Decrease In Length Of Hospital Stay Research Articles

8189 Demographics and Healthcare Utilization of Diabetic Versus Non-Diabetic Gastroparesis hospitalization in the United States Using the National Inpatient Sample database

Abstract Disclosure: S. Khan: None. L. Zia: None. M. Khan: None. M. Amin: None. M. Khan: None. F. Sattar: None. Background: Gastroparesis is commonly associated with neuropathy secondary to Diabetes and Non-Diabetic causes such as Idiopathic, Post-Viral and Surgical with a wide spectrum of clinical manifestations impairing quality of life, worsening morbidity, and mortality. The purpose of this study is to assess Demographic disparities and utilization of healthcare services between Diabetic (DG) Versus Non-Diabetic Gastroparesis (NDG) admissions. Methods: Data were extracted from the National Inpatient Sample Database for the year 2020. It comprises discharge data obtained from a 20% stratified sample of community hospitals across the country. We conducted a retrospective cohort study focusing on admissions of patients aged 18 years and above with diagnosis of DG and NDG were identified using ICD-10 codes. Multivariate regression analysis was used to estimate the Mean difference of the Average length of hospital stay (LOS), and total hospital charges (THC). Multivariate logistic and linear regression was used accordingly to adjust for confounders. Analysis was performed using STATA 18. Results: Our study identified 10330 patients hospitalized due to gastroparesis, among them 1446 (14%) had DG. Hospitalizations with DG in comparison with NDG had lower number of women (65% Vs 80.7%, P≤0.05), a higher proportion of black adults (36.5% Vs 17%), a lower proportion of white adults (46.4% Vs 70%), and a higher Charlson Comorbidity Index. In DG, 104(7.19%) patients had EGD and non-diabetic gastroparesis, 977 (11%) had EGD during admission. The mean LOS in hospital was 4.72 days and mean total hospital charges were 51327 USD. Comparing both cohorts, there was statistically significant decrease in the mean LOS in DG, Adjusted Mean difference of 1.27 days (P = 0.006). In addition, there was significant decrease in the total cost of hospitalization with an adjusted Mean difference of 13832 (P=0.001). Thirty patients with NDG died during hospital course and none with Diabetic gastroparesis. Conclusion: According to our findings, majority of admissions with gastroparesis are related with non-diabetic causes with higher healthcare utilization and mortality rate. Gastroparesis is a relatively frequent and poorly understood condition which needs considerate effort to have a better understanding of disease. Presentation: 6/2/2024

The Impact of the COVID-19 Pandemic on Surgical Services in Brazil's Healthcare System: A Retrospective Cross-Sectional Study.

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery, leading to the cancellation and postponement of various health services, including surgery. Numerous countries closed their borders and established laws mandating the use of face masks and social distancing and enforced lockdowns, and various activities were constrained. Brazil, the largest and most populous country in Latin America, also experienced a rapid and sustained surge in infections and deaths. Brazil was the most severely impacted nation in Latin America. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aimed to assess the impact of the COVID-19 pandemic on surgical services throughout the entire period. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022 and compared the following indicators: (1) number of hospital admissions, (2) length of hospital stay (LOS) (in days), and (3)volume of urgent and elective procedures. Data was divided into four time periods, pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the number of admissions and LOS based on surgical procedures performed by stratifying according to region, sex, age, and type of surgery (urgent versus elective). Results The number of admissions for surgical procedures ranged between 859,646and 4,015,624for 2019, 686,616and 3,419,234for 2020,787,791and 3,829,019for 2021, and760,512and 3,857,817for 2022 for the category of region; 4,260,900and 5,991,775for 2019, 3,594,117and 4,984,710for 2020,4,182,640 and 5,590,808for 2021, and4,077,651 and5,561,928for 2022 for the category of sex; and 2,170,288 and 3,186,117 for 2019, 1,516,830and2,825,189for 2020,1,748,202and3,030,272for 2021, and1,900,023and2,859,179for 2022 for the category of age.The variable age showed a comparable trend, albeit with an expressive decline for surgeries in the age range of 0-19 years. The LOS (in days)for surgical procedures ranged between110,157 and 910,846for 2019,58,562 and897,734for 2020,67,926 and904,137for 2021, and100,467and823,545for 2022. Thoracic surgery indicated no statistically significant difference in the number of admissions and LOS.Elective surgeries had a decline in the number of admissions and LOS, a 13% and 9.3% decline between 2019 and 2020, respectively. Urgent surgeries experienced a slight decrease in admissions and LOS, with a decline of 2.4% and 2.8% between 2019 and 2020, respectively. Conclusions Population characteristics, such as age, sex, and region, showed decreased hospital admissions during the pandemic, followed by a recovery towardpre-pandemic levels afterward. The number of surgical admissions and the length of hospital stays decreased during the pandemic but gradually returned to pre-pandemic levels in the recovery and post-pandemic phases. Notably, thoracic surgery remained statistically consistent across all periods, indicating its emergency nature compared to other surgeries. Thus, we conclude that the pandemic had minimal impact on thoracic surgery cases, contributing to a stable trend.

