30-d Readmission Research Articles

Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective

IntroductionFirearm-related injuries in America have been under increasing scrutiny over the last several years. Few studies have examined the burden of these injuries in the pediatric population. The objective of this study was to describe the incidence of firearm-related injuries in hospitalized pediatric patients in the United States and identify the risk factors associated with readmission in this young population. MethodsThe Nationwide Readmission Database was examined from 2010 to 2017. Pediatric patients (aged ≤18 y) who survived their index hospitalization for any firearm injury were analyzed to determine incidence rate, case fatality rate, risk factors for 30-d readmission, and financial health care burden. ResultsThere were 35,753 pediatric firearm injuries (86.8% male) with an overall incidence rate of 10.49 (95% confidence interval [CI]: 9.26-11.71) per 100,000 pediatric hospitalizations. Adolescents aged >12 y had the highest incidence rate (60.51, 95% CI: 55.19-65.84). In-hospital mortality occurred in 1948 cases (5.5%), with higher case fatality rates in males. There were 1616 (5.7%) unplanned 30-d readmissions. Multivariate analysis showed abdominal firearm injuries (hazard ratio: 1.13, 95% CI: 1.03-1.24; P = 0.006) and longer length of stay (hazard ratio: 1.27, 95% CI: 1.04-1.55; P = 0.016) were associated with a greater risk of 30-d readmission. The median health care cost for firearm-related injuries was $36,535 (interquartile range: $19,802-$66,443), 22% of which was due to readmissions. Cost associated with 30-d readmissions was $7978 (interquartile range: $4305-$15,202). ConclusionsFirearm-related injury is a major contributor to pediatric morbidity, mortality, and health care costs. Males are disproportionately affected by firearm injury, but females are more likely to require unplanned 30-d readmissions. Interventions should target female sex, injuries of suicidal intent, psychiatric comorbidities, prolonged index hospitalization, and abdominal injuries.

Emergency Surgery Rates Among Medicare Beneficiaries With Access Sensitive Surgical Conditions

IntroductionAccess sensitive surgical conditions should be treated electively with optimal access but result in emergency operations when access is limited. However, the rates of emergency procedures for these conditions are unknown. MethodsCross-sectional retrospective review of Medicare beneficiaries who underwent access sensitive surgical procedures (abdominal aortic aneurysm repair, colectomy for colorectal cancer, or incisional hernia repair) between 2014 and 2018. Risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, and Elixhauser comorbidities), hospital characteristics (ownership, size, geographic region, surgical volume) and type of operation were compared between planned and emergency (urgent and emergent) surgical procedures. Outcome measures were rates of emergency procedures as well as associated postoperative outcomes. ResultsOf the 744,818 Medicare beneficiaries undergoing access sensitive surgical procedures, 259,541 (34.9%) were done in the emergency setting. Risk-adjusted rates of emergency surgery varied widely across hospital service areas from 23.28% (lowest decile) to 54.88% (highest decile) (Odds Ratio 4.74; P < 0.001). Emergency procedures were associated with significantly higher rates of 30-d mortality (8.15% versus 3.65%, P < 0.001) and readmissions (16.28% versus 12.88%, P < 0.001) compared to elective procedures. Sensitivity analysis with younger and healthier beneficiaries demonstrated persistently high rates (23.3%) of emergency surgery with wide regional variation and worse patient outcomes. ConclusionsEmergency surgery for access sensitive surgical conditions is extremely common and varied almost fivefold across United States hospital service areas. This suggests there are opportunities to improve access for these common surgical conditions.

National Assessment of Early Discharge After Video-Assisted Thoracoscopic Surgery for Lung Resection.

