30-day Readmission Research Articles

An Assessment of Adverse Events in Patients with 22q11.2 Deletion Syndrome Undergoing Palatoplasty: An Analysis of the NSQIP Pediatric Database.

The National Surgical Quality Improvement Program (NSQIP) Pediatric database has been used to identify factors related to adverse surgical outcomes in pediatric and craniofacial surgical procedures. Focusing on a historically "higher-risk" population, our aim was to assess the impact of demographics, comorbidities, and 22q11.2 deletion syndrome (22QDS) diagnosis on 30-day postoperative complications in patients undergoing primary palatoplasty. We used the 2012-2020 NSQIP Pediatric database to identify patients ≤3 years with and without 22q11.2 deletion syndrome who underwent primary palatoplasty. Demographics, comorbidities, and perioperative characteristics were compared between those with and without 22QDS. Logistic regression was used to determine if children with 22QDS were more likely to experience a 30-day postoperative complication or readmission. There were 10,745 patients ≤3 years old who underwent primary palatoplasty; 83 (0.8%) of whom had 22QDS and 10,662 (99.8%) did not. Children with 22QDS were older when they underwent primary palatoplasty and more likely to have comorbidities. A total of 513 patients (4.8%) experienced a postoperative complication within 30 days and 255 were readmitted (2.4%). Of the 513, 8 (9.6%) had a 22QDS diagnosis and 505 (4.7%) did not. A diagnosis of 22QDS was not a significant independent risk factor for a complication (adjusted odds ratio (aOR) = 1.13; 95% confidence interval (CI): 0.50-2.54) or readmission (aOR = 1.74; 95% CI: 0.74-4.13) within 30 days. This study found that the diagnosis of 22QDS was not an independent predictor of post-palatoplasty complication risk, and in fact 30-day complications are rare for those patients undergoing cleft palate repair, even among those patients with 22QDS.

PAs and NPs in liver transplantation: Perceptions, implementation, and effect.

This study assessed the use and perceptions of physician associates/assistants (PAs) and NPs at liver transplant centers and sought to determine their financial effect. Leaders of liver transplant programs performing 25 or more transplants in 2020 were contacted to complete an 11-question survey about the role and effect of PAs and NPs in liver transplant. A single-center retrospective analysis compared length of stay (LOS) and readmission rates for primary liver transplants and simultaneous liver-kidney transplants before and after a dedicated PA team was established. Chi-square and t-test analyses were performed. The survey achieved a 77% response rate, and 98% of institutions reported using PAs and NPs. The single-center study found the mean LOS post-transplant was significantly shorter in the post-PA cohort (P = .0005). No significant difference was found in 30-day readmission rates. PAs and NPs are used broadly across the post-liver transplant care continuum. Using LOS as a surrogate financial marker suggests that a dedicated PA and NP team may contribute to cost savings.

Corticosteroid Prescribing Patterns in the Emergency Department for Acute COPD Exacerbations: A Retrospective Analysis Following an Educational Intervention.

COPD is a progressive lung disease with marked airflow limitation. It has a large global prevalence and is managed with antibiotics, bronchodilators, and corticosteroids. Despite the prevalence, corticosteroid prescribing regimens differ widely amongst providers. This study aims to evaluate baseline corticosteroid prescribing patterns, the ability to change corticosteroid prescribing patterns with the utilization of an educational initiative, and to evaluate the effect of corticosteroid dose on length of stay, 30-day hospital readmission, mortality, and total hospital insulin dosing. This study was conducted via a retrospective observational study. Providers at a single institution answered a baseline questionnaire on COPD corticosteroid prescribing patterns and subsequently received an educational presentation regarding evidence-based corticosteroid recommendations. Data were then retrospectively obtained and analyzed evaluating corticosteroid prescribing patterns both pre- and post-educational intervention. Data were analyzed using IBM SPSS Version 25. The provider survey revealed that most (95.3%) administered 125 mg of methylprednisolone to patients treated for AECOPD. The most common reason a particular dose of corticosteroid was administered was due to previous teaching or practice patterns. The mean initial steroid dose of methylprednisolone decreased following the educational initiative from 114.24 mg to 72.8 mg (p < 0.01). This corresponded to a 69% (n=41) decrease of providers using 125 mg methylprednisolone (p < 0.01), and increased prescribing of 62.5 mg methylprednisolone by 42.6% (n=66). The mean LOS following hospital admission for AECOPD in the pre-intervention group was 5.80 days, while the mean LOS following the targeted educational intervention decreased to 4.82 days (p = 0.01). The implementation of an educational intervention may change provider corticosteroid prescribing patterns. Additionally, lower corticosteroid dose in the Emergency Department may decrease patient length of stay. Keywords: Corticosteroid, COPD, LOS, recommendations, steroid.

