Difference In Composite Morbidity Research Articles

Clinical Outcomes, Blood Utilization, and Ethical Considerations for Pediatric Patients in a Bloodless Medicine and Surgery Program.

Pediatric patients requesting bloodless care represent a challenging clinical situation, as parents cannot legally refuse lifesaving or optimal interventions for their children. Here, we report clinical outcomes for the largest series of pediatric inpatients requesting bloodless care and also discuss the ethical considerations. We performed a single-institution retrospective cohort study assessing 196 pediatric inpatients (<18 years of age) who requested bloodless care between June 2012 and June 2016. Patient characteristics, transfusion rates, and clinical outcomes were compared between pediatric patients receiving bloodless care and those receiving standard care (including transfusions if considered necessary by the clinical team) (n = 37,271). Families were informed that all available measures would be undertaken to avoid blood transfusions, although we were legally obligated to transfuse blood if the child's life was threatened. The primary outcome was composite morbidity or mortality. Secondary outcomes included percentage of patients transfused, individual morbid events, length of stay, total hospital charges, and total costs. Subgroup analyses were performed after stratification into medical and surgical patients. Of the 196 pediatric patients that requested bloodless care, 6.1% (n = 12) received an allogeneic blood component, compared to 9.1% (n = 3392) for standard care patients ( P = .14). The most common indications for transfusion were perioperative bleeding and anemia of prematurity. None of the transfusions were administered under a court order. Overall, pediatric patients receiving bloodless care exhibited lower rates of composite morbidity compared to patients receiving standard care (2.6% vs 6.2%; P = .035). There were no deaths in the bloodless cohort. Individual morbid events, length of stay, and total hospital charges/costs were not significantly different between the 2 groups. After multivariable analysis, bloodless care was not associated with a significant difference in composite morbidity or mortality (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.12-1.11; P = .077). Pediatric patients receiving bloodless care exhibited similar clinical outcomes compared to patients receiving standard care, although larger studies with adequate power are needed to confirm this finding. There were no mortalities among the pediatric bloodless cohort. Although a subset of our pediatric bloodless patients received an allogeneic transfusion, no patients required a court order. When delivered in a collaborative and patient-centered manner, blood transfusions can be safely limited among pediatric patients.

Outcomes among Neonates after a Diagnosis of Persistent or Transient Fetal Growth Restriction Delivered at Term.

This study aimed to evaluate whether transient fetal growth restriction (FGR) that resolves prior to delivery confers a similar risk of neonatal morbidity as uncomplicated FGR that persists at term. This is a secondary analysis of a medical record abstraction study of singleton live-born pregnancies delivered at a tertiary care center between 2002 and 2013. Patients with fetuses that had either persistent or transient FGR and delivered at 38 weeks or later were included. Patients with abnormal umbilical artery Doppler studies were excluded. Persistent FGR was defined as estimated fetal weight (EFW) <10th percentile by gestational age from diagnosis through delivery. Transient FGR was defined as EFW <10th percentile on at least one ultrasound, but not on the last ultrasound prior to delivery. The primary outcome was a composite of neonatal morbidity: neonatal intensive care unit admission, Apgar's score <7 at 5 minutes, neonatal resuscitation, arterial cord pH <7.1, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis, or death. Baseline characteristics and obstetric and neonatal outcomes were compared using Wilcoxon's rank-sum and Fisher's exact test. Log binomial regression was used to adjust for confounders. Of 777 patients studied, 686 (88%) had persistent FGR and 91 (12%) had transient FGR. Patients with transient FGR were more likely to have a higher body mass index, gestational diabetes, diagnosed with FGR earlier in pregnancy, have spontaneous labor, and deliver at later gestational ages. There was no difference in the composite neonatal outcome (relative risk = 1.03, 95% confidence interval [CI] 0.72, 1.47) for transient versus persistent FGR after adjusting for confounders (adjusted relative risk = 0.79, 95% CI 0.54, 1.17). There were no differences in cesarean delivery or delivery complications between groups. Neonates born at term after transient FGR do not appear to have differences in composite morbidity compared with those where uncomplicated FGR persists at term. · No differences in neonatal outcomes in uncomplicated persistent versus transient FGR at term.. · Transient FGR pregnancies more likely to deliver at later gestational ages.. · No differences in mode of delivery or obstetric complications in persistent versus transient FGR at term..

