Difference In Total Hospital Charges Research Articles

The Impact of Obesity in Hospitalized MM Patients: A Nationwide Analysis

Introduction Obesity has become a global public health challenge with significant clinical implications. Although its impact has been studied extensively in various chronic diseases, the specific influence of obesity on the prognosis of multiple myeloma (MM) patients remains poorly understood. Using a nationwide dataset, we conducted a comprehensive investigation into the association between obesity and hospitalization outcomes, including length of stay, complication rates, and mortality among MM patients. Methods: Nationwide Inpatient Sample (NIS) was queried to determine adult hospitalized patients with a primary diagnosis of MM using ICD-10 codes. The primary outcome is defined as the effect of obesity on inpatient mortality in those patients. Secondary outcomes included LOS, total hospital charge, major pathological fractures and relapsing MM. We evaluated the baseline characteristics using the t-test and chi-square test as appropriate. Multivariable logistic regression analysis was performed to assess the association of MM with obesity and inpatient mortalitadjusted by age, gender, race, Charlson index, insurance, and household income. Results A total of 78975 MM patients were identified, Obesity prevalence in MM was 9.6%. Compared to MM patients without obesity, MM patients with obesity were younger (63 vs. 65.7 years, p < 0.001), more likely to be female (51.8% vs. 43.5%, p < 0.001), African American (27.7% vs. 22.6% p < 0.001), and have low-income (p= 0.05). There were no significant difference in the insurance types. MM with obesity had high Charlson Comorbidity index of > 5 (34.5% vs. 25.5%). Mean Charlson Comorbidity index was 4.1 in obesity group vs 3.6 in non-obese MM cohort. The overall inpatient mortality rate was 5% in MM. MM with obesity had lower mortality rate compared to MM without obesity(3.6% vs 5.1%). Age, Charlson index, hospital teaching status and hospital bedsize were found to be independently associated with inpatient mortality among hospitalized patients with MM. MM with obesity had a lower odds of ratio with increased all-cause mortality of 36% compared to MM without obesity (aOR 0.64, 95% CI 0.47-0.87, p=0.004). In addition, MM with obesity was associated with increased LOS (mean 11.8 vs. 11.2 P<0.038 ), however this difference was not significant after adjusted by cofounders. There was no significant difference in total hospital charges in the two groups. Presence of obesity had no association with development of relapsing MM (10.3% vs 11.2%, p=0.301). MM with obesity cohort had 9.4% major pathologic fractures while MM without obesity had 7.6% (p=0.07) Conclusion This nationwide analysis unveils an intriguing ‘obesity paradox’ in hospitalized multiple myeloma (MM) patients, where despite having a higher Charlson Comorbidity Index, obese MM patients had a lower inpatient mortality rate. The cause of this paradox remains unclear and could be influenced by various confounding factors. Although obesity was associated with a slightly increased length of stay, it did not lead to higher hospital charges, nor did it impact the rate of MM relapses or the prevalence of major pathological fractures. These findings highlight a complex relationship between obesity and MM outcomes, warranting further investigation to provide a more comprehensive understanding that can guide future patient management strategies.

Healthcare Utilization, Costs and Other Outcomes of Peroral Endoscopic Myotomy (POEM) Versus Heller Myotomy in the Inpatient Management of Achalasia in The United States: A 2016 to 2020 Nationwide Study

