The relation between household income and surgical outcome in the Dutch setting of equal access to and provision of healthcare

The effects of social determinants of health on rotator cuff repair utilization and outcomes: a systematic review

Background

Since various social determinants of health (SDOH) have the potential to impact the utilization and postoperative outcomes of rotator cuff repair (RCR), a review of the literature is warranted. Therefore, the purpose of this systematic review was to evaluate the effects of SDOH on RCR utilization and postoperative outcomes in order to recognize external factors that may influence patients' access to RCR and optimal clinical outcomes.

Methods

Search terms related to RCR, utilization, outcomes, and SDOH were used to identify studies that reported associations between any SDOH (as defined by the World Health Organization) and RCR utilization, access, cost, or postoperative outcomes. Articles that did not isolate RCR or did not evaluate an SDOH were excluded. Nonrandomized studies were evaluated for study quality using the Methodological Index for Nonrandomized Studies score. Due to the heterogeneity of the reported data, only qualitative analysis was possible.

Results

Overall, 842 articles were considered for inclusion and 14 studies were included in qualitative analysis. The average Methodological Index for Nonrandomized Studies score of included studies was 14.1 ± 5.0. The SDOH most frequently evaluated were insurance status and race/ethnicity. Non-White race is associated with lower odds of surgery and physical therapy (PT) utilization, as well as delayed treatment. Similarly, public insurance is associated with lower PT and surgery utilization rates and decreased acceptance for postoperative PT. Postoperatively, public insurance is associated with worse patient-reported outcome scores and lower return to work rates.

Conclusion

Various SDOH can influence access, utilization, and outcomes of RCR. Orthopedic surgeons should be aware of how factors of race and insurance type can influence a patient's treatment and recovery after RCR.

Hospital volume-outcome relationships for robot-assisted surgeries: a population-based analysis

BACKGROUND

Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology.

STUDY DESIGN

Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital.

RESULTS

A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3).

CONCLUSION

The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.

An Analysis on the Effect of Income Changes in the Resection of Early-Stage Pancreatic Adenocarcinoma

INTRODUCTION

The impact of socioeconomic inequalities on cancer care and outcomes has been well recognized and the underlying causes are likely multifactorial. Income is regarded as a cornerstone of socioeconomic status and has been assumed to correlate with access to care. We therefore sought to investigate whether income and changes in income would affect the rate of patients undergoing surgical resection for early-stage pancreatic cancer.

METHODS

Inflation-adjusted income data were obtained from the United States Census Bureau from 2010 to 2019. The cancer data were obtained from the SEER database. Counties present in both data sets were included in the analysis. Patients with stage I or II pancreatic cancer who underwent formal resection were deemed to have undergone appropriate surgical management. Patients were grouped into an early (2010-2014) and late (2015-2019) time period.

RESULTS

The final analysis included 23968 patients from 173 counties across 11 states. The resection rate was 45.1% for the entire study and rose from 42.8% to 47.4% from the early to late time periods (P < .001). The median change in income between the two time periods was an increase by $2387. The rate of resection was not dependent on income class or income change in our study population.

CONCLUSION

Our surgical care of pancreatic cancer is improving with more patients undergoing resection. In addition, there are now fewer disparities between patients of lower-income and higher-income groups with respect to receiving surgical intervention. This implies that our access to care has improved over the past decade. This is an encouraging finding with regards to reducing health care disparities.

Hospital learning curves for robot-assisted surgeries: a population-based analysis

BACKGROUND

Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures.

STUDY DESIGN

This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level.

RESULTS

A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87).

CONCLUSION

Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency.

The Influence of Hospital Type, Insurance Type, and Patient Income on 30-Day Complication and Readmission Rates Following Lumbar Spine Fusion

BACKGROUND CONTEXT

Several studies have shown that factors such as insurance type and patient income are associated with different readmission rates following certain orthopaedic procedures. The literature, however, remains sparse with regard to these demographic characteristics and their associations to perioperative lumbar spine fusion outcomes.

PURPOSE

The purpose of this study was to assess the associations between hospital type, insurance type, and patient median income to both 30-day complication and readmission rates following lumbar spine fusion.

