Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis

Background

Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations.

Methods

All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes.

Results

Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (β + 0.90 days, CI +0.68-1.12) and costs (β + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70).

Conclusions

Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.

Machine learning based predictive modeling of readmissions following extracorporeal membrane oxygenation hospitalizations

Background

Despite increasing utilization and survival benefit over the last decade, extracorporeal membrane oxygenation (ECMO) remains resource-intensive with significant complications and rehospitalization risk. We thus utilized machine learning (ML) to develop prediction models for 90-day nonelective readmission following ECMO.

Methods

All adult patients receiving ECMO who survived index hospitalization were tabulated from the 2016-2020 Nationwide Readmissions Database. Extreme Gradient Boosting (XGBoost) models were developed to identify features associated with readmission following ECMO. Area under the receiver operating characteristic (AUROC), mean Average Precision (mAP), and the Brier score were calculated to estimate model performance relative to logistic regression (LR). Shapley Additive Explanation summary (SHAP) plots evaluated the relative impact of each factor on the model. An additional sensitivity analysis solely included patient comorbidities and indication for ECMO as potential model covariates.

Results

Of ∼22,947 patients, 4495 (19.6 %) were readmitted nonelectively within 90 days. The XGBoost model exhibited superior discrimination (AUROC 0.64 vs 0.49), classification accuracy (mAP 0.30 vs 0.20) and calibration (Brier score 0.154 vs 0.165, all P < 0.001) in predicting readmission compared to LR. SHAP plots identified duration of index hospitalization, undergoing heart/lung transplantation, and Medicare insurance to be associated with increased odds of readmission. Upon sub-analysis, XGBoost demonstrated superior disclination compared to LR (AUROC 0.61 vs 0.60, P < 0.05). Chronic liver disease and frailty were linked with increased odds of nonelective readmission.

Conclusions

ML outperformed LR in predicting readmission following ECMO. Future work is needed to identify other factors linked with readmission and further optimize post-ECMO care among this cohort.

Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis

BACKGROUND

The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes.

METHODS

Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO).

RESULTS

Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; β -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (β -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open.

DISCUSSION

Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.

Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy

BACKGROUND

Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF.

METHODS

All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]).

RESULTS

Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (β+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF).

CONCLUSIONS

Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis

BACKGROUND

Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort.

METHODS

All non-elective pediatric (<18 years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE).

RESULTS

Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]).

CONCLUSION

Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis

BACKGROUND

Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort.

METHODS

All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest.

RESULTS

Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (β + 1.04 days, CI + .91-1.17) and greater costs (β+$3,490, CI + 2840-4140).

DISCUSSION

While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Off-Pump Coronary Artery Bypass Grafting Does Not Confer Superior Outcomes Among Frail Patients

Off-pump coronary revascularization (OPCAB) has been proposed to benefit patients who are at a greater surgical risk because it avoids the use of extracorporeal circulation. Although, historically, older patients were considered high-risk candidates, recent studies implicate frailty as a more comprehensive measure of perioperative fitness. Yet, the outcomes of OPCAB in frail patients have not been elucidated. Thus, using a national cohort of frail patients, we assessed the impact of OPCAB relative to on-pump coronary revascularization (ONCAB). Patients who underwent first-time elective coronary revascularization were tabulated from the 2010 to 2020 Nationwide Readmissions Database. Frailty was assessed using the previously-validated Johns Hopkins Adjusted Clinical Groups indicator. Multivariable models were used to consider the independent associations between OPCAB and the key outcomes. Of ∼26,529 frail patients, 6,322 (23.8%) underwent OPCAB. After risk adjustment and compared with ONCAB, OPCAB was linked with similar odds of in-hospital mortality but greater likelihood of postoperative cardiac arrest (adjusted odds ratio [AOR] 1.53, confidence interval [CI] 1.13 to 2.07) and myocardial infarction (AOR 1.44, CI 1.23 to 1.69). OPCAB was further associated with greater odds of postoperative infection (AOR 1.22, CI 1.02 to 1.47) but decreased need for blood transfusion (AOR 0.68, CI 0.60 to 0.77). In addition, OPCAB faced a +0.86-day increase in length of stay (CI 0.21 to 1.51) but similar costs (β $1,610, CI -$1,240 to 4,460) relative to ONCAB. Although OPCAB was associated with no difference in mortality compared with ONCAB, it was linked with greater likelihood of postoperative cardiac arrest and myocardial infarction. Our findings demonstrate that ONCAB remains associated with superior outcomes, even in the growing population of frail patients who underwent coronary revascularization.

Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation

OBJECTIVE

The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation.

BACKGROUND

Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated.

METHODS

All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001).

CONCLUSIONS

Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.

Trends, outcomes, and factors associated with in-hospital opioid overdose following major surgery

Background

With the growing opioid epidemic across the US, in-hospital utilization of opioids has garnered increasing attention. Using a national cohort, this study sought to characterize trends, outcomes, and factors associated with in-hospital opioid overdose (OD) following major elective operations.

Methods

We identified all adult (≥18 years) hospitalizations entailing select elective procedures in the 2016-2020 National Inpatient Sample. Patients who experienced in-hospital opioid overdose were characterized as OD (others: Non-OD). The primary outcome of interest was in-hospital OD. Multivariable logistic and linear regression models were developed to evaluate the association between in-hospital OD and mortality, length of stay (LOS), hospitalization costs, and non-home discharge.

Results

Of an estimated 11,096,064 hospitalizations meeting study criteria, 5375 (0.05 %) experienced a perioperative OD. Compared to others, OD were older (66 [57-73] vs 64 [54-72] years, p < 0.001), more commonly female (66.3 vs 56.7 %, p < 0.001), and in the lowest income quartile (26.4 vs 23.2 %, p < 0.001). After adjustment, female sex (Adjusted Odds Ratio [AOR] 1.68, 95 % Confidence Interval [CI] 1.47-1.91, p < 0.001), White race (AOR 1.19, CI 1.01-1.42, p = 0.04), and history of substance use disorder (AOR 2.51, CI 1.87-3.37, p < 0.001) were associated with greater likelihood of OD. Finally, OD was associated with increased LOS (β +1.91 days, CI [1.60-2.21], p < 0.001), hospitalization costs (β +$7500, CI [5900-9100], p < 0.001), and greater odds of non-home discharge (AOR 2.00, CI 1.61-2.48, p < 0.001).

Conclusion

Perioperative OD remains a rare but costly complication after elective surgery. While pain control remains a priority postoperatively, protocols and recovery pathways must be re-examined to ensure patient safety.

Prior bariatric surgery is associated with lower mortality and resource utilization following small bowel obstruction

Background

Small bowel obstruction (SBO) is a complication of bariatric surgery. However, outcomes of surgical intervention for SBO among patients with prior bariatric surgery remain ill-defined. We used a nationally representative cohort to characterize the outcomes of the SBO management approach in patients with a prior bariatric operation.

Methods

All adult hospitalizations for SBO were tabulated from the 2018-2020 National Readmissions Database. Patients with a prior history of bariatric surgery comprised the Bariatric cohort (others: Non-Bariatric). Multivariable models were subsequently developed to evaluate the association of prior bariatric surgery with outcomes of interest.