The Effect of Psychosocial Risk Factors on Outcomes After Aortic Valve Replacement

BackgroundPsychosocial risk factors (PSRFs) have emerged as important nontraditional risk factors that are associated with worse surgical outcomes but have not been well-characterized in valvular disease. ObjectivesThis study evaluates the impact of PSRFs on 30-day outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). MethodsAll adult patients (≥18 years of age) who underwent isolated TAVR or SAVR in the Nationwide Readmissions Database from 2016 to 2018 were included. Patients were classified as having 0 PSRFs vs ≥1 PSRF. PSRFs included limited cognitive understanding, substance use, psychiatric disease, low socioeconomic status, or uninsured status. Primary outcomes included 30-day mortality, readmission, and composite morbidity (stroke, pulmonary embolus, pacemaker implantation, bleeding complications, acute kidney injury, myocardial infarction, or new atrial fibrillation). ResultsA nationally weighted total of 74,763 SAVR and 87,142 TAVR patients met inclusion criteria. For SAVR, patients with PSRFs had significantly higher 30-day mortality (4.2% vs 3.7%; P = 0.048) and readmissions (13.1% vs 11.3%; P < 0.001), but there was no difference in composite morbidity. For TAVR, patients with PSRFs had significantly higher 30-day readmission (11.7% vs 10.7%; P = 0.012) but no difference in 30-day mortality or composite morbidity. On risk-adjusted analysis, presence of PSRFs was a significant predictor of higher 30-day readmissions following SAVR (adjusted OR: 1.10; 95% CI: 1.02-1.19). ConclusionsThe presence of PSRFs is associated with worse short-term outcomes following SAVR and TAVR, with a more profound impact in SAVR. This study highlights the importance of identifying at-risk patients and suggests that TAVR may be beneficial in patients with less social support.

An evaluation of seasonal maternal–neonatal morbidity related to trainee cycles

The existence of the "July phenomenon" (worse outcomes related to the presence of new physician trainees in teaching hospitals) has been debated in the literature and media. Previous studies of the phenomenon in obstetrics are limited by the quality and detail of data. To evaluate whether the months of June to August, when transitions in trainees occur, are associated with increased maternal and neonatal morbidity. Secondary analysis of an observational cohort of 115,502 mother-infant pairs that delivered at 25 hospitals from March 2008 to February 2011. Inclusion criteria were an individual who had a singleton, nonanomalous live fetus at the onset of labor, and delivered at a hospital with trainees. The primary outcomes were composites of maternal and neonatal morbidity. We evaluated the outcomes by academic quarter during which the delivery occurred, beginning July 1, and by duration of the academic year as a continuous variable. To account for clustering in outcomes at a given delivery location, we applied hierarchical logistic regression with adjustment for hospital as a random effect. Of 115,502 deliveries, 99,929 met the inclusion criteria. Race and ethnicity, insurance, body mass index, drug use, and the availability of 24/7 maternal-fetal medicine, anesthesia, and neonatology varied by quarter. In adjusted analysis, the frequency of the composite maternal and neonatal morbidity did not differ by quarter. No differences in composite morbidity were observed when using day of the year as a continuous variable (maternal morbidity adjusted odds ratio, 1.00; 95% confidence interval, 0.99-1.00 and neonatal morbidity adjusted odds ratio, 1.00; 95% confidence interval, 1.00-1.01) and after adjustment for hospital as a random effect. Odds of major surgical complications in quarter 2 were twice those in quarter 1. Neonatal injury and intensive care unit were less frequent in later quarters. Maternal and neonatal morbidity in teaching hospitals was not associated with the academic quarter during which delivery occurred, and there was no evidence of a "July phenomenon".

104 Induction of labor versus planned cesarean section for women with body mass index ≥ 45

To compare maternal and neonatal morbidity of women with BMI (body mass index) ≥ 45 who undergo induction of labor versus scheduled cesarean section. In this retrospective cohort study, we identified women with BMI ≥ 45 upon entry to prenatal care who underwent an induction of labor or planned cesarean section at a single institution from 1/1/2016 to 6/30/2019. Data for patients undergoing spontaneous labor were collected but excluded from analysis. The primary outcome measured was composite morbidity, which included maternal morbidity (severe, infectious, wound, other) and neonatal morbidity. Chi-squared tests and Fisher’s exact tests were used to compare cohorts and adjusted odds ratios for the primary outcomes were created using multivariate logistic regression analysis. There were 293 women who met enrollment criteria, 172 inductions of labor and 121 scheduled cesarean sections. Of the induction group, 77 were nulliparous. The rate of cesarean section in the total induction group was 32.6%, while the rate of cesarean section in the nulliparous induction subgroup was 59.7%. Using multivariate logistic regression, there was no significant difference in composite morbidity for induction of labor compared to scheduled cesarean section (adjusted odds ratio 1.20, 95% confidence interval 0.52-2.85). Further, there was no significant difference in composite morbidity for nulliparous induction of labor compared to scheduled cesarean section (adjusted odds ratio 1.46, 95% confidence interval 0.50-4.52). For women who enter prenatal care with BMI ≥ 45, there does not appear to be a difference in morbidity for induction of labor versus scheduled cesarean section.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1047 Placenta accreta spectrum in IVF pregnancies

