Post-discharge Mental Healthcare and Emergency General Surgery Readmission for Patients with Serious Mental Illness

OBJECTIVE

To determine the association between post-discharge mental healthcare and odds of readmission after emergency general surgery (EGS) hospitalization for patients with serious mental illness (SMI).

BACKGROUND DATA

A mental health visit (MHV) after medical hospitalization is associated with decreased readmissions for patients with SMI. The impact of a MHV after surgical hospitalization is unknown.

METHODS

Using Medicare claims, we performed a retrospective cohort study of hospitalized EGS patients with SMI aged >65.5 (2016-2018). EGS included colorectal, general abdominal, hepatopancreatobiliary, hernia, intestinal obstruction, resuscitation, and upper gastrointestinal conditions. SMI was defined as schizophrenia spectrum, mood, or anxiety disorders. The exposure was MHV within 30 days of discharge. The primary outcome was 30-day readmission. Secondary outcomes included emergency department presentation and psychiatric admission. Inverse probability weighting was used to evaluated outcomes.

RESULTS

Of 88,092 analyzed patients, 11,755 (13.3%) had a MHV within 30 days of discharge. 23,696 (26.9%) of patients were managed operatively, 64,395 (73.1%) non-operatively. After adjustment for potential confounders, patients with a post-discharge MHV had lower odds of acute care readmission than patients without a MHV in both operative (OR 0.60; 95% CI: [0.40-0.90]) and non-operative (OR 0.67; 95% CI [0.53-0.84]) cohorts. There was no association between post-discharge MHV and ED presentation or psychiatric admission in the operative or non-operative groups.

CONCLUSIONS

Post-discharge MHV after EGS hospitalization was associated with decreased odds of readmission for patients with SMI managed operatively and nonoperatively. In older EGS patients with SMI, coordination of MHVs may be a mechanism to reduce readmission disparities.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions

OBJECTIVE

Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time.

BACKGROUND

EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition.

METHODS

This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days.

RESULTS

Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management.

CONCLUSIONS

Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

Importance

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition.

Objective

To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition.

Design, Setting, and Participants

This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023.

Exposure

Follow-up with a PCP within 30 days after hospital discharge for the index admission.

Main Outcomes and Measures

The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission.

Results

The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups.

Conclusions and Relevance

In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study

INTRODUCTION

Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively.

METHODS

EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal-Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models.

RESULTS

Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001).

CONCLUSIONS

HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis

OBJECTIVE

To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions.

BACKGROUND

EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity.

METHODS

Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions.

RESULTS

Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients.

CONCLUSIONS

The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures

Importance

Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown.

Objective

To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults.

Design, Setting, and Participants

This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race.

Exposure

Primary care utilization in the year prior to presentation for an EGS operation.

Main Outcome and Measures

In-hospital, 30-day, 60-day, 90-day, and 180-day mortality.

Results

A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different.

Conclusions and Relevance

In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions

INTRODUCTION

Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially.

METHODS

We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients.

RESULTS

A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes.

CONCLUSIONS

The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair

OBJECTIVE

Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair.

METHODS

A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type.

RESULTS

We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients.

CONCLUSIONS

Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.

Effect of Serious Mental Illness on Surgical Consultation and Operative Management of Older Adults with Acute Biliary Disease: A Nationwide Study

BACKGROUND

Mental illness is associated with worse outcomes after emergency general surgery. To understand how preoperative processes of care may influence disparate outcomes, we examined rates of surgical consultation, treatment, and operative approach between older adults with and without serious mental illness (SMI).

STUDY DESIGN

We performed a nationwide, retrospective cohort study of Medicare beneficiaries aged 65.5 years or more hospitalized via the emergency department for acute cholecystitis or biliary colic. SMI was defined as schizophrenia spectrum, mood, and/or anxiety disorders. The primary outcome was surgical consultation. Secondary outcomes included operative treatment and surgical approach (laparoscopic vs open). Multivariable logistic regression was used to examine outcomes with adjustment for potential confounders related to patient demographics, comorbidities, and rates of imaging.

RESULTS

Of 85,943 included older adults, 19,549 (22.7%) had SMI. Before adjustment, patients with SMI had lower rates of surgical consultation (78.6% vs 80.2%, p < 0.001) and operative treatment (68.2% vs 71.7%, p < 0.001), but no significant difference regarding laparoscopic approach (92.0% vs 92.1%, p = 0.805). In multivariable regression models with adjustment for confounders, there was no difference in odds of receiving a surgical consultation (odds ratio 0.98 [95% CI 0.93 to 1.03]) or undergoing operative treatment (odds ratio 0.98 [95% CI 0.93 to 1.03]) for patients with SMI compared with those without SMI.

CONCLUSIONS

Older adults with SMI had similar odds of receiving surgical consultation and operative treatment as those without SMI. As such, differences in processes of care that result in SMI-related disparities likely occur before or after the point of surgical consultation in this universally insured patient population.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable

OBJECTIVE

To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.

BACKGROUND

Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.

METHODS

We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.

RESULTS

For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.

CONCLUSIONS

The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

A study analyzing outcomes after bariatric surgery by primary language

BACKGROUND

Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language.

METHODS

This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race.