PATIENT SAMPLE

Patients who underwent primary lumbar spine fusion (n = 596,568) from 2010-2016 were queried from the National Readmissions Database (NRD).

OUTCOME MEASURES

Incidence of 30-day complication and readmission rates.

METHODS

All relevant diagnoses and procedures were identified using International Classification of Disease, 9th and 10th Edition (ICD-9, 10) codes. Hospital types were categorized as metropolitan non-teaching (n = 212,131), metropolitan teaching (n = 364,752), and rural (n = 19,685). Insurance types included: Medicare (n = 213,534), Medicaid (n = 78,520), private insurance (n = 196,648), and out-of-pocket (n = 45,025). Patient income was divided into the following quartiles: Q1 (n = 112,083), Q2 (n = 145,755), Q3 (n = 156,276), and Q4 (n = 147,289), wherein quartile 1 corresponded to lower income ranges and quartile 4 to higher ranges. Statistical analysis was conducted in R. Kruskal-Wallis tests with Dunn's pairwise comparisons were performed to analyze differences in 30-day readmission and complication rates in patients who underwent lumbar spine fusion. Complications analyzed included infection, wound injury, hematoma, neurological injury, thromboembolic event, and hardware failure.

RESULTS

30-day readmission was significantly higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals and rural hospitals (P < .05). Patients from metropolitan teaching hospitals had significantly higher rates of infection (P < .001), wound injury (P < .001), hematoma (P = .018), and hardware failure (P < .002) compared to those treated at metropolitan non-teaching hospitals. Privately insured patients were significantly less likely to be readmitted at 30 days than those paying with Medicare or Medicaid (P < .01). Patients with private insurance also experienced significantly lower rates of hematoma formation than Medicare beneficiaries and out-of-pocket payers (P < .01), postoperative wound injury compared to Medicaid patients and out-of-pocket payers (P < .005), and infection compared to all other groups (P < .001). Patients in Quartile 4 experienced significantly greater rates of hematoma formation compared to those in Quartiles 1 and 2 and were more likely to experience a thromboembolic event compared to all other groups.

CONCLUSION

Patients undergoing lumbar spine fusion at metropolitan non-teaching hospitals and paying with private insurance had significantly lower 30-day readmission rates than their counterparts. Complications within 30 days following lumbar spine fusion were significantly higher in patients treated at metropolitan teaching hospitals and in Medicare and Medicaid beneficiaries. Aside from a few exceptions, however, patient income was generally not associated with differential complication rates.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

Traumatic Brain Injury Mortality and Correlates in Low- and Middle-Income Countries: A Meta-Epidemiological Study

BACKGROUND

It is estimated that up to 69 million people per year experience traumatic brain injury (TBI) with the highest prevalence found in low- and middle-income countries (LMICs). A paucity of data suggests that the mortality rate after severe TBI is twice as high in LMICs than in high-income countries.

OBJECTIVE

To analyze TBI mortality in LMICs and to evaluate what country-based socioeconomic and demographic parameters influence TBI outcomes.

METHODS

Four databases were searched for the period January 1, 2002, to January 1, 2022, for studies describing TBI outcomes in LMICs. Multivariable analysis was performed using multivariable linear regression, with the outcome as the pooled mortality by country and the covariates as the adjusted parameters.

RESULTS

Our search yielded 14 376 records of which 101 were included in the final analysis, totaling 59 197 patients and representing 31 LMICs. The pooled TBI-related mortality was 16.7% (95% CI: 13.7%-20.3%) without significant differences comparing pediatrics vs adults. Pooled severe TBI-related mortality was significantly higher than mild. Multivariable analysis showed a significant association between TBI-related mortality and median income ( P = .04), population percentage below poverty line ( P = .02), primary school enrollment ( P = .01), and poverty head ratio ( P = .04).

CONCLUSION

TBI-related mortality in LMICs is 3-fold to 4-fold higher than that reported in high-income countries. Within LMICs, parameters associated with poorer outcomes after TBI include factors recognized as social determinants of health. Addressing social determinants of health in LMICs might expedite the quest to close the care delivery gap after TBI.

