30-day Emergency Room Visits Research Articles

Equivalent Survivorship of Total Hip Arthroplasty in Patients Who Have Inflammatory Bowel Disease

BackgroundInflammatory bowel disease (IBD) can have orthopaedic manifestations related to decreased bone mineral density and increased fracture risk. The impact of IBD-spectrum diseases, including Crohn’s disease (CD) and ulcerative colitis (UC), on the overall performance of total hip arthroplasty (THA), is not well understood. The present study sought to evaluate whether patients who have IBD were at an increased risk of THA failure compared to those who did not have IBD. MethodsThe Statewide Planning and Research Cooperative System was used to compare postoperative outcomes between patients who have IBD (CD and UC) and patients who do not have IBD from 2010 to 2020. A total of 119,094 patients were included in the study, of whom 1,165 had a diagnosis of IBD. Overall, 501 of those had CD, while 664 had UC. ResultsWhen controlling for comorbidities, patients who had CD had longer hospital length of stay (CD: 3.6 ± 2.5 versus UC: 3.4 ± 2.1 versus control: 3.2 ± 2.3 days, P < 0.001), higher rates of 90-day readmission (CD: 13.6 versus UC: 8.3 versus control: 7.7%, P < 0.001) and 1-year readmission (CD: 20.4 versus UC: 15.1 versus control: 12.8%, P < 0.001), and higher rates of 90-day emergency room visits (CD: 15.4 versus UC: 12 versus control: 11.1%, P = 0.007). There were no differences in all-cause revision or revision for periprosthetic joint infection between CD and UC compared with control patients. ConclusionsPatients who have UC had more emergency room visits and hospital readmissions following THA; however, survival analysis demonstrated that IBD patients are not at an increased risk of revision or periprosthetic joint infection after THA.

Efficacy of Bowel Regimen in Decreasing Postoperative Constipation in Bariatric Surgery Patients.

Postoperative constipation after bariatric surgery is a common complaint, decreasing patient quality of life. No literature exists examining the efficacy of a preoperative bowel regimen in reducing postoperative constipation in this cohort. This study aims explore the efficacy of a well-established bowel regimen, polyethylene glycol (PEG), in reducing constipation frequency and severity after bariatric surgery. This was a retrospective study of adult patients undergoing primary and revisional bariatric procedures. The use of PEG bowel prep for bariatric patients was introduced as an institutional quality improvement measure. Patients during the first 3months after PEG implementation were surveyed for postoperative constipation. For the year after implementation, patients were followed for 30-day emergency room visits or hospitalization secondary to constipation. This cohort was compared to historical controls from the previous year. Student t-tests were used for statistical analysis. During the 3-month exploratory phase, 28/49 (57.14%) patients fully completed the bowel regimen. In total, 0/56 (0%) patients reported preoperative constipation, and 5/28 (17.9%) patients reported constipation at the 3-week follow-up. In the 1year post-implementation cohort, 2/234 (0.85%) patients had constipation-related occurrences at 30-day follow-up, compared to 8/219 patients (3.65%) in the historical cohort (p = 0.04). The implementation of a PEG-based bowel regimen did not eliminate self-reported constipation. However, there were significant differences in rates of constipation-related ED visits and hospital readmissions, suggesting that the bowel regimen decreases rates of severe constipation. Finally, patient compliance was limited. Future work should aim towards increasing compliance.

Complication rates of ciprofloxacin alone vs. ciprofloxacin plus fosfomycin for transrectal prostate biopsy.

