n = 1,120) from 2011-2018. Overall, primary outcomes were as follows: mortality 0.77% (n = 210) and stroke 1.87% (n = 507).Risk adjusted multivariate analysis showed that FS-D patients undergoing CEA had higher mortality (AOR 3.06, CI 1.90-4.92, P < 0.001), longer operative times (AOR 1.36, CI 1.17-1.58, P< 0.001) higher incidence of unplanned reoperation (AOR 1.68, CI 1.19-2.37, P = 0.003), postoperative pneumonia (AOR 5.43, CI 1.62 - 18.11, P = 0.006) and ≥3 day LOS (AOR 3.05, CI 2.62-3.56, P < 0.001) as compared to FS-I patients. FS-D patients undergoing CAS had higher incidence of postoperative pneumonia (AOR 20.81, CI 1.66-261.54, P = 0.019) and higher incidence of LOS ≥3 days (AOR 2.18, CI 1.21-3.93, P < .01) as compared to FS-I patients. Survival analysis showed that the best 30-day survival was observed in FS-I patients undergoing CEA, followed by FS-I patients undergoing CAS, followed by FS-D patients undergoing CEA, followed by FS-D patients undergoing CAS. FS-D status increased mortality after CEA by 2.11%. When the outcomes of CAS and CEA were compared to each other for the cohort of FS-D patients, CAS was associated with higher incidence of stroke (AOR 3.46, CI 0.32-1.97, P= 0.046), shorter operative times (AOR 0.25, CI 0.12-0.52, P < 0.001) and higher incidence of pneumonia (AOR 11.29, CI 1.32-96.74, P = 0.027). Symptomatic patients undergoing CEA had higher LOS as compared to symptomatic patients undergoing CAS, and asymptomatic patients undergoing CEA or CAS. CONCLUSIONS FS-D patients, undergoing CEA have higher mortality as compared to FS-I patients undergoing CAS. FS-D patients undergoing CAS have higher incidence of postoperative pneumonia and longer LOS as compared to FS-I patients. For the cohort of FS-D patients undergoing either CEA or CAS, CAS was associated with higher risk of stroke and reduced operative times. Risk benefit ratio for any carotid intervention should be carefully assessed before offering it to FS-D patients. Preoperative Dependent Functional Status Is Associated with Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients.
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Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy. Ann Vasc Surg 2021; 75:55-68. [PMID: 33838237 DOI: 10.1016/j.avsg.2021.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/20/2021] [Accepted: 02/20/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups. RESULTS A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05). CONCLUSIONS Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.
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Koivisto JM, Saarinen I, Kaipia A, Puukka P, Kivinen K, Laine KM, Haavisto E. Patient education in relation to informational needs and postoperative complications in surgical patients. Int J Qual Health Care 2020; 32:35-40. [PMID: 31016323 DOI: 10.1093/intqhc/mzz032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/31/2019] [Accepted: 03/01/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study surgical patients' informational expectations and the level of received knowledge at the time of hospital discharge. To examine if there is an association with postoperative complications and the patient´s level of received knowledge. DESIGN Comparative descriptive design. SETTING The data on patients admitted for non-cardiac surgery were collected in three phases during an eight-month period. PARTICIPANTS 258 in-ward non-cardiac general surgery and orthopedic surgery adult patients. INTERVENTIONS Questionnaires before admission (knowledge expectations) and at discharge (received knowledge). A telephone interview 30 days after discharge. MAIN OUTCOME MEASURES Received knowledge (as much or more / less) compared to expectations, and its association with post-discharge complications. RESULTS There were differences between patient groups in their perception of receiving enough knowledge and they were connected to gender (male vs. female OR 2.67, 95% CI 1.55-4.60, P = 0.0004) and procedure (elective orthopedic implant surgery vs. elective minor orthopedic and hand surgery: OR 3.25, 95% CI 1.72-6.17, P = 0.0003). Patients who received less knowledge than expected had more postoperative complications than those who received sufficient (as much or more than expected) information. CONCLUSIONS Patients differ in terms of informational needs, and preoperative education prepares the patient for the information provided postoperatively. Patient education may have an influence on recovery from surgery.
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Affiliation(s)
| | | | - Antti Kaipia
- Hospital District of Satakunta.,Department of Urology, University of Tampere
| | - Pauli Puukka
- Department of Nursing Science, University of Turku
| | | | | | - Elina Haavisto
- Hospital District of Satakunta.,Department of Nursing Science, University of Turku
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Aziz F, Lehman EB. Open Abdominal Aortic Aneurysm Repair Is Associated with Higher Mortality Among Nonobese Patients and Higher Risk of Deep Wound Infections Among Obese Patients. Ann Vasc Surg 2020; 67:354-369. [PMID: 32360433 DOI: 10.1016/j.avsg.2020.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prevalence of obesity in the United States is increasing. The impact of obesity on outcomes after endovascular and open abdominal aortic aneurysm (AAA) repair is largely unknown. The purpose of this analysis was to compare the postoperative outcomes between obese and nonobese patients after these operations. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2013-2015 was analyzed. Preoperative, intraoperative, and postoperative variables were compared between obese and nonobese patient groups. Then obese and nonobese patients were divided into 2 groups each, based on the type of surgery (endovascular repair of abdominal aortic aneurysms (EVAR) versus. open AAA repair), and the outcomes were compared. Then multivariant analysis was used to compare impact of operative modality on outcomes for obese and nonobese patients. RESULTS A total of 6,859 patients (men 80%, women 20%) underwent surgical procedures for AAA during this time period. Among these patients, 2,218 (32.3%) had body mass index (BMI) ≥30, and 4,641 (67.7%) had BMI <30. Obese patients were less likely to be > 80 years old, women, nonwhites, and smokers. Obese patients had lower mortality and higher risk of deep wound infections after surgery (P < 0.05). Among the obese patients, 83.1% underwent EVAR and 16.9% underwent open AAA repair; patients undergoing EVAR had shorter operative times, shorter length of hospital stays, and mortality (P < 0.05). Among nonobese patients, 81% underwent EVAR and 19% underwent open AAA repair. Patients undergoing EVAR had shorter duration of operation, length of hospital stay, and mortality (P < 0.05). Overall, mortality was the highest among nonobese patients undergoing open AAA repair (odds ratio (OR) 0.66, confidence interval (CI) 0.44-0.99, P < 0.05). Incidence of deep wound infections was the highest among obese patients undergoing open AAA repair (OR 4.3, CI: 1.2-14.6, P < 0.05). CONCLUSIONS Nonobese patients have high mortality after open AAA repair, and obese patients have higher incidence of deep wound infections after open AAA repair. For patients deemed appropriate anatomic candidates, EVAR should be preferred for nonobese patients to improve mortality and for obese patients to reduce the incidence of deep wound infections.