Are our patients becoming more complex? Trends in comorbidity and functional dependence in General Medicine 2011-2019.

Anecdotally, patients don't seem to be more unwell than they were 10 years ago, yet they still seem more 'complex'. The aim of this study was to use an objective measure to assess the trend in complexity of general medicine patients over a 9-year period. Complexity was pragmatically defined as a composite of comorbidity plus dependence/frailty. We selected 100 consecutive patients discharged from General Medicine at Monash Medical Centre (a tertiary hospital in Melbourne, Australia) in the month of April of each year from 2011 to 2019. For each patient, we retrospectively calculated their burden of comorbidity and their degree of dependency/frailty. Comorbidity was measured using the Charlson Comorbidity Index (CCI), and dependence/frailty was assessed using the Katz Index of Independence in Activities of Daily Living (Katz ADL) and the Braden Scale (BS). The BS is a pressure injury risk assessment tool. Additional demographic data were collected, including length of stay, admission and discharge residence, 30-day readmission rate and inpatient mortality. There was no statistically significant change in the CCI or the Katz ADL. The median BS did however significantly decrease from 19 in 2011 to 16 in 2019 (P = 0.006), reflecting an increased risk of pressure injuries. Despite a stable level of comorbidity, our finding of a decreasing BS score may suggest that patients are becoming more dependent. This increase in dependency rather than a change in chronic disease burden may be the cause of apparent increasing patient complexity.

ThP4.11 - Preoperative respiratory disease and outcomes of pancreatoduodenectomy performed for malignancy

Abstract Background Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy for malignancy (PD) remains a high-risk operation. Patients with pre-existing respiratory disease are likely to be at increased risk of developing postoperative complications but few prior studies have investigated this. This may be as few patients with significant respiratory pathology are considered appropriate surgical candidates. This study aimed to compare PD outcomes in patients with a prior respiratory condition to those without. The outcomes of interest were median length of stay (LoS), 30-day readmission, 90-day mortality, unplanned return to theatre rate and five-year survival. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing respiratory disease included a prior diagnosis of: asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pulmonary embolism, asbestosis, obstructive sleep apnoea, pleural effusion, tuberculosis, pulmonary sarcoidosis, pneumoconiosis or hypersensitivity pneumonitis. The Mann-Whitney U test and Fisher exact test were used to compare the two groups. Results Out of a total of 1484 cases, 142 patients (9.6%) had a pre existing respiratory comorbidity. Asthma and COPD both affected 4.2% of patients. All other included pathologies affected less than one percent of patients. 30-day readmission (8.5% vs 9.1%, p=0.1), 90-day mortality (1.4% vs 3.7%, p=0.2), and unplanned return to theatre rate (3.5% vs 5.1%, p=0.5) were similar between the two groups, however, median LoS was significantly longer in those with a prior respiratory disease (14 vs 13 days, p&amp;lt;0.0001). Five-year survival was also higher in those without respiratory disease but this was not statistically significant (24.6% vs 32.5%, p=0.06). Conclusion In our multicentre study of patients with confirmed malignancy, PD patients with a preoperative respiratory disease had significantly longer length of stay. There was a trend towards lower 5-year survival.