Infectious complications after transrectal prostate biopsy have been increasing, driven in large part, by rates of antibiotic resistance to conventional prophylaxis, such as ciprofloxacin. This study was designed to compare conventional antibiotic prophylaxis (oral ciprofloxacin) with ciprofloxacin and fosfomycin combination therapy prior to biopsy. This was a retrospective study looking at men between September 2021 and April 2023, who underwent transrectal prostate biopsy at several institutions in Alberta. The primary outcome was infectious complications within 30 days of prostate biopsy. Secondary outcomes included Clostridium difficile infections, urinary retention, gross hematuria, diarrhea, emergency room (ER ) visits, hospital admissions, and intensive care unit (ICU) admissions. Data was collected on resistance patterns and pathogens isolated in culture. During the study period, 2168 men underwent transrectal prostate biopsy. A total of 1216 men received ciprofloxacin alone and 877 received fosfomycin and ciprofloxacin. Infectious complications were significantly higher in the ciprofloxacin alone group (5.8% vs. 0.5%, p<0.0001). Thirty-day complications (7.2% vs. 2.1%, p<0.0001), 30-day ER visits (7.1% vs. 1.8%, p<0.0001), and 30-day hospitalizations (2.7% vs. 0.7%, p<0.001) were all higher in the ciprofloxacin alone group. The most isolated pathogen was E. coli in 54/60 (90%). Ciprofloxacin resistance in the isolated pathogens was high, with 52/60 (87%) showing resistance to ciprofloxacin and 51/54 (94%) E. coli strains resistant. No difference was seen in retention, C. difficile infections, bleeding, or diarrhea. The addition of fosfomycin for antibiotic prophylaxis prior to transrectal prostate biopsy was associated with significant improvement in infectious complications and healthcare utilization.

Systematic review and meta-analysis of economic and healthcare resource utilization outcomes for robotic versus manual total knee arthroplasty

The introduction of robotics in orthopedic surgery has led to improved precision and standardization in total knee arthroplasty (TKA). Clinical benefits of robotic versus manual TKA have been well established; however, evidence for economic and healthcare resource utilization outcomes (HRU) is lacking. The primary objective of this study was to compare economic and HRU outcomes for robotic and manual TKA. The secondary objective was to explore comparative robotic and manual TKA pain and opioid consumption outcomes. Multi-database literature searches were performed to identify studies comparing robotic and manual TKA from 2016 to 2022 and meta-analyses were conducted. This review included 50 studies with meta-analyses conducted on 35. Compared with manual TKA, robotic TKA was associated with a: 14% reduction in hospital length of stay (P = 0.022); 74% greater likelihood to be discharged to home (P < 0.001); and 17% lower likelihood to experience a 90-day readmission (P = 0.043). Robotic TKA was associated with longer mean operating times (incision to closure definition: 9.27 min longer, P = 0.030; general operating time definition: 18.05 min longer, P = 0.006). No differences were observed for total procedure cost and 90-day emergency room visits. Most studies reported similar outcomes for robotic and manual TKA regarding pain and opioid use. Coupled with the clinical benefits of robotic TKA, the economic impact of using robotics may contribute to hospitals’ quality improvement and financial sustainability. Further research and more randomized controlled trials are needed to effectively quantify the benefits of robotic relative to manual TKA.

Impact of Enhanced Recovery After Surgery(ERAS) Combined with Bariatric Surgery Targeting Opioid Prescriptions(BSTOP) Protocol on Patient Outcomes, Length of Stay and Opioid Prescription After Bariatric Surgery.

Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1-2) days vs. 1 (1-2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65-0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates.

Unplanned 30-Day ER Visit Rate and Factors Associated With ER Visits After Ambulatory Sinus Surgery.

Emergency room (ER) visits after surgery can be inconvenient and costly to the patient and the healthcare system. Estimates of the 30-day ER visit rate following ambulatory sinus procedures and their risk factors are largely unknown in the literature. To determine the 30-day postoperative ER visit rate following ambulatory sinus procedures and the causes and risk factors associated with ER visits. This is a retrospective, cohort study using data from the State Ambulatory Surgery and Services Databases (SASD) and the State Emergency Department Databases (SEDD) for California, New York, and Florida in 2019. We identified adult (18 years old) patients with chronic rhinosinusitis who underwent ambulatory sinus procedures from the SASD. Cases were linked to the SEDD to identify ER visits occurring within 30 days after the procedure. Logistic regression models were used to identify patient- and procedure-related risk factors associated with the 30-day postoperative ER visit. Among the 23 239 patients, the 30-day postoperative ER visit rate was 3.9%. The most common reason for ER visit was bleeding (32.7%). A total of 56.9% of the ER visits occurred within the first week. In the multivariate analysis, factors associated with ER visits included Medicare (odds ratio [OR] 1.29 [1.09-1.52], P = .003), Medicaid (OR 2.06 [1.69-2.51], P < .001), self-pay/no insurance (OR 1.44 [1.03-2.00], P = .031), chronic kidney disease/end-stage renal disease (OR 1.63 [1.06-2.51], P = .027), chronic pain/opioid use (OR 2.70 [1.02-7.11], P = .045), and a disposition other than home (OR 12.61 [8.34-19.06], P < .001). The most common reason for ER visit after ambulatory sinus procedures was bleeding. An increased ER visit rate was associated with certain demographic factors and medical comorbidities but not with procedure characteristics. This information can help us identify the patient populations who are at higher risk for ER visits to improve their postoperative recovery.