Video-assisted thoracoscopic surgery (VATS) techniques permit shorter postoperative length of stay (LOS). However, it remains unknown whether earlier discharge increases the risk of adverse postoperative events. We examined whether shorter LOS following elective VATS lung resection was associated with increased rates of readmission or postoperative complications. Patients who underwent elective thoracoscopic segmentectomy, lobectomy, or bilobectomy for lung neoplasms from 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Postoperative LOS was treated as an ordinal variable. The examined outcomes were 30-d readmission and 30-d postdischarge death or serious morbidity (DSM). Multivariable logistic regression models evaluated the association of LOS with outcomes. The most common readmission diagnoses were identified for each operation. Among 14,418 patients, 12,410 (86.1%) underwent lobectomy, 1764 (12.2%) underwent segmentectomy, and 244 (1.7%) underwent bilobectomy. The median LOS was 3d for patients undergoing lobectomy (IQR 2-5) and segmentectomy (IQR 2-4), and 4d for bilobectomy (IQR 3-6). Readmission rates varied with admission time and ranged from 5.0% for patients with LOS ≤1d to 8.5% for LOS ≥5d. The most common readmission diagnoses were pneumothorax (19.0%) and wound complications (13.4%). Each one-day increase in LOS was associated with an increased risk of readmission (OR 1.10, 95% CI 1.04-1.17, P<0.001). No association was seen between earlier discharge and DSM (OR 1.08, 95% CI 0.99-1.18, P=0.070). Early discharge following VATS lung resection is not associated with increased rates of readmission or postoperative complications among patients undergoing surgery for cancer, and may safely be considered for selected patients with uncomplicated postoperative recovery.

Outcomes of Femoropopliteal Bypass for Lifestyle-Limiting Claudication in the Endovascular Era

IntroductionOutcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era. MethodsA multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan–Meier curves and Cox proportional hazards ratios (HR). ResultsA total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011). ConclusionsFemoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era.

Machine Learning Improves Prediction Over Logistic Regression on Resected Colon Cancer Patients.

Despite advances, readmission and mortality rates for surgical patients with colon cancer remain high. Prediction models using regression techniques allows for risk stratification to aid periprocedural care. Technological advances have enabled large data to be analyzed using machine learning (ML) algorithms. A national database of colon cancer patients was selected to determine whether ML methods better predict outcomes following surgery compared to conventional methods. Surgical colon cancer patients were identified using the 2013 National Cancer Database (NCDB). The negative outcome was defined as a composite of 30-d unplanned readmission and 30- and 90-d mortality. ML models, including Random Forest and XGBoost, were built and compared with conventional logistic regression. For the accounting of unbalanced outcomes, a synthetic minority oversampling technique (SMOTE) was implemented and applied using XGBoost. Analysis included 528,060 patients. The negative outcome occurred in 11.6% of patients. Model building utilized 30 variables. The primary metric for model comparison was area under the curve (AUC). In comparison to logistic regression (AUC 0.730, 95% CI: 0.725-0.735), AUC's for ML algorithms ranged between 0.748 and 0.757, with the Random Forest model (AUC 0.757, 95% CI: 0.752-0.762) outperforming XGBoost (AUC 0.756, 95% CI: 0.751-0.761) and XGBoost using SMOTE data (AUC 0.748, 95% CI: 0.743-0.753). We show that a large registry of surgical colon cancer patients can be utilized to build ML models to improve outcome prediction with differential discriminative ability. These results reveal the potential of these methods to enhance risk prediction, leading to improved strategies to mitigate those risks.

Socioeconomic Status and Gastric Cancer Surgical Outcomes: A National Cancer Database Study.

Gastric cancer (GC) is the third leading cause of cancer-related death worldwide. Surgical resection is the gold standard of treatment. In the United States, race and socioeconomic status are associated with the diagnosis of GC; however, no studies have examined these as independent risk factors for surgical outcomes. Our study sought to investigate socioeconomic factors and GC surgical outcomes using a national cancer registry. GC patients between 2004 and 2016 were identified using the National Cancer Database. Univariate and multivariate logistic regression was used to analyze associations between socioeconomic factors and 30-d mortality, 90-d mortality, and unplanned readmission rate. A total of 96,990 patients who received nonpalliative surgical treatment for GC were identified. When controlling for other clinical and socioeconomic factors, older age, male sex, higher comorbidities, larger tumor size, advanced stage disease, and inadequate resection were correlated with worse 30- and 90-d mortality. Additionally, 30-d and 90-d mortality was significantly lower when the patient's income (odds ratio [OR] = 0.77 and OR = 0.43, respectively, for >$63,333/y versus <$40.227/y) and the percentage of residents with a high school degree in their zip code (OR = 0.69 and OR = 0.52, respectively, for <6.3% no high school degree versus≥17.6%) were higher. No significant disparate trends were identified in terms of race and insurance status or in unplanned readmissions on multivariate analysis. Lower income and the level of education at the place of residence were independently associated with higher 30-d and 90-d mortality in this study, highlighting the potential for a major socioeconomic disparity in this population.

