30-day Readmission Research Articles

Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality.

Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus. To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States. A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality. A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06). Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.

An analysis of length of stay and readmissions of COPD patients in the U.S. between 2010 and 2020

ABSTRACT Aim This study investigates the impact of hospital length of stay (LOS) on 30-day readmissions for Chronic Obstructive Pulmonary Disease (COPD) patients using a U.S. national dataset. It also aims to understand how discharge dispositions influence LOS and readmission risk trends and to offer valuable insights into the effectiveness of post-discharge care and its role in readmission outcomes. Methods Given the complexities of the relationship between LOS and readmissions, we employ instrumental variable (IV) analysis to mitigate potential biases. Our data cover 11 years to ensure the study's robustness and comprehensiveness. Results Our findings reveal that older, Medicare-insured patients, predominantly discharged routinely, constitute a significant portion of readmitted cases. Data visualization shows increasing readmission rates with extended LOS, particularly among patients discharged against medical advice. However, IV analysis indicates that longer LOS is associated with reduced readmission rates. Conclusions This study shows the critical role of insurance type, socio-economic factors, and hospital characteristics in determining both readmission rates and LOS among COPD patients. The results highlight the necessity for targeted interventions to reduce healthcare disparities, especially for Medicare and Medicaid beneficiaries. This study provides valuable insights for improving COPD patient care and addressing disparities in healthcare access and outcomes.

Impact of wearable device data and multi-scale entropy analysis on improving hospital readmission prediction.

Unplanned readmissions following a hospitalization remain common despite significant efforts to curtail these. Wearable devices may offer help identify patients at high risk for an unplanned readmission. We conducted a multi-center retrospective cohort study using data from the All of Us data repository. We included subjects with wearable data and developed a baseline Feedforward Neural Network (FNN) model and a Long Short-Term Memory (LSTM) time-series deep learning model to predict daily, unplanned rehospitalizations up to 90 days from discharge. In addition to demographic and laboratory data from subjects, post-discharge data input features include wearable data and multiscale entropy features based on intraday wearable time series. The most significant features in the LSTM model were determined by permutation feature importance testing. In sum, 612 patients met inclusion criteria. The complete LSTM model had a higher area under the receiver operating characteristic curve than the FNN model (0.83 vs 0.795). The 5 most important input features included variables from multiscale entropy (steps) and number of active steps per day. Data available from wearable devices can improve ability to predict readmissions. Prior work has focused on predictors available up to discharge or on additional data abstracted from wearable devices. Our results from 35 institutions highlight how multiscale entropy can improve readmission prediction and may impact future work in this domain. Wearable data and multiscale entropy can improve prediction of a deep-learning model to predict unplanned 90-day readmissions. Prospective studies are needed to validate these findings.

Machine Learning-Based Predictions of Mortality and Readmission in Type 2 Diabetes Patients in the ICU

Prognostic outcomes for patients with type 2 diabetes in the intensive care unit (ICU), including mortality and readmission rates, are critical for informed clinical decision-making. Although existing research has established a link between type 2 diabetes and adverse outcomes in the ICU, the potential of machine learning techniques for enhancing predictive accuracy has not been fully realized. This study seeks to develop and validate predictive models employing machine learning algorithms to forecast mortality and 30-day post-discharge readmission rates among ICU type 2 diabetes patients, thereby enhancing predictive accuracy and supporting clinical decision-making. Data were extracted and preprocessed from the MIMIC-III database, focusing on 14,222 patients with type 2 diabetes and their corresponding ICU admission records. Comprehensive information, including vital signs, laboratory results, and demographic characteristics, was utilized. Six machine learning algorithms—bagging, AdaBoost, GaussianNB, logistic regression, MLP, and SVC—were developed and evaluated using 10-fold cross-validation to predict mortality at 3 days, 30 days, and 365 days, as well as 30-day post-discharge readmission rates. The machine learning models demonstrated strong predictive performance for both mortality and readmission rates. Notably, the bagging and AdaBoost models showed superior performance in predicting mortality across various time intervals, achieving AUC values up to 0.8112 and an accuracy of 0.8832. In predicting 30-day readmission rates, the MLP and AdaBoost models yielded the highest performance, with AUC values reaching 0.8487 and accuracy rates of 0.9249. The integration of electronic health record data with advanced machine learning techniques significantly enhances the accuracy of mortality and readmission predictions in ICU type 2 diabetes patients. These models facilitate the identification of high-risk patients, enabling timely interventions, improving patient outcomes, and demonstrating the significant potential of machine learning in clinical prediction and decision support.