The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture

ObjectiveTo investigate the safety of using the anterior approach (AA), compared to the lateral approach (LA), in hemiarthroplasty for the treatment of displaced neck of femur fractures. DesignRetrospective case-control match cohort study. SettingLevel 1 trauma center. PatientsRetrospective review of prospectively collected data for 39 consecutive intracapsular hip fractures treated with hemiarthroplasty using an AA between 2017 and 2021. Patients operated with the AA were matched in 1:2 ratio with patients that had hemiarthroplasty via a LA. Main Outcome MeasuresDischarge destination, 90-day emergency room (ER) visit or readmission rate, inpatient and 90-day mortality rate, inpatient medical complications, 90-day mechanical complications, 90-day reoperation, and length of hospital stay (LOS). ResultsDischarge destination (p = 0.695), 90-day ER visit or readmission rate (p = 0.315), inpatient (p = 0.719) and 90-day mortality rate (p = 0.815), medical complications (p = 0.524), mechanical complications (p = 0.150) were similar between cohorts. Five patients, all in the LA-group, required re-operations within 90-days (p = 0.106). Patients in AA-group had shorter LOS (9.3 days, 95% CI [7.6–11.1] vs. 14.7 days [95% CI 12.2–17.3], p = 0.002). ConclusionsThe AA can be safely introduced for the treatment of hip fractures. Similar short-term outcomes relative to the LA were identified. The shorter LOS may reflect the improved early functional recovery offered from the muscle-sparing AA technique. Future, level-1 data should include early- and longer term functional outcome along with cost-effectiveness.

Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis.

Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys. The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone. Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomeswere acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models. A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06). This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.

Validation of the Outpatient Arthroplasty Risk Assessment tool for safe same-day discharge after primary shoulder arthroplasty: a retrospective expansion study

BackgroundEarly discharge has been a target of cost-control efforts given the growing demand for joint replacement surgeries. A multisystem medically-based risk-assessment tool known as the Outpatient Arthroplasty Risk Assessment (OARA) score has shown high predictive ability for safe early discharge following an outpatient lower extremity arthroplasty utilizing a score threshold ≤79. Shoulder arthroplasties have been shown to have lower associated medical risks than lower extremity arthroplasties. An OARA score threshold of 110 was recently shown to be safe for same-day discharge (SDD) following shoulder arthroplasties in a series of 422 patients. The purpose of this study is to re-examine the OARA score threshold for shoulder arthroplasties by evaluating its effectiveness in selecting patients for SDD utilizing a larger population of patients. We hypothesize that the OARA score threshold for shoulder arthroplasty will remain higher than the established threshold for lower-extremity arthroplasty. MethodsA retrospective review was performed on 734 consecutive patients who underwent a primary anatomic or reverse total shoulder arthroplasty between April 2018 and December 2020 by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room and urgent care visits were obtained from medical records. Analysis of variance testing, Chi-square testing, and screening test characteristics compared the performance of OARA scores to that of the American Society of Anesthesiologists Physical Status. A receiver operating characteristic analysis was completed to determine the optimal OARA score threshold for safe SDD. ResultsThe receiver operating characteristic analysis showed that 102.5 was the optimal preoperative OARA score threshold for safe SDD following a shoulder arthroplasty. The OARA score cutoff of ≤102.5 points demonstrated a sensitivity of 87.0% for identifying SDD patients. OARA scores ≤102.5 also showed a negative predictive value of 80.6% but remained incomprehensive with a specificity of 28.5% (P < .0001) and a positive predictive value of 39.2. Patients with OARA scores ≤102.5 were over 4 times less likely to have a 90-day emergency room visit (P < .001) than those with scores >102.5. There was no difference in 30-day and 90-day readmission rates for patients with OARA scores ≤102.5, ≤110, and ≤79 and American Society of Anesthesiologists Physical Status ≤2. ConclusionA preoperative OARA score threshold of ≤102.5 is effective and conservative in screening patients for SDD following a shoulder arthroplasty, with low rates of 90-day emergency room visits and readmissions. This threshold is a useful screening tool to identify patients that are not good candidates for SDD.