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Affiliation(s)
- Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University, College of Medicine, Hershey, PA
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Merhe A, Abou Heidar N, Hout M, Bustros G, Mailhac A, Tamim H, Wazzan W, Bulbul M, Nasr R. An evaluation of the timing of surgical complications following radical prostatectomy: Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Arab J Urol 2020; 18:136-141. [PMID: 33029422 PMCID: PMC7473202 DOI: 10.1080/2090598x.2020.1749478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective To perform a time-to-complication analysis for radical prostatectomy (RP) and computing risk factors for these complications, as RP is established as a first-line treatment for localised prostate cancer with excellent oncological outcomes but is not without its complications. Patients and methods We used the National Surgical Quality Improvement Program (NSQIP) database to analyse data of patients who underwent RP, between 2008 and 2015, with the primary endpoint of time-to-complications. Categorical variables were analysed using descriptive statistics and continuous variables were recorded as medians and interquartile ranges (IQRs) such as timing of complications. Multivariable regression analyses were used to analyse time-to-complication and its effect on other outcomes. A P < 0.05 was defined as statistically significant. Results The overall 30-day complication rate was 7.54% and was equally distributed before and after discharge. Bleeding/transfusion (3.37%), urinary tract infection (1.58%), deep venous thrombosis (DVT; 0.74%), and wound infection (1.08%) were the five most common complications after RP. The median (IQR) time-to-complication unique for each complication was: bleeding/transfusion occurred on the same operative day (1), renal complications occurred at 4 (2–6) days, sepsis at 12 (6.5–17.5) days, DVT at 11 (5.5–16.5) days, pneumonia at 4 (0.5–7.5) days, and cardiac arrest occurred at 5 (1.75–8.25) days. After discharge complications were associated with greater odds of re-admission (odds ratio [OR] 16.40, P < 0.001), but associated with a lesser length of stay (OR – 3.33, P < 0.001) when compared to pre-discharge complications. Conclusion Several risk factors predict pre- and post-discharge complication rates. Knowledge regarding the timing of complications and their respective risk factors should improve patient–physician communication and prediction, and thus patient care. Abbreviations ACS: American College of Surgeons; BMI: body mass index; DM: diabetes mellitus; DVT: deep venous thrombosis; Hct: haematocrit; IQR: interquartile range; LOS: length of stay; NSQIP: National Surgical Quality Improvement Program; OR: odds ratio; RP: radical prostatectomy
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Affiliation(s)
- Ali Merhe
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nassib Abou Heidar
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Hout
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerges Bustros
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aurelie Mailhac
- American University of Beirut Medical Center, Faculty of Medicine, Biostatistics and Clinical Research Unit, Beirut, Lebanon
| | - Hani Tamim
- American University of Beirut Medical Center, Faculty of Medicine, Biostatistics and Clinical Research Unit, Beirut, Lebanon
| | - Wassim Wazzan
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Muhammad Bulbul
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Nasr
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon
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Asymptomatic Deep Venous Thrombosis After Elective Hip Surgery Could Be Allowed to Remain in Place Without Thromboprophylaxis After a Minimum 2-Year Follow-Up. J Arthroplasty 2020; 35:563-568. [PMID: 31551160 DOI: 10.1016/j.arth.2019.08.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is not clear how to treat asymptomatic deep venous thromboses (DVTs) following elective hip arthroplasty because the natural course of DVTs is unclear. It is therefore valuable to understand the natural course of DVTs and their relation to thromboprophylactic methods. METHODS We followed 742 consecutive patients who underwent elective hip arthroplasty followed by mechanical or chemical prophylaxis of a DVT. All patients underwent preoperative and postoperative duplex ultrasonography of both limbs. Patients who developed postoperative DVT in the popliteal or calf vein were followed without thromboprophylaxis. DVT-positive patients were prospectively followed up with duplex ultrasonography at 3, 6, 12, and 24 months postoperatively. RESULTS Incidences of preoperative and postoperative DVTs were 3.9% and 33.0%, respectively. Nonfatal pulmonary embolism (PE) occurred in 1 patient after negative echography. All DVTs that developed in the calf vein postoperatively and without anticoagulation remained benign, and 93% of the DVTs ultimately disappeared. CONCLUSION These results confirmed that the natural course of asymptomatic distal DVTs is benign, with no risk of leading to PE. Thus, distal DVTs could be allowed to remain untreated without chemical prophylaxis to prevent PE in Asian populations.
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Yang Y, Lehman EB, Flohr TR, Radtka JF, Aziz F. Factors associated with symptomatic postoperative myocardial infarction after endovascular aneurysm repair. J Vasc Surg 2019; 71:806-814. [PMID: 31471233 DOI: 10.1016/j.jvs.2019.05.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/28/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) has now become the most common operation to treat abdominal aortic aneurysms (AAAs). One of the perceived benefits of EVAR over open AAA repair is reduced incidence of perioperative cardiac complications and mortality. The purpose of this study was to determine risk factors associated with postoperative myocardial infarction (POMI) in patients who have undergone EVAR. METHODS Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for the years 2012 to 2015 in the Participant Use Data File. All patients in the database who underwent EVAR during this time were identified. These patients were then divided into two groups: those with POMI and those without. Bivariate analysis was done for preoperative, intraoperative, and postoperative risk factors, followed by multivariable analysis to determine associations of independent variables with POMI. A risk prediction model for POMI was created to accurately predict incidence of POMI after EVAR. RESULTS A total of 7702 patients (81.3% male, 18.7% female) were identified who underwent EVAR from 2011 to 2015. Of these patients, 110 (1.4%) had POMI and 7592 (98.6%) did not. Several risk factors were related to an increased risk of POMI, including dependent functional health status, need for lower extremity revascularization, longer operation time, and ruptured AAA (P < .05, all).On multivariable analysis, the following factors were found to have significant associations with POMI: return to operating room (odds ratio [OR], 1.84; confidence interval [CI], 1.10-3.09; P = .020), ruptured AAA (OR, 1.87; CI, 1.18-2.95; P = .008), pneumonia (OR, 1.94; CI, 1.01-3.73; P = .048), age >80 years (compared with <70 years; OR, 2.30; CI, 1.36-3.86; P = .002), unplanned intubation (OR, 4.07; CI, 2.31-7.18; P < .001), and length of hospital stay >6 days (OR, 8.43; CI, 4.75-14.94; P < .001). The risk prediction model showed that in the presence of all these risk factors, the incidence of POMI was 58.3%. The incidence of cardiac arrest and death was significantly higher for patients with POMI compared with patients without POMI (cardiac arrest, 11.9% vs 1.3%; death, 10.2% vs 1.1%). CONCLUSIONS In patients who undergo EVAR, the risk of POMI is increased for those who are older, who present with a ruptured AAA, who have pneumonia, who have unplanned intubation, and who have prolonged hospital stay. Patients who suffer from POMI have higher risk of having cardiac arrest and death.
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Affiliation(s)
- Yang Yang
- Office of Medical Education, Drexel University, College of Medicine, Philadelphia, Pa
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Tanya R Flohr
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa
| | - John F Radtka
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa.