Factors associated with recurrent appendicitis after nonoperative management

BACKGROUND

The objective of this study is to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively.

METHODS

This is a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital. Patient demographics, radiographic information, management, and clinical outcomes were recorded. The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a time-to-event competing-risk analysis was performed.

RESULTS

Of the 699 patients presenting with appendicitis, 74 were treated nonoperatively (35 [47%] were women; median [IQR] age, 48 [33,64] years), and 21 patients (29%) had recurrent appendicitis. On univariate and multivariate analysis, presence of an appendicolith on imaging was the only factor associated with a higher risk of recurrent appendicitis (p = 0.02).

CONCLUSIONS

The presence of appendicolith was associated with an increased risk of developing recurrent appendicitis within 6 months.

Social vulnerability index (SVI) and poor postoperative outcomes in children undergoing surgery in California

INTRODUCTION

Area-based social determinants of health (SDoH) associated with disparities in children's surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions.

METHODS

This retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1-2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015-2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery.

RESULTS

Among 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02-2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03-2.98).

CONCLUSION

Neighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.

Impact of the Covid-19 pandemic on rates of emergency department utilization and hospital admission due to general surgery conditions

BACKGROUND

Recent literature reports a decrease in healthcare-seeking behaviours by adults during the Covid-19 pandemic. Given that emergency general surgery (GS) conditions are often associated with high morbidity and mortality if left untreated, the objective of this study was to describe and quantify the impact of the Covid-19 pandemic on rates of emergency department (ED) utilization and hospital admission due to GS conditions.

METHODS

This cohort study involved the analysis of an institutional database and retrospective chart review. We identified adult patients presenting to the ED in a network of three teaching hospitals in Montreal, Canada during the first wave of the Covid-19 pandemic (March13-May13, 2020) and a control pre-pandemic period (March13-May13, 2019). Patients with GS conditions were included in the analysis. ED utilization rates, admission rates and 30-day outcomes were compared between the two periods using multivariate regression analysis.

RESULTS

During the pandemic period, 258 patients presented to ED with a GS diagnosis compared to 351 patients pre-pandemically (adjusted rate ratio (aRR) 0.75; p < 0.001). Rate of hospital admission during the pandemic was also significantly lower (aRR = 0.77, p < 0.001). Patients had a significantly shorter ED stay during the pandemic (adjusted mean difference 5.0 h; p < 0.001). Rates of operative management during the pandemic were preserved compared to the pre-pandemic period. There were no differences in 30-day complications (adjusted odds ratio (aOR) 1.46; p = 0.07), ED revisits (aOR 1.10; p = 0.66) and (re)admissions (aOR 1.42; p = 0.22) between the two periods.

CONCLUSION

There was a decrease in rates of ED utilization and hospital admissions due to GS conditions during the first wave of the Covid -19 pandemic; however, rates of operative management, complications and healthcare reutilization were unchanged. Although our findings are not generalizable to patients who did not seek healthcare, it was possible to successfully uphold institutional standards of care once patients presented to the ED.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection

Objectives  The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design  This is a retrospective regression analysis. Setting  This study was done at a single, multihospital, urban academic medical center. Participants  Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures  Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results  Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p  = 0.015) and reoperation after index admission ( p  = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p  = 0.045) and decreasing but not significant reoperation after index admission ( p  = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion  Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Disparities in surgical outcomes for low socioeconomic status patients in Australia

Background

There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self‐reported unemployment and neighbourhood level socioeconomic status in Australia.

Methods

A retrospective administrative data review was conducted at a tertiary care centre over a 10‐year period (2008–2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed.

Results

106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50–2.82), OR 1.37 (1.15–1.64)), all complications (OR 1.43 (1.31–1.56), OR 1.21 (1.14–1.28)), failure to rescue (OR 2.03 (1.39–2.95), OR 1.38 (1.11–1.72)) and return to theatre (OR 1.42 (1.27–1.59), OR 1.24 (1.14–1.36)) (P < 0.005 for all).