Relationship between diabetes and its severity, frailty and adverse surgical outcomes among older adults with cancer.

e24023 Background: Presence and severity of comorbid conditions impact surgical outcomes of older adults with cancer. The aim of our study is to evaluate the relationship between diabetes mellitus (DM), and preoperative HgbA1c (pHgbA1c) with frailty and adverse surgical outcomes among older adults with cancer. Methods: Retrospective study of patients aged 65 and older who underwent elective cancer surgery with at least one-day hospital stay in 2015-18 at our institution. For our primary aim, we assessed the association between DM and frailty, sociodemographic and clinical characteristics by reporting the characteristics stratified by presence of DM. Frailty was assessed using the Memorial Sloan Kettering Frailty Index (MSK-FI), which composes of 10 comorbidities and one functional component. This score ranges from 0-11, with higher score corresponding to greater frailty. Our secondary aim to assess the association between pHgbA1c and frailty was evaluated by a linear regression with pHgbA1c as the outcome and MSK-FI as the predictor. For our tertiary aim to assess the association between pHgbA1c and adverse surgical outcomes, we used a univariable logistic regression model with the outcome as the composite definition of 30-day readmission, 30-day emergency room visit, 30-day major complication, or 90-day mortality, and pHgbA1c as the predictor. We also used a multivariable logistics regression model, adjusting for age, gender, American Society of Anesthesiologist Performance Status (ASA-PS), and operation time.Analyses related to pHgbA1c excluded patients without pHgbA1c records. Results: Among 4417 patients, 1024 (23%) had DM and among those 403 (39%) had pHgbA1c values recorded. The results showed patients with DM were older, had higher ASA-PS, more comorbidities and higher MSK-FI scores than those without DM. Moreover, pHgbA1c was not found to be statistically associated with degree of frailty (β for one unit change in MSK-FI 0.11, 95% CI 0.00, 0.21; p = 0.057). Lastly, in both unadjusted and adjusted models pHgbA1c was not associated with adverse surgical outcomes (OR for both models, 0.99, 95% CI 0.83, 1.16, p = 0.9). Conclusions: In this cohort of patients whose pHgbA1c values were recorded, pHgbA1c was not associated with adverse surgical outcomes. Further studies are needed to confirm this study with more focus on perioperative care process of patients with DM and find cohorts whose pHgbA1c measurements can better predict frailty and adverse surgical outcomes.

Actual compliance rate of Enhanced Recovery After Surgery protocol in laparoscopic distal gastrectomy.