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Yang Y, Lehman E, Aziz F. Increased Length of Hospital Stay after Endovascular Abdominal Aortic Aneurysm Repair: Role of Pulmonary Complications. Cureus 2019; 11:e4986. [PMID: 31467818 PMCID: PMC6706259 DOI: 10.7759/cureus.4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives The average hospital length of stay plays a significant role in healthcare costs, and is also used as a metric of hospital efficiency. An advantage of endovascular abdominal aortic aneurysm repair (EVAR) is the shorter postoperative time period after the surgery. The purpose of this study is to review the factors associated with increased length of stay after EVAR. Methods The records from American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database in 2013 were obtained using Procedure Participant User File. Pre-, intra-, and post-operative factors were assessed of patients undergoing EVAR in 2013. Multivariable logistic regression analysis was used to identify independent variables for a hospital length of stay of at least seven days. Results A total of 1,991 patients (18.7% female, 81.3% males) underwent EVAR in 2013. Among these patients, 223 (11.2%) had a hospital stay greater than seven days. Variables significantly associated with length of stay in a multivariable model included: total operation time greater than 180 minutes (vs. less than 90 minutes, OR 1.88, CI 1.03-3.41, p = 0.039), postoperative, and intraoperative transfusions (OR 2.60, CI 1.66-4.08, p < 0.001), return to operating room (OR 2.88, CI 1.55-5.38, p < 0.001), rupture indication for surgery (OR 5.59, CI 3.18-9.83, p < 0.001), myocardial infarction (OR 5.85, CI 2.22-15.43, p < 0.001), preoperative transfusion (OR 13.05, CI 4.26-39.99, p < 0.001), and on ventilator greater than 48 hours (OR 49.65, CI 10.72-230.07, p < 0.001). Conclusions Multiple factors affect length of hospital stay in patients who have undergone EVAR. Patients with postoperative respiratory failure after EVAR have a significantly higher risk for longer hospital stays.
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Affiliation(s)
- Yang Yang
- Vascular Surgery, Drexel University College of Medicine, Philadelphia, USA
| | - Erik Lehman
- Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
| | - Faisal Aziz
- Cardiac / Thoracic / Vascular Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
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Le CD, Lehman E, Aziz F. Development of Postoperative Pneumonia After Endovascular Aortic Aneurysm Repair is Associated with an Increased Length of Intensive Care Unit Stay. Cureus 2019; 11:e4514. [PMID: 31259123 PMCID: PMC6590861 DOI: 10.7759/cureus.4514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective Endovascular aortic aneurysm repair (EVAR) has increasingly replaced open aortic surgery for treatment of abdominal aortic aneurysms (AAA). One of the key advantages of EVAR is the reduced length of intensive care unit (ICU) stay and hospital stay. This study aimed to identify the risk factors associated with increased ICU length of stay (LOS) after EVAR. Methods The American College of Surgeons (ACS-NSQIP) database for the year 2013 was used. All patients who underwent EVAR were divided into two groups: ICU LOS <1 day vs. ≥1 day. Preoperative, intraoperative, and postoperative factors were compared between these two groups utilizing bivariate logistic regression analysis. Multivariable logistic regression analysis was then used to identify factors that were independently associated with ICU LOS ≥1 day after EVAR. Results A total of 2,468 patients (18.7% females, 81.3% males) were identified. Group 1 (ICU LOS <1 day) = 1,535 patients and Group 2 (ICU LOS ≥1 day) = 933 patients. Multivariable analysis identified the following factors to be associated with ICU LOS ≥1 day: ruptured AAA (OR 3.88, CI 1.97-7.65), the American Society of Anesthesiology (ASA) score of 4-5 (OR 2.82, CI 1.50-5.31), operative time ≥180 minutes (OR 2.10, CI 1.51-2.93), bilateral groin cut down (OR 1.37, CI 1.10-1.71), juxta-renal AAA (OR 1.65, CI 1.16-2.35), renal artery stent (OR 2.13, CI 1.42-3.21), aortic stent (OR 2.39, CI 1.60-3.55), emergency surgery (OR 2.56, CI 1.94-3.38), need for blood transfusion (OR 3.11, CI 2.08-4.65) and postoperative pneumonia (OR 7.04, CI 1.95-25.45). Conclusion Variables identified above can be used to predict the cohort of EVAR patients which will likely require ICU for ≥1 day. Development of postoperative pneumonia is associated with a 7.04 times increase in ICU LOS ≥1 day.
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Affiliation(s)
- Cam Dung Le
- Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
| | - Erik Lehman
- Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
| | - Faisal Aziz
- Cardiac / Thoracic / Vascular Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
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Corkum KS, Baumann LM, Lautz TB. Complication Rates for Pediatric Hepatectomy and Nephrectomy: A Comparison of NSQIP-P, PHIS, and KID. J Surg Res 2019; 240:182-190. [PMID: 30954859 DOI: 10.1016/j.jss.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/22/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Three large national data sets are commonly used to assess operative outcomes in pediatric surgery; National Surgical Quality Improvement Program Pediatric (NSQIP-P), Pediatric Health Information System (PHIS), and Kids' Inpatient Data set (KID). Hepatectomy and nephrectomy are rare pediatric surgical procedures, which may benefit from large administrative data sets for the assessment of short-term complications. MATERIALS AND METHODS A retrospective review of NSQIP-P (2012-2015), KID (2012), and PHIS (2012-2015) was performed for hepatectomy or nephrectomy cases for children aged 0 to 18 y. Thirty-day perioperative outcomes were collected, analyzed, and compared across data sets and surgical cohorts. RESULTS Rates of surgical site infection, wound dehiscence, central line infection, sepsis, and venous thromboembolism were similar across NSQIP-P, PHIS, and KID in both cohorts. Rates of pneumonia and renal insufficiency were higher in PHIS and KID versus NSQIP-P in both cohorts. Blood transfusions in NSQIP-P were higher than PHIS and KID in the hepatectomy group (50.9% versus 43.0% versus 32.4%, P < 0.001), but similar across data sets in the nephrectomy cohorts (12.0% versus 14.0% versus 13.0%, P = 0.15). PHIS reported higher readmission rates than NSQIP-P for both the hepatectomy (56.5% versus 17.9%, P < 0.001) and nephrectomy (32.6% versus 7.6%,P < 0.001) cohorts. Thirty-day mortality rates were similar between NSQIP-P and PHIS, but higher in KID as compared with NSQIP-P for hepatectomy (6.4% versus 0.4%, P < 0.001) and nephrectomy (2.0% versus 0.3%, P < 0.001) cases. CONCLUSIONS Administrative data sets provide large sample sizes for the study of low-volume procedures in children, but there are significant variations in the reported rates of perioperative outcomes between NSQIP-P, PHIS, and KID. Therefore, surgical outcomes should be interpreted within the context of the strengths and limitations of each data set.