Results

Of an estimated 299,983 hospitalizations for SBO, 15,788 (5.3 %) had a history of prior bariatric surgery. Compared to Non-Bariatric, Bariatric patients were younger (54 [46-62] vs 57 [47-64] years, P < 0.001) and were more frequently privately insured (45.1 vs 39.4 %, P < 0.001). On average, the Bariatric more frequently underwent operative management, relative to Non-Bariatric (44.8 vs 29.7 %, P < 0.001). Following risk adjustment, among those surgically managed, Bariatric demonstrated lower odds of mortality (Adjusted Odds Ratio [AOR] 0.69, 95 % Confidence Interval [CI] 0.55-0.87) compared to Non-Bariatric. Bariatric also demonstrated lower odds of infectious and renal complications. Furthermore, the Bariatric cohort had lower costs, length of stay, and non-home discharge.

Conclusions

Patients with prior bariatric surgery demonstrated a lower likelihood of mortality, decreased complications, and reduced resource utilization, relative to others. As the incidence of bariatric surgery continues to rise, future work is needed to minimize the incidence of SBO among these patients, especially in the current era of value-based healthcare.

National outcomes of expedited discharge following esophagectomy for malignancy

BACKGROUND

Expedited discharge following esophagectomy is controversial due to concerns for higher readmissions and financial burden. The present study aimed to evaluate the association of expedited discharge with hospitalization costs and unplanned readmissions following esophagectomy for malignant lesions.

METHODS

Adults undergoing elective esophagectomy for cancer were identified in the 2014-2019 Nationwide Readmissions Database. Patients discharged by postoperative day 7 were considered Expedited and others as Routine. Patients who did not survive to discharge or had major perioperative complications were excluded. Multivariable regression models were constructed to assess association of expedited discharge with index hospitalization costs as well as 30- and 90-day non-elective readmissions.

RESULTS

Of 9,886 patients who met study criteria, 34.6% comprised the Expedited cohort. After adjustment, female sex (adjusted odds ratio [AOR] 0.71, p = 0.001) and increasing Elixhauser Comorbidity Index (AOR 0.88/point, p<0.001) were associated with lower odds of expedited discharge, while laparoscopic (AOR 1.63, p<0.001, Ref: open) and robotic (AOR 1.67, p = 0.003, Ref: open) approach were linked to greater likelihood. Patients at centers in the highest-tertile of minimally invasive esophagectomy volume had increased odds of expedited discharge (AOR 1.52, p = 0.025, Ref: lowest-tertile). On multivariable analysis, expedited discharge was independently associated with an $8,300 reduction in hospitalization costs. Notably, expedited discharge was associated with similar odds of 30-day (AOR 1.10, p = 0.40) and 90-day (AOR 0.90, p = 0.70) unplanned readmissions.

CONCLUSION

Expedited discharge after esophagectomy was associated with decreased costs and unaltered readmissions. Prospective studies are necessary to robustly evaluate whether expedited discharge is appropriate for select patients undergoing esophagectomy.

Early discharge following colectomy for colon cancer: A national perspective

BACKGROUND

Although early discharge after colectomy has garnered significant interest, contemporary, large-scale analyses are lacking.

OBJECTIVE

The present study utilized a national cohort of patients undergoing colectomy to examine costs and readmissions following early discharge.

METHODS

All adults undergoing elective colectomy for primary colon cancer were identified in the 2016-2019 Nationwide Readmissions Database. Patients with perioperative complications or prolonged length of stay (>8 days) were excluded to enhance cohort homogeneity. Patients discharged by postoperative day 3 were classified as Early, and others as Routine. Entropy balancing and multivariable regression were used to assess the risk-adjusted association of early discharge with costs and non-elective readmissions. Importantly, we compared 90-day stroke rates to examine whether our results were influenced by preferential early discharge of healthier patients.

RESULTS

Of an estimated 153,996 patients, 45.5% comprised the Early cohort. Compared to Routine, the Early cohort was younger and more commonly male. Patients in the Early group more commonly underwent left-sided colectomy and laparoscopic operations. Following multivariable adjustment, expedited discharge was associated with a $4,500 reduction in costs as well as lower 30-day (adjusted odds ratio [AOR] 0.74, p<0.001) and 90-day non-elective readmissions (AOR 0.74, p<0.001). However, among those readmitted within 90 days, Early patients were more commonly readmitted for gastrointestinal conditions (45.8 vs 36.4%, p<0.001). Importantly, both cohorts had comparable 90-day stroke rates (2.2 vs 2.1%, p = 0.80).

CONCLUSIONS

The present work represents the largest analysis of early discharge following colectomy for cancer and supports its relative safety and cost-effectiveness.

Association of time to resection with survival in patients with colon cancer

PURPOSE

Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients.

METHODS

This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume.

RESULTS

Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection.

CONCLUSIONS

Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Short-term outcomes of bariatric surgery in patients with inflammatory bowel disease: a national analysis

BACKGROUND

While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD).

OBJECTIVES

The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery.

SETTING

Academic, university-affiliated; United States.

METHODS

All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest.

RESULTS

Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 ± 1.4; CD: 3.1 ± 1.5; non-IBD: 2.7 ± 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD.

CONCLUSIONS

Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.

Social determinants as predictors of resection and long-term mortality in Black patients with non-small cell lung cancer

BACKGROUND

Minorities diminished returns theory posits that socioeconomic attainment conveys fewer health benefits for Black than White individuals. The current study evaluates the effects of social constructs on resection rates and survival for non-small cell lung cancer (NSCLC).

METHODS

Patients with potentially resectable NSCLC stage IA to IIIA were identified using the 2004 to 2017 National Cancer Database. Patients were stratified into quartiles based on population-level education and income. Logistic regression was used to predict risk-adjusted resection rates. Mortality was assessed with Cox proportional hazard modeling.

RESULTS

Of the 416,025 patients identified, 213,643 (51.4%) underwent resection. Among White patients, the lowest income (adjusted odds ratio 0.76, 95% confidence interval 0.74-0.78, P < .01) and education quartiles (adjusted odds ratio 0.82, 95% confidence interval 0.79-0.84, P < .01) were associated with decreased odds of resection. The lowest education quartile among Black patients was not associated with lower resection rates. The lowest income quartile (adjusted odds ratio 0.67, 95% CI 0.61-0.74, P < .01) was associated with reduced resection. White patients in the lowest education and income quartiles experienced increased hazard of 5-year mortality (adjusted hazard ratio 1.13, 95% CI 1.11-1.15, P < .01 and adjusted hazard ratio 1.08, 95% CI 1.06-1.11, P < .01 respectively). In Black patients, there were no significant differences in 5-year survival between Black patients in the highest education and income quartiles and those in the lowest quartiles.

CONCLUSION

Among Black patients with NSCLC, educational attainment is not associated with increased resection rates. In addition, higher education and income were not associated with improved 5-year survival. The diminished gains experienced by Black patients, compared to Whites patients, illustrate the presence of pervasive race-specific mechanisms in observed inequalities in cancer outcomes.

Outcomes following major thoracoabdominal cancer resection in adults with congenital heart disease

BACKGROUND

While advances in medical and surgical management have allowed >97% of congenital heart disease (CHD) patients to reach adulthood, a growing number are presenting with non-cardiovascular malignancies. Indeed, adults with CHD are reported to face a 20% increase in cancer risk, relative to others, and cancer has become the fourth leading cause of death among this population. Surgical resection remains a mainstay in management of thoracoabdominal cancers. However, outcomes following cancer resection among these patients have not been well established. Thus, we sought to characterize clinical and financial outcomes following major cancer resections among adult CHD patients.

METHODS

The 2012-2020 National Inpatient Sample was queried for all adults (CHD or non-CHD) undergoing lobectomy, esophagectomy, gastrectomy, pancreatectomy, hepatectomy, or colectomy for cancer. To adjust for intergroup differences in baseline characteristics, entropy balancing was applied to generate balanced patient groups. Multivariable models were constructed to assess outcomes of interest.