Introduction: Per-Oral Endoscopic Myotomy (POEM) is the recommended first-line treatment for all achalasia subtypes due to its minimally invasive nature. We aim to evaluate the trends of utilization, costs, and outcomes (mortality and complications) of POEM versus Heller Myotomy (HM) in U.S. hospitals. Methods: This is a retrospective study of individuals admitted with a primary diagnosis of achalasia. Data was obtained from Nationwide Inpatient Sample databases from the years 2016 to 2020 using ICD-10 codes. We assessed the therapeutic procedures employed, the trends and outcomes associated with POEM versus HM in terms of hospital utilization, mortality, morbidity, and the baseline characteristics of our study population. Results: A total of 26 880 adult individuals were diagnosed with achalasia. Of these, 11% underwent POEM, while 59% underwent HM. POEM rates increased from 6% to 10% of achalasia admissions, while HM decreased from 49% to 41% during the study period. No significant differences in total hospital charges or length of stay were observed between the 2 procedures. Regarding procedural complications, HM was associated with significantly reduced odds of pneumonia (adjusted Odds Ratio [aOR] = 0.09, 95% CI: 0.02-0.41), pneumoperitoneum (aOR = 0.11, 95% CI: 0.03-0.36), and pneumomediastinum (aOR = 0.21, 95% CI: 0.06-0.68), with no difference in the odds of esophageal perforation (aOR = 1.33, 95% CI: 0.27-6.48) and sepsis (aOR = 2.04, 95% CI: 0.22-18.40). Conclusion: While HM rates are currently declining in the U.S., POEM usage appears to be increasing. Despite being a less invasive measure than HM, POEM remains underutilized in the U.S.

S1468 The Inpatient Outcomes of Autoimmune Hepatitis Among Obese Patients

Introduction: Evidence suggests that obesity may be a significant factor in the development of autoimmune diseases. However, there is a lack of data on how obesity affects the outcomes of autoimmune hepatitis. Thus, this study aims to evaluate the outcomes of autoimmune hepatitis in obese patients. Methods: Adult patients hospitalized with autoimmune hepatitis from the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality 2010-2014 were selected. Diagnoses were identified by using ICD-9 CM codes. Patient demographics and outcomes of autoimmune hepatitis were compared between the groups with and without obesity. The outcomes of interest were inpatient mortality, length of stay, total hospital charge, and hepatic complications, including cirrhosis, portal hypertension, hepatic encephalopathy, ascites, hepatorenal syndrome, varices/variceal bleeding, spontaneous bacterial peritonitis, and sepsis. Chi-squared tests and independent t-tests were used to compare proportions and means, respectively. Multivariate logistic regression analysis was performed to determine if obesity is an independent predictor of the outcomes, adjusting for age, sex, and race. Results: Among 17,963 patients hospitalized with autoimmune hepatitis, 2,259 patients were obese. Differences in total hospital charges, length of stay, and inpatient mortality were not statistically significant. After adjusting for age, sex, and race, obesity was an independent protective factor for portal hypertension (adjusted odds ratio (aOR) 0.78, 95% confidence interval (CI): 0.68-0.90, P < 0.05), ascites (aOR 0.69, 95% CI: 0.60-0.78, P < 0.05), varices/variceal bleeding (aOR 0.79, 95% CI: 0.67-0.92, P < 0.05), and spontaneous bacterial peritonitis (aOR 0.44, 95% CI: 0.28-0.70, P < 0.05). Adjusted odds ratios of other outcomes were not statistically significant. Conclusion: Our study shows that obesity is associated with better outcomes in patients hospitalized with autoimmune hepatitis, such as lower odds of portal hypertension, ascites, varices/variceal bleeding, and spontaneous bacterial peritonitis. The results suggest that weight loss may be associated with the progression of liver disease, and a higher weight in this population may indicate lower severity of autoimmune hepatitis.

Safety of anticoagulation use for treatment of portal vein thrombosis in liver cirrhosis and its effect on hospital-based outcomes: an insight from a US nationwide database

Background and aimAnticoagulation use for portal vein thrombosis (PVT) in patients with advanced liver disease is controversial. We investigated the effect of anticoagulation on outcomes in patients with PVT with...

Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures.

BackgroundHospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS.MethodsRetrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student’s t-test. Results9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges. ConclusionOptimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures.