RESULTS

Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes.

CONCLUSIONS

Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals

IMPORTANCE

Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.

OBJECTIVE

To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.

EXPOSURES

Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.

RESULTS

A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.

Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients

Importance

A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department.

Objective

To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition.

Design, Setting, and Participants

This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal.

Exposures

Black vs White race.

Main Outcomes and Measures

Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition.

Results

A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46).

Conclusions and Relevance

In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.

Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study

BACKGROUND

Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients.

STUDY DESIGN

Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions.

RESULTS

Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001).

CONCLUSIONS

Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.

Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study

BACKGROUND

Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients.

OBJECTIVE

The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery.

RESEARCH DESIGN

Retrospective observational study using state discharge data.

SUBJECTS

Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013).

MEASURES

Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status.

RESULTS

Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs.

CONCLUSIONS

Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.

Neurorrhaphy in Presence of Polyethylene Glycol Enables Immediate Electrophysiological Conduction in Porcine Model of Facial Nerve Injury

Facial nerve trauma often leads to disfiguring facial muscle paralysis. Despite several promising advancements, facial nerve repair procedures often do not lead to complete functional recovery. Development of novel repair strategies requires testing in relevant preclinical models that replicate key clinical features. Several studies have reported that fusogens, such as polyethylene glycol (PEG), can improve functional recovery by enabling immediate reconnection of injured axons; however, these findings have yet to be demonstrated in a large animal model. We first describe a porcine model of facial nerve injury and repair, including the relevant anatomy, surgical approach, and naive nerve morphometry. Next, we report positive findings from a proof-of-concept experiment testing whether a neurorrhaphy performed in conjunction with a PEG solution maintained electrophysiological nerve conduction at an acute time point in a large animal model. The buccal branch of the facial nerve was transected and then immediately repaired by direct anastomosis and PEG application. Immediate electrical conduction was recorded in the PEG-fused nerves (n = 9/9), whereas no signal was obtained in a control cohort lacking calcium chelating agent in one step (n = 0/3) and in the no PEG control group (n = 0/5). Nerve histology revealed putative-fused axons across the repair site, whereas no positive signal was observed in the controls. Rapid electrophysiological recovery following nerve fusion in a highly translatable porcine model of nerve injury supports previous studies suggesting neurorrhaphy supplemented with PEG may be a promising strategy for severe nerve injury. While acute PEG-mediated axon conduction is promising, additional work is necessary to determine if physical axon fusion occurs and the longer-term fate of distal axon segments as related to functional recovery.

Colorectal cancer disparities across the continuum of cancer care: A systematic review and meta-analysis

BACKGROUND

Disparate colorectal cancer outcomes persist in vulnerable populations. We aimed to examine the distribution of research across the colorectal cancer care continuum, and to determine disparities in the utilization of Surgery among Black patients.

METHODS

A systematic review and meta-analysis of colorectal cancer disparities studies was performed. The meta-analysis assessed three utilization measures in Surgery.

RESULTS

Of 1,199 publications, 60% focused on Prevention, Screening, or Diagnosis, 20% on Survivorship, 15% on Treatment, and 1% on End-of-Life Care. A total of 16 studies, including 1,110,674 patients, were applied to three meta-analyses regarding utilization of Surgery. Black patients were less likely to receive surgery, twice as likely to refuse surgery, and less likely to receive laparoscopic surgery, when compared to White patients.

CONCLUSIONS

Since 2011, the majority of research focused on prevention, screening, or diagnosis. Given the observed treatment disparities among Black patients, future efforts to reduce colorectal cancer disparities should include interventions within Surgery.

Race, Ethnicity, and Sex Among Senior Faculty in Radiation Oncology From 2000 to 2019

This cross-sectional study investigates intersections among race, ethnicity, and sex from 2000 to 2019 among senior faculty in radiation oncology.

Forgotten fatalities: British military, mining and maritime accidents since 1900

Background

Comparative long-term trends in fatal accident rates in the UK’s most hazardous occupations have not been reported.

Aims

To compare trends in fatal accident rates in six of the most hazardous occupations (the three armed forces, merchant shipping, sea fishing and coal mining) and the general British workforce during peacetime years since 1900.

Methods

Examinations of annual mortality reports, returns, inquiry files and statistics. The main outcome measure was the fatal accident rate per 100 000 population employed.

Results

These six occupations accounted for ~40% of all fatal accidents in the British workforce. Fatal accident rates were highest in merchant shipping to 1914 (400–600 per 100 000) and in the Royal Air Force and sea fishing by the early 1920s (around 300 per 100 000). Since the 1950s sea fishing has remained the most hazardous occupation (50–200). Widespread reductions in fatal accident rates for each occupation have been greatest in recent years in the three armed forces and merchant shipping. Compared with the general workforce, relative risks of fatalities have increased in recent decades in all these occupations except shipping.

Conclusions

All six occupations still have high fatal accident rates. The greatly increased fatalities in sea fishing generally and in the Royal Air Force during its early years reflect, for different reasons, cultures of extreme risk-taking in these two sectors. Reductions in fatality rates in the armed forces over the last 20 years are due largely to decreases in land transport accidents.