Interfacility Transfer for Nonelective Cholecystectomy in High MELD Patients: An ACS-NSQIP Analysis

IntroductionInterfacility transfer to a referral center is often considered for patients with liver disease undergoing nonelective cholecystectomy given management complexities and perioperative risk. We sought to determine the association between the Model for End Stage Liver Disease (MELD) score, transfer frequency, and outcomes in those patients using a national database. Materials and methodsThe ACS-NSQIP participant use files were queried for nonelective open or laparoscopic cholecystectomy from 2016 to 2018. Patients were grouped according to low (6-11), intermediate (12-18), or high (>18) MELD. In the high MELD group, patient characteristics and outcomes were compared between transferred and nontransferred patients and multivariate regression was performed to evaluate independent predictors of outcomes. Outcomes included in-hospital mortality, complications, length-of-stay (LOS), and 30-d reoperation and readmission. Results30,171 subjects were included. Transfer was more likely as MELD increased (19.5% high versus 12.1% low, P < 0.001). High MELD patients had increased LOS, reoperation, readmission, and mortality rates compared to low MELD. In high MELD patients (n = 1016), those transferred were more likely older, white, obese, and septic. Transferred patients had increased mortality (7.6% versus 4.2%, P = 0.044), LOS, reoperation, and complications. After controlling for differences between transferred and nontransferred patients, transfer status was not independently associated with mortality (OR = 1.593, P = 0.177), postoperative complications or LOS, but was associated with increased risk for reoperation. Sepsis and laparoscopic surgery were independently associated with higher and lower mortality, respectively. ConclusionsTransfer status is not independently associated with mortality, postoperative complications, or prolonged LOS, suggesting patients with advanced liver disease undergoing acute cholecystectomy may not benefit from interfacility transfer.

Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled.

Background.Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant.Methods.This is a single-center retrospective analysis comparing the outcomes of 20 adult kidney transplant recipients subjected to ERAS pathway with 20 adult recipients operated before ERAS with traditional standard of care.Results.There were no significant differences between both groups regarding age, gender, race, dialysis status, living donor percentage, cold ischemia time, and warm ischemia time. Median hospital stay for ERAS patients was 2 d. Overall median pain scores were significantly lower in the ERAS group versus non-ERAS group (morning after surgery pain score 2 versus 5; peak pain score 4.5 versus 10; lowest pain score 0 versus 2; P = 0.0001). ERAS patients had earlier ambulation (walking) and oral nutrition (regular diet) (first versus second day postoperatively in traditional group). Earlier bowel movement was observed in ERAS patients. There were no significant differences in graft function or 30-d readmission rates between both groups.Conclusions.Implementation of ERAS pathway in kidney transplantation is feasible. Using ERAS is associated with less pain, earlier ambulation and advancement of oral nutrition, and short hospital stay.

The Association Between Metabolic Derangement and Wound Complications in Elective Plastic Surgery