Abstract 17231: Adult Protein Energy Malnutrition is an Independent Risk Factor With Increased Odds of Cardiogenic Shock in Patients With Infective Endocarditis Who Had Valve Replacement

Introduction: Protein Energy Malnutrition (PEM) is common among adults with chronic medical conditions, especially in patients with chronic heart, lung disease and malignancies. These conditions are associated with worse in hospital outcomes. However, the complex relationship between chronic medical conditions and PEM make the true effect of PEM on outcomes difficult to ascertain. This is compounded by the relative underdiagnosis of PEM in adults. Our study aimed to determine if PEM is an independent risk factor for adverse outcomes among patients with infective endocarditis (IE) who had mitral valve (MV) and /or aortic valve (AV) replacement surgery. Methods: Data was obtained from the National Inpatient Sample for 2016 &amp; 2017. Studied cohort were patients with IE who underwent AV and /or MV replacement. This group was divided by presence or absence of PEM using ICD-10 codes. Primary outcome was inpatient mortality. Secondary outcomes were total hospital charges, length of stay (LOS), NSTEMI, post procedural cardiac complications, acute kidney failure (AKI) and need for intra aortic balloon pump (IABP). Multivariate logistic and linear regression models were used to compare outcomes. Results: A total of 4275 hospitalizations met the inclusion criteria, of which about a fifth (20.12%) had PEM.Patients with PEM had higher adjusted odds of post procedural cardiogenic shock (aOR: 3.65, 95% CI: 1.724 - 7.746), and need for IABP placement (aOR: 4.01, 95% CI: 1.958 - 8.199), as well as significantly higher mean difference in total hospital charges and length of stay, relative to patients without PEM. There was however no significant difference in mortality, composite post procedural cardiac complications, NSTEMI or AKI between the PEM and non-PEM subgroup. Conclusion: PEM is associated with post procedural cardiogenic shock and intra-aortic balloon pump placement in patients with infective endocarditis who underwent valve replacement surgery but this impact did not translate to higher mortality. More research is needed to elucidate the role of PEM as a major comorbidity.

Impact of Diabetes Mellitus on Outcomes of Patients With Knee Osteoarthritis Who Underwent Knee Arthroplasty: An Analysis of the Nationwide Inpatient Sample.

BackgroundKnee arthroplasty is one of the most common reasons for hospitalizations in the United States. Diabetes mellitus is thought to be associated with adverse perioperative outcomes. We sought to demonstrate the effect of comorbid diabetes on hospitalizations involving patients with knee osteoarthritis who had knee arthroplasty.Materials and methodsData was obtained from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. ICD-10 codes were used to obtain a cohort of patient who were principally admitted for knee osteoarthritis who underwent knee arthroplasty. The patients were further divided according to diabetic status. The primary outcome compared inpatient mortality. Secondary outcomes included mean length of hospital stay, total hospital charges, presence of secondary diagnoses on discharge of acute kidney injury, surgical site infection, sepsis, thromboembolic events, non-ST segment elevation myocardial infarction (NSTEMI).ResultsPatients with diabetes mellitus had a lower adjusted odds ratio for mortality (aOR: 0.45 95% CI: 0.221 - 0.920, p = 0.029), with no significant difference in total hospital charges and length of hospital stay. Interestingly, patients with diabetes had lower odds of NSTEMI; 0.53 (95% CI: 0.369 - 0.750, p < 0.001) sepsis; 0.64 (95% CI: 0.449 - 0.924, p = 0.017) and DVT; 0.67 (95% CI: 0.546 - 0.822, p < 0.001).ConclusionUncomplicated diabetes mellitus is not associated with adverse outcomes in patients hospitalized with knee osteoarthritis who had knee arthroplasty.

How Systemic Sclerosis Affects Healthcare Use and Complication Rates after Total Hip Arthroplasty.