SP4.14 - Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

Abstract Aims The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) reducing the risk of early recurrence. The MANCTRA-1 project disclosed a discrepancy in translating this evidence into clinical practice, estimating a 35 to 70% probability of narrowing this gap within 2025. This study assesses the safety of suboptimal ELC implementation in MABP, looking for risk factors for recurrent acute biliary pancreatitis (ABP) in patients awaiting interval cholecystectomy after an uneventful episode of MABP. Methods We conducted a post hoc analysis of the MANCTRA-1 registry. Clinicaltrials.gov ID NCT04747990. We included MABP patients who did not undergo ELC during the index hospitalization, excluding those who experienced disease-related complications. The primary outcome was the 30-day hospital readmission rate due to ABP recurrence. We performed univariable and multivariable logistic regression to identify risk factors for 30-day ABP recurrence. Results Between January 2019 and December 2020, a total of 2,253 MABP patients from 150 centres were included. The 30-day readmission rate due to ABP recurrence was 6%. The multivariable logistic regression showed that admission to a medical ward (internal medicine or gastroenterology) odds ratio (OR) 1.62 (95%[CI] 1.1;2.37), p=0.01 was an independent risk factor for 30-day ABP recurrence. Conclusion Our real-world analysis provides valuable insights to manage MABP, particularly in centres where ELC strategies cannot be fully implemented due to organizational and clinical constraints. Despite the admitting ward, it underscores the importance of timely access to surgical care in reducing the risk of early recurrence, disclosing the need to implement surgical consultation pathways in ABP care bundles.

Lactated Ringer vs Normal Saline Solution During Sickle Cell Vaso-Occlusive Episodes

Sickle cell disease (SCD), a clinically heterogenous genetic hemoglobinopathy, is characterized by painful vaso-occlusive episodes (VOEs) that can require hospitalization. Patients admitted with VOEs are often initially resuscitated with normal saline (NS) to improve concurrent hypovolemia, despite preclinical evidence that NS may promote erythrocyte sickling. The comparative effectiveness of alternative volume-expanding fluids (eg, lactated Ringer [LR]) for resuscitation during VOEs is unclear. To compare the effectiveness of LR to NS fluid resuscitation in patients with SCD and VOEs. This multicenter cohort study and target trial emulation included inpatient adults with SCD VOEs who received either LR or NS on hospital day 1. The Premier PINC AI database (2016-2022), a multicenter clinical database including approximately 25% of US hospitalizations was used. The analysis took place between October 6, 2023, and June 20, 2024. Receipt of LR (intervention) or NS (control) on hospital day 1. The primary outcome was hospital-free days (HFDs) by day 30. Targeted maximum likelihood estimation was used to calculate marginal effect estimates. Heterogeneity of treatment effect was explored in subgroups. A total of 55 574 patient encounters where LR (n = 3495) or NS (n = 52 079) was administered on hospital day 1 were included; the median (IQR) age was 30 (25-37) years. Patients who received LR had more HFDs compared with those who received NS (marginal mean difference, 0.4; 95% CI, 0.1-0.6 days). Patients who received LR also had shorter hospital lengths of stay (marginal mean difference, -0.4; 95% CI, -0.7 to -0.1 days) and lower risk of 30-day readmission (marginal risk difference, -5.8%; 95% CI, -9.8% to -1.8%). Differences in HFDs between LR and NS were heterogenous based on fluid volume received: among patients who received less than 2 L, there was no difference in LR vs NS; among those who received 2 or more L, LR was superior to NS. This cohort study found that, compared with NS, LR had a small but significant improvement in HFDs and secondary outcomes including 30-day readmission. These results suggest that, among patients with VOEs in whom clinicians plan to give volume resuscitation fluids on hospital admission, LR should be preferred over NS.