62 Does vitamin D deficiency lead to poorer health outcomes after (total) knee arthroplasty? A systematic review and meta-analysis

Abstract Aims Vitamin D deficiency is a predictor of poorer musculoskeletal disease outcomes and affects approximately 1-in-4 people. Prior literature has assessed the effects of vitamin D deficiency in joint arthroplasties. This updated systematic review and meta-analysis aims to evaluate and collate evidence available on vitamin D supplementation in total knee arthroplasty (TKA). Methods A targeted terms search related to vitamin D and TKA outcomes was conducted (data inception until 01/09/2021). PubMed, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, American Academy of Orthopaedic Surgeons and British Orthopaedic Association databases were used. Analyses consisted of forest plots with I2 heterogeneity statistics, pooled effects with 95% confidence intervals (CI) and, p-values. A p < 0.05 was considered statistically significant. Results 10 studies fitted inclusion criteria for narrative description and 3 for meta-analysis. 6 studies showed improved outcomes in revision surgery risk, joint infection incidence and postoperative function. Additionally, there were poorer outcomes in postoperative stiffness, prosthesis explanation and postoperative vascular events. Meta-analysis of the length of hospital stay (LOS) demonstrated a significant decrease in LOS between vitamin D sufficiency versus deficiency (standard mean difference = -0.54, 95% CI [-0.69, -0.38], p<0.00001) favouring vitamin D sufficiency. Conclusion Vitamin D supplementation demonstrated a statistically significant benefit for TKA patients regarding LOS. Most studies found positive effects of vitamin D supplementation improving patients’ health, reducing hospital resource use, and decreasing the burden on surgeons. Further research with standardised assessment scores is required to definitively prove the vitamin D screening and supplementation benefits in TKA.

HOSPITALIZATION TRENDS IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH POUCHITIS: A POPULATION-BASED STUDY

Abstract INTRODUCTION Pouchitis is a complication of total colectomy and ileal pouch-anal anastomosis for ulcerative colitis that can lead to hospitalization. We aimed to assess trends of hospitalization rates and health care utilization in patients with pouchitis from 2010 – 2019. METHODS We performed a retrospective cohort study using the National Inpatient Sample database from 2010 to 2019 of hospitalized patients with a primary discharge diagnosis of pouchitis and a secondary diagnosis of inflammatory bowel disease (IBD), or primary diagnosis of IBD and a secondary diagnosis of pouchitis. We compared baseline characteristics and outcomes of patients admitted from 2010-2014 to 2015-2019. The primary outcome was the rate of hospitalization for pouchitis between the two five-year periods. Secondary outcomes included length of hospital stay (LOS) and total hospitalization charges. We applied discharge weights to generate national estimates. RESULTS A total of 8215 hospitalizations with pouchitis were identified for IBD patients, with 3856 hospitalizations in the 2010 – 14 group and 4359 in the 2015- 19 group. The 2015-2019 group had less females (54.54% vs 46.67%, p =0.002) and increased hospitalization in urban teaching hospitals (71.95% vs 85.67%, p< 0.001) (Table 1). Hospitalizations with a primary diagnosis of pouchitis were lower in the 2015-2019 group (58.91% vs 53.21%, p= 0.024). Over the study period (2010-2019), there was a numeric increase in the pouchitis incidence among hospitalized IBD patients (2.68 in 2010 to 2.87 in 2019 per 1000 discharges, p=0.459), and the number of patients undergoing inpatient pouchoscopy (25.67% in 2010 and 26.55% in 2019, p=0.803). The average inflation-adjusted total hospitalization charges were $12,555 higher in 2019 compared to 2010 (p=0.045). However, there was a decrease in LOS over this period (5.99 days in 2010 to 5.39 in 2019, p=0.182) (Figure 1). DISCUSSION Over the past decade, the overall number of hospitalizations for IBD patients with pouchitis remained stable with a slight numeric increase, but the rate of hospitalization primarily for pouchitis has significantly decreased. Although LOS has numerically decreased, the overall cost of hospitalization has increased for IBD patients with pouchitis. This may be partly due to increased endoscopic evaluation performed during more recent years.