Clinical and utilization outcomes with short stay units vs hospital admission for lower risk decompensated heart failure: a systematic review and meta-analysis.

With over 1 million primary heart failure (HF) hospitalizations annually, nearly 80% of patients who present to the emergency department with decompensated HF (DHF) are hospitalized. Short stay units (SSU) present an alternative to hospitalization, yet the effectiveness of the SSU strategy of care is not well known. This study is to determine the effectiveness of a SSU strategy compared with hospitalization in lower-risk patients with DHF. Our primary outcome was a composite of 30-day mortality and re-hospitalization. Key secondary outcomes included 90-day mortality and re-hospitalization, costs, and 30-day days-alive-and-out-of-hospital (DAOOH). This is a systematic review and meta-analysis, following PRISMA guidelines. MEDLINE, EMBASE, CENTRAL, CINAHL, SCOPUS, and Web of Science were searched from inception through February 2024. Either randomized trials or comparative observational studies were included if they compared outcomes between low-risk ED DHF patients admitted to an SSU (defined as an observation unit with expected stay ≤ 48h) vs. admitted to the hospital. Two authors independently screened all titles and abstracts and then identified full texts for inclusion. Data extraction and risk of bias assessments were performed by two authors in parallel. The primary outcome was a composite of death or readmission within 30days, reported as relative risk (RR), where a RR < 1 favored the SSU strategy. Secondary outcomes included 90-day mortality and re-hospitalization, costs, and 1-month days-alive-and-out-of-hospital (DAOOH). Of the 467 articles identified by our search strategy, only 3 full text articles were included. In meta-analysis for the primary outcome of 30-day death or readmission, the RR was 0.95 (95% CI = 0.56 to 1.63; I2 = 0%) for patients randomized to SSU vs hospitalization (2 studies, 241 patients). There were only 2 total deaths at 30days in the 2 studies (total N = 258) which reported 30-day mortality, both in hospitalized patients. Only one study reported 90-day outcomes, showing no significant differences. Costs were lower in the SSU arm from one study, and 30-day DAOOH also favored SSU based on a single randomized trial. Based on very limited evidence, SSU provides similar efficacy for 30-day and 90-day mortality and readmission compared to hospitalization. An SSU strategy appears safe and may be cost effective.

Preoperative Congestive Heart Failure Is Associated with Higher 30-Day Myocardial Infarction and Pneumonia after Endovascular Repair of Abdominal Aortic Aneurysm

Introduction: Preoperative congestive heart failure (CHF) is associated with higher postoperative mortality and complications in noncardiac surgery. However, postoperative outcomes for patients with preoperative CHF undergoing endovascular aneurysm repair (EVAR) have not been thoroughly established. This study evaluated the effect of preoperative CHF on 30-day outcomes following nonemergent intact EVAR using a large-scale national registry. Methods: Patients who had infrarenal EVAR were identified in the ACS-NSQIP database from 2012 to 2022. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without preoperative CHF. Thirty-day postoperative outcomes were examined. Results: 467 (2.84%) CHF patients underwent intact EVAR. Meanwhile, 15,996 non-CHF patients underwent EVAR, where 2,248 of them were matched to all CHF patients. Patients with and without preoperative CHF had comparable 30-day mortality (3.02% vs. 2.62%, p = 0.64). However, CHF patients had higher myocardial infarction (3.02% vs. 1.47%, p = 0.03), pneumonia (3.23% vs. 1.73%, p = 0.04), 30-day readmission (p = 0.01), and longer length of stay (p < 0.01). Conclusion: While patients with and without preoperative CHF had comparable 30-day mortality rates, those with CHF faced higher risks of cardiopulmonary complications. Effective management of preoperative CHF may help prevent postoperative complications in these patients.