RESULTS

Of 905,830 patients undergoing cancer resection, 1,480 (0.2%) had concomitant CHD. The overall prevalence of such patients increased from <0.1% in 2012 to 0.3% in 2012 (P for trend<0.001). Following risk adjustment, CHD was linked with greater in-hospital mortality (AOR 2.00, 95%CI 1.06-3.76), as well as a notable increase in odds of stroke (AOR 8.94, 95%CI 4.54-17.60), but no statistically significant difference in cardiac (AOR 1.33, 95%CI 0.69-2.59) or renal complications (AOR 1.35, 95%CI 0.92-1.97). Further, CHD was associated with a +2.39 day incremental increase in duration of hospitalization (95%CI +1.04-3.74) and a +$11,760 per-patient increase in hospitalization expenditures (95%CI +$4,160-19,360).

CONCLUSIONS

While a growing number of patients with CHD are undergoing cancer resection, they demonstrate inferior clinical and financial outcomes, relative to others. Novel screening, risk stratification, and perioperative management guidelines are needed for these patients to provide evidence-based recommendations for this complex and unique cohort.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Association of neighborhood socioeconomic disadvantage with use of minimally invasive resection for non-small cell lung cancer

OBJECTIVE

Minimally invasive resection for non-small cell lung cancer has been linked to decreased postoperative morbidity. This work sought to characterize factors associated with receiving minimally invasive surgery for surgically resectable non-small cell lung cancer.

METHODS

All adults undergoing lobectomy/sublobar resection for stage I non-small cell lung cancer were identified using the 2010-2020 National Cancer Database. Those undergoing thoracoscopic/robotic procedures comprised the minimally invasive resection cohort (others: open). Hospitals were stratified by minimally invasive resection procedure volume, with the top quartile considered high minimally invasive resection volume centers. Multivariable models were constructed to assess the independent association between the patients, diseases, and hospital factors and the likelihood of receiving minimally invasive resection.

RESULTS

Of 217,762 patients, 112,304 (52%) underwent minimally invasive resection. The proportion of minimally invasive resection procedures increased from 27% in 2010 to 72% in 2020 (P < .001). After adjustment, several factors were independently associated with decreased odds of receiving minimally invasive resection, including lower quartiles of median neighborhood income (51st-75th percentile adjusted odds ratio, 0.92, 95% CI, 0.89-0.94; 26th-50th percentile adjusted odds ratio, 0.86, CI, 0.83-0.89; 0-25th percentile adjusted odds ratio, 0.78, CI, 0.75-0.81; reference: 76th-100th percentile income) and care at community hospitals (adjusted odds ratio, 0.70, CI, 0.68-0.71; reference: academic centers). Among patients receiving care at high minimally invasive resection volume centers, lowest income remained linked with reduced likelihood of undergoing minimally invasive resection from 2010 to 2015 (adjusted odds ratio, 0.85, CI, 0.77-0.94), but did not alter the odds of minimally invasive resection in later years (adjusted odds ratio, 1.01, CI, 0.87-1.16; reference: highest income).

CONCLUSIONS

This study identified significant community income-based disparities in the likelihood of undergoing minimally invasive resection as definitive surgical treatment. Novel interventions are warranted to expand access to high-volume minimally invasive resection centers and ensure equitable access to minimally invasive surgery.

Persistent racial disparities in refusal of resection in non-small cell lung cancer patients at high-volume and Black-serving institutions

BACKGROUND

Surgical resection is the standard of care for early-stage non-small cell lung cancer. Black patients have higher surgical refusal rates than White patients. We evaluated factors associated with the refusal of resection and subsequent non-small cell lung cancer outcomes.

METHODS

We identified patients with non-small cell lung cancer stages IA to IIIA eligible for surgical resection (lobectomy or pneumonectomy) listed between 2004 and 2017 in the National Cancer Database. We stratified hospitals by the proportion of Black patients served and lung cancer resection volume. We used multivariable regression models to identify factors associated with refusal of resection and assessed 5-year mortality using Kaplan-Meier analysis and Cox proportional hazard modeling.

RESULTS

Of 221,396 patients identified, 7,753 (3.5%) refused surgery. Black race was associated with increased refusal (adjusted odds ratio 2.06, 95% confidence interval 1.90-2.22). Compared to White race, Black race was associated with increased refusal across the highest (adjusted odds ratio 2.29, 95% confidence interval 1.94-2.54), intermediate (adjusted odds ratio 2.05, 95% confidence interval 1.78-2.37), and lowest (adjusted odds ratio 1.77, 95% confidence interval 1.58-1.99) volume tertiles. Similarly, Black race was associated with increased refusal across the highest (adjusted odds ratio 1.97, 95% confidence interval 1.78-2.17), intermediate (adjusted odds ratio 2.08, 95% confidence interval 1.80-2.40), and lowest (adjusted odds ratio 1.53, 95% confidence interval 1.13-2.06) Black-serving tertiles. However, surgical resection yielded similar 5-year survival for Black and White patients.

CONCLUSION

Racial disparities in non-small cell lung cancer surgery refusal persist regardless of hospital volume or proportion of Black patients served. These findings suggest that a better understanding of patient and patient-provider level interventions could facilitate a better understanding of treatment decision-making.

Expanded Criteria Donor Heart Allograft Utilization: National Trends and Outcomes

BACKGROUND

To examine recent trends in the use of expanded criteria donor organs in heart transplantation, this study assessed center-level variation in acceptance of these allografts and analyzed their posttransplantation outcomes.

METHODS

Adult (aged ≥18 years) heart transplant recipients between 2011 and 2022 were identified in the Organ Procurement and Transplantation Network database. Expanded criteria allografts were defined using a previously validated risk score. After stratifying centers by cumulative transplantation volume, those centers in the top tertile (≥23/year) were considered high volume. Subsequently, the ratio of transplantations using expanded criteria allografts to total transplantations was calculated for each high-volume center. On the basis of tertiles, centers were then categorized as high-, medium-, and low-use centers. The primary outcome was death after transplantation.

RESULTS

Of 23,290 transplantations performed, 5017 (22%) used expanded criteria donor allografts. High-volume heart transplantation centers performed 72% (3628) of these transplantations-1183 (75%) between 2011 and 2014, 1383 (73%) between 2015 and October 2018, and 1062 (68%) between November 2018 and June 2021. Compared with low-volume programs, undergoing expanded criteria heart transplantation at high-volume centers was associated with a significantly reduced hazard of mortality at 1 year (hazard ratio, 0.78; CI, 0.65-0.94; P = .01) and 5 years (hazard ratio, 0.85; CI, 0.75-0.98; P = .02). During the study period, survival rates 1 year after transplantation were similar across high-volume centers, regardless of their use of expanded criteria allografts.

CONCLUSIONS

Undergoing heart transplantation with an expanded criteria donor allograft at a high-volume transplantation center provides a significant survival benefit. Further, the use of more expanded criteria criteria organs, in the right clinical settings, does not negatively affect overall patient outcomes at high-volume centers.

Association of frailty with postoperative outcomes following thoracic transplantation: A national analysis

Objective

Frailty has been repeatedly associated with inferior outcomes after surgical hospitalizations. However, a thorough evaluation of the impact of frailty on the clinical and financial outcomes of patients undergoing solid-organ thoracic transplantation is sparse in the literature. We evaluated the association of frailty, as determined by an administrative tool, with postoperative outcomes and healthcare resource use after heart or lung transplantation.