PurposeThe Enhanced Recovery After Surgery (ERAS) protocol enhances recovery rate after laparoscopic distal gastrectomy (LDG). An ERAS protocol has been applied to most patients who underwent LDG at our center. In this study, we determined the actual compliance rate of the ERAS protocol and analyzed the risk factors for noncompliance.MethodsMedical records of 1,013 patients who underwent LDG from March 2016 to December 2017 were reviewed retrospectively. The compliance group (A) included 327 patients who were discharged within four days postoperatively. The noncompliance group (B) comprised 686 patients who were not discharged within four days postoperatively.ResultsThe compliance rate of the ERAS protocol was 32.3%. Potential compliance rate was 53.2%. Most common reasons for noncompliance were fever (n = 115) and ileus (n = 111). The 30-day emergency room visit rate was significantly lower in group A than that in group B (p = 0.006). Median age, American Society of Anesthesiologists (ASA) physical status classification, operation time, and pathologic stage were significantly higher in group B than those in group A (p < 0.001, p < 0.001, p = 0.005, and p < 0.001, respectively). Risk factors for noncompliance were ASA classification of ≥III (odds ratio [OR], 2.251; p = 0.007), age of ≥70 years (OR, 1.572; p = 0.004), operation time of ≥180 minutes (OR, 1.475; p = 0.003), and pathologic stage of ≥III (OR, 2.224; p < 0.001).ConclusionThe current ERAS protocols should be applied to patients without risk factors.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme.

Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

Synchronous Artificial Urinary Sphincter and Inflatable Penile Prosthesis Implantation: Short-Term Outcomes from a Statewide Claims Database.

The 2 most common adverse effects of radical prostatectomy are erectile dysfunction and stress urinary incontinence which often require surgical management with penile prosthesis (PP) and artificial urinary sphincter (AUS) implantation, respectively. There are conflicting reports regarding whether these procedures should be combined into 1 surgical setting or staged. We sought to evaluate the safety of performing these procedures in the same operative setting. We performed a retrospective analysis using the Healthcare Cost and Utilization (HCUP) State Inpatient Database (SID) and State Ambulatory Surgery Database (SASD) for the states of California (2007-2011) and Florida (2009-2014). ICD-9-CM diagnosis and CPT codes were used to identify adult males who underwent both PP and AUS implantation and outcomes regarding readmissions, emergency room (ER) presentations, and complications were reviewed. Patients undergoing synchronous PP-AUS implantation had significantly higher 90-day readmission rates (13.9% vs 7.2%, p <0.001), suffered higher rates of device complications (6.1% vs 3.4%, p=0.021), and were more likely to have minor complications (8.89% vs 2.35%, p <0.001) compared to nonsynchronous device placement. No differences in major complications or 90-day ER visits were observed. Synchronous PP and AUS implantation is feasible but may be associated with higher readmission rates, device complications and postoperative complications compared to a staged approach. This further validates findings from prior studies.

Postoperative Outcomes Following Posterior Lumbar Fusion in Patients With Multiple Sclerosis.

Multiple sclerosis (MS) is a chronic inflammatory disease that can cause physical and neurological dysfunction. Patients with MS are living longer and undergoing more orthopedic procedures, but the risk of patients with MS undergoing posterior lumbar fusion (PLF) has not been studied in literature before. This study aims to (1) analyze the rates of postoperative complications of MS patients undergoing primary PLF and (2) analyze the economic burden associated with these surgeries in the MS population compared with patients without MS. A retrospective review of the Medicare database was conducted on all patients who underwent PLF and/or posterior lumbar interbody fusion between the years of 2006 and 2013. Cases involving same-day anterior or revision procedures and patients with a history of spine, infection, and trauma, or neoplasm were excluded from the study. Demographics, comorbidities, 90-day postoperative complications, cost, and length of stay were calculated. All outcomes of interest were analyzed using multivariate logistic regression, adjusting for age, sex, and comorbidity burden. Significance was defined as P-value <0.05. There were 2363 patients with MS and 23,569 matched controlled patients. We found a significant increase in the risk of sepsis [odds ratio (OR)=1.85, P=0.034], urinary tract infection (OR=1.89, P<0.001), deep vein thrombosis (OR=1.4, P=0.044), 90-day emergency room visit (OR=1.14, P=0.027), and 90-day readmissions (OR=1.20, P=0.011) compared with patients without a history of MS. Patients with MS also incurred $4379 extra in total hospital charge, a $1679 increase in the cost of hospitalization, and an increase in length of stay (4.05 vs. 3.61, P<0.001). A diagnosis of MS is associated with a significant increase in postoperative complications and higher costs after hospitalization. It is imperative for physicians to understand the risk factors of patients undergoing PLF and/or posterior lumbar interbody fusion with MS to better counsel them about postoperative complications before surgery. Level III.