To assess whether outcomes after primary total hip arthroplasty (THA) differ in systemic sclerosis (SSc). We used the 1998-2014 US National Inpatient Sample. THA and SSc were identified using procedure and diagnostic codes, respectively. Multivariable-adjusted logistic regression analyses assessed the association of SSc with in-hospital complications (implant infection, revision, transfusion, mortality) post-THA and associated healthcare use (hospital charges, hospital stay, discharge to non-home setting), adjusting for age, sex, race, Deyo-Charlson comorbidity index, primary diagnosis for THA, household income, and insurance payer. Of the 4,116,485 primary THA performed in the United States in 1998-2014, SSc patients made up 0.06% (n = 2672). In multivariable-adjusted analyses, compared to people without SSc, people with SSc had higher adjusted OR (95% CI) of the following post-primary THA: (1) non-home discharge, 1.25 (95% CI 1.03-1.50); (2) hospital stay > 3 days, 1.61 (95% CI 1.35-1.92); (3) transfusion, 1.54 (95% CI 1.28-1.84); and (4) in-hospital revision, 9.53 (95% CI 6.75-13.46). Differences in in-hospital mortality had a nonsignificant trend [2.19 (95% CI 0.99-4.86)]. There were no differences in total hospital charges or implant infection rates. SSc was associated with a higher rate of in-hospital complications and healthcare use after primary THA. Future studies should examine whether pre- or postoperative interventions can reduce the risk of post-THA complications in people with SSc.

Impact of implementation of an enhanced recovery program in gynecologic surgery on healthcare costs

Enhanced recovery programs have been associated with improved outcomes after gynecologic surgery. There are limited data on the effect of enhanced recovery programs on healthcare costs or healthcare service use. The purpose of this study was to evaluate differences in hospital charges for women who undergo surgery for a suspected gynecologic cancer that is managed in an enhanced recovery program as compared with conventional perioperative care. We performed a retrospective cohort study of women who underwent open abdominal surgery for a suspected gynecologic cancer before and after the implementation of an enhanced recovery after surgery program. Consecutive patients from May to October 2014 and from November 2014 to November 2015 comprised the conventional perioperative care (before enhanced recovery after surgery) and enhanced recovery after surgery cohorts, respectively. Patients were excluded if they underwent surgery with a multidisciplinary surgical team or minimally invasive surgery. All technical and professional charges were ascertained for all healthcare services from the day of surgery until postoperative day 30. Charges for adjuvant treatment were excluded. Charges were classified according to the type of clinical service provided. The primary outcome was the difference in total hospital charges between the pre-enhanced recovery after surgery and the enhanced recovery after surgery groups. Secondary outcomes were between group differences in hospital charges within clinical service categories. A total of 271 patients were included in the analysis (58 patients in the pre-enhanced recovery after surgery and 213 patients in the enhanced recovery after surgery cohort). A total of 70,177 technical charges and 6775 professional charges were identified and classified. The median hospital charge for a patient decreased 15.6% in the enhanced recovery after surgery group compared with the pre-enhanced recovery after surgery group (95% confidence interval, 5-24.5%; P=.008). Patients in the enhanced recovery after surgery group also had lower charges for laboratory services (20% lower; 95% confidence interval, 0--39%; P=.04), pharmacy services (30% lower; 95% confidence interval, 14--41%; P<.001), room and board (25% lower; 95% confidence interval, 20--47%; P=.005), and material goods (64% lower; 95% confidence interval, 44--81%; P<.001). No differences in charges were observed for perioperative services, diagnostic procedures, emergency department care, transfusion-related services, interventional radiology procedures, physical/occupational therapy, outpatient care, or other services. Hospital charges and healthcare service use were lower for enhanced recovery patients compared with patients who received conventional perioperative care after open surgery for a suspected gynecologic cancer. Enhanced recovery programs may be considered to be high value in healthcare because they provide improved outcomes while lowering resource use.

Regional differences in total hospital charges between open and robotically assisted radical prostatectomy in the United States.