Methods

The Nationwide Readmissions Database was used to identify all adult hospitalizations for heart or lung transplant from 2014 to 2020. Patients were grouped as frail or nonfrail using International Classification of Diseases codes associated with conditions in the Johns Hopkins Adjusted Clinical Groups cluster. Multivariable regression models were developed to evaluate the association of frailty status on in-hospital mortality, complications, length of stay, costs, and unplanned readmissions.

Results

Of an estimated 35,862 heart or lung transplant recipients, 7316 (20.4%) were considered frail. After multivariable adjustment, frailty in heart transplantation was associated with greater odds of in-hospital mortality (adjusted odds ratio, 1.54; 95% CI, 1.19-1.99) and infectious complications (adjusted odds ratio, 1.77; 95% CI, 1.45-2.15; P < .001). Frailty in lung transplantation was also associated with higher odds of in-hospital mortality (adjusted odds ratio, 1.38; 95% CI, 1.11-1.69) and infectious complications (adjusted odds ratio, 1.93; 95% CI, 1.60-2.31). In addition, frailty in both heart transplantation and lung transplantation was associated with increased postoperative length of stay and greater costs.

Conclusions

Among transplant recipients, those classified as frail were associated with increased in-hospital mortality, perioperative complications, and resource use.

Association of dementia with clinical and financial outcomes following lobectomy for lung cancer

Objective

The number of adults with dementia is rising worldwide. Although dementia has been linked with inferior outcomes following various operations, this phenomenon has not been fully elucidated among patients undergoing elective lung resection. Using a national cohort, we evaluated the association of dementia with clinical and financial outcomes following lobectomy for cancer.

Methods

Adults undergoing lobectomy for lung cancer were identified within the 2010-2020 Nationwide Readmissions Database. Patients with a comorbid diagnosis of dementia were considered the Dementia cohort (others: Non-Dementia). Multivariable regressions were developed to evaluate the association between dementia and key outcomes.

Results

Of ∼314,436 patients, 2863 (0.9%) comprised the Dementia cohort. Compared with Non-Dementia, the Dementia cohort was older (75 vs 68 years, P < .001), less commonly female (49.4 vs 53.9%, P = .01), and had a greater burden of comorbid conditions. After adjustment, dementia remained associated with similar odds of in-hospital mortality (adjusted odds ratio [aOR], 0.86; 95% confidence interval [CI], 0.54-1.38) but greater likelihood of pneumonia (aOR, 1.31; CI, 1.04-1.65) and infectious complications (aOR, 1.37; CI, 1.01-1.87). Further, dementia was associated with longer length of stay (β +0.96 days; CI, 0.51-1.41), but no difference in hospitalization cost (β $1528; CI, -92 to 3148).

Conclusions

Patients with dementia faced similar odds of mortality, but greater complications and resource use following lobectomy for lung cancer. Novel interventions are needed to improve care coordination and develop standardized recovery pathways for this growing cohort.

Combined Heart-Liver vs Isolated Heart Transplantation in Adults With Congenital Heart Disease

BACKGROUND

Despite an increasing number of adults with congenital heart disease undergoing combined heart-liver transplantation (CHLT), there is a paucity of literature analyzing posttransplant outcomes. We analyzed the incidence and outcomes of congenital heart disease patients undergoing CHLT compared with those undergoing isolated heart transplantation (HT).

METHODS

This was a retrospective analysis of all adult (≥18 years) congenital heart disease patients undergoing CHLT or HT between 2000 and 2020 in the Organ Procurement and Transplantation Network database. The primary outcome was death at 30 days and 1 year after transplantation.

RESULTS

Of 1214 recipients included for analysis, 92 (8%) underwent CHLT and 1122 (92%) underwent HT. Patients undergoing CHLT and HT were similar in the distribution of age, sex, and serum bilirubin. Upon adjusted analysis with HT as the reference, undergoing CHLT was associated with a similar hazard of 30-day mortality between 2000 and 2017 (hazard ratio [HR], 0.51; 95% CI, 0.12-2.08; P = .35) and 2018 and 2020 (HR, 2.32; 95% CI, 0.88-6.13; P = .09). Similarly, there was no difference in the hazard of 1-year mortality for patients undergoing CHLT between 2000 and 2017 (HR, 0.60; 95% CI, 0.22-1.63; P = .32) and 2018 and 2020 (HR, 1.52; 95% CI, 0.66-3.53; P = .33) compared with HT.

CONCLUSIONS

The number of adults undergoing CHLT continues to rise. Given comparable survival outcomes between CHLT and HT, our findings demonstrate the former as a viable option for complex congenital heart disease patients with failing cavopulmonary circulation and associated liver disease. Future studies should delineate factors associated with early hepatic dysfunction to help identify congenital heart disease patients that would benefit from CHLT.

Association of postoperative length of stay with outcomes following orthotopic heart transplantation-A national analysis

BACKGROUND

In the absence of standardized recovery protocols, there is little evidence to guide postoperative care to ensure optimal in-hospital and long-term outcomes following heart transplantation (HT). Using two national databases, we examined the association between postoperative length of stay (LOS) with patient/graft survival, index hospitalization costs, and non-elective readmissions.

METHODS

Adult HT recipients from 2010 to 2019 were identified and analyzed within the Organ Procurement and Transplantation Network (OPTN) Database and Nationwide Readmissions Database (NRD). The risk-adjusted relationship between 1-year mortality and LOS was assessed with restricted cubic splines and subsequently used to stratify patients into Expedited (7-11 days), Routine (12-16 days), and Delayed (>16) discharge groups. Survival outcomes were analyzed using Restricted Means Survival Time analysis (RMST) and multivariable Cox models.

RESULTS

Of 9995 HT recipients within the OPTN, 3777 (38%) were categorized as Expedited, and 3040 (30%) as Routine. After adjustment, expedited discharge was not associated with inferior 90-day (ΔRMST -.01, p = .91) and 1-year patient survival (ΔRMST -.02, p = .53). Additionally, expedited was not associated with increased odds of non-elective readmission at 90-days (HR 1.04, CI .77-1.43) relative to Routine discharge. Counterfactual analysis revealed an estimated cost saving of $50 million if all Routine patients received an expedited discharge.

CONCLUSION

Expedited discharge after HT seems to be cost-effective and is not associated with inferior outcomes. Institutional-level outcome analyses should be performed to identify patients that would benefit from expedited discharge, and future studies should analyze the feasibility of implementing standardized discharge protocols following HT.

Impact of surgeon specialty on clinical outcomes following esophagectomy for cancer

BACKGROUND

The impact of surgeon and hospital operative volume on esophagectomy outcomes is well-described; however, studies examining the influence of surgeon specialty remain limited. Therefore, we evaluated the impact of surgeon specialty on short-term outcomes following esophagectomy for cancer.

METHODS

The 2016-2019 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) was queried to identify all patients undergoing esophagectomy for esophageal cancer. Surgeon specialty was categorized as general (GS) or thoracic (TS). Entropy balancing was used to generate sample weights that adjust for baseline differences between GS and TS patients. Weights were subsequently applied to multivariable linear and logistic regressions, which were used to evaluate the independent association of surgeon specialty with 30-day mortality, complications, and postoperative length of stay.

RESULTS

Of 2657 esophagectomies included for analysis, 54.1% were performed by TS. Both groups had similar distributions of age, sex, and body mass index. TS patients more frequently underwent transthoracic esophagectomy, while GS patients more commonly received minimally invasive surgery. After adjustment, surgeon specialty was not associated with altered odds of 30-day mortality (adjusted odds ratio [AOR] 1.10 p = 0.73) or anastomotic leak (AOR 0.87, p = 0.33). However, TS patients exhibited a 40-min reduction in operative duration and faced greater odds of perioperative transfusion, relative to GS.