44 Risk factors for readmission after minimally invasive pelvic organ prolapse surgery

Our objective was to report risk factors for 30-day readmission and emergency department visits after minimally invasive pelvic organ prolapse surgery. This retrospective cohort study included all minimally invasive urogynecologic prolapse procedures with and without concomitant hysterectomy performed within a large managed organization of 4.5 million members from 2008 through 2018. We queried the system-wide medical record for CPT and ICD-9/10 codes for all included procedures and patient demographic and perioperative data. Our primary outcome was 30-day hospital readmission, and our secondary outcome with 30-day emergency room visits. Risk factors including demographics and characteristics for 30-day outcomes were examined using odds ratios and using chi-square for categorical variables and Wilcoxon rank sum for continuous variables. Of the 13,445 patients undergoing prolapse surgery, 6,171 patients underwent concomitant hysterectomy while 7,274 did not. For those who had a concomitant hysterectomy, the patient factors that were associated with increased 30-day readmission risk were hypertension (OR=1.54, 95% CI 1.03-2.31, P=0.03) and COPD (OR=2.52, 95% CI 1.32-4.81, P<0.01). For those whose prolapse procedure did not include concomitant hysterectomy, the patient factors that were associated with increased 30-day readmission risk were age (OR=1.05, 95% CI 1.02-1.07, P<0.01), and heart failure (OR=3.26, 95% CI 1.68-6.33, P<0.01). For those who had a concomitant hysterectomy, the patient factors that were associated with increased 30-day emergency department visit were heart failure (OR=2.41, 95% CI 1.23-4.62, P<0.01) and COPD (OR=1.42, 95% CI 1.16-1.72, P<0.01). For those whose prolapse procedure did not include concomitant hysterectomy, the patient factors that were associated with increased 30-day emergency department visit risk were (non-white) race (OR=0.75, 95% CI 0.64-0.90, P<0.01), heart failure (OR=1.77, 95% CI 1.14-2.75, P=0.01), and hypertension (OR=1.37, 95% CI 1.13-1.66, P<0.01). In women undergoing minimally invasive pelvic organ prolapse surgery, patient comorbidities and factors were associated with 30-day readmission and emergency department visits. Clinicians may consider these factors when counseling patients about their risks following minimally invasive pelvic organ prolapse surgery.

A Rapid Recovery Protocol Applied to Total Joint Arthroplasty Reduced Readmissions for Surgical but Not Medical Reasons Over a 5-Year Period.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed procedures that are expected to continue increasing in demand. Although they are proven to be safe and effective, emergency room (ER) visits or hospital readmissions within 90 days after these procedures account for more than one-third of the total cost of postacute care. Purpose: We sought to identify changes in reasons for 90-day ER visits and readmissions after total joint arthroplasty (TJA) during a 5-year period over which rapid recovery protocols evolved. Methods: We conducted a retrospective cohort study comparing 1980 patients who had undergone TJA from July 2017 to June 2018 with a previously published cohort of 7466 patients who had undergone TJA from July 2013 to June 2017. All procedures were performed at a single institution. Changes in the proportion of patients returning for medical and surgical reasons were compared using univariate analysis. Results: For patients discharged home, the 2017-2018 cohort showed a significant reduction in the proportion of ER visits due to pain and swelling and wound infection and an increase in visits for medical reasons. This cohort had a higher proportion of readmissions for medical reasons. In patients discharged to a skilled nursing facility (SNF), similar reasons for ER visits were observed across time periods, and a decrease in the proportion of readmissions for wound infections was observed in the 2017-2018 cohort. Falls and nausea, vomiting, or diarrhea increased significantly to account for 9.5% of readmissions each in 2017-2018. Conclusion: The results of a comparison of 2 cohorts demonstrate the heterogeneous and dynamic nature of unplanned return-to-hospital events and the importance of patient support throughout the surgical episode. As we strive toward minimizing ER visits and readmissions after TJA, rapid recovery protocols must continue to evolve to address the complexity of this patient population.

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer.