Robotically assisted radical prostatectomy (RARP) has become the most frequently used surgical approach for patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa). Previous studies reported higher total hospital charges (THCs) for RARP than open RP (ORP). We hypothesized that based on increasing RARP surgical expertise, differences in THCs between RARP and ORP should have decreased or even disappeared in the United States in most contemporary years. Within the National Inpatient Sample database (2008-2015), we identified patients who underwent RARP or ORP. Multivariable linear regression models with adjustment for clustering were used to test for differences in THCs. Subgroup analyses focused on geographical regions, defined as West, Midwest, South and Northeast. Of 83,693 RP patients, 51,363 (61.4%) underwent RARP. RARP rates increased from 13.1 to 81.5% (p = 0.04). Overall, median THCs were $11,898 vs. $10,162 (p < 0.001) for RARP vs. ORP, respectively. After adjustment for complications, length of stay and clustering, RARP was associated with higher THCs ($3124 more for each RARP, p < 0.001). Additional charges for RARP did not change over time (p = 0.3). However, additional charges for RARP were highest in the West ($4610, p < 0.001), followed by the Midwest ($3278, p < 0.001), the South ($2906, p < 0.001) and the Northeast ($2216, p < 0.001). RARP rates have increased exponentially from 13.1 to over 80%. Similar rates were identified across all four geographical regions. RARP THCs exceeded those of ORP. Finally, important regional differences in RARP THCs were identified and persisted even after most detailed adjustment for population differences.

Thursday, September 27, 2018 1:05 PM–2:05 PM Understanding Anxiety and Depression when Performing Spine Surgery: 117. Psychiatric diagnosis impacts outcomes in surgical treatment of cervical myelopathy

BACKGROUND CONTEXT Cervical myelopathy is a common disorder of the spine caused by numerous disease processes and is often treated surgically. Psychiatric diagnoses are known to impact outcomes of surgical procedures; however, the impact of psychiatric disorders on postoperative outcomes for the diagnosis of cervical myelopathy is not well understood. PURPOSE The purpose of this study was to assess the impact of psychiatric comorbidities on postoperative outcomes in patients undergoing surgical treatment for cervical myelopathy. STUDY DESIGN/SETTING This was a retrospective cohort analysis performed on a national database using a 20% stratified sample of discharges from United States hospitals. This database did not include rehabilitation and long-term acute care facilities and is the largest publicly available inpatient, all-payer database in the U.S. PATIENT SAMPLE The Healthcare Cost and Utilization Project National Inpatient Sample database 2013-2014 was queried for hospitalizations with a diagnosis of cervical myelopathy based on International Classification of Diseases ninth revision clinical modification (ICD-9-CM) code 721.1. The analysis included only those undergoing a procedure. OUTCOME MEASURES Primary outcomes queried were relevant complications listed in the NIS, overall complication rate, discharge disposition, length of stay, mortality and total hospital charges. METHODS Descriptive statistics were used to characterize cases with psychiatric comorbidities versus those without. Demographic data was compared using Chi-square and Student's t-test and multivariate analysis was used to identify the impact of a psychiatric diagnosis for various outcomes. RESULTS A total of 24,142 hospitalizations met the inclusion criteria. Of these, 1,002 (4.2%) had a diagnosed psychiatric disorder. Hospitalizations with a psychiatric comorbidity tended to be younger (58.9 vs. 62.0, p CONCLUSIONS Patients with psychiatric comorbidities undergoing surgical treatment for cervical myelopathy have an increased risk of nonhome discharge, a longer length of hospital stay, but no increased risk of postoperative complications or mortality, nor any significant difference in total hospital charges. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases.

The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. The 2009-2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

Does Day of Surgery Affect Hospital Length of Stay and Charges Following Minimally Invasive Transforaminal Lumbar Interbody Fusion?