ThP4.4 - Is it always just a Whipple? A not insignificant number of patients require a concomitant procedure at the time of pancreatoduodenectomy

Abstract Background Some patients may need to undergo an additional procedure at the time of their pancreatoduodenectomy (PD). This study aimed to investigate the proportion of patients that this includes and to describe the additional procedures that these patients undergo. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study (29 centres from eight countries, n=1484). The group that underwent a concomitant procedure was compared to the group that did not (chi-squared test). Results Out of 1484 PD patients, 79 (5.3%) underwent a concomitant procedure (seven excluded due to missing data). This was most commonly: right hemicolectomy (14, 17.7%), liver excision biopsy (12, 15.2%), appendicectomy (11, 13.9%), adhesiolysis (6, 11.4%), cholangioscopy (5, 6.3%), incisional/ventral hernia repair (5, 6.3%), diagnostic laparoscopy (5, 6.3%) and splenectomy (5, 6.3%). When those who underwent an additional procedure were compared to those who did not, length of stay (both 13 days, p=0.7), as well as rates of return to theatre (7.6% vs 4.9%, p=0.3), 90-day mortality (5.1% vs 3.6%, p=0.5) and five-year survival (38.0% vs 31.5%) did not differ significantly. However, 30-day readmission was significantly higher among those who underwent a concomitant procedure (16.4% vs 8.7%, p=0.02). Conclusion In our multicentre study of PD outcomes, 5.3% of patients underwent an additional procedure at the time of their Whipple. These patients more commonly had an unplanned return to theatre.

SP4.3 - Pancreatoduodenectomy for malignancy with concomitant arterial resection: results from the Recurrence After Whipple’s (RAW) study

Abstract Background Most centres are reluctant to perform pancreatoduodenectomy (PD) with concomitant arterial resection (AR) in patients with a cancer affecting the pancreatic head. This is because outcomes are poor and the potential benefits of an aggressive resection are unlikely to outweigh the potential risks, particularly in a patient with an aggressive tumour and limited life expectance. AR has been shown to correlate with higher rates of morbidity, reoperation and mortality, and reduced overall survival. However, AR may be justified in selected patients in specialist centres. This study aimed to compare the outcomes of PD patients who underwent AR to those who did not. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres from eight countries, n=1484). Patients who underwent AR were identified and compared to those who did not undergo AR using the chi-squared test. The following were compared: length of stay (LoS), incidence of postpancreatectomy haemorrhage (PPH), and rates of unplanned return to theatre, 30-day readmission, 90-day mortality, and five-year survival. Results Out of 1484 patients, 8.8% did not have data regarding their AR status recorded so they were excluded. Of the rest, 25 (1.8%) underwent AR. Despite the small sample size, these patients had significantly higher rates of PPH (20.0 vs 5.9%, p=0.0004) and reduced five-year survival (12.0% vs 33.1%, p=0.03). Conclusion AR should be reserved for selected PD patients in specialist units. Despite our small sample size, our multicentre study demonstrated that these patients have higher incidence of PPH and reduced long-term survival

WP7.6 - Unplanned Re-admisisons - How are we doing; Phase 1 study

Abstract Introduction 30-day unplanned re-admissions provide an indicator of performance in the NHS Framework. Average readmission rate is around 15 to 17%, however surgical re-admission is less published. Therefore, a study was set up to assess the factors influencing surgical re-admissions in a Tertiary Centre. Methods Retrospective study of prospectively collected data from the tertiary centre database including all ‘Unplanned Re-admissions’(URA) aged &amp;gt;15 years in general surgery between January and December 2022. URA &amp;lt;15 years old and to other surgical specialties were excluded. ANOVA test and descriptive statistics were used to analyse the data. Results 289 (58%) of 498 readmissions were URA with 150 (52%) female and 139 (48%) male. 57 (19%) were aged 15-30 years, 121 (42%) 31-60 years, 109 (38%) 61-90 years and 2 &amp;gt; 90 years (Median age 54 years; p&amp;lt;0.05). 191 (66%) were from ED, 84 (29%) were GP referrals, 10 (3%) from clinics and 4 (2%) transferred from network. 178 (62%) URA were within 10 days of discharge, 72 (25%) between 11-20 days and 39 (13%) &amp;gt; 20 days (p &amp;lt; 0.05). The commonest cause of URA was biliary diseases (n = 40, 14%) followed by lower (n=32, 11%) and upper abdominal pain (n=17, 5%) and nonspecific abdominal pain (n=22, 7%). Other causes included appendicitis (n=8, 3%), pancreatitis (n=8, 3%), post-op complications (n=14, 5%) and obstruction (n=24, 8%). Conclusions URA significantly impacts health care provision and patients’ confidence. An initial study has identified reasons and patterns of re-admissions, the next phase involves analysing specific reasons to mitigate factors leading to URA.