Transitions of Care From Hospital to Home: Can Continuous Glucose Monitoring Improve Outcomes for Patients With Diabetes?

The purpose of this study was to examine the impact of continuous blood glucose monitoring (CGM) on transitions of care as patients with diabetes are discharged from the hospital on insulin. This is a descriptive study with 2 cohorts of patients (transition to home with CGM and transition to home without CGM) who were assessed prior to discharge (baseline) and 30 days post discharge (follow-up). The key outcome measures were satisfaction with diabetes management, diabetes-related quality of life, frequency of blood glucose monitoring, and 30-day readmission rates. Patients in the CGM group reported significantly higher levels of satisfaction with diabetes self-care management and higher levels of diabetes-related quality of life compared to those patients discharged without CGM. The results of this study suggest that CGM enables a smoother transition from hospital to home for patients with diabetes placed on insulin at discharge. CGM was associated with higher satisfaction and diabetes-related quality of life, perhaps as a result of timely, ongoing information about glucose levels without the burden and pain of finger sticks. CGM may provide greater confidence in self-care decisions regarding insulin dosing, food intake, and exercise. Further research is needed to confirm our results and explore the additional factors associated with greater quality of life and satisfaction.

Heterogeneity in the surgical approach to recurrent abdominal wall hernias: an opportunity for quality improvement.

Despite being a challenging and morbid clinical problem, operative approaches to recurrent abdominal wall hernia repairs receive little attention. Given this, we performed a retrospective study to evaluate surgical techniques of recurrent abdominal wall hernias requiring reoperation. Adult patients from the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR) were included in this study. All elective ventral hernia operations performed between January 1, 2020, and March 31, 2023, were included. Descriptive analyses via t-tests and Fisher exact tests were conducted to evaluate sociodemographic, operative, and hernia-specific attributes associated with primary and recurrent hernia repairs. We identified 8587 patients who underwent elective abdominal wall hernia repair. Of these, 7887 (91.8%) underwent primary repair, and 700 (8.2%) underwent recurrent repair. Patients who underwent recurrent hernia repair were older (mean age 57.9years vs. 54.1years, p < 0.001), more often female (53.8% vs. 41.9%, p < 0.001), and had higher BMI (34.0 vs. 32.6, p < 0.001). Patients with recurrent hernias were more likely to have comorbid conditions including hypertension (p < 0.001), diabetes (p < 0.005), COPD (p < 0.01), and BMI > 40 (p < 0.05). Recurrent hernia repairs were more likely to have any 30-day complication (6.4% versus 1.9%, p < 0.001), including higher rates of all surgical site infections. There was no difference in 30-day readmission rates. Considerable variation persists in operative management of recurrent abdominal wall hernias. Importantly, not all recurrent hernias were managed with mesh, which may precipitate additional recurrences and further morbidity. Understanding outcomes for these varied approaches to recurrent hernia repairs is critical to optimize management of this complex clinical problem and prevent future episodes of recurrence.

Clinical Outcomes in Relation to Total Hospital Surgical and Transcatheter Aortic Valve Replacement Volumes.