Unplanned visits (UPV) - re-admissions and emergency room (ER) visits - are markers of healthcare system quality. Radical prostatectomy (RP) is a commonly performed cancer procedure, where variation in UPV represents a gap in care for prostate cancer patients. Here, we systematically synthesize the rates, reasons, predictors, and interventions for UPV after RP to inform evidence-based quality improvement (QI) initiatives. A systematic review was performed for studies from 2000-2020 using keywords: "re-admission," "emergency room/department," "unplanned visit," and "prostatectomy." Studies that focused on UPV following RP and that reported rates, reasons, predictors, or interventions, were included. Data was extracted via a standardized form. Meta-analysis was completed. Sixty studies, with 406 107 RP patients, were eligible; 16 028 UPV events (approximately 5%) were analyzed from 317 050 RP patients. UPV rates after RP varied between studies (ER visit range 6-24%; re-admissions range 0-56%). The 30-day and 90-day ER visit rates were 12% and 14%, respectively; the 30-day and 90-day re-admission rates were 4% and 9%, respectively. A total of 55% of all re-admissions after RP are directly due to postoperative genitourinary (GU)-related complications, such as strictures, obstructions, fistula, bladder-related, incontinence, urine leak, renal problems, and other unspecified urinary complications. The next most common re-admission reasons were anastomosis-related, infection-related, cardiovascular/pulmonary events, and wound-related issues. Thirty-four percent of all ER visits after RP are directly due to urine-related issues, such as retention, urinoma, obstruction, leak, and catheter problems. The next most common ER visit reasons were abdominal/gastrointestinal issues, infection-related, venous thromboembolic events, and wound-related issues. Predictors for increased re-admission included: open RP, lymph node dissection, Charlson comorbidity index ≥2, low surgeon/hospital case volume, and socioeconomic determinants of health. Of the 10 interventions evaluated, a 3.4% average reduction in UPV rate was observed, highlighting an approximate two-fold decrease. Meta-analysis demonstrated a significant benefit of interventions over controls, with odds ratio 0.62 (95% confidence interval 0.46-0.84). Interventions that used multidisciplinary, nurse-centered, programs, with patient self-care/empowerment were more beneficial than algorithmic patient care pathways and preoperative patient education. Twenty years of international, retrospective experience suggests UPV after RP are often related to GU complications and infection- or wound-related factors. QI interventions to reduce UPV should target these factors. While many re-admissions after RP appear to be unavoidable, ER visits have more opportunity for volume reduction by QI. The interventions evaluated herein have the potential to reduce UPV after RP.

Comparison of Healthcare Costs Associated With Patients Receiving Traditional Negative Pressure Wound Therapies in the Post-Acute Setting.

ObjectiveA retrospective national insurance claims database analysis evaluated total and wound-related costs for acute and chronic wound patients treated with negative pressure wound therapy (NPWT), comparing a product specific NPWT (NPWT-K) to other NPWT systems (NPWT-O).MethodsPatients with one or more NPWT claims between January 2016 and September 2018 in an outpatient setting with continuous medical and pharmacy benefits for six months before the initial (index) NPWT claims and 12 months post index were assessed. The cohorts were propensity score matched based on age, gender, comorbidities, and payer type. Each cohort included 3,368 patients after matching. Costs were evaluated at 30 days, three months, and 12 months after initial NPWT placement. Hospital admission rates, emergency room (ER) visits, and NPWT device switching were evaluated at 30 days. Differences were analyzed by t-test and chi-square test.ResultsAt 30 days, wound-related costs were $8,583 and $11,334, and total cost to treat was $17,809 and $24,405 for NPWT-K and NPWT-O, respectively (p < 0.0001). NPWT-O patients had higher NPWT, wound-related, and total costs across all time periods, as well as a longer average length of therapy (p = .0039). There was no statistical difference in 30-day hospital admissions (p = 0.089); although 30-day ER visits were higher for NPWT-K (4.9% vs. 3.3%, p = 0.0007). A higher degree of switching from NPWT-O to NPWT-K occurred at 30 days (NPWT-O 2.5% vs. 0.4%, p < 0.0001).ConclusionsThis comparative effectiveness analysis indicates differences remain across NPWT suppliers in wound-related and total cost to treat for patients who receive durable NPWT in the outpatient setting.