S20 Impact of Anxiety on Patients With IBD: Insights From the National Inpatient Database (NIS)- 2015-2019

Background: Inflammatory Bowel Disease (IBD) can have numerous complications involving all systems of the body. People with inflammatory bowel disease (IBD) are at increased risk of developing mental health disorders, such as anxiety. The aim of our study was to examine the impact of anxiety on the outcomes of patients with IBD. Methods: The Nationwide Inpatient Sample (NIS) database encompasses approximately 7 million inpatient hospitalizations annually in the United States. Data were extracted from the National Inpatient Sample (NIS) Database for the years 2015-2019. Patients aged 18 years and above with diagnoses of IBD and anxiety were identified using ICD codes. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, the average length of hospital stay (LOS), and hospital charges using STATA 17. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. Results: We identified 1,198,839 patients with IBD of which 235,880 patients were matched to those with anxiety. Average age was 52.04 years. There was a significant decrease in inpatient mortality (OR 0.56, CI 0.51-0.62, P < 0.0001) and total cost of hospitalization (-$3,242.13, CI -4,259.55 - -2224.70, P < 0.0001), but hospital length of stay increased (0.27 days, CI 0.20-0.34, P < 0.0001) between patients with IBD with cannabis use when compared to IBD patients without cannabis use. Conclusion(s): The different clinical manifestations and symptoms of IBD may cause several psychological changes in patients. Past studies demonstrated that psychological stress and disorders can trigger flares and relapses in patients with IBD. Our study showed that there was a statistically significant decrease in inpatient mortality and hospital LOS for patients with both IBD and anxiety compared to those with only IBD. Anxiety is known to be 2 to 3 times higher in patients with IBD, but it reduces morbidity and mortality. This may be due to the increased surveillance and treatment to this subgroup of patients. Given the known association between IBD and anxiety, clinicians be vigilant in detecting and treating concomitant anxiety as this could lead to better outcomes in this patient population, as our study revealed. Future randomized control trials are needed to further study the impact of anxiety on IBD.

32: ENHANCED RECOVERY AFTER SURGERY CAN IMPROVE PATIENTS’ OUTCOMES AND REDUCE HOSPITAL COST OF GASTRECTOMY FOR CANCER IN THE WEST. A PROPENSITY SCORE-BASED ANALYSIS

Abstract Background and aim Data on ERAS for gastrectomy are scarce and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical conditions and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center. Methods We conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate and compliance with ERAS items. A propensity score (PS) was built on confounding variables. Results Compliance with ERAS items after the program was ≥70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in ERAS group. PS-based multivariable analysis confirmed a significant 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not significantly change. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted: median reduction was one day and €775, respectively. Conclusion ERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality or readmission.

Reducing the Healthcare-Associated Infections in a Rehabilitation Hospital under the Guidance of Lean Six Sigma and DMAIC.

The reduction of healthcare-associated infections (HAIs) is one of the most important issues in the healthcare context for every type of hospital. In three operational units of the Scientific Clinical Institutes Maugeri SpA SB, a rehabilitation hospital in Cassano delle Murge (Italy), some corrective measures were introduced in 2017 to reduce the occurrence of HAIs. Lean Six Sigma was used together with the Define, Measure, Analyze, Improve, Control (DMAIC) roadmap to analyze both the impact of such measures on HAIs and the length of hospital stay (LOS) in the Rehabilitative Cardiology, Rehabilitative Neurology, Functional Recovery and Rehabilitation units in the Medical Center for Intensive Rehabilitation. The data of 2415 patients were analyzed, considering the phases both before and after the introduction of the measures. The hospital experienced a LOS reduction in both patients with and without HAIs; in particular, Cardiology had the greatest reduction for patients with infections (−7 days). The overall decrease in HAIs in the hospital was 3.44%, going from 169 to 121 cases of infections. The noteworthy decrease in LOS implies an increase in admissions and in the turnover indicator of the hospital, which has a positive impact on the hospital management as well as on costs.