There is a paucity of data regarding the relationship between overall hospital volumes for total aortic valve replacement (AVR; transcatheter AVR [TAVR] or surgical AVR [SAVR]) and patient outcomes. We queried the 2019 Nationwide Readmission Database for patients undergoing AVR. Based on procedural volumes of TAVR or SAVR, we classified hospitals as high (≥50th percentile) or low (<50th percentile) volume centers and categorized hospitals as high TAVR/high SAVR, high TAVR/low SAVR, high SAVR/low TAVR, and low TAVR/low SAVR. Multivariable regression models were employed. The main study outcomes were in-hospital mortality and 30-day readmission after total AVR. Our final analysis included 72 123 patients undergoing AVR at 400 hospitals across the United States. The median (interquartile range) hospital procedural volumes for total AVR, TAVR, and SAVR were 137 (86-210), 82 (50-127), and 56 (31-87) procedures, respectively. There was an inverse correlation between hospital procedural volumes of AVR, TAVR, or SAVR and in-hospital mortality after total AVR but not with 30-day readmission. Using high TAVR/high SAVR hospitals as reference, there was higher in-hospital mortality after total AVR among low TAVR/low SAVR hospitals (adjusted odds ratio [OR], 1.29 [95% CI, 1.07-1.56]) but similar in-hospital mortality among high TAVR/low SAVR hospitals and low TAVR/high SAVR volumes. There was no difference in 30-day readmission rates after total AVR among the 4 hospital categories. Nationwide data revealed that in-hospital mortality after total AVR (SAVR or TAVR) is inversely related to hospital total volumes of AVR. Patients with aortic stenosis have better outcomes if they are managed among experienced centers with high case volumes of both TAVR and SAVR.

Addressing Social Determinants of Health in Primary Care Patients May Reduce Hospital Readmissions: A Quasi-Experimental Study.

Health care systems are increasingly partnering with community-based organizations to address social determinants of health (SDH). We established a program that educates and connects patients with SDH needs at a primary care clinic to community services and facilitated referrals. To evaluate the effect of addressing SDH soon after discharge on hospital readmission in a clinic population. Pre/post, quasi-experimental design with longitudinal data analysis for quality improvement. Clinic patients (n = 754) having at least one hospital discharge between June 1, 2020, and October 31, 2021, were included. Of these, 145 patients received the intervention and 609 served as comparison. A primary care liaison was employed to assess and educate recently discharged clinic patients for SDH needs and refer them for needed community services from June 1, 2020, to October 31, 2021. Hospital readmissions within 30, 60, and 90days of discharge were tracked at 6-month intervals. Covariates included patient age, sex, race/ethnicity, insurance status, income, Hierarchical Condition Category risk scores, and Clinical Classification Software diagnosis groups. Data for all hospital discharges during the intervention period were used for the main analysis and data for the year before the intervention were extracted for comparison. Overall, patients in the intervention group were older, sicker, and more likely to have public insurance. The reductions in 30-, 60-, and 90-day readmissions during the intervention period were 14.39%, 13.28%, and 12.04% respectively in the intervention group, while no significant change was observed in the comparison group. The group difference in reduction over time was statistically significant for 30-day (Diff = 12.54%; p = 0.032), 60-day (Diff = 14.40%; p = 0.012), and 90-day readmissions (Diff = 14.71%; p = 0.036). Our findings suggest that screening clinic patients for SDH, and educating and connecting them to community services during post-hospital care may be associated with reductions in hospital readmissions.

Conquering the common bile duct: outcomes in minimally invasive transcystic common bile duct exploration versus ERCP.

Given the increasing interest for surgeons to reclaim the common bile duct in managing choledocholithiasis, there is a growing movement to perform common bile duct exploration (CBDE). Advantages of concomitant CBDE with cholecystectomy include fewer anesthetic events and decreased length of stay. As there is a paucity of literature evaluating the use of the robotic platform for CBDE, our study aims to compare intraoperative and post-operative outcomes between robotic-assisted one-stage and two-stage management of choledocholithiasis. A retrospective chart review was performed from May 1, 2022 to December 31, 2023, identifying patients with choledocholithiasis who underwent robot-assisted laparoscopic cholecystectomy and transcystic CBDE with choledochoscopy (one-stage management). Preoperative, intraoperative, and post-operative variables were compared to a control group of subjects with choledocholithiasis who underwent laparoscopic cholecystectomy with pre- or post-operative ERCP (two-stage management). Statistical analysis was performed using Chi-squared, Fisher's exact, Student's T, or Mann-Whitney test. Fifty-three subjects who underwent one-stage management and 101 subjects who underwent two-stage management met inclusion criteria. Groups had similar demographics and medical history. Time to CBD clearance (45.2h vs 47.0h, p = .036), total length of stay (3.9days vs 5.1days, p = .007), fluoroscopy time (70.3s vs 151.4s, p < .001), and estimated radiation dose (23.0mSv vs 40.3mSv, p = .002) were significantly lower in the one-stage group compared to two-stage. Clearance rates, complication rates, and 30-day readmission rates were similar for both groups. Total length of stay and radiation exposure remained significantly lower on subanalysis comparing one-stage management to two-stage management with ERCP either before or after cholecystectomy. Robotic-assisted laparoscopic cholecystectomy with transcystic common bile duct exploration via choledochoscopy is a safe and feasible option in the management of choledocholithiasis. It offers a shorter time to duct clearance, shorter length of stay, and less radiation exposure when compared to two-stage management.