To evaluate placenta accreta spectrum (PAS) in pregnancies conceived by in vitro fertilization (IVF) compared to non-IVF with regards to PAS risk factors, antepartum diagnosis and severe maternal morbidity. Retrospective, single center cohort study of pregnancies complicated by PAS from 2015 to 2017. Cases of PAS with delivery >23 weeks gestation were identified and graded in accordance with FIGO clinical and pathologic criteria. Maternal, pregnancy and delivery characteristics of IVF pregnancies (IVF-PAS) were compared to non-IVF pregnancies (N-PAS). A composite of severe morbidity was evaluated including hemorrhage requiring transfusion of at least four units of blood or at least two units of blood and plasma; hemorrhage requiring balloon tamponade, compression suture or embolization; pulmonary edema, bowel injury, acute kidney injury, thromboembolism, unplanned hysterectomy, reoperation, or death. Logistic regression was used to adjust for covariates. There were 113 cases of PAS from 2015 to 2017, of which 40.7% were IVF-PAS. Those with IVF-PAS were less likely than N-PAS to have a prior cesarean or to have placenta previa at delivery. However, they were more likely to have resolved previa or Asherman’s. Additionally, women with IVF-PAS were less likely than N-PAS to have an antepartum diagnosis of PAS or to be cared for by a multidisciplinary PAS team. There was no difference in risk of invasive PAS (grades 2 or 3). There was no difference in composite or individual morbidity outcomes after adjustment for age, parity, Asherman’s and multiple gestation. Subgroup analyses for placenta previa and presence of uterine scar also did not demonstrate a difference in composite morbidity. Compared to pregnancies conceived without IVF, those conceived with IVF were less likely to have traditional risk factors of prior cesarean or placenta previa; however, PAS grade and rates of morbidity were similar. The lower rate of antepartum diagnosis among IVF-PAS patients calls for awareness when adherent placenta is encountered in this group.

Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures.

IntroductionThe use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).MethodsData were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables.ResultsA total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting.ConclusionsHbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.

Placenta Accreta Spectrum: The Effect of Establishing a Systematic Program for Diagnosis and Management [27M

INTRODUCTION: Improvements in management of placenta accreta spectrum (PAS) can reduce maternal morbidity and mortality. Our objective was to determine the effect on outcomes following the introduction of a systematic program for diagnosis and management of PAS at our institution. METHODS: This was a retrospective cohort study of deliveries complicated by PAS at New York Presbyterian Queens (NYPQ) from November 2011 to July 2019. NYPQ implemented a systematic program for diagnosis and management of PAS in January 2015. The program included an emphasis on antenatal diagnosis, required scans for all repeat cesarean deliveries and multidisciplinary team management. Group 1 is designated as before and Group 2 is after establishment of the program. A composite outcome which included unplanned hysterectomy, ICU admission, return to the operating room or transfusion of ≥4 units of blood) was also examined. Chi square and Mann Whitney U tests were used in statistical analysis. IRB approval was obtained. RESULTS: Of 124 cases eligible cases, 35 (28%) had confirmed PAS (6 cases in Group 1, 29 cases in Group 2). The two groups were similar in terms of maternal age, parity, BMI and number of prior cesarean deliveries. There was no difference in composite morbidity between Groups 1 and 2 (66.7% vs 48.3%, P=.42). There was a trend toward improvement in unplanned hysterectomy and blood transfusion in Group 2. CONCLUSION: The establishment of our accreta program allowed us to demonstrate improvement in several outcome measures that did not achieve statistical significance due to small numbers.

Maternal morbidity of induction of labor compared to planned cesarean delivery in twin gestations