ThP4.7 - The outcome of a single stage Laparoendoscopic rendezvous ERCP and laparoscopic cholecystectomy for cholecystocholedocholithiasis in a DGH

Abstract Cholecystocholedocholithiasis is managed surgically by laparoscopic cholecystectomy (LC) and simultaneous common bile duct (CBD) exploration or by preoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by LC. Rendezvous ERCP (RERCP) is an innovative laparoendoscopic technique combining LCs and ERCPs. As a single staged procedure, a LC is performed and selective canulisation of the CBD is aided by laparoscopic transcystic placement of a guide-wire into the duodenum. We present a case series of RERCPs within a DGH. This case series collected retrospective data (2014-2023) involving 33 patients, of which 21 underwent RERCP. Preoperative variables included age, indication, gender, ASA grade, Charlson comorbidity index (CCI), frailty score and indication. Postoperative variables analysed were operating time, complications, 30-day re-admission rates and length of stay in hospital (LOSH). Of the 21 patients who underwent a RERCP, 76% (n=16) were female. The average age was 60±17years and 59% (n=13) of all procedures were elective. The ASA range was I to III, average CCI and frailty score were 2.4±1.9 and 0.1±0.4 respectively. 52% (n=11) of patients had a previous failed ERCP. The average operating time was 152±39mins. The average LOSH was 3.5±2.8days and 2.5±2.1days following the RERCP. Biliary (including pancreatitis) and non-biliary complications were 9.5% (n=2) and 9.5% (n=2) respectively. The 30-day readmission rate was 9.5% (n=2). There was no significant difference in the operating time (p=0.16), LOSH (p=0.19) complication (p=0.13) and readmission rates (p=0.50) between emergencies and elective procedures. RERCP remains a valuable option when managing cholecystocholedocholithiasis in emergency and elective settings.

Outcomes of total knee replacement versus unicompartmental knee arthroplasty in an enhanced recovery after surgery protocol

IntroductionUnicompartmental Knee Arthroplasty (UKA) has become popular due to faster recovery and improved range of motion. However, concerns have been made regarding increased risk of early failure. Furthermore, the use of Enhanced Recovery After Surgery (ERAS) protocols have shown to allow faster return to activities, improved satisfaction, and reduced complication rates.This study aims to compare the 6 month functional outcomes of patients undergoing Total Knee Replacement (TKR) versus UKA under the ERAS protocol. MethodsPatient characteristics and comorbidities, 30-day post-operation readmission and infection rates were analyzed. Patient reported outcomes measures namely the Knee Society Function and Knee Score (KSFS, KSKS), Oxford Knee Score (OKS) and both the Physical and Mental component of the Short-Form Health Survey (SF-36) were assessed pre-operatively and 6 months post-operatively.Univariate analysis was used to compare differences in characteristics and comorbidities between the 2 groups. Finally, a multiple linear regression was performed to compare the post-operative outcomes. ResultsUnivariate analysis showed significantly better preoperative and 6 month post-operative KSKS and SF-36 MCS in UKA patients. Multivariate analysis showed no difference in the 6 month post-operative functional outcome scores between UKA and TKR patients. No UKA patients required revision surgery while 4 TKR patients required revision surgery for infection. ConclusionUKA achieves equivalent functional outcomes at 6 months post-operatively as compared to TKR patients and has lower infection rates. UKA is a reasonable option to offer for unicompartmental knee osteoarthritis patients.

Impact of Social Risk Screening on Discharge Care Processes and Postdischarge Outcomes: A Pragmatic Mixed-Methods Clinical Trial During the COVID-19 Pandemic.