Retrospective Cohort. To determine if an association exists between surgery day and length of stay or hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Length of inpatient stay after orthopedic procedures has been identified as a primary cost driver, and previous research has focused on determining risk factors for prolonged length of stay. In the arthroplasty literature, surgery performed later in the week has been identified as a predictor of increased length of stay. However, no such investigation has been performed for MIS TLIF. A surgical registry of patients undergoing MIS TLIF between 2008 and 2016 was retrospectively reviewed. Patients were grouped based on day of surgery, with groups including early surgery and late surgery. Day of surgery group was tested for an association with demographics and perioperative variables using the student t test or χ analysis. Day of surgery group was then tested for an association with direct hospital costs using multivariate linear regression. In total, 438 patients were analyzed. In total, 51.8% were in the early surgery group, and 48.2% were in the late surgery group. There were no differences in demographics between groups. There were no differences between groups with regard to operative time, intraoperative blood loss, length of stay, or discharge day. Finally, there were no differences in total hospital charges between early and late surgery groups (P=0.247). The specific day on which a MIS TLIF procedure occurs is not associated with differences in length of inpatient stay or total hospital costs. This suggests that the postoperative course after MIS TLIF procedures is not affected by the differences in hospital staffing that occurs on the weekend compared with weekdays.

A Prospective Randomised Comparative Study between Clip Less Versus Conventional Laparoscopic Cholecystectomy

Introduction: For the surgical treatment of gall bladder diseases, laparoscopic Chole cystectomy has been accepted as&#x0D; the gold standard. The minimally invasive procedure is undeniably superior in various respects when compared with&#x0D; open surgery and this is also true on the aesthetic criteria when the conventional laparoscopic cholecystectomy (CLC) is&#x0D; compared with the mini-laparoscopic cholecystectomy (MLC).&#x0D; Objective: Evaluate the hospital charges associated with these procedures and specify the differences concerning these&#x0D; techniques.&#x0D; Method: Comparative and retrospective study of hospital charges, with 40 consecutive patients, who underwent&#x0D; laparoscopic cholecystectomy.&#x0D; There were two groups with 20 patients each. One group underwent conventional laparoscopic cholecystectomy and in&#x0D; the other the minimally invasive approach was performed. The arithmetic mean was used to compare the total charges&#x0D; for the entire procedures.&#x0D; Results: The MLC procedures showed no significant difference in total hospital charges compared to the CLC approach.&#x0D; Conclusion: The equivalence of hospital charges for the two procedures suggests that the mini-laparoscopic&#x0D; cholecystectomy (MLC) should be widely recognized among surgeons as offering better aesthetic results the&#x0D; conventional laparoscopic procedure. Studies comparing patient satisfaction with the surgical result, difference in postoperative&#x0D; morbidity, pain, and recuperation for the two procedures are needed. &#x0D; &#x0D; charges, surgery, laparoscopy, needlescopic instruments

Does Parkinson Disease Increase the Risk of Perioperative Complications After Total Hip Arthroplasty? A Nationwide Database Study