Economic analysis of 90-day return to the emergency room and readmission after elective lumbar spine surgery: a single-center analysis of 5444 patients.

In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity and/or use a proxy for actual cost. The purpose of this study was to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions after elective lumbar spine surgery. A prospective, multisurgeon, single-center electronic medical record was queried for elective lumbar spine fusion surgeries from 2013 to 2017. Predictive models were created for 90-day ER visits and readmissions. Of 5444 patients, 729 (13%) returned to the ER, most often for pain (n = 213, 29%). Predictors of an ER visit were prior ER visit (OR 2.5), underserved zip code (OR 1.4), and number of chronic medical conditions (OR 1.4). In total, 421 (8%) patients were readmitted, most frequently for wound infection (n = 123, 2%), exacerbation of chronic obstructive pulmonary disease (n = 24, 0.4%), and sepsis (n = 23, 0.4%). Predictors for readmission were prior ER visit (OR 1.96), multiple chronic conditions (OR 1.69), obesity (nonobese, OR 0.49), race (African American, OR 1.43), admission status (ER admission, OR 2.29), and elevated hemoglobin A1c (OR 1.80). The mean direct hospital cost for an ER visit was $1971, with 75% of visits costing less than $1890, and the average readmission cost was $7347, with 75% of readmissions costing less than $8820. Over the 5-year study period, the cost to the institution for 90-day return ER visits was $5.1 million. Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient counseling, appropriate postoperative pain management, and optimization of modifiable risk factors prior to surgery are areas to focus future efforts to lower 90-day ER visits and readmissions and reduce healthcare costs.

Patients with Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following Hallux Valgus Procedures

Category:Ankle; Bunion; Midfoot/Forefoot; OtherIntroduction/Purpose:Patients with a history of opioid use disorder (OUD) have been shown to incur more severe medical complications, higher readmission rates, and increased cost following various orthopedic procedures. There is a scarcity in the literature investigating the effects of OUD following a hallux valgus procedure. Therefore, the purpose of this study was to evaluate whether OUD patients undergoing a hallux valgus correction are at greater odds of: 1) readmission rates, 2) emergency room (ER) visits, and 3) costs.Methods:Patients undergoing a hallux valgus correction with a history of OUD were identified using a health insurance claims database. To search for patients undergoing hallux valgus surgical corrections the following current procedural terminology (CPT) medical codes were used: 28290, 28292, 28293, 28294, 28296, 28297, 28298, 28299, 28306, and 28307. To include all eligible patients the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were also utilized, including: 77.51 and 77.59. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day emergency room visit, and 90-day episode of care costs. Pearson’s chi-squared test was used to compare demographics. Logistic regression analysis calculated odds-ratios for readmission and ER visits. Welch’s t-test was used for significance in ECI and cost between cohorts.Results:The query yielded 6,318 patients (OUD=1,276; NUD=5,042) who underwent a hallux valgus correction. There were no significant difference between any of the compared age ranges (p=0.859, p=0.952, p=0.909, p=0.961), ECI (p=1.000) and comorbidities between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission rates (9.56 vs. 6.04%; OR: 1.55, p<0.001) and 30-day ER visits (.86 vs. .35%; OR: 2.42, p=0.021) compared to controls. OUD patients also incurred significantly greater 90-day episode of care costs ($7,208.28 vs. $6,134.75, p<0.0001) compared to NUD patients.Conclusion:Patients with a history of OUD who underwent a hallux valgus correction had a higher odds ratio of 90-day readmission rates, 30-day emergency room visits, and 90-day total global episode of care cost compared to those with NUD. These findings expand on a rapidly growing body of current literature that demonstrate OUD increases numerous costs associated with outcomes of foot and ankle surgery. OUD is a risk factor for poor post operative outcomes for patients undergoing a hallux valgus correction. The findings of this study are likely to improve preoperative counseling and selection when addressing patients with preoperative opioid use.