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Affiliation(s)
- Kristine S Corkum
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lauren M Baumann
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Timothy B Lautz
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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Anaesthesia care team improves outcomes in surgical patients compared with solo anaesthesiologist. Eur J Anaesthesiol 2019; 36:64-69. [DOI: 10.1097/eja.0000000000000891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Short-term outcomes following posterior cervical fusion among octogenarians with cervical spondylotic myelopathy: a NSQIP database analysis. Spine J 2018; 18:1603-1611. [PMID: 29454135 DOI: 10.1016/j.spinee.2018.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative changes in the cervical spine occur in an age-dependent manner. As the US population continues to age, the incidence of age-dependent, multilevel, degenerative cervical pathologies is expected to increase. Similarly, the average age of patients with cervical spondylotic myelopathy (CSM) will likely trend upward. Posterior cervical fusion (PCF) is often the treatment modality of choice in the management of multilevel cervical spine disease. Although outcomes following anterior cervical fusion for degenerative disease have been studied among older patients (aged 80 years and older), it is unknown if these results extend to octogenarian patients undergoing PCF for the surgical management of CSM. PURPOSE The present study aimed to quantify surgical outcomes following PCF for the treatment of CSM among the octogenarian patient population compared with patients younger than 80 years old. STUDY DESIGN/SETTING This was a retrospective study that used the National Surgical Quality Improvement Program (NSQIP). PATIENT SAMPLE The sample included patients aged 60-89 who had CSM and who underwent PCF from 2012 to 2014. OUTCOME MEASURES The outcome measures were multimorbidity, prolonged length of stay (LOS), discharge disposition (to home or skilled nursing/rehabilitation facility), 30-day all-cause readmission, and 30-day reoperation. METHODS The NSQIP database was queried for patients with CSM (International Classification of Disease, Ninth Revision, Clinical Modification code 721.1) aged 60-89 who underwent PCF (Current Procedural Terminology code 22600) from 2012 to 2014. Cohorts were defined by age group (60-69, 70-79, 80-89). Data were collected on gender, race, elective or emergent status, inpatientor outpatient status, where patients were admitted from (home vs. skilled nursing facility), American Society of Anesthesiologists class, comorbidities, and single- or multilevel fusion. After controllingfor these variables, logistic regression analysis was used to compare outcome measures in the different age groups. RESULTS A total of 819 patients with CSM who underwent PCF (416 aged 60-69, 320 aged 70-79, and 83 aged 80-89) were identified from 2012 to 2014. Of the PCF procedures, 79.7% were multilevel. There were no significant differences in the odds of multimorbidity, prolonged LOS, readmission, or reoperation when comparing octogenarian patients with CSM with patients aged 60-69 or 70-79. Patients aged 60-69 and 70-79 were significantly more likely to be discharged to home than patients over 80 (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.8-10.4, p<.0001, and OR 2.7, 95% CI 1.1-6.4, p=.0005, respectively). CONCLUSIONS Compared with patients aged 60-69 and 70-79, octogenarian patients with CSM were significantly more likely to be discharged to a location other than home following PCF. After controlling for patient comorbidities and demographics, 80- to 89-year-old patients with CSM who underwent PCF did not differ in other outcomes when compared with the other age cohorts. These results can improve preoperative risk counseling and surgical decision-making.
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Factors affecting patients' functional status and their impact on outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg 2018; 68:712-719. [DOI: 10.1016/j.jvs.2017.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022]
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Ambur V, Park P, Gaughan JP, Golarz S, Schmieder F, Van Bemmelen P, Choi E, Dhanisetty R. The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia. J Vasc Surg 2018; 69:491-496. [PMID: 30154013 DOI: 10.1016/j.jvs.2018.05.229] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/28/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia. METHODS The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications. RESULTS The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01). CONCLUSIONS CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.
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Affiliation(s)
- Vishnu Ambur
- Department of Surgery, Temple University Hospital, Philadelphia, Pa.
| | - Peter Park
- Department of Surgery, Temple University Hospital, Philadelphia, Pa
| | - John P Gaughan
- Biostatistics Department, Cooper Medical School of Rowan University, Camden, NJ
| | - Scott Golarz
- Division of Vascular Surgery, Temple University Hospital, Philadelphia, Pa
| | - Frank Schmieder
- Division of Vascular Surgery, Temple University Hospital, Philadelphia, Pa
| | - Paul Van Bemmelen
- Division of Vascular Surgery, Temple University Hospital, Philadelphia, Pa
| | - Eric Choi
- Division of Vascular Surgery, Temple University Hospital, Philadelphia, Pa
| | - Ravi Dhanisetty
- Division of Vascular Surgery, Temple University Hospital, Philadelphia, Pa
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Chaudhary MA, Jiang W, Lipsitz S, Hashmi ZG, Koehlmoos TP, Learn P, Haider AH, Schoenfeld AJ. The Transition to Data-Driven Quality Metrics: Determining the Optimal Surveillance Period for Complications After Surgery. J Surg Res 2018; 232:332-337. [PMID: 30463738 DOI: 10.1016/j.jss.2018.06.059] [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: 03/05/2018] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Thirty-day complications frequently serve in the surgical literature as a quality indicator. This metric is not meant to capture the full array of complication resulting from surgical intervention. However, this period is largely based on convention, with little evidence to support it. This study sought to determine the optimal surveillance period for postsurgical complications, defined as the shortest period that also encompassed the highest proportion of postsurgical adverse events. METHODS TRICARE data (2006-2014) were queried for adult (18-64 y) patients who underwent one of 11 surgical procedures. Patients were assessed for complications up to 90 d after surgery. Kaplan-Meier curves, linear spline regression models at each incremental postsurgical day, and adjusted R-squared values were used to identify critical time point cutoffs for the surveillance of complications. Optimal length of surveillance was defined as the postsurgical day on which the model demonstrated the highest R-squared value. A supplemental analysis considered these measures for orthopedic and general surgical procedures. RESULTS One lakh ninety-eight patients met the inclusion criteria. A total of 21.8% patients experienced at least one complication during the follow-up period, with 59% occurring within the first 15 d. Kaplan-Meier curves for complications showed a demonstrable inflection before 20 d and 14-15 d possessed the highest R-squared values. CONCLUSIONS In this analysis, the optimal surveillance period for postsurgical complications was 15 d. While the conventional 30-d period may still be appropriate for a variety of reasons, the shorter interval identified here may represent a superior quality measure specific to surgical practice.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zain G Hashmi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Peter Learn
- Uniformed Services University, Bethesda, Maryland
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Is 30-Day Posthospitalization Mortality Lower Among Racial/Ethnic Minorities?: A Reexamination. Med Care 2018; 56:665-672. [PMID: 29877955 DOI: 10.1097/mlr.0000000000000938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multiple studies have reported that risk-adjusted rates of 30-day mortality after hospitalization for an acute condition are lower among blacks compared with whites. OBJECTIVE To examine if previously reported lower mortality for minorities, relative to whites, is accounted for by adjustment for do-not-resuscitate status, potentially unconfirmed admission diagnosis, and differential risk of hospitalization. RESEARCH DESIGN Using inpatient discharge and vital status data for patients aged 18 and older in California, we examined all admissions from January 1, 2010 to June 30, 2011 for acute myocardial infarction, heart failure, pneumonia, acute stroke, gastrointestinal bleed, and hip fracture and estimated relative risk of mortality for Hispanics, non-Hispanic blacks, non-Hispanic Asians, and non-Hispanic whites. Multiple mortality measures were examined: inpatient, 30-, 90-, and 180 day. Adding census data we estimated population risks of hospitalization and hospitalization with inpatient death. RESULTS Across all mortality outcomes, blacks had lower mortality rate, relative to whites even after exclusion of patients with do-not-resuscitate status and potentially unconfirmed diagnosis. Compared with whites, the population risk of hospitalization was 80% higher and risk of hospitalization with inpatient mortality was 30% higher among blacks. Among Hispanics and Asians, disparities varied with mortality measure. CONCLUSIONS Lower risk of posthospitalization mortality among blacks, relative to whites, may be associated with higher rate of hospitalizations and differences in unobserved patient acuity. Disparities for Hispanics and Asians, relative to whites, vary with the mortality measure used.