Effect of a perioperative immune-enhancing diet in clean-contaminated head and neck cancer surgery: A randomized controlled trial

BackgroundMalnutrition is a common problem in head and neck cancer patients and is associated with an increased risk of postoperative complications and prolonged length of hospital stay (LOS). The purpose of this study was to evaluate the effect of an immune-enhancing diet with supplementary arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery. Materials and methodsA randomized controlled trial study in clean-contaminated head and neck cancer surgery patients was conducted. Patients undergoing surgery received either an immune-enhancing diet or hospital-prepared blenderized diet 7 days preoperatively and 14 days postoperatively. Clinical outcomes (mucocutaneous fistula, wound infection, general infection, LOS, and hospital costs) and nutritional parameters (body weight, prealbumin, transferrin, and albumin) were compared between the two groups. Results116 patients were included in the analysis, 60 in the immune-enhancing diet group and 56 in the blenderized diet group. There was a significant association between the immune-enhancing diet and the decrease in fistula rate (8.3 % vs. 23.2 %, p = 0.039), LOS (24 days vs. 29 days, p = 0.043), hospital costs (6312 US dollars vs. 7461 US dollars, p = 0.048), and higher prealbumin level on postoperative day 7 and 14 (p = 0.015 and 0.001, respectively) and transferrin level on postoperative day 14 (p = 0.047). In addition, the immune-enhancing diet also had a positive effect on body weight on postoperative day 14 (p = 0.028). However, there was no difference in nutrition-related adverse events between the two groups. ConclusionThe administration of a perioperative diet containing arginine, glutamine, and fish oil in clean-contaminated head and neck cancer surgery patients led to a significant reduction in mucocutaneous fistula, LOS, and hospital costs. Results also indicated improved nutritional status, including body weight, prealbumin, and transferrin levels.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis

PurposeEnhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint.MethodsWe selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study.ResultsAfter PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey.ConclusionThe introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.

Enhanced Recovery After Surgery can Improve Patient Outcomes and Reduce Hospital Cost of Gastrectomy for Cancer in the West: A Propensity-Score-Based Analysis

BackgroundData on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center.MethodsWe conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables.ResultsCompliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively.ConclusionsERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.

Quels facteurs expliquent la durée d’hospitalisation pour anorexie mentale: revue systématique de la littérature

ObjectivesThe cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN. MethodsSystematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category. ResultsThirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation–SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population. DiscussionFactors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract. ConclusionsTaking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.

Enhanced Recovery After Surgery Pathway for Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Decreases Length of Stay and Opioid Consumption.

Opioid requirements in the perioperative period in patients undergoing lumbar spine fusion surgery remain problematic. Although minimally invasive surgery (MIS) techniques have been developed, there still remain substantial challenges to reducing length of hospital stay (LOS) because of postoperative opioid requirements. To study the effect of implementing an enhanced recovery after surgery (ERAS) pathway in patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF) at our institution. We implemented an ERAS pathway in patients undergoing an elective single-level MIS TLIF for degenerative changes at a single institution. Consecutive patients were enrolled over a 20-mo period and compared with a pre-ERAS group prior to the implementation of the ERAS protocol. The primary outcome was LOS. Secondary outcomes included reduction in morphine milligram equivalent units (MME), pain scores, postoperative urinary retention (POUR), and incidence of postoperative delirium. Patients were compared using the chi-square and Welch's 2-sample t-tests. A total of 299 patients were evaluated in this study: 87 in the ERAS group and 212 in the pre-ERAS group. In the ERAS group, there was a significant reduction in LOS (3.13± 1.53vs 3.71± 2.07 d, P=.019), total admission MME (252.74± 317.38vs 455.91± 498.78 MME, P=.001), and the number of patients with POUR (48.3%vs 65.6%, P=.008). There were no differences in pain scores. This is the largest ERAS MIS fusion cohort published to date evaluating a single cohort of patients in a generalizable manner. This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period. There is further work to be done to evaluate patients undergoing other complex spine surgical interventions.