IntroductionThe incidence of metabolically unhealthy obesity is rising nationally. In this study, we compare wound and overall complications between metabolically unhealthy obese and healthy patients undergoing elective plastic surgery and model how operative time influences a complication risk. MethodsPatients undergoing elective breast and body plastic surgery procedures in the 2009-2019 National Surgical Quality Improvement Program (NSQIP) dataset were identified. Complications were compared between metabolically unhealthy obese (body mass index [BMI] > 30 with diabetes and/or hypertension) versus metabolically healthy obese patients (BMI > 30 without diabetes or hypertension). Logistic regression was used to model the probability of wound complications across operative times stratified by metabolic status. ResultsOf 139,352 patients, 13.4% (n = 18,663) had metabolically unhealthy obesity and 23.8% (n = 33,135) had metabolically healthy obesity. Compared to metabolically healthy patients, metabolically unhealthy patients had higher incidence of wound complications (6.9% versus 5.6%; P < 0.001) and adverse events (12.4% versus 9.6%; P < 0.001), in addition to higher 30-d readmission, returns to the operating room, and length of stay (all P < 0.001). After adjustment, BMI (Odds ratio [OR] 7.86), hypertension (OR 1.15), and diabetes (OR 1.25) were independent risk factors for wound complications (all P < 0.001). Among metabolically unhealthy patients, the operative time was log-linear with a wound complication risk (OR 1.21; P < 0.001). ConclusionsDiabetes and hypertension are additive risk factors with obesity for wound complications in elective plastic surgery. Among patients with metabolically unhealthy obesity, a risk of wound complications increases logarithmically with operative time. This distinction with regard to metabolic state might explain the unclear impact of obesity on surgical outcomes within existing surgical literature.

Early Cardiac Rehabilitation to Reduce Heart Failure Readmissions.

This research was conducted to determine whether early participation in cardiac rehabilitation (CR) reduces readmissions following heart failure (HF) hospitalization. A retrospective quasiexperimental comparison group design was used. Electronic medical records were abstracted for HF patients discharged between March 2013 and December 2017. The treatment group was defined as patients with HF who attended ≥1 CR session within 6 wk following discharge. The comparison group was defined as patients with HF without additional HF hospitalizations during the previous year, discharged to home/self-care, and did not attend CR within 6 wk. Readmission rates at 30 d and 6 wk were compared between groups using χ 2 analysis and logistic regression. Out of 8613 patients with HF, 205 (2.4%) attended ≥1 CR within 6 wk post-discharge. The treatment group had lower, but not statistically significant, readmission rates than the comparison group for 30-d readmissions for HF ( P = .13), and 6-wk readmission rates for HF ( P = .05). The treatment group had lower all-cause readmissions at 30 d (P < .01) and 6 wk ( P < .01) than the comparison group. Multivariable logistic regression revealed that early CR attendance was associated with reduced 30-d all-cause readmissions (adjusted OR = 0.4: 95% CI, 0.2-0.7) and 6-wk all-cause readmissions (adjusted OR = 0.5: 95% CI, 0.3-0.8). This study contributes to the existing evidence for allowing early unrestricted CR participation with the aim of improving the health of patients with HF and reducing rehospitalization rates.

The Impact of a Home Respiratory Therapist to Reduce 30-Day Readmission Rates for Exacerbation of COPD.

In 2015, the Centers for Medicare and Medicaid Services limited payments to hospitals with high readmission rates for patients admitted with COPD exacerbation. Decreasing readmissions in this patient population improves patient health and decreases health care utilization of resources. We hypothesized a COPD disease management program delivered by a respiratory therapist (RT) in the patient's home may reduce readmission rates for COPD exacerbation. We performed a pre/post interventional study comparing hospital readmissions for subjects with COPD exacerbation that received standard of care in the home versus an RT-led home COPD disease management program. Subjects discharged home from Atlantic Health System with COPD exacerbation were enrolled in the pre-intervention group. Subsequently, an evidence-based home COPD disease management program was implemented by an RT from At Home Medical in the home. The home COPD Disease Management Program was implemented from April 2017-September 2019, and this served as the post-intervention group. The primary end point was readmission rates at 30 d. Secondary end points included 60-d and 90-d readmission rates. A total of 1,093 participants were included in the study, 658 in the pre-intervention cohort and 435 participants in the post-intervention group. Approximately 22.3% (n = 147) of subjects in the pre-intervention group was readmitted within 30 d of discharge compared to 12.2% (n = 53) in the post-intervention group (P < .001). A reduction in 60-d (33.9% vs 12.0%, P < .001) and 90-d all-cause readmissions (43.5% vs 13.1%, P < .001) was also seen. Participation in the COPD Disease Management Program was significantly associated with decreased 30-, 60-, and 90-d readmission rates adjusting for age, gender, race, ethnicity, and smoking status (odds ratio 0.48 [95% CI 0.33-0.70]; odds ratio 0.26 [95% CI 0.18-0.38]; odds ratio 0.20 [95% CI 0.14-0.27];P < .001, for all 3 readmission rates). The COPD Disease Management Program is significantly associated with decreased readmission adjusting for demographics and smoking status.