CONCLUSION

Among ACS NSQIP participating centers, surgeon specialty influenced operative duration and blood product utilization, but not mortality and anastomotic leak. Our results support the relative safety of esophagectomy performed by select GS and TS.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis

BACKGROUND

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

METHODS

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

RESULTS

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

CONCLUSIONS

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

Dementia is Associated With Inferior Outcomes Following Emergency General Surgery

INTRODUCTION

Given the steadily aging United States population, we used a national database to examine the association of dementia with clinical and financial outcomes following emergency general surgery.

METHODS

All adults undergoing non-elective appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or lysis of adhesions were identified within the 2016-2019 Nationwide Readmissions Database. Entropy balancing and multivariable regressions were used to assess the risk-adjusted association between dementia and in-hospital mortality, complications, length of stay, costs, non-home discharge, and 30-day unplanned readmissions.

RESULTS

Of an estimated 1,332,922 patients, 2.7% had dementia. Compared to those without, patients with dementia were older, more commonly male, and had a greater burden of chronic conditions. Following entropy balancing and multivariable risk-adjustment, dementia was associated with increased odds of mortality and sepsis across all operations except perforated ulcer repair. Dementia was also linked to greater likelihood of pneumonia across all operative categories. Moreover, dementia was associated with increased length of stay for patients in all operative categories except perforated ulcer repair, while costs were only increased for those undergoing appendectomy, cholecystectomy, and lysis of adhesions. Dementia was also linked to higher odds of non-home discharge following all operations, while non-elective readmissions were only increased for patients undergoing cholecystectomy.

CONCLUSIONS

The present study found dementia to be associated with a significant clinical and financial burden. Our findings may help inform shared decision making with patients and their families.

Acute Outcomes of Cardiac Operations in Patients With Autoimmune Disorders: A National Analysis

BACKGROUND

Accelerated atherosclerosis, inflammation, and valve pathology are known complications of autoimmune connective tissue diseases (AID). However, outcomes of coronary artery bypass graft surgery (CABG) or valve operations among these patients remain underexamined.

METHODS

All adult hospitalizations for elective CABG or valve procedures were identified from the 2010-2019 Nationwide Readmissions Database. Autoimmune connective tissue disease was defined to include systemic lupus erythematosus (SLE), antiphospholipid syndrome (APLS), polymyalgia rheumatica (PMR), and other autoimmune AIDs. Entropy balancing was applied to generate balanced patient cohorts. Multivariable regression models were constructed to assess the independent associations between AID and outcomes of interest.

RESULTS

Of ∼1 652 573 patients, 21 019 (1.3%) had AID (23.7% SLE, 17.2% APLS, 29.5% PMR, and 29.6% other). Autoimmune connective tissue disease patients were more frequently female (60.8 vs 33.1%, P < .001) and insured by Medicare (71.4 vs 62.2%, P < .001) and presented with a higher comorbidity index (5.2 ± 1.8 vs 4.1 ± 1.8, P < .001). Further, AID less frequently underwent isolated CABG (39.0 vs 52.3%) but more commonly isolated valve operations (41.9% vs 31.0%, P < .001), relative to non-AID. Following risk-adjustment, AID was not linked with increased odds of mortality or cardiac complications. However, AID was linked with a greater risk of thrombotic complications, blood transfusion, and non-elective readmission within 30 days, as well as a +$900 decrement in hospitalization costs.

DISCUSSION

Autoimmune connective tissue disease patients demonstrated acceptable outcomes following CABG and valve procedures. However, novel prophylactic care pathways should be developed and instituted to address greater thrombotic and blood transfusion risk. Further investigation is needed to identify factors contributing to greater non-elective readmissions among these patients.

Moving beyond frailty: Obesity paradox persists in lung resection

BACKGROUND

The apparent protective effect of high body mass index on postoperative outcomes, termed the "obesity paradox," has been postulated to reflect the relative frailty of patients without obesity. We wanted to examine the independent association between body mass index and outcomes after anatomic lung resection.

METHODS

All adults undergoing elective lung resection for cancer were identified in the 2012-2020 National Surgical Quality Improvement Program. The modified Frailty Index quantified degree of patient frailty. Malnutrition was defined as a preoperative serum albumin <3.5g/dL. Multivariable regressions were used to examine the independent association of body mass index and major adverse events, analyzed as a composite of 30-day mortality, postoperative complications, and unplanned reoperation.

RESULTS

Of an estimated 20,099 patients meeting study criteria, 6,424 (32.0%) had obesity. Relative to others, patients with obesity were significantly younger (49.3 vs 50.3 years), more commonly White (78.1 vs 74.9%), and more frequently frail (modified Frailty Index >1: 35.7 vs 22.5%, all P < .001). There was no significant difference in malnutrition rates (7.6 vs 8.4%, P = .05) or extent of resection between groups. After adjustment, obesity was associated with decreased odds of major adverse events (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.94).

CONCLUSION

The present findings uphold the canonical obesity paradox in anatomic lung resection, despite adjustment for frailty and malnutrition. Further studies are warranted to characterize the nature of this association; however, our results may inform efforts to optimize risk stratification and patient selection for surgical intervention.

Failure to rescue among octogenarians undergoing cardiac surgery in the United States

BACKGROUND

A rapidly growing population, octogenarians are considered at high-risk for mortality and complications after cardiac surgery. Given the recent addition of failure to rescue as a Society of Thoracic Surgeons quality metric, a better understanding of patient and operative factors predictive of failure to rescue in this cohort is warranted.

METHODS

The 2010-2020 Nationwide Readmissions Database was used to identify all patients ≥80 years undergoing first-time, elective coronary artery bypass grafting or concomitant valve operations. Patients experiencing failure to rescue, defined as mortality after a major or minor complication, were classified as Failure to Rescue (others: Non-Failure to Rescue). Multivariable regression models were developed to ascertain significant perioperative factors associated with failure to rescue.

RESULTS

Of ∼562,794 octogenarian patients, 76,473 (13.6%) developed complications. Of these, 7,055 (9.2%) experienced failure to rescue. The incidence of failure to rescue decreased across the study time course (9.7% in 2010 to 7.6% in 2019, P = .001). After risk adjustment, age (adjusted odds ratio, 1.05/year; 95% confidence interval, 1.03-1.07), female sex (adjusted odds ratio, 1.40; 95% confidence interval, 1.27-1.53), congestive heart failure (adjusted odds ratio, 1.54; 95% confidence interval, 1.38-1.71), late-stage kidney disease (adjusted odds ratio, 2.38; 95% confidence interval, 1.79-3.17), liver disease (adjusted odds ratio, 9.59; 95% confidence interval, 8.17-11.26), and cerebrovascular disease (adjusted odds ratio, 2.42; 95% confidence interval, 2.12-2.76) were associated with failure to rescue. Relative to isolated coronary artery bypass grafting, combined coronary artery bypass grafting-valve (adjusted odds ratio, 1.67; 95% confidence interval, 1.43-1.95) and multi-valve procedures (adjusted odds ratio, 2.23; 95% confidence interval, 1.75-2.85) were linked with greater odds of failure to rescue. There was no association between failure to rescue and hospital volume.

CONCLUSION

Despite improvements in perioperative management, failure to rescue occurs in ∼9% of octogenarians undergoing elective cardiac operations. Although incidence has declined over the past decade, the continued prevalence of failure to rescue underscores the need for novel risk assessments and targeted interventions.