Looking Beyond the Numbers: Increasing Diversity and Inclusion Through Holistic Review in General Surgery Recruitment

OBJECTIVE

The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program.

DESIGN

A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups.

SETTING

General Surgery residency program at a tertiary, academic center.

PARTICIPANTS

Medical students applying for and matriculated to categorical positions.

RESULTS

After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior "traditional" approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09).

CONCLUSIONS

Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process.

The Cost of Quarantine: Projecting the Financial Impact of Canceled Elective Surgery on the Nation's Hospitals

OBJECTIVE

We sought to quantify the financial impact of elective surgery cancellations in the US during COVID-19 and simulate hospitals' recovery times from a single period of surgery cessation.

BACKGROUND

COVID-19 in the US resulted in cessation of elective surgery-a substantial driver of hospital revenue-and placed patients at risk and hospitals under financial stress. We sought to quantify the financial impact of elective surgery cancellations during the pandemic and simulate hospitals' recovery times.

METHODS

Elective surgical cases were abstracted from the Nationwide Inpatient Sample (2016-2017). Time series were utilized to forecast March-May 2020 revenues and demand. Sensitivity analyses were conducted to calculate the time to clear backlog cases and match expected ongoing demand in the post-COVID period. Subset analyses were performed by hospital region and teaching status.

RESULTS

National revenue loss due to major elective surgery cessation was estimated to be $22.3 billion (B). Recovery to market equilibrium was conserved across strata and influenced by pre- and post-COVID capacity utilization. Median recovery time was 12-22 months across all strata. Lower pre-COVID utilization was associated with fewer months to recovery.

CONCLUSIONS

Strategies to mitigate the predicted revenue loss of $22.3B due to major elective surgery cessation will vary with hospital-specific supply-demand equilibrium. If patient demand is slow to return, hospitals should focus on marketing of services; if hospital capacity is constrained, efficient capacity expansion may be beneficial. Finally, rural and urban nonteaching hospitals may face increased financial risk which may exacerbate care disparities.

Mentoring Residents Underrepresented in Medicine: Strategies to Ensure Success

OBJECTIVE

To provide a framework for effective mentorship of residents underrepresented in medicine (UIM) situated in the context of their experiences in healthcare teams.

DESIGN

A perspective summarizing the important elements for the effective mentorship of UIM residents.

CONCLUSION

Mentorship of trainees is of profound importance in medical education as it provides tangible benefits for professional and personal development. However, given their unique experiences and position in our teams as well as the larger healthcare construct, the mentorship of UIM residents requires special consideration and focus. Implementing programs that foster diversity, cross-cultural mentorship, and sponsorship are imperative.

A Systematic Review and Meta-analysis of Paediatric Inflammatory Bowel Disease Incidence and Prevalence Across Europe

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] is often one of the most devastating and debilitating chronic gastrointestinal disorders in children and adolescents. The main objectives here were to systematically review the incidence and prevalence of paediatric IBD across all 51 European states.

METHODS

We undertook a systematic review and meta-analysis based on PubMed, CINAHL, the Cochrane Library, searches of reference lists, grey literature and websites, covering the period from 1970 to 2018.

RESULTS

Incidence rates for both paediatric Crohn's disease [CD] and ulcerative colitis [UC] were higher in northern Europe than in other European regions. There have been large increases in the incidence of both paediatric CD and UC over the last 50 years, which appear widespread across Europe. The largest increases for CD have been reported from Sweden, Wales, England, the Czech Republic, Denmark and Hungary, and for UC from the Czech Republic, Ireland, Sweden and Hungary. Incidence rates for paediatric CD have increased up to 9 or 10 per 100 000 population in parts of Europe, including Scandinavia, while rates for paediatric UC are often slightly lower than for CD. Prevalence reported for CD ranged from 8.2 per 100 000 to approximately 60 and, for UC, from 8.3 to approximately 30.

CONCLUSIONS

The incidence of paediatric IBD continues to increase throughout Europe. There is stronger evidence of a north-south than an east-west gradient in incidence across Europe. Further prospective studies are needed, preferably multinational and based on IBD registries, using standardized definitions, methodology and timescales.

Suicide following acute admissions for physical illnesses across England and Wales

BACKGROUND

The study aim was to establish and quantify suicide risk following acute admissions for all major physical illnesses, for confirmatory purposes, from two independent information sources from different countries.

METHODS

Record linkage of inpatient and death certificate data for 11 004 389 acute admissions for physical illnesses in England and 713 496 in Wales. The main outcome measure was standardised mortality ratios (SMRs) for suicide at 1 year following discharge from hospital.

RESULTS

There were 1781 suicides within 1 year of discharge in England (SMR = 1.7; 95% = 1.6-1.8) and 131 in Wales (SMR = 2.0; 1.7-2.3). Of 48 major physical illnesses that were associated with at least eight suicides in either country, there was high consistent suicide mortality (significant SMR >3) in both countries for constipation (SMR = 4.1 in England, 7.5 in Wales), gastritis (4.4 and 4.9) and upper gastrointestinal bleeding (3.4 and 4.5). There was high suicide mortality in one country for alcoholic liver disease, other liver disease and chronic pancreatitis; for epilepsy and Parkinson's disease; for diabetes, hypoglycaemia and hypo-osmolality & hyponatraemia; and for pneumonia, back pain and urinary tract infections.