Social risk screening during inpatient care is required in new CMS regulations, yet its impact on inpatient care and patient outcomes is unknown. To evaluate whether implementing a social risk screening protocol improves discharge processes, patient-reported outcomes, and 30-day service use. Pragmatic mixed-methods clinical trial. Overall, 4130 patient discharges (2383 preimplementation and 1747 postimplementation) from general medicine and surgical services at a 528-bed academic medical center in the Intermountain United States and 15 attending physicians. Documented family interaction, late discharge, patient-reported readiness for hospital discharge and postdischarge coping difficulties, readmission and emergency department visits within 30 days postdischarge, and coded interviews with inpatient physicians. A multivariable segmented regression model indicated a 19% decrease per month in odds of family interaction following intervention implementation (OR=0.81, 95% CI=0.76-0.86, P<0.001), and an additional model found a 32% decrease in odds of being discharged after 2 pm (OR=0.68, 95% CI=0.53-0.87, P=0.003). There were no postimplementation changes in patient-reported discharge readiness, postdischarge coping difficulties, or 30-day hospital readmissions, or ED visits. Physicians expressed concerns about the appropriateness, acceptability, and feasibility of the structured social risk assessment. Conducted in the immediate post-COVID timeframe, reduction in family interaction, earlier discharge, and provider concerns with structured social risk assessments likely contributed to the lack of intervention impact on patient outcomes. To be effective, social risk screening will require patient/family and care team codesign its structure and processes, and allocation of resources to assist in addressing identified social risk needs.

Impact of Obesity, Smoking, and Age on 30-Day Postoperative Outcomes of Patients Undergoing Arthroscopic Meniscus Surgery.

The purpose of this study was to evaluate the impact that obesity, smoking, and older age have on 30-day postoperative complications, reoperations, and readmissions of patients undergoing arthroscopic meniscectomy or meniscus repair. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify meniscus surgeries and operative outcomes between 2008 and 2016. Controlled regression analysis was then performed to evaluate for an association between obesity, age, and smoking and these outcomes. While obesity showed no influence on adverse postoperative complications or reoperations, class I obesity was associated with a lower rate of readmission. Older age, smoking, and comorbidity burden were significant predictors of postoperative complications, reoperations, and/or readmissions. Age 80 years or older was particularly predictive of 30-day complications (odds ratio, 3.5; P<.001) and readmissions (odds ratio, 2.5; P=.004). Obesity is not a major risk factor for complications when undergoing meniscus surgery, while age older than 70 years predicts negative short-term postoperative outcomes. [Orthopedics. 20XX;4X(X):XXX-XXX.].

Reducing 30-Day Readmissions in Patients With Alcohol Use Disorder

The 30-day hospital readmission rate for alcohol use disorder (AUD) at a Veteran’s Affairs hospital is 2% higher than the national benchmark. This quality improvement project aimed to implement a holistic approach to care of veterans with AUD through optimization of the Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised protocol and development of a revised and evidence-based alcohol withdrawal syndrome order set. After implementation, there was a statistically significant decrease in 30-day readmissions and an increase in prescription of adjuvant therapies such as gabapentin and hydroxyzine. This quality improvement project improved the processes of care related to treatment of veterans with AUD admitted with alcohol withdrawal syndrome.

What's Behind it all: A Retrospective Cohort Study of Retrogastric Pancreatic Necrosis Management.