Trends of alcoholic liver cirrhosis readmissions from 2010 to 2018: Rates and healthcare burden associated with readmissions.

BACKGROUNDAlcoholic liver cirrhosis (ALC) is a chronic liver disease with varying disease severity. Readmissions of ALC are associated with poor outcomes.AIMTo identify and assess trends of readmissions for ALC over an eight-year period.METHODSThis retrospective interrupted trend study analysed 30-d readmissions of ALC in the United States from 2010 to 2018 using the National Readmissions Database. Hospitalization for ALC was the reason for index admission obtained using the International Classification of Diseases codes (571.2 and K70.3X). Biodemographic characteristics and hospitalization trends were highlighted over time. A multivariate regression analysis model was used to calculate the trend for risk-adjusted odds of 30-d all-cause ALC readmissions, ALC specific readmission rate, ALC readmission proportion, inpatient mortality, mean length of stay (LOS) and mean total hospital cost (THC) following adjustments for age, gender, grouped Charlson Comorbidity Index, insurance, mean household income, and hospital characteristics.RESULTSThere was a trend towards increasing total 30-d readmissions of ALC from 7660 in 2010 to 15085 in 2018 (P < 0.001). Patients readmitted for ALC were noted to have an increasing comorbidity burden over time. We noted a rise in the risk-adjusted 30-d all-cause readmission of ALC from 24.9% in 2010 to 29.9% in 2018 (P < 0.001). ALC-specific readmission rate increased from 6.3% in 2010 to 8.4% in 2018 (P < 0.001) while ALC readmission proportion increased from 31.4% in 2010 to 36.3% in 2018 (P < 0.001). Inpatient mortality for 30-d readmissions of ALC declined from 10.5% in 2010 to 8.2% in 2018 (P = 0.0079). However, there was a trend towards increasing LOS from 5.6 d in 2010 to 6.3 d in 2018 (P < 0.001) and increasing THC from 13790 dollars in 2010 to 17150 dollars in 2018 (P < 0.001). The total days of hospital stay attributable to 30-d readmissions of ALC increased by 119.2% while the total attributable hospital costs increased by 149% by the end of 2018. CONCLUSIONThere was an increase in the 30-d readmission rate and comorbidity burden for ALC; however, inpatient mortality declined. Additionally, there was a trend towards increasing LOS and THC for these readmissions.

Effect of perioperative probiotic supplements on postoperative short-term outcomes in gastric cancer patients receiving neoadjuvant chemotherapy: A double-blind, randomized controlled trial

ObjectivesSurgery can significantly improve the prognosis of patients with gastric cancer. However, some patients are at a later stage at diagnosis and need to receive neoadjuvant chemotherapy (NACT). Previous studies have shown that NACT may lead to more postoperative complications. Probiotics have the potential to reduce postoperative complications and infections, but no similar clinical trials have been conducted in patients with gastric cancer receiving NACT. The aim of this study was to investigate the effect of probiotics on postoperative infections and other short-term outcomes in patients with gastric cancer receiving NACT. MethodsThis was a randomized, double-blind, controlled trial. All patients who underwent minimally invasive surgery after NACT were included and randomized into a probiotic group (PG; n = 33) or a control group (CG; n = 33). Postoperative infectious complications, recovery of gastrointestinal function, postoperative hospital stay, medical costs, time to initiate adjuvant chemotherapy, 30-d readmission and mortality, and common laboratory inflammatory indexes were observed. ResultsPG patients had significantly fewer postoperative infections (P = 0.027). Time to first flatus and bowel movement was quicker (P = 0.001 and P < 0.001, respectively) and inflammatory indexes were lower in the PG patients. Postoperative hospital length of stay was shorter in the PG than in the CG (P = 0.001). Due to fewer postoperative infections and faster recovery, adjuvant chemotherapy was initiated earlier in PG patients (P < 0.001). ConclusionsPerioperative probiotic supplements can reduce postoperative infection, improve short-term clinical outcomes, and reduce the level of common inflammatory indicators in patients with gastric cancer receiving NACT. Patients in the PG started adjuvant chemotherapy earlier than CG patients.