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Aziz F, Lehman EB. Preexisting Conditions Determine the Occurrence of Unplanned Readmissions after Procedures for Treatment of Peripheral Arterial Disease. Ann Vasc Surg 2018; 50:60-72. [PMID: 29481929 DOI: 10.1016/j.avsg.2018.01.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/27/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Readmissions after surgical procedures are increasingly considered a metric to indicate the quality of care received during the index hospitalization. Patients with peripheral arterial disease (PAD) requiring peripheral vascular interventions (PVIs) or lower extremity bypasses (LEBs) often have several serious medical comorbidities. Risk factors associated with readmission after PVI and LEB have previously been identified. The purpose of this study is to compare the readmissions among patients receiving PVI and LEB procedures to identify risk factors associated with high risk of readmission. METHODS The 2013 Procedure-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery ACS-NSQIP Program User Files were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing PVI and LEB were assessed. Odds ratios (ORs) with confidence intervals (CIs) for PVI versus LEB groups within the subgroups of these characteristics were then obtained where significant associations existed between the study groups. RESULTS A total of 3,742 patients (males: 2,384 [63.7%] and females: 1,358 [36.3%]) underwent surgical procedures for lower extremity PAD during the year 2013. Among these patients, 1,096 (29.3%) were treated with endovascular interventions and 2,646 (70.7%) were treated with surgical bypasses. Patients were divided into 2 groups: PVI (n = 1,096) and LEB (n = 2,646) groups. Each group was further subdivided into 2 groups: readmission and no readmission. The incidence of readmission was as follows: PVI group (n = 147, 13.4%) and LEB (n = 425, 16.1%). The PVI and LEB groups showed a significant association with readmission within the following factors: dialysis dependency (PVI 32.6% vs. LEB 19.1%, OR: 2.06, CI: 1.13-3.75, P < 0.001), emergency operation (PVI 40.4% vs. LEB 18.7%, OR: 2.96, CI: 1.45-6.03, P < 0.001), chronic obstructive pulmonary disease (COPD; PVI 23.7% vs. LEB 14.6%, OR: 1.82, CI: 1.08-3.07, P = 0.001), cardiac arrest (PVI 45.5% vs. LEB 9.5%, OR: 7.92, CI: 1.21-51.9, P = 0.017), and body mass index > 30 (PVI 9.9% vs. LEB 18.4%, OR: 0.49, CI: 0.33-0.73, P = 0.009). CONCLUSIONS Readmissions after lower extremity endovascular or surgical interventions can be used as a quality metric. Patients with dialysis dependency, COPD, in need of emergent operation, or having cardiac arrest are highly likely to be readmitted if treated with endovascular interventions. Similarly, patients with high body mass index are highly likely to be readmitted if treated with open surgical bypasses.
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Affiliation(s)
- Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University, College of Medicine, Hershey, PA
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Abstract
BACKGROUND Death rates after surgery are increasingly analysed for clinical audit and quality assessment. Many studies commonly provide information only on deaths that occur during hospital stay, known as in-hospital death rates. By using hospital data set linked to death certificate registry, we recorded in- and out-hospital deaths within 30 and 60 post-operative days. METHODS The study included all consecutive surgical procedures (denominator) under general or locoregional anaesthesia in adult patients admitted for elective or non-elective inpatient surgery. Patients undergoing planned day-case surgery or obstetrical procedures were excluded. The primary outcome was 30- and 60-day post-operative mortality rate (numerator) whether before or after discharge. RESULTS The study material consisted of a sample of 36,494 surgical procedures corresponding to 28,202 patients. At 30-day, 384 (crude mortality rate of 1.1%) patients died, 314 (82%) during their hospitalisation and 70 (18%) after discharge. Factors that were associated with in-hospital mortality are ASA scores, emergency, duration of surgery and rate of admission to critical care unit. Within the 30-60 days interval, we recorded 231 supplemental deaths, 103 (45%) after discharge. CONCLUSION In-hospital mortality alone is an incomplete measure of mortality even within 30 days of care. To identify the missing deaths, hospital records need to be linked to data from death certificate. This connection with the national death registry will allow obtaining the rate of in-hospital and out-hospital death.
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Affiliation(s)
- Philippe Dony
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
| | - Magali Pirson
- Health Economics, Health Facility Administration and Nursing Science, Free University of Brussels, Brussels, Belgium
| | - Jean G. Boogaerts
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
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Grasso G. “July Effect” on Care for Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 110:71-72. [DOI: 10.1016/j.wneu.2017.10.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
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Modified Frailty Index Can Be Used to Predict Adverse Outcomes and Mortality after Lower Extremity Bypass Surgery. Ann Vasc Surg 2018; 46:168-177. [DOI: 10.1016/j.avsg.2017.07.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 12/21/2022]
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Goltz DE, Baumgartner BT, Politzer CS, DiLallo M, Bolognesi MP, Seyler TM. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Has a Role in Predicting Discharge to Post-Acute Care in Total Joint Arthroplasty. J Arthroplasty 2018; 33:25-29. [PMID: 28899592 DOI: 10.1016/j.arth.2017.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/31/2017] [Accepted: 08/09/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patient demand and increasing cost awareness have led to the creation of surgical risk calculators that attempt to predict the likelihood of adverse events and to facilitate risk mitigation. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool available for a wide variety of surgical procedures, and has not yet been fully evaluated in total joint arthroplasty. METHODS A single-center, retrospective review was performed on 909 patients receiving a unilateral primary total knee (496) or hip (413) arthroplasty between January 2012 and December 2014. Patient characteristics were entered into the risk calculator, and predicted outcomes were compared with observed results. Discrimination was evaluated using the receiver-operator area under the curve (AUC) for 90-day readmission, return to operating room (OR), discharge to skilled nursing facility (SNF)/rehab, deep venous thrombosis (DVT), and periprosthetic joint infection (PJI). RESULTS The risk calculator demonstrated adequate performance in predicting discharge to SNF/rehab (AUC 0.72). Discrimination was relatively limited for DVT (AUC 0.70, P = .2), 90-day readmission (AUC 0.63), PJI (AUC 0.67), and return to OR (AUC 0.59). Risk score differences between those who did and did not experience discharge to SNF/rehab, 90-day readmission, and PJI reached significance (P < .01). Predicted length of stay performed adequately, only overestimating by 0.2 days on average (rho = 0.25, P < .001). CONCLUSION The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator has fair utility in predicting discharge to SNF/rehab, but limited usefulness for 90-day readmission, return to OR, DVT, and PJI. Although length of stay predictions are similar to actual outcomes, statistical correlation remains relatively weak.