Survival After Cardiac Transplantation in Adults With Single-Ventricle Congenital Heart Disease

BACKGROUND

Without large-scale analyses of adults with single-ventricle congenital heart disease (CHD) undergoing heart transplantation, little evidence exists to guide listing practices and patient counseling.

OBJECTIVES

This study aims to evaluate survival after heart transplantation in adults with single and biventricular CHD and compare it to that of non-CHD transplant recipients.

METHODS

In this 15-year (2005-2020) retrospective analysis, outcome-blinded investigators used probability-linkage to merge the National (Nationwide) Inpatient Sample and Organ Procurement and Transplantation Network data sets.

RESULTS

Of 382 adult (≥18 years of age) heart transplant recipients with CHD, 185 (48%) had single-ventricle physiology. Compared to biventricular CHD, single-ventricle patients showed significantly reduced survival at 1 (80% vs 91%; HR: 2.50; 95% CI: 1.40-4.49; P = 0.002) and 10 years (54% vs 71%; HR: 2.10; 95% CI: 1.38-3.18; P < 0.001). Among patients who survived the first post-transplantation year, biventricular CHD patients exhibited similar 10-year survival as single-ventricle patients, except for those with hypoplastic left heart syndrome (79% vs 71%; HR: 1.58; 95% CI: 0.85-2.92; P = 0.15). Additionally, biventricular CHD transplant recipients showed significantly better 10-year conditional survival compared to their non-CHD counterparts (79% vs 68%; HR: 0.73; 95% CI: 0.59-0.90; P = 0.003).

CONCLUSIONS

Among adult CHD transplant recipients, single-ventricle physiology correlated with higher short-term mortality. However, 10-year conditional survival was similar for biventricular and most single-ventricle CHD patients, and notably better for biventricular CHD patients compared to non-CHD heart transplant recipients. These findings have significant implications towards patient selection and listing strategies, easing concerns related to heart transplantation in adults with CHD and destigmatizing most subtypes of single-ventricle CHD.

Evaluation of hospital readmission rates as a quality metric in adult cardiac surgery

OBJECTIVE

To assess the reliability of 30-day non-elective readmissions as a quality metric for adult cardiac surgery.

BACKGROUND

Unplanned readmissions is a quality metric for adult cardiac surgery. However, its reliability in benchmarking hospitals remains under-explored.

METHODS

Adults undergoing elective isolated coronary artery bypass grafting (CABG), surgical aortic valve replacement/repair (SAVR) or mitral valve replacement/repair (MVR) were tabulated from 2019 Nationwide Readmissions Database. Multi-level regressions were developed to model the likelihood of 30-day unplanned readmissions and major adverse events (MAE). Random intercepts were estimated, and associations between hospital-specific risk-adjusted rates of readmissions and were assessed using the Pearson correlation coefficient (r).

RESULTS

Of an estimated 86 024 patients meeting study criteria across 298 hospitals, 62.6% underwent CABG, 22.5% SAVR and 14.9% MVR. Unadjusted readmission rates following CABG, SAVR and MVR were 8.4%, 9.3% and 11.8%, respectively. Unadjusted MAE rates following CABG, SAVR and MVR were 35.1%, 32.3% and 37.0%, respectively. Following adjustment, interhospital differences accounted for 4.1% of explained variance in readmissions for CABG, 7.6% for SAVR and 10.0% for MVR. There was no association between readmission rates for CABG and SAVR (r=0.10, p=0.09) or SAVR and MVR (r=0.09, p=0.1). A weak association was noted between readmission rates for CABG and MVR (r=0.20, p<0.001). There was no significant association between readmission and MAE for CABG (r=0.06, p=0.2), SAVR (r=0.04, p=0.4) and MVR (r=-0.03, p=0.6).

CONCLUSION

Our findings suggest that readmissions following adult cardiac surgery may not be an ideal quality measure as hospital factors do not appear to influence this outcome.

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database.

METHODS

Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis.

RESULTS

Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (β -0.10, 95% -0.13, -0.07), reduced costs (β -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96).

CONCLUSIONS

Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes

BACKGROUND

Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking.

METHODS

This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts.

RESULTS

Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors.

CONCLUSIONS

Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.

Effect of surgical timing on outcomes after cholecystectomy for mild gallstone pancreatitis

BACKGROUND

Retrospective and single-center studies have demonstrated that early cholecystectomy is associated with shorter length of stay in patients with mild gallstone pancreatitis. However, these studies are not powered to detect differences in adverse events. Using a nationally representative cohort, we evaluated the association of timing for cholecystectomy with clinical outcomes and resource use in patients with gallstone pancreatitis.

METHODS

All adult hospitalizations for gallstone pancreatitis were tabulated from the 2016-2019 Nationwide Readmissions Database. Using International Classification of Disease, 10th Revision codes, patient comorbidities and operative characteristics were determined. Patients with end-organ dysfunction or cholangitis were excluded to isolate those with only mild gallstone pancreatitis. Major adverse events were defined as a composite of 30-day mortality and perioperative (cardiovascular, respiratory, neurologic, infectious, and thromboembolic) complications. Timing of laparoscopic cholecystectomy was divided into Early (within 2 days of admission) and Late (>2 days after admission) cohorts. Multivariable logistic and linear regression were then used to evaluate the association of cholecystectomy timing with major adverse events and secondary outcomes of interest, including postoperative hospital duration of stay, costs, non-home discharge, and readmission rate within 30 days of discharge.

RESULTS

Of an estimated 129,451 admissions for acute gallstone pancreatitis, 25.6% comprised the Early cohort. Compared to patients in the Early cohort, Late cohort patients were older (56 [40-69] vs 53 [37-66] years, P < .001), more likely male (36.6 vs 32.8%, P < .001), and more frequently underwent preoperative endoscopic retrograde cholangiopancreatography (22.2 vs 10.9%, P < .001). In addition, the Late cohort had higher unadjusted rates of major adverse events and index hospitalization costs, compared to Early. After risk adjustment, late cholecystectomy was associated with higher odds of major adverse events (adjusted odds ratio 1.40, 95% confidence interval 1.29-1.51) and overall adjusted hospitalization costs by $2,700 (95% confidence interval 2,400-2,800). In addition, compared to the Early group, those in the Late cohort had increased odds of 30-day readmission (adjusted odds ratio 1.12, 95% confidence interval 1.03-1.23) and non-home discharge (adjusted odds ratio 1.42, 95% confidence interval 1.31-1.55).

CONCLUSION

Cholecystectomy >2 days after admission for mild gallstone pancreatitis was independently associated with increased major adverse events, costs, 30-day readmissions, and non-home discharge. Given the significant clinical and financial consequences, reduced timing to surgery should be prioritized in the overall management of this patient population.

Association of body mass index with morbidity following elective ventral hernia repair

Background

Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.

Methods

Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.

Results

Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.

Conclusion

BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care.

Key message

Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Association of opioid use disorder with outcomes of hospitalizations for acute myocardial infarction in the United States

OBJECTIVE

While Opioid Use Disorder (OUD) has been linked to inferior clinical outcomes, studies examining the clinical outcomes and readmission of OUD patients experiencing Acute Myocardial Infarction (AMI) remain lacking. The authors analyze the clinical and financial outcomes of OUD in a contemporary cohort of AMI hospitalizations.