How to Establish the Bipolar Forceps Dissection Method in Robotic Inguinal Hernia Repair.

The number of robotic inguinal hernia repair (RIHR) surgeries performed by younger surgeons and surgical residents has been growing worldwide. As a result, there has been growing interest in the pace at which surgeons develop their competencies. In Japan, the number of robotic surgeries with the double bipolar technique for gastric cancer is increasing. We devised an RIHR technique for a right‐hand‐dominant surgeon. This article describes the procedure and step‐by‐step instructions for this technique. We also assessed the learning curve of a surgeon experienced in the laparoscopic transabdominal preperitoneal (TAPP) approach and robotic gastrectomy. This was a retrospective review of 31 inguinal hernia patients (40 lesions) between December 2018 and April 2021 operated by a single surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing the times for peritoneal flap creation, mesh placement, and peritoneal closure. The postoperative course, namely, the length of hospital stay, 30‐d complications, and 30‐d readmission rates, was evaluated. The CUSUM graph for the total time for each phase indicated an initial decrease at lesion 12 and another decrease at lesion 36, generating three distinct performance phases: learning (n = 12 procedures), competence (n = 24), and mastery (n = 4). Between the early and late periods, no significant differences in patient characteristics or surgical outcomes were found. The learning curve for this technique was divided into three performance phases, and the technique was safely achievable in 36 procedures by a surgeon with previous experience in laparoscopic TAPP.

Unwarranted Between-hospital Variation in Mortality, Readmission, and Length of Stay of Urological Admissions: An Important Trigger for Prioritising Quality Targets

BackgroundUnwarranted between-hospital variation is a persistent health care quality issue. It is unknown whether urology patients are prone to this variation. ObjectiveTo examine between-hospital variation in mortality, readmission, and length of stay for all 22 urological All Patient Refined Diagnosis Related Groups (APR-DRGs). Design, setting, and participantsThis study included administrative data from 320640 urological admissions in 99 (98%) Belgian acute-care hospitals between 2016 and 2018. Outcome measurements and statistical analysisWe used hierarchical mixed-effect logistic regression models to estimate hospital-specific and APR-DRG–specific risk-standardised rates for in-hospital mortality, 30-d readmission, and length of stay above the APR-DRG–specific 90th percentile. Between-hospital variation was assessed based on the estimated variance components. Associations of outcomes with patient and hospital characteristics and time trends were examined. Results and limitationsOur analysis revealed important between-hospital variation in mortality, readmission, and length of stay for urological pathologies, particularly for medical diagnoses. Significant variation was shown in all three outcomes for kidney and urinary tract infections; other kidney and urinary tract diagnoses, signs, and symptoms; urinary stones and acquired upper urinary tract obstruction; and kidney and urinary tract procedures for nonmalignancy. Lowering of mortality rates in upper-quartile hospitals to the median could potentially save 41.5% of deaths in these hospitals, with the largest absolute gain for kidney and urinary tract infections and kidney and urinary tract malignancy. Limitations included a likely underestimation of readmission rates. ConclusionsUrological patient outcomes are characterised by unwarranted between-hospital variation. We recommend improvement initiatives to prioritise kidney and urinary tract infections because of significant variation across the three outcomes and the largest potential gain in lives saved. Patient summaryWe found notable between-hospital variation in mortality, readmission, and length of stay for urological hospital admissions in Belgium. As much as 41.5% of deaths could potentially be avoided if underperforming hospitals improved. Targeting kidney and urinary tract infections could help reduce variation.

Effectiveness of enhanced recovery after surgery in the perioperative management of patients with bone surgery in China.