Conclusions

Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

Risk factors of postoperative complications following total knee arthroplasty in Korea: A nationwide retrospective cohort study

BACKGROUND

The number of patients undergoing total knee arthroplasty (TKA) is gradually increasing and there is also increase in postoperative complications. The patient's demographic, socio-economic factors, hospital and clinical factors are all factors that can influence postoperative complications. The purpose of this study was to determine the risk factors associated with complications following TKA in a large national cohort.

METHODS

Among patients diagnosed with primary knee arthrosis, a total of 560,954 patients older than 50 years who underwent TKA from January 1, 2005 to December 31, 2018 were included in the study. The risk of postoperative complications (surgical site infection, sepsis, cardiovascular complications, respiratory complications, pulmonary embolism, stroke, acute renal failure, periprosthetic joint infection, and periprosthetic fracture) were assessed with eight independent variables: gender, age, place of residence, household income, hospital bed size, procedure type (unilateral or bilateral, primary or revision TKA), length of stay (LOS), use of transfusion. Multivariable Cox Proportional Hazard model analysis was used. The significant predictors for complications (P < .05) were as follows.

RESULTS

Surgical site infection: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Sepsis: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Cardiovascular complications: male, age, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Respiratory complications: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Pulmonary embolism: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Stroke: male, age, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Acute renal failure: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic joint infection: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic fracture: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion.

CONCLUSION

In summary, male, procedure type (bilateral, revision), LOS (≥35 days), and use of transfusion were shown to be risk factors of postoperative complications following TKA.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center

Objectives  The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design  This is a retrospective regression analysis. Setting  The study conducted at a single, multihospital, urban academic medical center. Participants  A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013-April 26, 2019) was included in this analysis. Main Outcome Measures  Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results  Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion  This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.

Risk Factors for Non-Resilient Outcomes in Older Adults after Total Knee Replacement in the FORCE-TJR Cohort

BACKGROUND

Total knee replacement (TKR) is a common procedure in older adults. Physical resilience may be a useful construct to explain variable outcomes. We sought to define a simple measure of physical resilience and identify risk factors for non-resilient patient outcomes.

METHODS

Secondary analysis of FORCE-TJR cohort study, a prospective registry of total joint replacement. Analysis included 7,239 adults ages 60 or older who underwent TKR between 2011- 2015. Measures included sociodemographic and health factors. Outcomes were categorized as physically resilient versus non-resilient based on the change from baseline to 1-year follow up for three patient-reported outcomes: the physical component summary (PCS), bodily pain (BP), and vitality (VT) from the Short Form-36 (SF-36) subcomponent scores, at pre-op and 1-year post-procedure. Associations were expressed as relative risk of physically non-resilient outcomes using generalized linear regression models, with Poisson distribution and log link.

RESULTS

Age, BMI, and Charlson Comorbidity Index (CCI) were associated with increased risk of physically non-resilient outcomes across PCS, BP, and VT: age, per 5-years for PCS (RR=1.18[1.12-1.23]), BP (RR=1.06[1.01-1.11), and VT (RR=1.09[1.06-1.12]); BMI, per 5 Kg/m 2, for PCS (RR=1.13[1.07-1.19]), BP (RR=1.06[1.00-1.11]), and VT (RR=1.08[1.04-1.11]); and CCI for PCS CCI=1 (RR=1.38[1.20-1.59]), CCI=2-5 (RR=1.59[1.35-1.88]), CCI>=6 (RR=1.55[1.31-1.83]. Household-income >$45,000 associated with lower risk for PCS (RR=0.81[0.70-0.93]), BP (RR=0.80[0.69-0.91],), and VT (RR=0.86[0.78-0.93]).

CONCLUSIONS

We operationalized physical resilience and identified factors predicting resilience after TKR. This approach may aid clinical risk stratification, guide further investigation of causes, and ultimately aid patients through the design of interventions to enhance physical resilience.

The impact of gender on long-term outcomes following supratentorial brain tumor resection

PURPOSE

Gender is a known social determinant of health which has been linked disparities in medical care. This study intends to assess the impact of gender on 90-day and long-term morbidity and mortality outcomes following supratentorial brain tumor resection in a coarsened-exact matched population.