Unplanned hospital readmission after cholecystectomy in adults with cerebral palsy.

Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy. Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates. A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1days. After open cholecystectomy, 30 and 90day readmission rates were 16.9% and 30.3% with an average LOS of 14.6days. Infection was the most common cause for 30 and 90day readmission. Factors associated with 30day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition. Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures.

Efficacy and safety of the VASCADE® MVP venous vascular closure device in patients undergoing percutaneous left atrial appendage occlusion with WATCHMAN.

The VASCADE MVP venous vascular closure system is commonly used for percutaneous venotomy closure in catheter-based procedures utilizing sheath sizes 6-12 French. However, its application with larger sheaths such as ones required in left atrial appendage occlusion (LAAO) has yet to be explored. This study compared the efficacy and safety of VASCADE MVP versus conventional Figure-of-8 sutures (Fo8) for femoral venotomy closure in patients undergoing Watchman LAAO. This single-center retrospective analysis included patients who underwent post-LAAO femoral venotomy closure with either VASCADE MVP or Fo8 sutures. The primary efficacy endpoint was time to hemostasis (TTH). Primary safety endpoints were 30-day access site-related readmissions and major complications. Minor access-site-related complications were also assessed. 107 patients underwent post-LAAO femoral venotomy closure with VASCADE MVP, of which 101 were successful (94.4%). 99 patients underwent conventional closure with Fo8 sutures and supplemental manual pressure. Baseline characteristics were similar between groups. TTH was significantly shorter with VASCADE MVP (152.9 vs. 335.8 s, p = 0.001). Major safety outcomes were comparable. However, the conventional group experienced a higher incidence of ecchymosis (16.2% vs 4.7%, p = 0.007) and 30-day all-cause readmission (18.2% vs 8.4%, p = 0.038). VASCADE MVP significantly reduced TTH compared to Fo8 sutures after LAAO. While demonstrating a similar safety profile, VASCADE MVP may offer a more efficient approach to femoral vein closure in this patient population.

Assessment of mechanical bowel preparation prior to nephrectomy in the minimally invasive surgery era: insights from a national database analysis in the United States.

This study was performed to evaluate the association between mechanical bowel preparation (MBP) and perioperative outcomes following nephrectomy in the minimally invasive surgery (MIS) era. All partial and radical nephrectomies between 2019 and 2021 from the National Surgical Quality Improvement Program database were evaluated. Thirty-day perioperative outcomes were compared between groups where MBP was performed vs. not, in both the MIS and open surgery (OS) cohorts. A propensity score matching technique was utilized within MIS cases to control for covariates. The chi-square and t tests were used to determine significance. A total of 11,869 cases met the inclusion criteria and were included in the analysis. Of these, 8,204 (69.1%; comprising 65.3% robotic and 34.7% laparoscopic) underwent MIS, while 3,655 (30.9%) underwent OS. The rate of MBP was higher in the MIS group (16.0% vs. 10.0%, p < 0.001). Within the MIS group, MBP was associated with reduced rates of postoperative ileus (0.9% vs. 1.9%, p = 0.02), while other complications were comparable. Propensity score matching showed no association between MBP and postoperative ileus. However, a lower rate of 30-day readmission in the MBP group became statistically significant (4.4% vs. 6.4%, p = 0.01). Conversely, patients in the MBP group also demonstrated higher rates of pneumonia (1.29% vs. 0.46%, p = 0.002) and pulmonary embolism (0.6% vs. 0%, p < 0.001) after matching. MBP practice prior to nephrectomy is infrequent in both OS and MIS cases, with minor differences in perioperative outcomes for patients undergoing MIS. Routine MBP should continue to be excluded from the standard of care for nephrectomy in the MIS era.