CONCLUSIONS

There is little or no increased suicide mortality following acute admissions for most physical illnesses. Much of the increased suicide mortality relates to gastrointestinal disorders that are often alcohol related or specific chronic conditions, which may be linked to side effects from certain therapeutic medications. Acute hospital admissions for physical illnesses may therefore provide an opportunity for targeted suicide prevention among people with certain conditions, particularly alcohol related disorders.

Weekend admission and mortality for gastrointestinal disorders across England and Wales

BACKGROUND

Little has been reported on mortality following admissions at weekends for many gastrointestinal (GI) disorders. The aim was to establish whether GI disorders are susceptible to increased mortality following unscheduled admission on weekends compared with weekdays.

METHODS

Record linkage was undertaken of national administrative inpatient and mortality data for people in England and Wales who were hospitalized as an emergency for one of 19 major GI disorders.

RESULTS

The study included 2 254 701 people in England and 155 464 in Wales. For 11 general surgical and medical GI disorders there were little, or no, significant weekend effects on mortality at 30 days in either country. There were large consistent weekend effects in both countries for severe liver disease (England: 26·2 (95 per cent c.i. 21·1 to 31·6) per cent; Wales: 32·0 (12·4 to 55·1 per cent) and GI cancer (England: 21·8 (19·1 to 24·5) per cent; Wales: 25·0 (15·0 to 35·9) per cent), which were lower in patients managed by surgeons. Admission rates were lower at weekends than on weekdays, most strongly for severe liver disease (by 43·3 per cent in England and 51·4 per cent in Wales) and GI cancer (by 44·6 and 52·8 per cent respectively). Both mortality and the weekend mortality effect for GI cancer were lower for patients managed by surgeons.

DISCUSSION

There is little, or no, evidence of a weekend mortality effect for most major general surgical or medical GI disorders, but large weekend effects for GI cancer and severe liver disease. Lower admission rates at weekends indicate more severe cases. The findings for severe liver disease may suggest a lack of specialist hepatological resources. For cancers, reduced availability of end-of-life care in the community at weekends may be the cause.

The impact of social deprivation on mortality following hip fracture in England and Wales: a record linkage study

We used routine hospital data to investigate whether socially deprived patients had an increased risk of dying following hip fracture compared with affluent patients. We found that the most deprived patients had a significantly increased risk of dying at 30, 90 and 365 days compared with the most affluent patients.

INTRODUCTION

To identify whether social deprivation has any effect on mortality risk after emergency admission with hip fracture and to determine whether any increased mortality observed among deprived groups was associated with patient and hospital-related factors.

METHODS

We used routine, linked hospital inpatient and mortality data for emergency admissions with a hip fracture in both England and Wales between 2004 and 2011. Mortality rates at 30, 90 and 365 days were reported. Logistic regression was used to identify any significant increases in mortality with higher levels of social deprivation and the influence of other risk factors on any increased mortality among the most deprived group.

RESULTS

Mortality rates at 30, 90 and 365 days were 9.3, 17.4 and 29.0 % in England and 8.3, 16.1 and 27.9 % in Wales. Social deprivation was significantly associated with increased mortality in the most deprived quintile compared with the least deprived quintile at 30, 90 and 365 days in England (OR = 1.187, 1.185 and 1.154, respectively) and at 90 and 365 days in Wales (1.135 and 1.203). There was a little interaction between deprivation and other risk factors influencing 30- and 365-day mortality except for patient age, pre-fracture residence and hospital size.

CONCLUSIONS

We demonstrated a positive association between social deprivation and increased mortality at 30 days post-admission for hip fracture in both England and Wales that was still evident at 90 and 365 days. We found little influence of other factors on social inequalities in mortality risk at 30 and 365 days post-admission.

Review article: the prevalence of Helicobacter pylori and the incidence of gastric cancer across Europe

BACKGROUND

There is little up-to-date review evidence on the prevalence of Helicobacter pylori across Europe.

AIM

To establish regional and national patterns in H. pylori prevalence across Europe. Secondly, to establish trends over time in H. pylori prevalence and gastric cancer incidence and, thirdly, to report on the relationship between H. pylori prevalence and age group across Europe.

METHODS

A review of H. pylori prevalence from unselected surveys of adult or general populations across 35 European countries and four European regions since 1990. Secondly, an analysis of trends over time in H. pylori prevalence and in gastric cancer incidence from cancer registry data.

RESULTS

Helicobacter pylori prevalence was lower in northern and western Europe than in eastern and southern Europe (P < 0.001). In 11 of 12 European studies that reported on trends, there were sharp reductions in H. pylori prevalence (mean annual reduction = 3.1%). The mean annual reduction in the incidence of gastric cancer across Europe from 1993 to 2007 was 2.1% with little variation regionally across Europe (north 2.2%, west 2.3%, east 1.9% and south 2.0%). Sharp increases in age-related prevalence of H. pylori often levelled off for middle age groups of about 50 years onwards, especially in areas with high prevalence.

CONCLUSIONS

This review shows that H. pylori prevalence is much higher in less affluent regions of Europe and that age-related increases in prevalence are confined to younger age groups in some areas. There were sharp reductions in both H. pylori prevalence and gastric cancer incidence throughout Europe.