MATERIALS AND METHODS

A total of 1970 consecutive patients at a single, university-wide health system undergoing supratentorial brain tumor resection over a six-year period (09 June 2013 to 26 April 2019) were analyzed retrospectively. Coarsened Exact Matching was employed to match patients on key demographic factors including history of prior surgery, smoking status, median household income, American Society of Anesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI), amongst others. Primary outcomes assessed included readmission, ED visit, unplanned reoperation, and mortality within 90 days of surgery. Long-term outcomes such as mortality and unplanned return to surgery during the entire follow-up period were also recorded.

RESULTS

Whole-population regression demonstrated significantly increased mortality throughout the entire follow-up period for the male cohort (p = 0.004, OR = 1.32, 95% CI = 1.09 - 1.59); however, no significant difference was found after coarsened exact matching was performed (p = 0.08). In both the whole-population regression and matched-cohort analysis, no significant difference was observed between gender and readmission, ED visit, unplanned reoperation, or mortality in the 90-day post-operative window, in addition to return to surgery after throughout the entire follow-up period.

CONCLUSION

After controlling for confounding variables, female birth gender did not significantly predict any difference in morbidity and mortality outcomes following supratentorial brain tumor resection. Difference between mortality outcomes in the pre-matched population versus the matched cohort suggests the need to better manage the underlying health conditions of male patients in order to prevent future disparities.

The role of socioeconomic status on outcomes following cerebellopontine angle tumor resection

PURPOSE

It is well documented that the interaction between many social factors can affect clinical outcomes. However, the independent effects of economics on outcomes following surgery are not well understood. The goal of this study is to investigate the role socioeconomic status has on postoperative outcomes in a cerebellopontine angle (CPA) tumor resection population.

MATERIALS AND METHODS

Over 6 years (07 June 2013 to 24 April 2019), 277 consecutive CPA tumor cases were reviewed at a single, multihospital academic medical center. Patient characteristics obtained included median household income, Charlson Comorbidity Index (CCI), race, BMI, tobacco use, amongst 23 others. Outcomes studied included readmission, ED evaluation, unplanned return to surgery (during and after index admission), return to surgery after index admission, and mortality within 90 days, in addition to reoperation and mortality throughout the entire follow-up period. Univariate analysis was conducted amongst the entire population with significance set at a p value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p value <0.05. Stepwise regression was conducted to determine the correlations amongst study variables and identify confounding factors.

RESULTS

Regression analysis of 273 patients did not find household income to be associated with any of the long-term outcomes assessed. Similarly, a Q1 vs Q4 comparison did not yield significantly different odds of outcomes assessed.

CONCLUSION

Although not statistically significant, the odds ratios suggest socioeconomic status may have a clinically significant effect on postsurgical outcomes. Further studies in larger, matched populations are necessary to validate these findings.

Declining Rates of Surgery for Inflammatory Bowel Disease in the Era of Biologic Therapy

BACKGROUND

Medical therapy for inflammatory bowel disease (IBD) has markedly advanced since the introduction of biologic therapeutics, although surgery remains an important therapeutic strategy for both Crohn's disease (CD) and ulcerative colitis (UC). This study evaluated how rates of bowel resection surgery and post-operative mortality for IBD have changed over the last decade in the era of biologic therapies.

METHODS

The Nationwide Readmission Database (NRD) was queried for patients with IBD (based on ICD-9 and -10 diagnosis and procedure codes) who were hospitalized between 2010 and 2017. Longitudinal trends in bowel resection surgery, urgent surgery, and post-operative mortality were analyzed.

RESULTS

During the 8-year period, a total of 1795,266 IBD-related hospitalizations (1,072,110 with CD and 723,156 with UC) were evaluated. There was an increase in the annual number of IBD patients hospitalized, but a statistically significant decrease in the proportion of IBD patients undergoing surgery, from 10 to 8.8% (p < 0.001) for CD and 7.7 to 7.5% (p < 0.001) for UC. From 2014 through 2017, the proportion of urgent surgeries remained stable around 25% (p = 0.16) for CD and decreased from 21 to 14% (p < 0.001) for UC. For CD, the rate of post-operative 30-day mortality varied between 1.2 and 1.6% and for UC decreased from 5.8 to 2.3% (p < 0.001).