BACKGROUNDEnhanced recovery after surgery (ERAS) was introduced in China in 2007. Over time, the scope of ERAS has expanded from abdominal surgery to orthopedics, urology and other fields. Continuous development and research has contributed to progress of ERAS in China. In 2019, to promote the application of ERAS in bone tumor surgery, we formed the “Consensus of Experts on Perioperative Management of Accelerated Rehabilitation in Major Surgery of Bone Tumors in China”.AIMTo evaluate the effect of enhanced recovery after bone tumor surgery in perioperative management in China.METHODSOne hundred and seven patients who underwent bone tumor surgery at the Second Affiliated Hospital of Xi’an Jiaotong University between May 2019 and April 2021 were randomized into a study group (53 cases) and a control group (54 cases). The study group adopted the ERAS protocol and the control group adopted conventional care. Main outcome measures included postoperative length of stay (LOS), postoperative complications, mortality, and 30-d readmission rates. Secondary outcomes included postoperative visual analog scale (VAS) score of pain, number of blood transfusions, drainage volume in 24 h after operation, patient satisfaction 30 d after discharge, VAS score at 30 d after discharge, and daily standing walking time. RESULTSThere were no significant differences in the baseline data, clinical features and surgical site between the two groups. The LOS in the study group with the ERAS protocol was 7.72 ± 3.34 d compared with 10.28 ± 4.27 d in the control group who followed conventional care. The incidence of postoperative nausea and vomiting (PONV) in the study group was 19% and 37% in the control group. The VAS scores of pain on postoperative day 1 (POD1) and POD3 in the study group were 4.79 ± 2.34 and 2.79 ± 1.53 compared with 5.28 ± 3.27 and 3.98 ± 2.27 in the control group. The drainage volume in 24 h after the operation was 124.36 ± 23.43 mL in the study group and 167.43 ± 30.87 mL in the control group. The number of blood transfusions in the study group was also lower. The patient satisfaction rate was higher in the study group than in the control group. CONCLUSIONThe ERAS protocol in the perioperative period of bone tumor surgery can decrease LOS, PONV, and postoperative pain, blood transfusion and 24-h drainage, improve patient satisfaction and accelerate recovery.

Overlap Before the Critical Step of Lumbar Fusion Does Not Lead to Increased Short-Term Morbidity.

Few studies have assessed the impact of overlapping surgery during different timepoints of neurosurgical procedures. To evaluate the impact of overlap before the critical portion of surgery on short-term patient outcomes following lumbar fusion. In total, 3799 consecutive patients who underwent single-level, posterior-only lumbar fusion over 6 yr (2013-2019) at an academic hospital system were retrospectively studied. Outcomes included 30-d emergency department (ED) visit, readmission, reoperation, mortality, overall morbidity, and overall morbidity/surgical complications. Duration of overlap that occurred before the critical portion of surgery was calculated as a percentage of total beginning operative time. Univariate logistic regression was used to assess the impact of incremental 1% increases in the duration of overlap within the whole population and patients with beginning overlap. Subsequently, univariate analysis was used to compare exact matched patients with the least (bottom 40%) and most amounts of overlap (100% beginning overlap). Coarsened exact matching was used to match patients on key demographic factors, as well as attending surgeon. Significance was set at a P-value <.05. Increased duration of beginning overlap was associated with a decrease in 30-d ED visit (P=.03) within all patients with beginning overlap, but not within the whole population undergoing lumbar fusion. Duration of beginning overlap was not associated with any other short-term morbidity or mortality outcome in either the whole population or patients with beginning overlap. Increased duration of overlap before the critical step of surgery does not predict adverse short-term outcomes after single-level, posterior-only lumbar fusion.

Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis

Background Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. Objective To evaluate rates of adverse outcomes after CAS and CEA in a large national database. Methods We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. Results In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. Conclusion In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization

Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care. Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes. Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P=0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant. At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. To evaluate rates of adverse outcomes after CAS and CEA in a large national database. We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n=81 361) or CEA (n=2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n=2821) cohorts through logistic regression. In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.