The Personal Impact of Epilepsy Scale (PIES)

OBJECTIVE

The impact of epilepsy is manifest by effects related to seizures and side effects of therapy and comorbidities such as depression. This report describes the development of a brief patient-reported outcome (PRO) instrument, the Personal Impact of Epilepsy Scale (PIES), to measure the influence of epilepsy overall and in each of these domains.

METHODS

Instrument development followed standard procedures and an FDA Guidance. People with epilepsy were surveyed with open-ended questions to derive major themes of their concerns, resulting in 4 key areas: seizures, side effects, comorbidities, and overall quality of life (QOL). A preliminary set of 152 questions was based on these themes and completed by 50 patients, age 42.7 (range: 21-71) years, concurrent with comparator instruments, including the NH Seizure Severity Scale (NHSSS), the Liverpool Adverse Events Profile (LAEP), the Quality of Life in Epilepsy (QOLIE-31) scale, the Beck Depression Inventory, and the Epilepsy Foundation Depression: A Checklist. A multiple regression model indicated which PIES measures were associated with scores from the comparator instruments. Questions in each of the domains were selected for correlations and nonduplication. Test-retest consistency at a 3-day interval was completed by 38 subjects and a final set of questions constructed.

RESULTS

The final question set comprised 25 items: 9 about characteristics of seizures, 7 about medication side effects, 8 about comorbidities, and 1 about overall quality of life. All items had 5 response choices (0-4), with higher scores reflecting more negative status. A total of 46 subjects completed the 25 questions. Cronbach's alpha was 0.87, indicating good internal consistency. Each of the three domains correlated well with the overall QOL item. The questions pertaining to seizures correlated with the NHSSS, the side effect questions with the LAEP, and the comorbidity questions with the QOLIE-31.

CONCLUSION

The PIES provides a simple, brief PRO measure as a profile of overall impact of seizures, medication side effects, comorbidities, and overall QOL for people with epilepsy. Further study will explore sensitivity to change quantification of the minimal clinically significant change.

Fatal accidents and injuries among merchant seafarers worldwide

BACKGROUND

The British merchant fleet has expanded in recent years but it is not known whether this expansion has led to proportionate changes in mortality.

AIMS

To investigate mortality from accidents and injuries in British merchant shipping, to determine whether this has increased in recent years, to compare fatal accident rates across British industries and to review fatal accident rates in merchant shipping worldwide over the last 70 years.

METHODS

Examinations of marine accident investigation files, death registers and death inquiry files, national mortality statistics, worldwide surveys and review methodology. The main outcome measure was the fatal accident rate per 100 000 worker-years.

RESULTS

Of 66 deaths in British shipping from 2003 to 2012, 49 were caused by accidents, which largely affected deck ratings. The fatal accident rate in British shipping increased by 4.7% per annum from 2003, although this was not significant (95% confidence interval: -5.1 to 15.6%). During 2003-12, the fatal accident rate in shipping (14.5 per 100 000) was 21 times that in the general British workforce, 4.7 times that in the construction industry and 13 times that in manufacturing. Of 20 merchant fleets worldwide with population-based fatal accident rates, most have shown large reductions over time.

CONCLUSIONS

The expansion of the British merchant fleet in recent years does not appear to have had a major impact on fatal accidents. Further preventive measures should target fatalities during mooring and towing operations. Internationally, most shipping fleets have over time experienced large decreases in fatal accident rates.

The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors

BACKGROUND

The incidence of acute pancreatitis has increased sharply in many European countries and the USA in recent years.

AIM

To establish trends in incidence and mortality for acute pancreatitis in Wales, UK, and to assess how incidence may be linked to factors including social deprivation, seasonal effects and alcohol consumption.

METHODS

Use of record linked inpatient, mortality and primary care data for 10,589 hospitalised cases of acute pancreatitis between 1999 and 2010.

RESULTS

The incidence of acute pancreatitis was 30.0 per 100,000 population overall, mortality was 6.4% at 60 days. Incidence increased significantly from 27.6 per 100,000 in 1999 to 36.4 in 2010 (average annual increase = 2.7% per year), there was little trend in mortality (0.2% average annual reduction). The largest increases in incidence were among women aged <35 years (7.9% per year) and men aged 35-44 (5.7%) and 45-54 (5.3%). Incidence was 1.9 times higher among the most deprived quintile of patients compared with the most affluent (3.9 times higher for alcoholic acute pancreatitis and 1.5 for gallstone acute pancreatitis). Acute pancreatitis was increased significantly during the Christmas and New Year weeks by 48% (95% CI = 24-77%) for alcoholic aetiology, but not for gallstone aetiology (9%). Alcoholic admissions were increased with higher consumption of spirits and beer, but not wine.

CONCLUSIONS

The study shows an elevated rate of alcoholic acute pancreatitis during the Christmas and New Year period. Acute pancreatitis continues to rise, most rapidly for young women, while alcoholic acute pancreatitis is linked strongly with social deprivation.