CONCLUSIONS

Analysis of a nationwide dataset from 2010 to 2017 determined that despite an increase in total admissions for IBD, a smaller proportion of hospitalized patients underwent surgery. A greater proportion of surgeries for UC were performed on an elective basis, and overall the rates of post-operative mortality for CD and UC decreased. The growth of biologic medical therapy during the study period highlights a probable contributing factor for the observed changes.

Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery

Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.

A radical change: A qualitative study of patients' experiences of eating and daily living through the first year after oesophageal resection

PURPOSE

The purpose of this study is to explore the lived experiences of patients in terms of eating and consequences in everyday life in the first year after oesophageal cancer surgery.

METHODS

Thirteen patients participated in qualitative interviews one year after surgery for oesophageal cancer. Descriptions capturing the meaning of the lived experiences of patients were then derived from subsequent analysis and interpretation of the interviews. A phenomenological hermeneutical approach comprised the epistemological stance, and theoretical perspectives were drawn from Schutz' theory of everyday life.

RESULTS

Patient descriptions of their experiences with food, eating and everyday life in the first year after oesophageal cancer surgery fell into four themes: Adjusting to a different anatomy - food and eating as a dominant and difficult activity; changed body - food and eating as an underlying shadow; feeling different - social consequences of changed eating; a nutritional jungle - guidance and support in an uncertain time.

CONCLUSION

The physical and social consequences of oesophageal cancer resection upend everyday structures, requiring patients to adopt a new, conscious and reflexive approach to food and eating as a social activity. Continuous support from healthcare professionals and patient-to-patient interaction can help redefine everyday life.

Socioeconomic Status and Days Alive and Out of Hospital after Major Elective Noncardiac Surgery: A Population-based Cohort Study

BACKGROUND

Socioeconomic status is an important but understudied determinant of preoperative health status and postoperative outcomes. Previous work has focused on the impact of socioeconomic status on mortality, hospital stay, or complications. However, individuals with low socioeconomic status are also likely to have fewer supports to facilitate them remaining at home after hospital discharge. Thus, such patients may be less likely to return home over the short and intermediate term after major surgery. The newly validated outcome, days alive and out of hospital, may be highly suited to evaluating the impact of socioeconomic status on this postdischarge period. The study aimed to determine the association of socioeconomic status with short and intermediate term postoperative recovery as measured by days alive and out of hospital.

METHODS

The authors evaluated data from 724,459 adult patients who had one of 13 elective major noncardiac surgical procedures between 2006 and 2017. Socioeconomic status was measured by median neighborhood household income (categorized into quintiles). Primary outcome was days alive and out of hospital at 30 days, while secondary outcomes included days alive and out of hospital at 90 and 180 days, and 30-day mortality.

RESULTS

Compared to the highest income quintile, individuals in the lowest quintile had higher unadjusted risks of postoperative complications (6,049 of 121,099 [5%] vs. 6,216 of 160,495 [3.9%]) and 30-day mortality (731 of 121,099 [0.6%] vs. 701 of 160,495 [0.4%]) and longer mean postoperative length of stay (4.9 vs. 4.4 days). From lowest to highest income quintile, the mean adjusted days alive and out of hospital at 30 days after surgery varied between 24.5 to 24.9 days.

CONCLUSIONS

Low socioeconomic status is associated with fewer days alive and out of hospital after surgery. Further research is needed to examine the underlying mechanisms and develop posthospital interventions to improve postoperative recovery in patients with fewer socioeconomic resources.

The Impact of Household Economics on Short-Term Outcomes in a Posterior Fossa Tumor Population

Background

Disparities exist in medical care and may result in avoidable negative clinical care outcomes for those affected. There remains a paucity in the literature regarding the impact of economic disparities on neurosurgical outcomes.

Methods

A total of 283 consecutive posterior fossa brain tumor resections, excluding cerebellopontine angle tumors, over a six-year period (June 07, 2013, to April 29, 2019) at a single, multihospital academic medical center were analyzed retrospectively. Outcomes evaluated included 30-day readmission and mortality, emergency department (ED) evaluation, unplanned return to surgery within 30 days, and return to surgery after index admission within 30 days. The population was divided into quartiles based on median household income, and univariate analysis was conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p < 0.05. Stepwise regression was conducted to determine the correlations among study variables and identify confounding factors.