Bayesian network analysis of open, laparoscopic, and robot-assisted radical cystectomy for bladder cancer

We have performed the direct and network meta-analysis to evaluate the safety and efficacy of robot-assisted (RARC) versus laparoscopic (LRC) versus open radical cystectomy (ORC) for bladder cancer (BCa). A systematic search of PubMed, Cochrane Library, and Embase was performed up until Dec 20, 2019. Outcome indexes include oncologic outcomes (the recurrence rate, mortality), pathologic outcomes (lymph node yield (LNY), positive lymph node (PLN), positive surgical margins (PSM)), perioperative outcomes (operating time (OP), estimated blood loss (EBL), blood transfusion rate, the length of hospital stay (LOS) and the time to regular diet) and postoperative 90-day complications. We have analyzed 6 RCTs, 23 prospective studies, and 25 retrospective studies (54 articles: 6382 patients). On one hand, the direct meta-analysis shows RARC is better than LRC or ORC. On the other hand, the clinical effects of the recurrence rate, Morbidity, PSM, LNY, PLN, and postoperative 90-day complications of RARC, LRC and ORC are all no statistical significance by network meta-analysis. Moreover, the probability rank shows that the comprehensive rank of RARC is better than LRC or ORC. The clinical effects of OP, EBL, LOS, blood transfusion rate and the time to regular diet are all statistical significance by network meta-analysis. There are ORC > LRC > RARC in the EBL ranking. Patients with RARC exhibited a decrease of LOS compared to those with LRC or ORC. Patients with RARC exhibited a decrease in blood transfusion rate and the time to regular diet compared to those with ORC. Patients with ORC exhibited an increase of OP compared to those with RARC or LRC. The heterogeneity tests of most studies are < 50%. Most studies have no publication bias and the quality of the selected studies is good. The direct meta-analysis and network meta-analysis suggest that RARC is better than LRC or ORC according to comprehensive analysis. However, we need a large sample size and more high-quality studies to verify and improve in the further.

Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis.

To review the evidence regarding the outcomes of laparoscopic techniques in cases of splenomegaly. Endoscopic approaches such as laparoscopic, hand-assisted laparoscopic, and robotic surgery are commonly used for splenectomy, but the advantages in cases of splenomegaly are controversial. We conducted a systematic review using PRISMA guidelines. PubMed/MEDLINE, ScienceDirect, Scopus, Cochrane Library, and Web of Science were searched up to February 2020. Nineteen studies were included for meta-analysis. In relation tolaparoscopic splenectomy (LS) versus open splenectomy (OS), 12 studies revealed a significant reduction in length of hospital stay (LOS) of 3.3days (p = <0.01) in the LS subgroup. Operative time was higher by 44.4min (p < 0.01) in the LS group. Blood loss was higher in OS 146.2cc (p = <0.01). No differences were found regarding morbimortality. The global conversion rate was 19.56%. Five studies compared LS and hand-assisted laparosocpic splenectomy(HALS), but no differences were observed in LOS, blood loss, or complications. HALS had a significantly reduced conversion rate (p < 0.01). In two studies that compared HALS and OS (n = 66), HALS showed a decrease in LOS of 4.5days (p < 0.01) and increase of 44min in operative time (p < 0.01), while OS had a significantly higher blood loss of 448cc (p = 0.01). No differences were found in the complication rate. LS is a safe approach for splenomegaly, with clear clinical benefits. HALS has a lower conversion rate. Higher-quality confirmatory trials with standardized splenomegaly grading are needed before definitive recommendations can be provided. Prospero registration number: CRD42019125251.

Enhanced recovery after surgery (ERAS) following radical cystectomy: is it worth implementing for all patients?

To report the overall effect of ERAS protocol implementation in patients undergoing radical cystectomy and its impact on the length of hospital stay (LOS) and surgical outcomes considering their comorbid conditions. Retrospective cohort study including 296 patients (146 non-ERAS patients vs. 150 ERAS patients) undergoing radical cystectomy and urinary diversion from 2010 to 2018. Age-adjusted Charlson Comorbidity Index (ACCI) score eight was set as cut off value between low-risk and high-risk patients. The primary outcome was LOS. Secondary outcomes were time to bowel movements, tolerance of regular diet, the incidence of postoperative ileus, postoperative complications, and 30- and 90-day readmission rates. A higher comorbidity burden was identified in the ERAS group compared to non-ERAS patients (p = 0.04). Median (IQR) LOS for non-ERAS was group 8(4) and 8(5) for ERAS group (p = 0.07). ERAS group demonstrated shorter time to resume bowel movements as well as time to tolerance of regular diet (p = 0.007, p = 0.023, respectively). Low-risk patients managed by the ERAS protocol demonstrated a significantly shortened gastrointestinal (GIT) recovery time (p = 0.001) as well as a reduction of LOS (p = 0.04). No significant reduction of LOS was identified for patients with higher comorbidity when placed on the ERAS protocol (p = 0.65). There were no significant differences in postoperative complications or readmission rates between groups. ERAS protocol implementation following radical cystectomy showed significant improvements in GIT recovery, nevertheless, it did not result in a decrease in LOS or readmission rates. Low-risk patients appeared to derive more benefit from ERAS protocol implementation than high-risk patients.

Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency

IntroductionCOVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak.Materials and methodsFrom 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and examined.ResultsNo statistical difference was found in complications rate, clinical data and surgical procedures (p > 0.05). Awake breast conservative surgery (BCS) was the most frequent procedure in COVID-19-BC (p = 0.006). A statistically significant decrease in ORT and LOS was reported in COVID-19-BC (p = 0.040 and p = 0.0015 respectively), while comparable time resulted for ST (p = 0.976). Mean ORT and LOS reduction were 20.79 min and 0.57 hospital bed days.ConclusionIn the “COVID-19 era”, fast track awake breast surgery provides a reduction of ORT, LOS and potentially surgical treatment for a wider number of oncological patients.

PD60-07 ACUTE KIDNEY INJURY WITH ENHANCED RECOVERY AFTER SURGERY PROTOCOL IN RADICAL CYSTECTOMY SURGERY: A PROPENSITY SCORE-MATCHED STUDY

You have accessJournal of UrologyBladder Cancer: Invasive VI (PD60)1 Apr 2020PD60-07 ACUTE KIDNEY INJURY WITH ENHANCED RECOVERY AFTER SURGERY PROTOCOL IN RADICAL CYSTECTOMY SURGERY: A PROPENSITY SCORE-MATCHED STUDY Peter Hanna*, Matthew Peterson, Arveen Kalapera, Subodh Regmi, Kalyana Srujana, Joseph Zabell, Darrel Randle, Badrinath Konety, Joyce Wahr, and Christopher Weight Peter Hanna*Peter Hanna* More articles by this author , Matthew PetersonMatthew Peterson More articles by this author , Arveen KalaperaArveen Kalapera More articles by this author , Subodh RegmiSubodh Regmi More articles by this author , Kalyana SrujanaKalyana Srujana More articles by this author , Joseph ZabellJoseph Zabell More articles by this author , Darrel RandleDarrel Randle More articles by this author , Badrinath KonetyBadrinath Konety More articles by this author , Joyce WahrJoyce Wahr More articles by this author , and Christopher WeightChristopher Weight More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000977.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fluid management within enhanced recovery after surgery is a crucial element aiming to maintain optimum fluid balance through the perioperative period. We assessed the effect of enhanced recovery after surgery (ERAS) protocol mandated intraoperative fluid restriction on kidney function and incidence of postoperative acute kidney injury (AKI). METHODS: A total of 115 radical cystectomy patients managed by ERAS protocol were compared to a propensity- matched group of patients undergoing radical cystectomy without being subject to the ERAS protocol. Average creatinine, blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) were recorded preoperatively and on. Incidence of AKI was assessed on subset of patients (99 patients, [86.1 %] in pre-ERAS group and 97 patients [84.3 %] in ERAS cohorts) whom had normal preoperative baseline serum creatinine according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Length of hospital stay (LOS), time of return of bowel function, incidence of postoperative complications and readmission status were also recorded. RESULTS: Increased rate of postoperative AKI was observed in patients undergoing cystectomy using the ERAS protocol mandated fluid restrictions (15.4 % vs 6 %, OR = 2.72, p= 0.039). For ERAS patients, average creatinine was significantly changed from baseline creatinine on postoperative day 1 (POD 1) (p=0.0001), POD 3 (p=0.011) and on discharge (p=0.03). Average BUN was significantly changed compared to preoperative baseline BUN on POD 1 (p=002), POD 2 (p= 0.006), POD 3 (p < 0.0001), on discharge (p < 0.0001) and on 3 months follow up (p=<0.0001). However, average postoperative eGFR (POD 2, 3, on discharge and 3 months follow up) wasn’t significantly changed from baseline eGFR except on POD 1 (p=0.0001). ERAS protocol implementation was associated with significant reduction of GIT recovery time (p=0.002), but it wasn’t significantly associated with decrease of LOS (p= 0.185) or 30 days readmission rate (p= 0.28). CONCLUSIONS: Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, careful monitoring and readjustment of fluids during protocol implementation are recommended to reduce the likelihood of acute kidney injury. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1276-e1277 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Hanna* More articles by this author Matthew Peterson More articles by this author Arveen Kalapera More articles by this author Subodh Regmi More articles by this author Kalyana Srujana More articles by this author Joseph Zabell More articles by this author Darrel Randle More articles by this author Badrinath Konety More articles by this author Joyce Wahr More articles by this author Christopher Weight More articles by this author Expand All Advertisement PDF downloadLoading ...