High-risk occupations for suicide

BACKGROUND

High occupational suicide rates are often linked to easy occupational access to a method of suicide. This study aimed to compare suicide rates across all occupations in Britain, how they have changed over the past 30 years, and how they may vary by occupational socio-economic group. Method We used national occupational mortality statistics, census-based occupational populations and death inquiry files (for the years 1979-1980, 1982-1983 and 2001-2005). The main outcome measures were suicide rates per 100 000 population, percentage changes over time in suicide rates, standardized mortality ratios (SMRs) and proportional mortality ratios (PMRs).

RESULTS

Several occupations with the highest suicide rates (per 100 000 population) during 1979-1980 and 1982-1983, including veterinarians (ranked first), pharmacists (fourth), dentists (sixth), doctors (tenth) and farmers (thirteenth), have easy occupational access to a method of suicide (pharmaceuticals or guns). By 2001-2005, there had been large significant reductions in suicide rates for each of these occupations, so that none ranked in the top 30 occupations. Occupations with significant increases over time in suicide rates were all manual occupations whereas occupations with suicide rates that decreased were mainly professional or non-manual. Variation in suicide rates that was explained by socio-economic group almost doubled over time from 11.4% in 1979-1980 and 1982-1983 to 20.7% in 2001-2005.

CONCLUSIONS

Socio-economic forces now seem to be a major determinant of high occupational suicide rates in Britain. As the increases in suicide rates among manual occupations occurred during a period of economic prosperity, carefully targeted suicide prevention initiatives could be beneficial.

Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study

BACKGROUND

Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists.

AIM

To establish the hospitalized incidence and case fatality for upper GI bleeding, and to determine how they are associated with factors including day of admission, hospital size, social deprivation and distance from hospital.

METHODS

Systematic record linkage of hospital in-patient and mortality data for 24 421 admissions for upper GI bleeding among 22 299 people in Wales from 1999 to 2007.

RESULTS

The hospitalized incidence of upper GI bleeding was 134 per 100 000. Case fatality was 10.0%. Incidence was stable from 1999 to 2007; case fatality fell from 11.4% in 1999-2000 to 8.6% in 2006-7. Incidence was associated significantly with social deprivation. Compared with weekday admissions, case fatality was 13% higher for weekend admissions and 41% higher for admissions on public holidays. There was little variation in case fatality according to social deprivation, hospital size or distance from hospital.

CONCLUSIONS

Incidence, but not case fatality, was associated significantly with social deprivation. The higher mortality for weekend and public holiday admissions could not be explained by measures of case mix and may indicate a possible impact of reduced staffing levels and delays to endoscopy at weekends in some hospitals.

Perinatal risk factors and coeliac disease in children and young adults: a record linkage study

BACKGROUND

Little is known about perinatal risk factors and coeliac disease.

AIM

To investigate the relationship between perinatal risk factors and subsequent coeliac disease among offspring.

METHODS

Record linked abstracts of birth registrations, maternity, in-patient and day case records in a defined population of southern England.

RESULTS

Using univariate analysis, coeliac disease in the child was associated with maternal coeliac disease (odds ratio = 20.6; 95% CI = 5.04-84.0; based on two cases in both mother and child) and with social class, year of birth, maternal smoking and parity. Multivariate analysis confirmed an increased risk of coeliac disease of 3.79 (95% CI = 1.85-7.79) for classes IV and V compared with I and II, an increased risk of 1.92 (1.06-3.49) for births during 1975-1979 compared with 1970-1974 and an increased risk of 1.80 (1.05-3.09) for 'subsequent' compared with 'first' births. Smoking during pregnancy was no longer associated with coeliac disease. Because numbers were small, maternal coeliac disease was excluded from the multivariate analysis.

CONCLUSIONS

This study shows increased risks of coeliac disease for manual social classes, births during the late 1970s and 'subsequent' births. Overall, perinatal risk factors seem to have a limited role in the aetiology of coeliac disease in children and young adults.

Incidence and case fatality for acute pancreatitis in England: geographical variation, social deprivation, alcohol consumption and aetiology--a record linkage study

BACKGROUND

Regional studies in the UK indicate that the incidence of acute pancreatitis increased from the 1940s to the 1990s, while case fatality fell until the 1970s but has levelled-off since.

AIMS

To establish incidence and case fatality for acute pancreatitis in England from 1998 to 2003, to study geographical variation and recent trends in incidence and to study associations with social deprivation and alcohol consumption.

METHODS

Use of national record linkage of in-patient and mortality data for 52 096 people.

RESULTS

Overall incidence was 22.4 per 100 000 population, increasing by 3.1% annually, with largest increases for women aged under 35 years (11% per year) and for men aged 35 to 45 (5.6%). Incidence was higher in northern regions than in southern regions and in areas with high social deprivation and binge drinking. Case fatality was 6.7% at 60 days, higher for alcoholic than gallstones aetiology and was associated with social deprivation and geography.

CONCLUSIONS

Acute pancreatitis is a growing problem in England, particularly among younger women. The findings indicate strongly that alcohol consumption is the main reason for recent increases in incidence, the higher incidence in socially-deprived areas and for the lack of recent improvement in prognosis.

Perinatal factors associated with subsequent diabetes mellitus in the child: record linkage study

AIMS

To report on associations between perinatal factors and the subsequent development of diabetes mellitus under the age of 30 years in the offspring.