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Affiliation(s)
- Daniel E Goltz
- Duke University School of Medicine, Duke University Medical Center Greenspace, Durham, North Carolina
| | - Billy T Baumgartner
- Duke University School of Medicine, Duke University Medical Center Greenspace, Durham, North Carolina
| | - Cary S Politzer
- Duke University School of Medicine, Duke University Medical Center Greenspace, Durham, North Carolina
| | - Marcus DiLallo
- Duke University School of Medicine, Duke University Medical Center Greenspace, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Gupta PK, Brahmbhatt R, Kempe K, Stickley SM, Rohrer MJ. Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels. J Vasc Surg 2017; 66:1653-1658.e1. [DOI: 10.1016/j.jvs.2017.04.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/20/2017] [Indexed: 11/16/2022]
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Aziz F, Lehman E, Blebea J, Lurie F. Postoperative complications after lower extremity arterial bypass increase the risk of new deep venous thrombosis. Phlebology 2017; 33:558-566. [PMID: 29041831 DOI: 10.1177/0268355517737455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Deep venous thrombosis after any surgical operations is considered a preventable complication. Lower extremity bypass surgery is a commonly performed operation to improve blood flow to lower extremities in patients with severe peripheral arterial disease. Despite advances in endovascular surgery, lower extremity arterial bypass remains the gold standard treatment for severe, symptomatic peripheral arterial disease. The purpose of this study is to identify the clinical risk factors associated with development of deep venous thrombosis after lower extremity bypass surgery. Methods The American College of Surgeons' NSQIP database was utilized and all lower extremity bypass procedures performed in 2013 were examined. Patient and procedural characteristics were evaluated. Univariate and multivariate logistic regression analysis was used to determine independent risk factors for the development of postoperative deep venous thrombosis. Results A total of 2646 patients (65% males and 35% females) underwent lower extremity open revascularization during the year 2013. The following factors were found to be significantly associated with postoperative deep venous thrombosis: transfusion >4 units of packed red blood cells (odds ratio (OR) = 5.21, confidence interval (CI) = 1.29-22.81, p = 0.03), postoperative urinary tract infection (OR = 12.59, CI = 4.12-38.48, p < 0.01), length of hospital stay >28 days (OR = 9.30, CI = 2.79-30.92, p < 0.01), bleeding (OR = 2.93, CI = 1.27-6.73, p = 0.01), deep wound infection (OR = 3.21, CI = 1.37-7.56, p < 0.01), and unplanned reoperation (OR = 4.57, CI = 2.03-10.26, p < 0.01). Of these, multivariable analysis identified the factors independently associated with development of deep venous thrombosis after lower extremity bypass surgery to be unplanned reoperation (OR = 3.57, CI = 1.54-8.30, p < 0.01), reintubation (OR = 8.93, CI = 2.66-29.97, p < 0.01), and urinary tract infection (OR = 7.64, CI = 2.27-25.73, p < 0.01). Presence of all three factors was associated with a 54% incidence of deep venous thrombosis. Conclusions Development of deep venous thrombosis after lower extremity bypass is a serious but infrequent complication. Patients who require unplanned return to the operating room, reintubation, or develop a postoperative urinary tract are at high risk for developing postoperative deep venous thrombosis. Increased monitoring of these patients and ensuring adequate deep venous thrombosis prophylaxis for such patients is suggested.
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Affiliation(s)
- Faisal Aziz
- 1 Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Erik Lehman
- 2 Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - John Blebea
- 3 Department of Surgery, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Fedor Lurie
- 4 Vascular Surgery, Jobst Vascular Institute, Toledo, OH, USA
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Aziz F, Ferranti K, Lehman EB. Unplanned return to operating room after endovascular repair of abdominal aortic aneurysm (EVAR) is associated with increased risk of hospital readmission. Vascular 2017; 26:151-162. [PMID: 28886677 DOI: 10.1177/1708538117721622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Hospital readmissions after surgical operations are considered serious events. Centers for Medicare and Medicaid (CMS) consider surgical readmissions as preventable and hold hospitals responsible for them. Endovascular abdominal aortic aneurysm (EVAR) has become the first line modality of treatment for suitable patients with abdominal aortic aneurysm (AAA). The purpose of this study is to retrospectively review the factors associated with hospital readmission after EVAR. Methods The 2013 EVAR targeted American College of Surgeons (ACS-NSQIP) database and generalized 2013 general and vascular surgery ACS-NSQIP participant use files were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing EVAR surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for hospital readmission within 30 days after surgery. Results A total of 2277 patients (81% males, 19% females) underwent EVAR operations in the year 2013. Indications for operations included: asymptomatic large diameter (79%), symptomatic (5.7%), rupture without hypotension (4.3%), and rupture with hypotension (2.8%). Among these patients, 178 (7.8%) were readmitted to the hospital within 30 days after surgery. About 53% of all readmissions were within two weeks after the discharge. Risk factors, associated with readmission included: body mass index (per 5-units, OR 1.23, CI 1.06-1.42, p < 0.05), days from admission to operation (per 1 day, OR 1.26, CI 1.12-1.41, p < 0.05), prior abdominal aortic surgery (OR 1.60, CI 1.10-2.31, p < 0.05), urinary tract infection (OR 5.93, CI 2.09-16.88, p < 0.05), superficial surgical site infection (OR 6.57, CI 2.53-17.09, p < 0.05), unplanned return to the operating room (OR 11.29, CI 6.29-20.28, p < 0.05), myocardial infarction (OR 11.30, CI 4.42-28.89, p < 0.05), deep venous thrombosis (OR 11.52, CI 2.89-45.86, p < 0.05 and deep incisional surgical site infection (OR 38.0, CI 2.87-373.56, p < 0.05). Risk of readmission for patients with presence of all these seven factors was 99.9%. Conclusions Readmission after EVAR is a serious occurrence. Various factors predispose a patient at a high risk for readmission. Unplanned return to operating room after EVAR is associated with a 11-fold increase in hospital readmission.
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Affiliation(s)
- Faisal Aziz
- 1 Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Katelynn Ferranti
- 1 Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Erik B Lehman
- 2 Department of Public Health Sciences, Pennsylvania State University, College of Medicine, Hershey, PA, USA
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Aziz F, Bohr T, Lehman EB. Wound Disruption after Lower Extremity Bypass Surgery is a Predictor of Subsequent Development of Wound Infection. Ann Vasc Surg 2017; 43:176-187. [DOI: 10.1016/j.avsg.2016.10.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/17/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
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Ali TZ, Lehman EB, Aziz F. Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission. J Vasc Surg 2017; 65:1735-1744.e2. [DOI: 10.1016/j.jvs.2016.12.121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/09/2016] [Indexed: 10/19/2022]
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Gupta PK, Kempe K, Brahmbhatt R, Gupta H, Montes J, Forse RA, Stickley SM, Rohrer MJ. Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Vasc Endovascular Surg 2017; 51:357-362. [PMID: 28514895 DOI: 10.1177/1538574417703562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. MATERIALS AND METHODS Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. RESULTS No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). CONCLUSION Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.