To compare outcomes of laparoscopic transgastric necrosectomy (LTN) and direct endoscopic necrosectomy (DEN) in the management of retrogastric walled-off necrosis. Surgical and endoscopic transgastric approaches are used to manage retrogastric pancreatic necrosis. Studies comparing these treatment modalities are lacking but would influence contemporary practice patterns. LTN or DEN treated patients at Stanford University Hospital between 2011 and 2023 were identified. Cohort data included demographics, core pancreatitis care benchmarks, and clinical outcomes (total debridement time, new-onset endocrine and exocrine pancreatic insufficiency) as well as re-intervention, 30-day readmission, complication, and mortality rates. Long-term follow-up was also compared between intervention arms. Multivariable linear regression was used to assess the interaction between admission APACHE-II score and intervention on length of stay (LOS). 106 patients (62% LTN, 38% DEN) were identified. Demographic and core pancreatitis benchmark data were similar between cohorts. 30-day readmission, complication, and mortality rates for surgical and endoscopic approaches were also similar: 23% vs. 25% (P = 0.98), 42% vs. 40% (P = 0.97), and 3% vs. 3% (P > 0.99). Median LTN total debridement time (minutes) was 131 vs. 134 for DEN, however, complete debridement was achieved with only 1 LTN compared to 3 DENs (P<0.01). While not statistically significant, LOS and unplanned intervention rates were less for LTN (8 vs. 10 days, P = 0.41 and 6% vs. 15%, P = 0.24). Multivariable analysis revealed a significant interaction between APACHE-II scores and LOS for LTN compared to DEN, which translated into a length of stay reduction for higher APACHE-II scoring patients (P = 0.02). LTN is a safe and efficient treatment modality for walled-off necrosis, and compared to DEN, can reduce the LOS in high APACHE-II score patients. While additional comparative research between the two intervention types is needed, this study supports a role for a surgical approach in the management of retrogastric pancreatic necrosis.

Outcomes of Femoral Popliteal Bypass in Octogenarians.

Femoral-popliteal bypass (FPB) surgery is a common lower extremity revascularization procedure. As the population continues to age, this procedure is being performed increasingly on older patients. This study investigated whether outcomes differ in this population. Patients over and less than 80 years old who underwent FPB between 2009-2013 were queried using an existing hospital registry. Demographics, comorbidities, intraoperative complications, perioperative outcomes, and two-year patencies were compared. Twenty-four patients in the octogenarian cohort (OC) and 72 patients in the non-octogenarian cohort (NOC) were identified. There was a lower prevalence of smoking (p=0.018) and higher prevalence of hypertension (p=0.021) among octogenarians. Other medical characteristics were similar (p<0.05). There were no differences in use of vein versus PTFE (p=0.002) as a conduit, or above (OC 20.0% vs. NOC 36.7%), versus below knee (OC 80.0% vs. NOC 63.3%) distal anastomosis (p>0.05) between the groups. There was a difference (p<0.01) in indication for procedure (OC/NOC): claudication (0%/44%), limb salvage (71%/31%), and rest pain (29%/25%). There were no differences in 30-day readmissions (17% vs. 21%; p=0.59) or incidence of postoperative (25% vs. 19%; p=0.56) or intraoperative complications (8.3% vs. 4.2%; p=0.52). Length of stay (LOS) was longer and statistically significant in octogenarians (12 days vs. 7 days; p=0.032) and remained significant after multivariate linear regression (p=0.015). Patencies in OC were lower and dropped faster after six months; however, there were no statistically significant differences in patencies at any time interval (p>0.05). The position of the distal anastomosis relative to the knee, conduit type, and indication were not independently predictive of patency outcomes (p>0.05). The safety and efficacy of FPB in octogenarians is similar to the general population despite LOS in octogenarians being 5.98 days longer. While the difference in indication suggests that vascular surgeons are more conservative in treating octogenarians, our analysis did not reveal significant differences between populations and suggests that lower extremity bypass can be performed safely with comparable results in this cohort. A larger cohort is needed to validate these results.

Social Risks and Health Care Use in Medically Complex Patients

Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions. To evaluate the association of social risks with health care use among patients with complex multimorbidity. This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control). Social risks (eg, requiring medical financial assistance and self-reported social barriers to care). Inpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024). The sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks. In this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