METHODS

Analysis of linked hospital statistical records, comparing perinatal factors relating to the birth of 518 people admitted to hospital for diabetes with the same factors in 292 845 others, in a defined population in southern England from 1963 to 1999.

RESULTS

Diabetes mellitus was much more common in children of mothers with diabetes than in others (odds ratio 6.42; 95% confidence interval 4.18-9.86). There was no significant association with birthweight or gestational age separately. Diabetes was more common in those in the highest quintile of 'birthweight for gestational age' compared with the lowest four quintiles combined (odds ratio 1.33; 95% confidence interval 1.08-1.64), but there was no consistent gradient of increasing frequency of diabetes across the lowest four quintiles. There were no significant associations between diabetes and mothers' age, parity, social class, or smoking during pregnancy, or between babies' mode of delivery or any other perinatal factors investigated. All results were similar when the analysis was confined to diabetes in people aged < 15 years.

CONCLUSIONS

We found a strong association between diabetes in the child-mainly, if not entirely Type 1 diabetes-and maternal diabetes. Diabetes was slightly more common in the heaviest quintile of birthweight for gestational age than in other quintiles. There were no significant associations between diabetes and the other perinatal factors studied.

The effect of low-dose ritonavir monotherapy on fasting serum lipid concentrations

OBJECTIVES

Ritonavir (RTV) at doses of 400 mg twice a day (bid) or higher adversely affects serum lipids. However, the effect of RTV 100 mg bid on serum lipids is unknown. We conducted a study to evaluate the effect of RTV 100 mg bid on fasting serum lipid profiles in HIV-negative healthy volunteers.

METHODS

Ritonavir 100 mg bid was administered for 14 days to 20 healthy HIV-seronegative adults with normal serum lipids. After a 7-day washout, lopinavir/ritonavir (LPV/RTV) 400/100 mg bid was administered for 14 days. Fasting serum lipid parameters were measured twice at baseline, after 14 days of RTV, and after 14 days of LPV/RTV, and comparisons were made at each time-point for levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, the total/HDL cholesterol ratio and triglycerides.

RESULTS

After 14 days of RTV 100 mg bid, total cholesterol level increased by 10.2% (P<0.001), LDL cholesterol level increased by 16.2% (P<0.001), triglyceride levels increased by 26.5% (P<0.001), HDL cholesterol level decreased by 5.4% (P<0.01) and the total/HDL cholesterol ratio increased by 17.3% (P<0.001). The addition of LPV 400 mg bid to RTV 100 mg bid resulted in no significant further changes in LDL cholesterol or triglyceride level or total/HDL cholesterol ratio, but there were significant increases in both total cholesterol (8.0% increase; P=0.007) and HDL cholesterol levels (6.7% increase; P=0.008).

CONCLUSIONS

Ritonavir dosed at 100 mg bid significantly increased the concentration of total cholesterol, LDL cholesterol, total/HDL cholesterol ratio and triglycerides and reduced HDL cholesterol concentration. The addition of LPV 400 mg bid to RTV 100 mg bid further increased both total and HDL cholesterol levels without affecting the total/HDL ratio.

Coccygectomy for coccydynia: case series and review of literature

STUDY DESIGN

This is a case series in which case notes review and telephone interview update were used to assess the outcome following coccygectomy.

OBJECTIVE

To correlate the clinical results of coccygectomy with histology and discography of the sacrococcygeal and intercoccygeal segments.

SUMMARY OF BACKGROUND DATA

Clinicians regard chronic disabling pain in the sacrococcygeal region with much dismay because of the reputed unpredictability of the treatment outcome.

METHODS

A total of 38 patients had coccygectomy for intractable coccydynia, and 31 were available for follow-up. The excised specimen with intact sacrococcygeal joint was sent for histologic examination in 22 patients. There were 6 patients investigated using sacrococcygeal and intercoccygeal discography.

RESULTS

Mean postoperative follow-up was 6.75 years (range 2-16). There were 16 patients who benefited highly from the surgery, and 6 benefited to some extent, giving an overall beneficial result of 71%. Of all specimens, 86.3% had histologic changes of degeneration. Moderate-to-severe degenerate changes in sacrococcygeal and intercoccygeal joints on histology were found in 54.5% of patients. Of these patients, 83.3% did well with surgery. Only 57.1% of those patients with mild changes did well. There were 2 patients who had positive discography, and both did well with surgery. Three patients had negative diskographies, and 2 of them had a poor result, and 1 had only some relief.

CONCLUSIONS

It is possible that degenerate changes in sacrococcygeal discs and/or intercoccygeal discs are associated with pain. Surgical results are better in those with a severe degree of degenerative change. Coccygectomy remains a successful treatment for a majority of severely disabled patients with coccydynia.

Trends in mortality after hospital admission for liver cirrhosis in an English population from 1968 to 1999

BACKGROUND

Population based mortality rates from liver cirrhosis, and alcohol consumption, have increased sharply in Britain in the past 35 years. Little is known about the long term trends over time in mortality rates after hospital admission for liver cirrhosis.

AIMS

To analyse time trends in mortality in the year after admission for liver cirrhosis from 1968 to 1999.