Education Program to Improve the Adherence to Guidelines for Use of Blood Transfusions in Sickle Cell Disease

Background: An expert panel convened by the NHLBI in 2014 provided guidelines and indications for blood transfusions in patients with sickle cell disease (SCD). These recommendations were to help conserve the use of blood transfusions in SCD patients in order to reduce the complications of iron overload, transmission of blood-borne pathogens and development of alloantibodies. In a retrospective review of SCD patients who received blood during inpatient admissions we identified deviations from guideline recommendations including transfusions for pain, and asymptomatic drops in hemoglobin(hgb). A standardized education program was subsequently developed and implemented to improve compliance with NHLBI recommendations for transfusion use in hospitalized patients with SCD. Methods: A standardized education program was developed based on American Society of Hematology (ASH) and NHLBI recommendations. This program included a PowerPoint presentation which was delivered to small groups of hematologists, hospitalists, emergency room and primary care physicians, nurse practioners and medical residents who regularly manage inpatient SCD admissions. A post-test of knowledge was administered and completed by 65 individuals. Additionally, the ASH pocket guide app was placed on physician's smartphones. Following completion of the program, transfusion use and indications were reassessed over the next 6 months. The hospital database was screened for admissions of patients with the diagnosis of SCD (HbSS, HbSβ0, HbSβ+, HbSC) who were billed for a blood transfusion between 8/1/2015 to 8/31/2016. This served as the baseline data. All patients were &gt;18 years of age. Each chart was reviewed individually to assess the clinical setting and reasons for transfusion. The following parameters were documented: age, sex, length of hospital stay (LOS), hgb at time of transfusion, baseline hgb, number of units transfused, documented reason for transfusion, presence of alloantibodies and ferritin level. We defined the infusion of blood as a transfused event which included single or multiple units of blood. We excluded transfusions given for acute bleeding. Following the educational program, this same methodology was used to collect a second cohort of SCD patients admitted to the hospital between 1/2/2019-6/22/2019 wherein the indications and outcomes of blood transfusion were compared with the first, pre-educational cohort. Results: In phase one (pre-education cohort), a total of 87 SCD patients were analyzed and the majority of inpatient transfusions were not indicated by national guidelines with only 34.5% of transfusion events meeting expert panel recommendations. In this phase of our study, we reviewed a second cohort of 53 SCD patients (post-education). A total of 123 units of blood were transfused. 73.5% of patients had HbSS disease, 22.6% had HbSβ0 disease and 3.77% had HbSC disease. The mean age was 32.5 years and 69.8% were female. Compared to management of patients prior to the education program, less blood was administered for the non-guideline indications of acute pain crisis (15% vs 28%) and Hgb drop &gt;2gm (9% vs 21%) (see Figure 1). The mean level of ferritin in the second cohort was 1751 and 7.54% of patients had alloantibodies, compared to the baseline group with ferritin of 2483 and alloantibodies of 17%. The average LOS in the baseline group was 9 days and in the second cohort was 8.4 days with an average LOS for uncomplicated pain or a drop of hemoglobin in the baseline group of 8.9 days and in the second cohort of 6.6 days. The most common indicated guideline reasons for transfusion in both cohorts were for symptomatic anemia and acute chest syndrome. Conclusion: This educational program was able to reduce transfusion use in SCD patients who were hospitalized for vaso-occlusive crises and asymptomatic anemia. There was a trend towards decrease in LOS for patients when they had less transfusions. Face to face education in combination with the use of the readily available ASH pocket app on smartphones are effective tools to increase adherence to national guidelines for transfusion in SCD. Disclosures Cohen: Global Therapeutics: Other: Trial for GBT440.