METHODS

All non-elective adult (≥ 18 years) hospitalizations for AMI were tabulated from the 2016‒2019 Nationwide Readmissions Database using relevant International Classification of Disease codes. Patients were grouped into OUD and non-OUD cohorts. Bivariate and regression analyses were performed to identify the independent association of OUD with outcomes after non-elective admission for AMI, as well as subsequent readmission.

RESULTS

Of an estimated 3,318,257 hospitalizations for AMI meeting study criteria, 36,057 (1.1%) had a concomitant diagnosis of OUD. While OUD was not significantly associated with mortality, OUD patients experienced superior cardiovascular outcomes compared to non-OUD. However, OUD was linked to increased odds of non-cardiovascular complications, length of stay, costs, non-home discharge, and 30-day non-elective readmission.

CONCLUSIONS

Patients with OUD presented with AMI at a significantly younger age than non-OUD. While OUD appears to have a cardioprotective effect, it is associated with several markers of increased resource use, including readmission. The present findings underscore the need for a multifaceted approach to increasing social services and treatment for OUD at index hospitalization.

Risk and factors associated with venous thromboembolism following abdominal transplantation

Background

Venous thromboembolism (VTE) remains under-studied among patients undergoing kidney, liver and pancreas (abdominal) transplantation. We characterized the risk and predictors of VTE using a nationally-representative cohort.

Methods

The 2014-2019 Nationwide Readmissions Database was queried to identify all adults undergoing abdominal transplantation. Patients who developed pulmonary embolism or deep venous thrombosis were considered the VTE cohort (others: nonVTE). Multivariable models were developed to identify factors linked with VTE and assess the independent associations between VTE and key outcomes.

Results

Of ~141,977 transplant recipients, 1.9 % (2722) developed VTE. The VTE cohort was similarly female (39.2 vs 38.0, p = 0.51), but more often demonstrated a higher Elixhauser comorbidity index (4.19 ± 1.40 vs 3.93 ± 1.39, p < 0.001).After adjustment, congestive heart failure (AOR 1.54, 95%CI 1.25-1.91), cardiac arrhythmias (AOR 1.54, 95%CI 1.34-1.78), peripheral vascular disease (AOR 1.29, 95%CI 1.02-1.63), coagulopathies (AOR 1.63, 95%CI 1.38-1.92), previous history of VTE (AOR 1.14, 95%CI 1.06-1.22), and heparin-induced thrombocytopenia (AOR 2.61, 95%CI 2.07-3.28) were associated with VTE. The development of VTE was linked with significantly greater in-hospital mortality (AOR 4.56, 95%CI 2.07-10.10), as well as infectious (AOR 2.59, 95%CI 1.55-4.21), cardiac (AOR 2.59, 95%CI 1.39-4.82), and respiratory (AOR 1.78, 95%CI 1.21-2.63) complications. VTE was further associated with increased length of stay (+8.18 days, 95%CI +1.32-15.41), expenditures (+$42,000, 95%CI $24,800-59,210), and odds of VTE upon readmission (AOR 4.51, 95%CI 1.32-15.41).

Conclusions

VTE after abdominal transplantation is linked with significantly greater in-hospital mortality, complications, resource utilization, and risk of VTE at readmission. Novel risk assessments and prophylaxis protocols are needed to reduce VTE incidence and sequelae.

Acute clinical and financial outcomes of esophagectomy at safety-net hospitals in the United States

BACKGROUND

While safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy.

METHODS

All adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010-2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days.

RESULTS

Of an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03-1.50), intraoperative complications (AOR 1.45, 95% CI 1.20-1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35-1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64-2.10), costs (+10,400, 95% CI 6,900-14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00-1.23).

CONCLUSIONS

Care at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.

Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States

BACKGROUND

Hypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair.

METHODS

Adults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission.

RESULTS

Of 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission.

CONCLUSION

We used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians

BACKGROUND

Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population.

METHODS

Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes.

RESULTS

Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200).

CONCLUSION

Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

Textbook outcomes in heart transplantation: A quality metric for the modern era

BACKGROUND

Traditional quality metrics like one-year survival do not fully encapsulate the multifaceted nature of solid organ transplantation in contemporary practice. Therefore, investigators have proposed using a more comprehensive measure, the textbook outcome. However, the textbook outcome remains ill-defined in the setting of heart transplantation.

METHODS

Within the Organ Procurement and Transplantation Network database, the textbook outcome was defined as having: (1) No postoperative stroke, pacemaker insertion, or dialysis, (2) no extracorporeal membrane oxygenation requirement within 72 hours of transplantation, (3) index length of stay <21 days, (4) no acute rejection or primary graft dysfunction, (5) no readmission for rejection or infection, or re-transplantation within one year, and (6) an ejection fraction >50% at one year.

RESULTS

Of 26,885 heart transplantation recipients between 2011 to 2022, 9,841 (37%) achieved a textbook outcome. Following adjustment, textbook outcome patients demonstrated significantly reduced hazard of mortality at 5- (hazard ratio 0.71, 95% CI 0.65-0.78; P < .001) and 10-years (hazard ratio 0.73, CI 0.68-0.79; P < .001), and significantly greater likelihood of graft survival at 5- (hazard ratio 0.69, CI 0.63-0.75; P < .001) and 10-years (hazard ratio 0.72, CI 0.67-0.77; P < .001). Following estimation of random effects, hospital-specific, risk-adjusted rates of textbook outcome ranged from 39% to 91%, compared to a range of 97% to 99% for one-year patient survival. Multi-level modeling of post-transplantation rates of textbook outcomes revealed that 9% of the variation between transplant programs was attributable to inter-hospital differences.

CONCLUSION

Textbook outcomes offer a nuanced, composite alternative to using one-year survival when evaluating heart transplantation outcomes and comparing transplant program performance.

Disparate Utilization of Breast Conservation Therapy in the Surgical Management of Early-Stage Breast Cancer

BACKGROUND

Despite evidence suggesting oncologic equipoise of breast conservation therapy (BCT) for early-stage (stages I and II) breast cancer, mastectomy is still widely utilized.

PATIENTS AND METHODS

The 2004-2015 National Cancer Database was used to tabulate all adult women receiving mastectomy or BCT for early-stage breast cancer. Multivariable regression was used to evaluate factors associated with utilization of BCT, relative to mastectomy.

RESULTS

Of 1,079,057 women meeting study criteria, 57.4% underwent BCT. BCT patients were older and more commonly White, compared to mastectomy. They were more commonly privately insured, in the highest income quartile, and treated at metropolitan, nonacademic institutions. After adjustment, increasing age (AOR 1.01/year), Black race (AOR 1.21, Ref: White), and care at a community hospital (AOR 1.08, Ref: Academic; all P< .05) were associated with increased odds of undergoing BCT. Conversely, Asian or Pacific Islander (AAPI) race (AOR 0.74), Medicare (AOR 0.89) or Medicaid (AOR 0.95) coverage, and being in the lowest (AOR 0.95) and second lowest (AOR 0.98, all P< .05) income quartiles were associated with reduced odds of undergoing BCT. Finally, increasing tumor size (AOR 0.97, P< .05) was associated with decreased adjusted odds of undergoing BCT.

CONCLUSION

Our results suggest persistent socioeconomic and racial disparities in BCT utilization for early-stage breast cancer. Directed strategies should be implemented in order to reduce treatment inequality in this patient population.

Thyroid surgery outcomes in octogenarians: A national analysis

BACKGROUND

The incidence of thyroid pathology increases with age. Yet octogenarians may face increased rates of complications after thyroid surgery. Using a nationally representative cohort, we evaluated the outcomes of thyroidectomy among octogenarians.