SUBJECTS

A total of 8192 people who were admitted to hospital in a defined population of Southern England.

METHODS

Analysis of hospital discharge statistics linked to death certificate data. The main outcome measures were case fatality rates (CFRs) and standardised mortality ratios (SMRs).

RESULTS

At 30 days after admission, CFR was 15.9% and the SMR was 93 (86 in men and 102 in women, compared with 1 in the general population). At one year, the overall CFR was 33.6% and SMR was 16.3. There was no improvement from 1968 to 1999 in mortality rates. SMRs were highest for alcoholic cirrhosis of the liver (27.4 at one year) but lower for biliary cirrhosis (11.4) and chronic hepatitis (10.0). Mortality from most of the main causes of death, including accidents and suicides, was increased.

CONCLUSIONS

The high mortality rates after hospital admission, and the fact that they have not fallen in the past 30 years, show that liver cirrhosis remains a disease with a very poor prognosis. Increased mortality from accidents, suicides, and mental disorders, particularly among those with alcoholic cirrhoses, indicates that prognosis is influenced by behavioural as well as by physical pathology.

Trends in mortality and hospital admission rates for abdominal aortic aneurysm in England and Wales, 1979-1999

BACKGROUND

The aim of this study was to investigate trends in population-based mortality, hospital admission and case fatality rates for abdominal aortic aneurysm (AAA) from 1979 to 1999.

METHODS

This was an analysis of routine statistics from 79 495 death certificates in England and Wales and 3217 hospital inpatient admissions in the Oxford Region.

RESULTS

Mortality rates for all AAAs increased between 1979 and 1999 from 13 to 25 per million in women and from 80 to 115 per million in men. Admission rates increased in the same time interval from three to 22 admissions per million per year in women, and from 52 to 149 per million per year in men. Case fatality rates for all non-ruptured AAAs that were operated on decreased from 25.8 to 9.0 per cent and for all ruptured AAAs from 69.9 to 54.4 per cent.

CONCLUSION

Mortality rates and hospital admission rates for AAA rose in men and even more so in women between 1979 and 1999. Perioperative mortality for ruptured AAA declined a little during the study but nonetheless was still very high at the end. This reinforces the importance of detecting and treating AAA before rupture occurs.

Traumatic work related mortality among seafarers employed in British merchant shipping, 1976-2002

AIMS

To establish the causes and circumstances of all traumatic work related deaths among seafarers who were employed in British merchant shipping from 1976 to 2002, and to assess whether seafaring is still a hazardous occupation as well as a high risk occupation for suicide.

METHODS

A longitudinal study of occupational mortality, based on official mortality files, with a population of 1,136,427 seafarer-years at risk.

RESULTS

Of 835 traumatic work related deaths, 564 were caused by accidents, 55 by suicide, 17 by homicide, and 14 by drug or alcohol poisoning. The circumstances in which the other 185 deaths occurred, including 178 seafarers who disappeared at sea or were found drowned, were undetermined. The mortality rate for 530 fatal accidents that occurred at the workplace from 1976 to 2002, 46.6 per 100,000 seafarer-years, was 27.8 times higher than in the general workforce in Great Britain during the same time period. The fatal accident rate declined sharply since the 1970s, but the relative risk of a fatal accident was 16.0 in 1996-2002. There was no reduction in the suicide rate, which was comparable to that in most high risk occupations in Britain, from 1976 to 1995; but a decline since 1995.

CONCLUSIONS

Although there was a large decline in the fatal accident rate in British shipping, compared to the general workforce, seafaring has remained a hazardous occupation. Further prevention should focus on improvements in safety awareness among seafarers and shipping companies, reductions in hazardous working practices, and improvements in care for seafarers at risk of suicide.

Occupational mortality in British commercial fishing, 1976-95

AIMS

To establish the causes and circumstances of all deaths occurring at work or related to work among fishermen in British commercial fishing between 1976 and 1995.

METHODS

A retrospective study, based on official mortality files, with a population of 440 355 fishermen-years at risk.

RESULTS

Of 616 deaths in British fishing, 454 (74%) were due to accidents at work, and 394 (87%) of these fishermen drowned. A total of 270 accidents were caused by casualties to vessels and 184 by personal accidents. There was no significant decline in the fatal accident rate, 103.1 per 100 000 fishermen-years, between 1976 and 1995. The fatal accident rate was 52.4 times higher (95% CI 42.9 to 63.8) than for all workers in Great Britain during the same period, and this relative risk increased through the 1980s up to 76.6 during 1991-95. Relative risks with the construction (12.3) and manufacturing (46.0) industries were higher than 5 and 20 respectively, during 1959-68. Trawlers foundering in adverse weather was the most frequent cause of mortality from casualties to vessels (115 deaths), and 82 of 145 personal accidents at sea arose during operations involving trawling nets.

CONCLUSIONS

When compared with shore based industries, fishing remains at least as hazardous as before. Prevention should be aimed, most importantly, at the unnecessary operation of small vessels and trawling net manoeuvres in hazardous weather and sea conditions. Other measures should focus on preventing falls overboard, reducing fatigue, a more widespread use of personal flotation devices, and improvements in weather forecast evaluation.