Association of the Swiss Diagnosis-Related Group Reimbursement System With Length of Stay, Mortality, and Readmission Rates in Hospitalized Adult Patients

In 2012, hospital reimbursement in Switzerland changed from a fee-for-service per diem system to a diagnosis-related group (SwissDRG) system. Whether this change in reimbursement is associated with harmful implications for quality of care and patient outcomes remains unclear. To examine the association of the SwissDRG implementation with length of hospital stay (LOS), in-hospital mortality, and 30-day readmission rates in the overall adult inpatient population and stratified by 5 individual diagnoses. This cohort study used administrative data from the Swiss Federal Statistical Office to investigate medical hospitalizations in Switzerland from January 1, 2009, through December 31, 2015. All hospitalizations for adult medical inpatients were included in the main analysis. Patients who presented with 1 of the 5 common medical diagnoses were included in the subanalyses: community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, acute myocardial infarction, acute heart failure, and pulmonary embolism. An interrupted time series model was used to determine changes in time trends for risk-adjusted LOS, in-hospital mortality, and 30-day readmission after the implementation of SwissDRG in 2012. Analyses were performed from March 1, 2018, to June 30, 2018, and from November 1, 2018, to December 18, 2018. Monthly patient-level data for LOS, in-hospital mortality, and 30-day readmission rates. The sample included a total of 2 426 722 hospitalized adult patients. Of this total, 1 018 404 patients (41.9%; 531 226 [52.2%] male, median [interquartile range (IQR)] age of 69 [55-80] years) composed the before-SwissDRG period; 1 408 318 patients (58.0%; 730 228 [51.9%] male, median [IQR] age of 70 [56-81] years) composed the after-SwissDRG period. The overall LOS gradually decreased from unadjusted mean (SD) 8.0 (12.7) days in 2009 to 7.2 (17.3) days in 2015. This reduction in LOS, however, was not substantially greater with the implementation of SwissDRG in 2012 (risk-adjusted slope, -0.0166 days; 95% CI, -0.0223 to -0.0110 days), with an adjusted difference in slopes of 0.0000 days (95% CI, -0.0072 to 0.0072 days). Risk-adjusted all-cause in-hospital mortality declined from 4.9% in 2009 to 4.6% in 2015, with a substantially greater decline after implementation of SwissDRG (difference between monthly slopes before and after implementation, -0.0115%; 95% CI, -0.0190% to -0.0039%). In the same period, risk-adjusted 30-day readmission rates increased from 14.4% in 2009 to 15.0% in 2015, with a greater increase after SwissDRG implementation (change in monthly slope, 0.0339%; 95% CI, 0.0254%-0.0423%). Patients with acute myocardial infarction were found to have a substantially greater increase after SwissDRG implementation in 30-day readmission rates (adjusted difference in slopes, 0.1144%; 95% CI, 0.0617%-0.1671%). Among medical hospitalizations in Switzerland, SwissDRG implementation appeared to be associated with an increase in readmission rates and a decrease in in-hospital mortality but not with the gradual decrease in LOS observed in the historical control period.

Decreasing Length of Hospital Stay and Postoperative Complications After Primary Total Hip Arthroplasty: A Decade Analysis From 2006 to 2016

BackgroundIn an attempt to decrease costs without increasing complication burden, the development of rapid recovery protocols has led to an increased push for decreased length of hospital stay (LOS) following total hip arthroplasty (THA). The purpose of this study was to analyze trends in LOS and complications following THA over a 10-year period. MethodsUsing the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on the year of surgery (2006-2009 [N = 3873], 2010-2013 [N = 45,992], 2014-2016 [N = 86,099]). Differences in LOS, operative time, readmission rates, and 30-day postoperative medical complications were compared using bivariate and multivariate analyses. ResultsMultivariate regression analysis identified a significant decrease in LOS in days for the 2010-2013 cohort (3.2 ± 4.8, P < .001) and 2014-2016 cohort (2.7 ± 2.5, P < .001) compared to the 2006-2009 cohort (3.8 ± 2.5). Despite decreasing LOS, there were significantly lower complications in the later cohorts, with significantly lower rates of all complications (5.27% [2006-2009], 3.77% [2009-2013], 3.14% [2013-2016]), sepsis (0.70%, 0.31%, 0.16%), and urinary tract infection (1.94%, 1.23%, 0.83%) using both bivariate and multivariate analyses (P < .001). In addition, there was no significant difference in unplanned 30-day readmissions (3.66% [2010-2013] vs 3.5% [2014-2016], P = .142). ConclusionOver the last decade, there has been a decrease in LOS and an improved short-term complication profile for THA. With continually increasing rates of utilization of THA along broader patient demographics, these changes are important to help mitigate the costs of higher volume.