Mapping Segregation Patterns of Hospital Care among Patients with Limited English Proficiency.

Individuals with limited English proficiency (LEP) are disproportionately more likely to experience suboptimal care outcomes compared to English-proficient individuals, attributed to multi-level social determinants of health, including the quality of the hospital where LEP patients are more likely to receive care. Evidence demonstrates that racial minority patients are more often admitted to lower-quality hospitals serving high proportions of minority patients, despite living closer to higher-quality hospitals. Less is known about where individuals with LEP reside, where they seek hospital care, and the quality of care in these hospitals. Using Geographic Information Systems (GIS) methods, we developed a density map characterizing residential patterns of the LEP population across zip code tabulation areas in New Jersey and designated hospitals as high, middle, or low-LEP volume. We described differences in 30-day hospital wide readmission rates for hospitals across varying LEP volume status using Centers for Medicare and Medicaid Services Hospital Care Compare Data. Most hospitals in ZCTAs with higher LEP populations serve a high proportion of LEP patients (i.e. their patients' demographics are reflective of the community in which they are located). However, our results also show instances in which LEP patients may be forgoing receiving care at closer hospitals to instead receive care at further-distanced, high-LEP volume hospitals. significant. High-LEP volume hospitals have higher 30-day hospital wide readmission rates (20.1%) compared to middle (15%) and low (11.3%)-LEP volume hospitals (p < .001), indicating lower quality of care within high-LEP volume hospitals.

The impact of facility type on surgical outcomes in colon cancer patients: analysis of the national cancer database.

The type of facility wherepatients with colon cancer are treated may play a significant role in their outcomes. We aimed to investigate the influence of facility types included in the National Cancer Database (NCDB) on surgical outcomes of colon cancer. Retrospective cohort analysis of all patients with stage I-III colon cancer included in the NCDB database between 2010 and 2019 was performed. Patients were grouped based on facility type: Academic/Research Programs (ARP), Community Cancer Programs (CCP), Comprehensive Community Cancer Programs (CCCP), and Integrated Network Cancer Programs (INCP). Studyoutcomes included overall survival, 30- and 90-day mortality, 30-day readmission and conversion to open surgery. 125,935 patients were included with a median age of 68.7years (50.5% females). Most tumors were in the right colon (50.6%). Patient were distributed among facility types as ARP (n = 34,321, 27%), CCP (n = 12,692, 10%), CCCP (n = 54,356, 43%), and INCP (n = 24,566, 19%). In terms of surgical approach, laparoscopy was more commonly used in ARP (46%) (p < 0.001). Laparotomy was more common in CCP (58.7%) (p < 0.001), and conversely, CCP had the least amount of robotic surgery (3.9%) (p < 0.001). Median overall survival was highest in ARP (129months, 95% CI 127.4-134.1) and lowest in CCP (103.7months, 95% CI 100.1-106.7) (p < 0.001). Conversion rates were comparable between ARP (12%), CCCP (12%) and INCP (11.8%) but were higher in CCP (15.5%) (p < 0.001). 30-day readmission rates and 30-day mortality rates were significantly lower in ARP compared to other facility types (p < 0.001). Our findings display differences in surgical outcomes of colon cancer patients among facility types. The findings suggest better outcomes in terms of operative access and survival at ARP as compared to other facilities. These findings underscore the importance of understanding facility-specific factors that may influence patient outcomes and can guide resource allocation and targeted interventions for improving colon cancer care.