METHODS

All patients ≥55 years who underwent inpatient thyroidectomy were identified using the 2010 to 2020 National Readmissions Database. Patients ≥80 years were classified as octogenarians (others: nonoctogenarians). Multivariable models were built to evaluate independent associations between octogenarians and key clinical and financial outcomes.

RESULTS

Of 120,164 hospitalizations, 9,163 (7.6%) were octogenarians. The proportion of octogenarians undergoing thyroidectomy increased from 7.7% (2010) to 8.7% (2020) (nptrend <0.001). Octogenarians were more frequently female (72.1 vs 70.5%, P < .001), presented with a higher Elixhauser comorbidity index (3 [2-4] vs 2 [1-3], P < .001), and more commonly faced thyroid cancer (41.3 vs 32.7%, P < .001). After risk adjustment, octogenarians were associated with greater odds of experiencing any perioperative complication (adjusted odds ratio 1.36, 95% confidence interval 1.25-1.48). Octogenarians were further linked with greater odds of respiratory (adjusted odds ratio 1.82, 95% confidence interval 1.52-2.17) and renal complications (adjusted odds ratio 1.90, 95% confidence interval 1.45-2.49), dysphagia (adjusted odds ratio 1.51, 95% confidence interval 1.33-1.72), laryngeal edema (adjusted odds ratio 2.03, 95% confidence interval 1.30-3.18), vocal cord paralysis (adjusted odds ratio 1.79, 95% confidence interval 1.53-2.09), and stridor (adjusted odds ratio 1.42, 95% confidence interval 1.01-2.00). No difference in hypocalcemia was observed. Furthermore, octogenarians demonstrated an increased likelihood of in-hospital mortality (adjusted odds ratio 6.34, 95% confidence interval 3.11-12.53), hospitalization expenditures (+$910, 95% confidence interval +$420-1,400), and nonelective readmission within 30 days of discharge (adjusted odds ratio 1.54, 95% confidence interval 1.32-1.79).

CONCLUSION

Octogenarians are associated with greater morbidity after thyroidectomy. Patients ≥80 years should be counseled about increased perioperative risk when discussing surgical versus nonsurgical treatments for thyroid disease.

Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals

OBJECTIVE

Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use.

METHODS

All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest.

RESULTS

Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs.

CONCLUSIONS

Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.

Expanding the heart donor pool: Can left ventricular assist devices substitute for marginal donor heart allografts?

BACKGROUND

Generally, heart transplantation with marginal donor allografts is reserved for a subset of high-risk patients. However, given the improved survival rates for patients on left ventricular assist devices, it is worth analyzing if they could potentially substitute for marginal donor allografts. This study aimed to compare survival outcomes of waitlisted patients with left ventricular assist devices who did not undergo heart transplantation to those who underwent heart transplantation with marginal allografts.

METHODS

This was a retrospective cohort study of adults (≥18 years) listed for heart transplantation between 2010 and 2022 in the Organ Procurement and Transplantation Network database. A previously validated risk score was used to define marginal donor organs. The primary outcome was death after transplantation or on the waitlist, as appropriate.

RESULTS

Of 5,713 patients with left ventricular assist devices, 4,683 (82%) comprised the left ventricular assist devices group and 1,030 (18%) the marginal group. The marginal cohort was older (57 [49-64] vs 55 [45-62] years, P < .001), similarly female (26 vs 24%, P = .16), and less often White (51 vs 60%, P < .001). Relative to the left ventricular assist devices group, the marginal group demonstrated higher 5-year survival from 2010 to 2014 (81 vs 43%, P < .001) and from 2015 to 2019 (77 vs 66%, P < .001). After adjustment, marginal patients demonstrated a significantly reduced hazard of 5-year mortality for those listed from 2010 to 2014 (hazard ratio 0.25, confidence interval 0.20-0.31; P < .001) and from 2015 to 2019 (hazard ratio 0.46, confidence interval 0.37-0.57; P < .001).

CONCLUSION

Our study validates the superiority of transplantation relative to left ventricular assist devices but also underscores the survival benefit of heart transplantation with marginal donor allografts, even in high-risk patients.

A contemporary analysis of the volume-outcome relationship for extracorporeal membrane oxygenation in the United States

BACKGROUND

A paradoxical increase in mortality following extracorporeal membrane oxygenation at high-volume centers has previously been demonstrated. We examined the association between annual hospital volume and outcomes within a contemporary, national cohort of extracorporeal membrane oxygenation patients.

METHODS

All adults requiring extracorporeal membrane oxygenation for postcardiotomy syndrome, cardiogenic shock, respiratory failure, or mixed cardiopulmonary failure were identified in the 2016 to 2019 Nationwide Readmissions Database. Patients undergoing heart and/or lung transplantation were excluded. A multivariable logistic regression with hospital extracorporeal membrane oxygenation volume parametrized as restricted cubic splines was developed to characterize the risk-adjusted association between volume and mortality. The volume corresponding to the maximum of the spline (43 cases/year) was used to categorize centers as low- or high-volume.

RESULTS

An estimated 26,377 patients met the study criteria, and 48.7% were managed at high-volume hospitals. Patients at low- and high-volume hospitals had similar age, sex, and rates of elective admission. Notably, patients at high-volume hospitals less frequently required extracorporeal membrane oxygenation for postcardiotomy syndrome but more commonly for respiratory failure. After risk adjustment, high-volume hospital status was associated with reduced odds of in-hospital mortality, relative to low-volume hospitals (adjusted odds ratio 0.81, 95% confidence interval 0.78-0.97). Interestingly, patients at high-volume hospitals faced a 5.2-day increment in length of stay (95% confidence interval 3.8-6.5) and $23,500 in attributable costs (95% confidence interval 8,300-38,700).

CONCLUSION

The present study found that greater extracorporeal membrane oxygenation volume was associated with decreased mortality but higher resource use. Our findings may help inform policies regarding access to and centralization of extracorporeal membrane oxygenation care in the United States.

Care Fragmentation After Hospitalization for Acute Myocardial Infarction

Care fragmentation (CF), or readmission at a nonindex hospital, has been linked to inferior clinical and financial outcomes for patients. However, its impact on patients with acute myocardial infarction (AMI) is unclear. This study investigated the prevalence and impact of CF on the outcomes of patients with AMI. All US adult (≥18 years) hospitalizations for AMI from January 2010 to November 2019 were identified using the Nationwide Readmissions Database. Patients were stratified by readmission at an index or nonindex center. Multivariable models were developed to evaluate factors associated with CF, and independent associations with mortality, complications, and resource utilization. A total of 413,819 patients with AMI requiring nonelective readmission within 30 days of discharge were included for analysis. Of these, 25.4% (n = 104,966) experienced CF. The incidence of CF increased from 2010 to 2019 (nptrend <0.001). After adjustment, patients insured by Medicaid faced higher odds of nonindex readmission. CF was associated with in-hospital mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] 1.01 to 1.18), and cardiac (AOR 1.12, 95% CI 1.03 to 1.22), respiratory (AOR 1.14, 95% CI 1.12 to 1.26), and infectious complications (AOR 1.14, 95% CI 1.07 to 1.22). Further, CF was linked to increased odds of nonhome discharge (AOR 1.18, 95% CI 1.11 to 1.24) and an additional ∼$5,000 in per-patient hospitalization costs (95% CI 4,260 to 5,100). Approximately 25% of AMI patients experienced CF, which was independently associated with excess mortality, complications, and expenditures. Given the growing national burden of cardiovascular disease, new efforts are needed to mitigate the significant clinical and financial implications of nonindex readmissions and improve value-based healthcare.