Hospital Readmissions Among Infants With Neonatal Opioid Withdrawal Syndrome

Although cases of neonatal opioid withdrawal syndrome (NOWS) increased 5-fold in recent years, no study has examined national hospital readmission rates for these infants. To examine hospital readmissions for infants with and without NOWS. This retrospective cohort study analyzed serial cross-sectional samples of US hospital discharge records from the Nationwide Readmissions Database for calendar years 2016 to 2020. Infants with NOWS were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The data analysis was performed between January 5, 2023, and May 6, 2024. Neonatal opioid withdrawal syndrome. Survey-weighted logistic regression was used to examine 90-day all-cause and cause-specific hospital readmissions. Multivariable models adjusted for sex, low birth weight, gestational age, multiple gestation, type of insurance, and year of birth. Of the 13 855 246 newborns identified in this weighted analysis, 89 018 (0.6%) were diagnosed with NOWS, of whom 53.8% were male and 81.1% born full-term (>36 weeks gestation). The 90-day all-cause readmission rate was 4.2% for infants with NOWS compared with 3.0% for those without NOWS (P < .001). After risk adjustment, the odds of all-cause readmission were higher among infants with NOWS (adjusted odds ratio [AOR], 1.18; 95% CI, 1.08-1.29). Infants with NOWS had significantly higher odds of readmissions for seizures (AOR, 1.58; 95% CI, 1.01-2.46), failure to thrive (AOR, 1.99; 95% CI, 1.36-2.93), traumatic brain injury (AOR, 2.95; 95% CI, 1.76-4.93), and skull fractures (AOR 3.72; 95% CI, 2.33-5.93). Infants with NOWS had higher odds of receiving a diagnosis of confirmed maltreatment (AOR, 4.26; 95% CI, 2.19-8.27), including for neglect (AOR, 14.18; 95% CI, 5.55-36.22) and physical abuse (AOR, 2.42; 95% CI, 0.93-6.29); however, the latter finding was not statistically significant. In this nationally representative cohort study, infants with NOWS were at increased risk of readmission for any cause as well as for trauma and confirmed maltreatment. These findings may in part reflect the dual stressors that mothers with opioid use disorder face in caring for a newborn with NOWS in the context of a substance use disorder and underscore the need for family-based, in-home services that focus concurrently on substance use treatment and parenting support.

Comparison of the Cost-Effectiveness and Safety between Staged Bilateral Total Knee Arthroplasty and Simultaneous Bilateral Total Knee Arthroplasty: A Retrospective Cohort Study between 2001 and 2022.

A substantial proportion of Hong Kong's aging population suffers from osteoarthritis in both knees. Bilateral total knee arthroplasty (BTKA) is a surgical option for addressing this condition and can be performed via two approaches: simultaneous BTKA (SimBTKA) and staged BTKA (StaBTKA). We compared the cost-effectiveness and safety of these two methods in our institution. We retrospectively reviewed 2,372 patients (SimBTKA, 772; StaBTKA, 1,600; females, 1,780; males, 592; mean age at SimBTKA, 70.4 ± 7.99 years; mean age at StaBTKA, 66.4 ± 7.50 years; p < 0.001) who underwent BTKA in our institution from 2001 to 2022. Patients were categorized according to the surgical approach. Patients undergoing BTKA in our institution were included. Particularly for SimBTKA, patients were assessed by anesthetists to be medically fit before undergoing the procedure according to their age, American Society of Anesthesiologists status, and osteoarthritis severity. The primary outcome was the length of stay (LOS) after surgery. The secondary outcomes were the 30-day unintended readmission, intensive care unit (ICU) admission, and death. SimBTKA had a shorter mean total LOS (acute hospital + rehabilitation center; SimBTKA, 13.09 days; StaBTKA, 18.12 days; p < 0.001) and mean LOS in acute hospital (SimBTKA, 7.70 days; StaBTKA, 10.42 days; p < 0.001). However, no significant difference was found in the mean LOS in rehabilitation centers (SimBTKA, 5.47 days; StaBTKA, 6.32 days; p > 0.05) between the two approaches. The 30-day unintended readmission rate was lower in SimBTKA (SimBTKA, 2.07%; StaBTKA, 3.30%; odds ratio [OR] = 1.60; p > 0.05) but statistically insignificant. SimBTKA was less costly than StaBTKA by US$ 8,422.22 per patient. No significant differences in ICU admission and death rates were found (p > 0.05) between the two groups. SimBTKA had a shorter LOS and lower cost than StaBTKA and comparable complication rates. Therefore, SimBTKA should be indicated in medically stable patients.