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Affiliation(s)
- Prateek K Gupta
- 1 Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,2 Methodist Le Bonheur Healthcare, Memphis, TN, USA
| | - Kelly Kempe
- 1 Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,2 Methodist Le Bonheur Healthcare, Memphis, TN, USA.,3 Regional One Medical Center, Memphis, TN, USA
| | - Reshma Brahmbhatt
- 1 Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,2 Methodist Le Bonheur Healthcare, Memphis, TN, USA
| | - Himani Gupta
- 2 Methodist Le Bonheur Healthcare, Memphis, TN, USA
| | - Jorge Montes
- 4 Doctors Hospital at Renaissance Health Care System, Edinburg, TX, USA
| | - R Armour Forse
- 4 Doctors Hospital at Renaissance Health Care System, Edinburg, TX, USA
| | - Shaun M Stickley
- 1 Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,3 Regional One Medical Center, Memphis, TN, USA
| | - Michael J Rohrer
- 1 Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,2 Methodist Le Bonheur Healthcare, Memphis, TN, USA
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Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS. Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults. JAMA Surg 2017; 152:e170123. [PMID: 28329352 DOI: 10.1001/jamasurg.2017.0123] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and Relevance Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Anne H Cain-Nielsen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor3Department of Health Management and Policy, University of Michigan, Ann Arbor4Department of Economics, University of Michigan, Ann Arbor
| | - Lena M Chen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Integrated Delivery System, Dartmouth-Hitchcock, Hanover, New Hampshire6Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
| | - Jonathan S Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
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Aziz F, Chu Y, Lehman EB. Lower Extremity Bypass Surgery on Patients Transferred from Other Hospitals is Associated with Increased Morbidity and Mortality. Ann Vasc Surg 2017; 41:205-213.e2. [PMID: 28258020 DOI: 10.1016/j.avsg.2016.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/14/2016] [Accepted: 09/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite advances in endovascular surgery, lower extremity arterial bypass remains the gold standard treatment for severe, symptomatic peripheral arterial disease (PAD). Patients who are transferred to other hospitals have generally complex medical problems compared to those patients who are directly admitted from home. The purpose of this study is to identify factors associated with an interfacility transfer in patients with PAD and compare the postoperative outcomes of these patients to those who are directly admitted to the hospital. METHODS The 2013 lower extremity revascularization-targeted American College of Surgeons (ACS-National Surgical Quality Improvement Program [NSQIP]) database and generalized 2013 general and vascular surgery ACS-NSQIP Participant Use File were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity bypass surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for transfer to another hospital. RESULTS A total of 2,646 patients (65% male, 35% female) were identified in the NSQIP database that underwent lower extremity open revascularization during the year 2013. A total of 287 patients (11%) were transferred from other institutions: acute care hospital inpatient (4%), nursing home/chronic care/intermediate care (3%), outside emergency department (3%), and other (1%). Factors associated with increased risk of interfacility transfer included need for emergency surgery (odds ratio [OR]: 5.51, P < 0.05), infected wounds (OR: 2.77, P < 0.05), and age >85 years (OR: 2.24, P < 0.05). Postoperative outcome associated with transfer was mortality <30 days postop (OR: 1.96) and length of stay >30 days (OR: 2.04; P < 0.05). CONCLUSIONS Multiple factors affect an interfacility transfer of patients including advanced age, need for emergency procedure, contaminated wounds. Patients who are transferred from another institution for a lower extremity bypass surgery are at a substantially higher risk for postoperative morbidity and mortality.
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Affiliation(s)
- Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Youngmin Chu
- Office of Medical Education, Pennsylvania State University, College of Medicine, Hershey, PA
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University, College of Medicine, Hershey, PA
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Dony P, Dramaix M, Boogaerts JG. Hypocapnia measured by end-tidal carbon dioxide tension during anesthesia is associated with increased 30-day mortality rate. J Clin Anesth 2016; 36:123-126. [PMID: 28183549 DOI: 10.1016/j.jclinane.2016.10.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 09/28/2016] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To evaluate the relationship between intraoperative end-tidal carbon dioxide (etco2) values and clinical outcomes with special attention on 30-day postoperative mortality and secondarily on hospital length of stay (LOS). DESIGN Retrospective, observational study. SETTING Surgical theaters of the University Hospital Center of Charleroi. PATIENTS Five thousand three hundred seventeen patients ASA I-IV undergoing various surgical procedures (except pediatric and cardiac surgery) under general anesthesia. INTERVENTIONS No intervention on the patients. MEASUREMENTS The mean etco2 level measured during anesthesia was secondarily extracted from an electronic information management system. Patients were divided into 2 separate groups based on etco2 values less than or greater than or equal to 35 mm Hg. The primary end point was the in- and outhospital mortality in the 30-day period after surgery. The second was the LOS more than 6 days. MAIN RESULTS Hypocapnia occurred in 66% of the patients. Mortality rate at 30-day was 84 of 3554 (2.4%) in the low etco2 group vs 15 of 1763 (0.9%) in the other (odds ratio, 2.99 [1.69-5.28]; P<.001). In multivariate analysis, age and ASA scores had significant independent associations with mortality rate. Adjusting for these factors had an effect on the relative odds ratio of etco2 on mortality of 1.99 ([1.11-3.56]; P<.001). Patients with low etco2 experienced higher LOS (14.1±9.4 vs 13.1±8.9 days; P<.001). Thirty five percent of the patients in the low etco2 group were still hospitalized more than 6 days compared with 30% in the other (P<.001). CONCLUSION Low etco2 level during anesthesia is associated with an increase in postoperative mortality rate and LOS. These results emphasize the importance of preventing hypocapnia during anesthesia to improve surgical outcomes.
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Affiliation(s)
- Philippe Dony
- Department of Anesthesiology, University Hospital Center of Charleroi, Belgium
| | - Michele Dramaix
- School of Public Health, Research Center for Epidemiology, Free University of Brussels, 1070 Brussels, Belgium
| | - Jean G Boogaerts
- Department of Anesthesiology, University Hospital Center of Charleroi, Belgium.
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Hjelle KM, Johannesen TB, Beisland C. Postoperative 30-day Mortality Rates for Kidney Cancer Are Dependent on Hospital Surgical Volume: Results from a Norwegian Population-based Study. Eur Urol Focus 2016; 3:300-307. [PMID: 28753795 DOI: 10.1016/j.euf.2016.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/21/2016] [Accepted: 10/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND To improve cancer care in Norway, the government introduced surgical volume requirements for hospitals in 2015. To treat kidney cancer (KC) in Norway, the lower limit is 20 surgical procedures per year. OBJECTIVES To compare the impact of hospital volume on outcome with regard to 30-d mortality (TDM) following KC surgery. DESIGN, SETTING, AND PARTICIPANTS We identified all KC patients from the Cancer Registry of Norway diagnosed during 2008-2013 whose surgical treatment involved partial or radical nephrectomy. Hospitals were divided into three volume groups: low (LVH), intermediate (IVH), and high (HVH) volume. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relationships with outcome were analysed using multivariate logistic regression. RESULTS AND LIMITATIONS In total, 3273 patients were identified. The TDM rate was 0.89% overall, 0.73% for localised KC, and 2.6% for metastatic KC. The mean (median, interquartile range) numbers of procedures for LVH, IVH and HVH were 5.2 /yr (3, 1.3-8.7), 27 /yr (26, 23-30) and 53 /yr (53, 48-58), with TDM rates of 2.2%, 0.83%, and 0.39%, respectively (p=0.001). In a multivariate logistic regression model, tumour stage, age, and hospital volume remained independent TDM predictors. The odds ratio for TDM was 4.98 (confidence interval 1.72-14.4) for LVH compared to HVH (p=0.003). Study limitations include a lack of data for surgical complications and other possible confounders. CONCLUSIONS TDM is associated with age, stage, and hospital volume. The study supports the new regulation for hospital volume introduced in Norway. PATIENT SUMMARY The risk of dying within 30 d following kidney cancer surgery is low. Advanced disease and older age are risk factors for higher mortality. In this study, we also showed that more patients die within 30 d in hospitals performing fewer operations per year than in hospitals performing many operations.