Results

Whole population univariate analysis demonstrated lower socioeconomic status (SES) to be correlated with increased mortality within 30 post-operative days and increased return to surgery after index admission. No significant difference was found with regard to 30-day readmission, ED evaluation, unplanned reoperation, or return to surgery after index admission. Decreasing, but not significant, mortality was demonstrated between Q1 and Q4 socioeconomic quartiles.

Conclusions

This study suggests that low SES, when defined by household income, correlates with increased mortality within 30 days and an increased need for return to surgery within 30 days. There may be an opportunity for hospitals and care providers to use SES to proactively identify high-risk patients and test the impact of supports in the post-operative setting.

Risk Factors, Causes, and Costs of Hospital Readmission After Head and Neck Cancer Surgery Reconstruction

Importance

Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking.

Objective

To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction.

Design, Setting, and Participants

This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017.

Exposures

Pedicled or free flap reconstruction of an oncologic head and neck defect.

Main Outcomes and Measures

The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions.

Results

Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15 916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40).

Conclusions and Relevance

Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.

Low Socioeconomic Status Is Associated with Worse Outcomes After Curative Surgery for Colorectal Cancer: Results from a Large, Multicenter Study

BACKGROUND

Socioeconomic status (SES) has been associated with early mortality in cancer patients. However, the association between SES and outcome in colorectal cancer patients is largely unknown. The aim of this study was to investigate whether SES is associated with short- and long-term outcome in patients undergoing curative surgery for colorectal cancer.

METHODS

Patients who underwent curative surgery in the region of Rotterdam for stage I-III colorectal cancer between January 2007 and July 2014 were included. Gross household income and survival status were obtained from a national registry provided by Statistics Netherlands Centraal Bureau voor de Statistiek. Patients were assigned percentiles according to the national income distribution. Logistic regression and Cox proportional hazard regression were performed to assess the association of SES with 30-day postoperative complications, overall survival and cancer-specific survival, adjusted for known prognosticators.

RESULTS

For 965 of the 975 eligible patients (99%), gross household income could be retrieved. Patients with a lower SES more often had diabetes, more often underwent an open surgical procedure, and had more comorbidities. In addition, patients with a lower SES were less likely to receive (neo) adjuvant treatment. Lower SES was independently associated with an increased risk of postoperative complications (Odds ratio per percent increase 0.99, 95%CI 0.99-0.998, p = 0.004) and lower cancer-specific mortality (Hazard ratio per percent increase 0.99, 95%CI 0.98-0.99, p = 0.009).

CONCLUSION

This study shows that lower SES is associated with increased risk of postoperative complications, and poor cancer-specific survival in patients undergoing surgery for stage I-III colorectal cancer after correcting for known prognosticators.

Previous Use of Mammography as a Proxy for General Health Checks in Association with Better Outcomes after Major Surgeries

Although previous studies have shown that health checks may improve several risk factors for chronic diseases, the effect of preoperative health checks on postoperative recovery in surgical patients remains unknown. We aimed to investigate the association between preoperative use of mammography and the risk of perioperative complications. We conducted a matched cohort study of 152,411 patients aged ≥47 years who received mammography screening and later underwent major surgery from 2008 to 2013. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 152,411 controls who underwent surgery but were not screened were selected. We collected patients’ characteristics and medical conditions from claims data of Taiwan’s National Health Insurance. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative complications and in-hospital mortality associated with mammography screening. Patients receiving mammography prior to major surgery had significantly lower risks of perioperative complications, including pneumonia, septicemia, acute renal failure, stroke, urinary tract infection, deep wound infection, acute myocardial infarction, intensive care unit stay, and 30 day in-hospital mortality (OR 0.45, 95% CI 0.38–0.53). The association was consistent across each stratum of age, number of hospitalizations, emergency visits, and comorbidities. In conclusion, preoperative use of mammography was strongly associated with fewer perioperative complications and less in-hospital mortality after major surgeries. The evidence provided by this study justifies the implementation of preoperative health checks in clinical practice.