Challenges and Importance of Finding Hidden Confounders When Conducting Comparative Effectiveness Studies Using Registry Data

Hybrid surgery: a comparison of early postoperative outcomes between anterior cervical discectomy and fusion and cervical disc arthroplasty

OBJECTIVE

Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications.

RESULTS

This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery-related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors.

CONCLUSIONS

The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

"Turn downs" in aortic emergencies: Reassurance or uncertainty?

"Turn-down" rate has been reported to have a significant influence on outcomes, and being turned down for an operation is associated with significant short-term mortality risk. A study examining the impact of the pandemic on the "turn-down" rates of acute aortic syndromes in the United Kingdom reported an overall "turn-down" rate of  7.3% in the early part of the pandemic. This review examines the significance of "turn-downs" in this setting and scrutinizes the adequacy of reporting this complex variable.

Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making

PURPOSE OF REVIEW

There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). These patients are older, have complex coronary disease, and a substantial comorbidity burden including frailty. The procedural risks and outcomes of CABG and PCI in these patients are more difficult to assess based on the available literature, which has generally studied a younger population with a lower comorbidity burden.

RECENT FINDINGS

There have been initiatives to recalibrate and expand risk models derived from procedural registries to inform the care of complex higher-risk patients, including patients "turned down" for CABG. There is greater recognition of the need for improved assessment of risk, quality, and benefits of coronary revascularization in higher-risk SIHD patients with a substantial comorbidity burden. Clinicians and patients should be aware that there are significant evidence gaps regarding revascularization in complex high-risk patients. The limitations of procedural-derived risk scores should be understood when presenting treatment options. Future randomized controlled trials and expanded registries are greatly desired and should be achievable. Meanwhile, a multidisciplinary heart team approach should be employed for proper decision-making.