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Affiliation(s)
- Karin M Hjelle
- Department of Urology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Christian Beisland
- Department of Urology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Aziz F, Lehman EB, Reed AB. Increased Duration of Operating Time for Carotid Endarterectomy Is Associated with Increased Mortality. Ann Vasc Surg 2016; 36:166-174. [DOI: 10.1016/j.avsg.2016.02.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/18/2016] [Accepted: 02/19/2016] [Indexed: 10/21/2022]
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Woelber E, Schrick EJ, Gessner BD, Evans HL. Proportion of Surgical Site Infections Occurring after Hospital Discharge: A Systematic Review. Surg Infect (Larchmt) 2016; 17:510-9. [DOI: 10.1089/sur.2015.241] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Erik Woelber
- University of Washington School of Medicine, Seattle, Washington
| | - Emily J. Schrick
- University of Washington College of Arts and Sciences, Seattle, Washington
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Keller DS, Cologne KG, Senagore AJ, Haas EM. Does one score fit all? Measuring risk in ulcerative colitis. Am J Surg 2016; 212:433-9. [DOI: 10.1016/j.amjsurg.2015.10.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/13/2015] [Accepted: 10/28/2015] [Indexed: 12/12/2022]
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Sutton E, Miyagaki H, Bellini G, Shantha Kumara HMC, Yan X, Howe B, Feigel A, Whelan RL. Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database. J Surg Res 2016; 207:205-214. [PMID: 27979478 DOI: 10.1016/j.jss.2016.08.082] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/14/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Superficial surgical site infection (sSSI) is one of the most common complications after colorectal resection. The goal of this study was to determine the comorbidities and operative characteristics that place patients at risk for sSSI in patients who underwent rectal cancer resection. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried (via diagnosis and Current Procedural Terminology codes) for patients with rectal cancer who underwent elective resection between 2005 and 2012. Patients for whom data concerning 27 demographic factors, comorbidities, and operative characteristics were available were eligible. A univariate and multivariate analysis was performed to identify possible risk factors for sSSI. RESULTS A total of 8880 patients met the entry criteria and were included. sSSIs were diagnosed in 861 (9.7%) patients. Univariate analysis found 14 patients statistically significant risk factors for sSSI. Multivariate analysis revealed the following risk factors: male gender, body mass index (BMI) >30, current smoking, history of chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists III/IV, abdominoperineal resection (APR), stoma formation, open surgery (versus laparoscopic), and operative time >217 min. The greatest difference in sSSI rates was noted in patients with COPD (18.9 versus 9.5%). Of note, 54.2% of sSSIs was noted after hospital discharge. With regard to the timing of presentation, univariate analysis revealed a statistically significant delay in sSSI presentation in patients with the following factors and/or characteristics: BMI <30, previous radiation therapy (RT), APR, minimally invasive surgery, and stoma formation. Multivariate analysis suggested that only laparoscopic surgery (versus open) and preoperative RT were risk factors for delay. CONCLUSIONS Rectal cancer resections are associated with a high incidence of sSSIs, over half of which are noted after discharge. Nine patient and operative characteristics, including smoking, BMI, COPD, APR, and open surgery were found to be significant risk factors for SSI on multivariate analysis. Furthermore, sSSI presentation in patients who had laparoscopic surgery and those who had preoperative RT is significantly delayed for unclear reasons.
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Affiliation(s)
- Elie Sutton
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York; Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Hiromichi Miyagaki
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York; Department of Surgery, Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Geoffrey Bellini
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York
| | - H M C Shantha Kumara
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York
| | - Xiaohong Yan
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York
| | - Brett Howe
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York
| | - Amanda Feigel
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York
| | - Richard L Whelan
- Department of Colon and Rectal Surgery, Mount Sinai West Hospital, New York, New York.
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Aziz F, Azab A, Schaefer E, Reed AB. Endovascular Repair of Ruptured Abdominal Aortic Aneurysm Is Associated with Lower Incidence of Post-operative Acute Renal Failure. Ann Vasc Surg 2016; 35:147-55. [DOI: 10.1016/j.avsg.2016.01.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/28/2015] [Accepted: 01/11/2016] [Indexed: 11/16/2022]
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Lieber BA, Appelboom G, Taylor BES, Malone H, Agarwal N, Connolly ES. Assessment of the “July Effect”: outcomes after early resident transition in adult neurosurgery. J Neurosurg 2016; 125:213-21. [DOI: 10.3171/2015.4.jns142149] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Each July, 4th-year medical students become 1st-year resident physicians and have much greater responsibility in making management decisions. In addition, incumbent residents and fellows advance to their next postgraduate year and face greater challenges. It has been suggested that among patients who have resident physicians as members of their neurosurgical team, this transition may be associated with increased rates of morbidity and mortality, a phenomenon known as the “July Effect.” In this study, the authors compared morbidity and mortality rates between the initial and later months of the academic year to determine whether there is truly a July Effect that has an impact on this patient population.
METHODS
The authors compared 30-day postoperative outcomes of neurosurgery performed by surgical teams that included resident physicians in training during the first academic quarter (Q1, July through September) with outcomes of neurosurgery performed with resident participation during the final academic quarter (Q4, April through June), using 2006–2012 data from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Regression analyses were performed on outcome data that included mortality, surgical complications, and medical complications, which were graded as mild or severe. To determine whether a July Effect was present in subgroups, secondary analyses were performed to analyze the association of outcomes with each major neurosurgical subspecialty, the postgraduate year of the operating resident, and the academic quarter during which the surgery was performed. To control for possible seasonal trends in certain diseases, the authors compared patient outcomes at academic medical centers to those at community-based hospitals, where procedures were not performed by residents. In addition, the efficiency of academic centers was compared to that of community centers in terms of operative duration and total length of hospital stay.
RESULTS
Overall, there were no statistically significant differences in mortality, morbidity, or efficiency between the earlier and later quarters of the academic year, a finding that also held true among neurosurgical subspecialties and among postgraduate levels of training. There was, however, a slight increase in intraoperative transfusions associated with the transitional period in July (6.41% of procedures in Q4 compared to 7.99% in Q1 of the prior calendar year; p = 0.0005), which primarily occurred in cases involving junior (2nd- to 4th-year) residents. In addition, there was an increased rate of reoperation (1.73% in Q4 to 2.19% in Q1; p < 0.0001) observed mainly among senior (5th- to 7th-year) residents in the early academic months and not paralleled in our community cohort.
CONCLUSIONS
There is minimal evidence for a significant July Effect in adult neurosurgery. Our results suggest that, overall, the current resident training system provides enough guidance and support during this challenging transition period.
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Affiliation(s)
- Bryan A. Lieber
- 1Department of Neurosurgery, New York University, and
- 2Department of Neurosurgery and
| | | | | | | | - Nitin Agarwal
- 4Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - E. Sander Connolly
- 2Department of Neurosurgery and
- 3Neurointensive Care Unit, Columbia University Medical Center, New York, New York; and
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