Concomitant hiatal hernia repair with transoral incisionless fundoplication for the treatment of refractory gastroesophageal reflux disease: a systematic review.

Transoral incisionless fundoplication (TIF) is safe and effective in select patients with hiatal hernias ≤ 2 cm with refractory gastroesophageal reflux disease (GERD). For patients with hiatal hernias > 2 cm, concomitant hiatal hernia (HH) repair with TIF (cTIF) is offered as an alternative to conventional anti-reflux surgery (ARS). Yet, data on this approach is limited. Through a comprehensive systematic review, we aim to evaluate the efficacy and safety of cTIF for managing refractory GERD in patients with hernias > 2 cm. We conducted a systematic review of studies evaluating cTIF outcomes from PubMed, EMBASE, SCOPUS, and Cochrane databases up to February 14, 2024. Primary outcomes included complete cessation of proton pump inhibitors (PPIs). Secondary outcomes included objective GERD assessment, adverse events, and treatment-related side effects. Pooled analysis was employed wherever feasible. Seven observational studies (306 patients) met the inclusion criteria. Five were retrospective cohort studies and two were prospective observational studies. The median rate of discontinuation of PPIs was 73.8% (range 56.4-94.4%). Significant improvements were observed in disease-specific, validated GERD questionnaires. The median rate for complications was 4.4% (range 0-7.9%), and the 30-day readmission rate had a median of 3.3% (range 0-5.3%). The incidence of dysphagia was 11 out of 164 patients, with a median of 5.3% (range 0-8.3%), while the incidence of gas bloating was 15 out of 127 patients, with a median of 6.9% (range 0-13.8%). Current data on cTIF suggests a promising alternative to ARS with comparable short-term efficacy and safety profile for managing refractory GERD with a low side effect profile. However, longer-term data and comparative efficacy studies are needed.

Procedural volume is linearly associated with mortality, major complications, and readmissions in patients undergoing malignant brain tumor resection.

Improved outcomes have been noted in patients undergoing malignant brain tumor resection at high-volume centers. Studies have arbitrarily chosen high-volume dichotomous cutoffs and have not evaluated volume-outcome associations at specific institutional procedural volumes. We sought to establish the continuous association of volume with patient outcomes and identify cutoffs significantly associated with mortality, major complications, and readmissions. We hypothesized that a linear volume-outcome relationship can estimate likelihood of adverse outcomes when comparing any two volumes. The patient cohort was identified with ICD-10 coding in the Nationwide Readmissions Database(NRD). The association of volume and mortality, major complications, and 30-/90-day readmissions were evaluated in multivariate analyses. Volume was used as a continuous variable with two/three-piece splines, with various knot positions to reflect the best model performance, based on the Quasi Information Criterion(QIC). From 2016 to 2018, 34,486 patients with malignant brain tumors underwent resection. When volume was analyzed as a continuous variable, mortality risk decreased at a steady rate of OR 0.988 per each additional procedure increase for hospitals with 1-65 cases/year(95% CI 0.982-0.993, p < 0.0001). Risk of major complications decreased from 1 to 41 cases/year(OR 0.983, 95% CI 0.979-0.988, p < 0.0001), 30-day readmissions from 1 to 24 cases/year(OR 0.987, 95% CI 0.979-0.995, p = 0.001) and 90-day readmissions from 1 to 23 cases/year(OR 0.989, 95% CI 0.983-0.995, p = 0.0003) and 24-349 cases/year(OR 0.9994, 95% CI 0.999-1, p = 0.01). In multivariate analyses, institutional procedural volume remains linearly associated with mortality, major complications, and 30-/90-day readmission up to specific cutoffs. The resulting linear association can be used to calculate relative likelihood of adverse outcomes between any two volumes.

Safety and Outcomes of Reoperative Robotic Tricuspid Valve Surgery.