Objective To compare maternal morbidity associated with induction of labor (IOL) with planned cesarean delivery (CD) in twin gestations. Methods This was a retrospective cohort study of vertex-presenting twin pregnancies ≥24-week gestation delivering at our institution from 2016 to 2017. We compared patients undergoing IOL with patients undergoing planned CD. Demographic and pregnancy outcome data were abstracted from the medical record. Our primary outcome was composite maternal morbidity including severe postpartum hemorrhage (PPH) (EBL >1500 cc), hysterectomy, transfusion, ICU admission, use of ≥2 uterotonic medications or maternal death. These morbidities were also assessed independently. Secondary analyses of maternal morbidity among unplanned CD versus planned CD and successful IOL versus planned CD was also performed. Chi-square, Mann–Whitney U and multivariate logistic regression were used in statistical analysis. Results Of 211 twin gestations included, 70.6% were nulliparous, the median age was 35.5 years [32–38], and the median gestational age at delivery was 37 weeks [35–38]. One hundred and five underwent IOL and 106 had a planned CD. Composite morbidity was higher in the IOL group versus planned CD group (30.5 versus 11.3%, p = .001). In the IOL group, 64 (61.0%) achieved a vaginal delivery. Patients in the planned CD group were more likely to be >35 years of age (62.3 versus 48.6%, p = .045), nulliparous (80.2 versus 61.0%, p = .002) and deliver preterm (53.8 versus 38.1%, p = .022). Patients with a planned CD had a significantly lower risk of composite morbidity compared to those who had CD after failed IOL (11.3 versus 48.8%, p ≤ .001) and there was no significant difference in composite morbidity in the successful IOL compared to the planned CD group (18.8 versus 11.3%, p = .18). There were four peri-partum hysterectomies, all within the IOL group. Conclusion Labor induction in twins was associated with increased maternal morbidity compared to planned CD. The increase in adverse maternal outcomes was due to those who underwent an IOL and ultimately required CD.

Association of Patient Race With Surgical Practice and Perioperative Morbidity After Myomectomy.

To compare surgical approach, operative time, and perioperative morbidity after myomectomy by patient race. In this retrospective cohort study, data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database on 8,438 women undergoing myomectomy between January 1, 2012, and December 31, 2015. Myoma burden and approach to myomectomy were determined based on Current Procedural Terminology coding. Surgical approach and perioperative morbidity were examined in African American, Asian American, and Hispanic American women using non-Hispanic Caucasian women as the referent population. Adjusted means and odds ratios (ORs) with 95% CI were calculated using propensity score matching accounting for age, ethnicity, body mass index (BMI), myoma burden, preoperative anemia, hypertension, smoking, and operative time. Data were available for 2,533 Caucasian, 3,359 African American, 664 Asian American, and 700 Hispanic American women. Smoking, BMI, hypertension, myoma burden, and anemia varied by race (P<.001, all comparisons). In adjusted analysis, African American women were twice as likely to undergo abdominal myomectomy (adjusted OR 1.9, 95% CI 1.7-2.0), Asian American women were more than twice as likely (adjusted OR 2.3, 95% CI 1.8-2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (adjusted OR 1.5, 95% CI 1.2-1.9) when compared with Caucasian women. African American women were 50% more likely to experience composite morbidity after abdominal myomectomy (adjusted OR 1.5, 95% CI 1.2-1.7) and Asian American women were more than three times as likely to experience composite morbidity after laparoscopic myomectomy (adjusted OR 3.7, 95% CI 1.7-8.1) compared with Caucasian women. There were no differences in composite morbidity in other racial groups. Minority women are substantially more likely to undergo abdominal myomectomy when compared with Caucasian women. African American women had 50% increased odds of morbidity after abdominal myomectomy, and Asian American women were more than three times as likely to experience morbidity after laparoscopic myomectomy. Further examination into the etiology and prevention of these racial disparities is needed.

Does a maternal-fetal medicine–centered labor and delivery coverage model put the ‘M’ back in MFM?

Maternal morbidity is increasing in the United States. Our objectives were to examine whether a labor and delivery (L&D) provider model with regular maternal-fetal medicine (MFM) coverage decreases the rates of maternal morbidity during delivery hospitalizations and has an impact on obstetrician-gynecologist residents' perceptions of safety and education. We performed a retrospective cohort study to compare the rates of maternal morbidity before and after the implementation of an MFM-centered coverage model on L&D. Outcomes were identified using International Classification of Diseases, ninth revision, codes. The primary outcome was a composite of severe maternal morbidity. Additionally, obstetrician-gynecologist residents completed an anonymous survey asking them to compare coverage models, and their Council on Resident Education in Obstetrics and Gynecology examination scores were compared. Data from 4715 deliveries were included. There were no differences in composite morbidity or individual adverse outcomes. Most residents (81.3%) preferred the new provider model, with median 5-point Likert scores indicating perceived increases in safety and education. Mean Council on Resident Education in Obstetrics and Gynecology scores improved in the 18 residents exposed to both models. Although the MFM-centered provider model appears to have had a positive impact on residents' perceptions of safety and education, it was not associated with significant changes in severe maternal morbidity.

Environmental rather than genetic fetal overgrowth: defining the difference and hints for diagnosis and management

Environmental rather than genetic fetal overgrowth: defining the difference and hints for diagnosis and management