Reoperative surgery for isolated tricuspid valve (TV) pathology has been associated with high morbidity and mortality rates; however, the current guidelines recommend intervention for severe, symptomatic TV regurgitation or mild to moderate symptoms with progressive right ventricular dysfunction. There are minimal data regarding reoperative intervention for TV disease. Similarly, there are no large series describing robot-assisted reoperative TV surgery. Institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database data were used to identify patients with previous cardiac surgery undergoing robot-assisted TV surgery from 2017 to 2022 from 2 tertiary referral hospitals. Patient demographics, preoperative characteristics, disease progression, operative details, and outcomes were analyzed. The primary outcome was 30-day mortality. Secondary outcomes were 30-day readmission, length of stay, and adverse events. Descriptive and summative statistics were used to describe clinical data and examine differences in outcomes of patients with primary versus secondary etiology using bivariate analyses. Twenty-four patients were divided into 2 arms, primary TV pathology and secondary dysfunction due to comorbid cardiac conditions. The overall mortality was 8.3%. Major complications, including respiratory failure, renal failure, and reoperation were 12.5%, 8.3%, and 8.3%, respectively. No permanent pacemakers were required, and the 30-day readmission rate was 4.5%. Reoperative robotic TV surgery is a safe and viable alternative to traditional sternotomy for both primary and secondary TV pathology. TV repair and replacement are possible using the minimally invasive technique. The morbidity and mortality rates are acceptable when compared with traditional approaches with decreased need for pacemaker placement in the minimally invasive approach.

One Year Patient Reported Outcomes After Single-Level Lumbar Fusion at Orthopedic Specialty Hospital Compared to Tertiary Referral Center

Lumbar spinal fusion is an increasingly common operation to treat symptoms related to degenerative disorders of the spine including radiculopathy and pain. As the volume of spine surgeries grows, it is becoming increasingly common for procedures to take place in non-tertiary care centers, including orthopaedic specialty hospitals (OSH). While previous research demonstrates that surgical outcomes at an OSH are non-inferior to those at a tertiary referral center (TRC), the implications of this difference on patient-reported outcome measures (PROMs) have not been sufficiently assessed. The objectives of this study were (1) to determine if changes in patient reported outcome measures (PROMs) after elective lumbar spinal fusion surgery differ between patients who undergo surgery at an orthopedic specialty hospital (OSH) and those who undergo surgery at a tertiary referral center (TRC) and (2) to characterize differences in short-term outcomes between hospitals. Retrospective cohort study. Adult patients (≥ 18 years old) who underwent primary, elective single-level posterior lumbar decompression and fusion between January 2014 and December 2021 at a tertiary referral center or an orthopaedic specialty hospital. PROMs: Oswestry Disability Index (ODI), Short-form 12 (SF12) Mental Component Summary (MCS); SF12 Physical Component Summary (PCS); Visual Analogue Back and Leg (VAS Back/Leg) METHODS: PROMs were collected preoperatively, 6 months after surgery, and 1 year after surgery. Six-month and 1-year delta PROM values were calculated by subtracting the preoperative PROM score from the 6-month or 1-year score, respectively. Multivariable linear regression analyses were conducted to assess the independent effect of hospital location on postoperative PROM scores. A total of 288 patients were identified as part of the study cohort including 205 patients who underwent surgery at the tertiary hospital and 83 patients who underwent surgery at the OSH. OSH patients had shorter length of stay (1.57 ± 0.72 vs. 3.28 ± 1.32, p<0.001), however there was no difference in discharge disposition or 90-day readmission rates between hospitals (p>0.05). At 6 months, having surgery at the specialty hospital was associated with higher PCS (estimate = 2.96, confidence interval: 0.21 - 5.71, p=0.035). At 1-year postoperatively, the location of surgery no longer demonstrated significant associations with PROM scores. Preoperative PROM scores demonstrated significant associations with 6-month and 1-year scores for each PROM (p<0.05) except VAS leg at 6 months postoperatively. To our knowledge, this is one of the largest studies investigating PROMs at OSH versus TRCs for single-level lumbar fusions. We demonstrated that at one-year follow-up, there is not a significant difference in PROM improvement between patients who undergo surgery at a TRC and patients who do so at an OSH.