BackgroundParkinson disease (PD) is the second most common neurodegenerative disorder in the United States, affecting over 1 million people. As part of the disease process, PD can cause poor bone quality and other musculoskeletal problems that can affect a patient's quality of life. With advances in treatment, PD patients can be more active and may be candidates for total hip arthroplasty (THA). However, there is a paucity of literature on the outcomes of THA in PD patients. Therefore, the purpose of this study was to evaluate the perioperative outcomes of PD patients who underwent THA. Specifically, we assessed: (1) perioperative surgical and medical complications; (2) lengths of stay (LOSs); and (3) total hospital charges. MethodsUsing the Nationwide Inpatient Sample, patients who had PD and underwent THA between 2002 and 2013 were identified. With the use of propensity scores, PD patients were matched in a 1:3 ratio to patients without PD by the year of surgery, age, gender, race, Charlson/Deyo score, and insurance type. This yielded a total of 10,519 PD and 31,679 non-PD THA patients. Regression analyses were used to compare the risk of perioperative complications (any, surgical, medical), the percent differences in mean LOS, and the percent differences in total hospital charges. ResultsCompared with the matched cohort, PD patients had a 52% higher risk for any complication (odds ratio [OR] = 1.52; 95% confidence interval [CI], 1.37-1.69), a 30% higher risk for any surgical complication (OR = 1.30; 95% CI: 0.88-1.91), and a 54% higher risk for any medical complication (OR = 1.54; 95% CI, 1.38-1.71). Specifically, PD patients were more likely to have postoperative delirium (OR = 2.61; 95% CI: 1.77-3.85), altered mental status (OR = 3.01; 95% CI: 1.35-6.71), urinary tract infection (OR = 1.34; 95% CI: 1.09-1.76), and blood transfusion (OR = 1.62; 95% CI: 1.44-1.82). Also, PD patients had a mean LOS that was 8.57% longer (P < .0001), and mean total hospital charges that were 3.85% higher (P < .0001). ConclusionOrthopedic surgeons and neurologists should be involved in the preoperative counseling of PD patients regarding their potential increased risks associated with THA, which could help optimize their preoperative care. Furthermore, the risk of complications and higher costs could potentially lead to the development of different reimbursement methods in this population of patients.

National Trends in the Treatment of Penile Prosthesis Infections by Explantation Alone vs. Immediate Salvage and Reimplantation

A penile prosthesis infection (PPI) is either treated with explantation of the prosthesis with a possible delayed reimplantation or a salvage procedure with an immediate reimplantation of the prosthesis. We used a large, all-payer national database to investigate the use of the salvage procedure in the setting of PPI. The study used years 2000-2009 of the Nationwide Inpatient Sample to identify PPIs treated with immediate salvage or explantation alone. Admissions were then stratified by various parameters to compare differences in the salvage rates. Salvage Rate of Penile Prosthesis infection. A total of 1,557 patients were treated with an explantation only (82.7%) or salvage (17.3%) for PPI, a proportion that remained stable over the study period. The patients treated with salvage were younger (60.4 vs. 65.1 years), more likely to be discharged home (87.3% vs. 61.9%), and were less likely to have a severe presentation (7.2% vs. 31.6%) than those who were explanted only (P < 0.001). These factors were confirmed on multivariate regression analysis. The regression also revealed that treatment at rural hospitals had lower odds of salvage than treatment at urban teaching hospitals. Race, comorbid diabetes, and insurance status did not independently affect the salvage rate. There was no significant difference in total hospital charges between groups. Salvage rates have remained low over the past decade. Our study elucidated several factors decreasing the chances of salvage after PPI including age, severity of presentation, and hospital setting.

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Introduction: Insurance status on admission has been associated with mortality after trauma. Hypothesis: We hypothesized that outcome and care delivery is unaffected by insurance stauts in our trauma center Methods: We retrospectively reviewed patients admitted to our center over 10 years. Baseline demographics, insurance status, injuries, toxicology, type of insurance (public vs. private) co-morbidities, and admission physiology were abstracted from the trauma registry. Logistic regression was used to determine the independent effect of insurance status on in-hospital mortality. Results: 62,073 patients were analyzed. Mortality was 4.4%. 27.8% were uninsured. Unadjusted mortality for uninsured vs. insured patients was 5.9% vs. 3.8% (p<0.0001). Adjusting for demographics, injury severity, number of co-morbidities, mechanism of injury, toxicology, and admission physiology, mortality was not associated with insurance status (OR=0.87, CI=0.74-1.02). In adjusted analysis there was also no difference in hospital charges between patients with and without insurance. When looking at types of insurance, crude mortality rates were 2.7% for private insurance, 9.4% for Medicare, and 5.2% for Medicaid (p<0.0001). In adjusted analysis, there was no difference in mortality when comparing those with public insurance vs. no insurance (OR=0.90, 0.71-1.15 for Medicare; OR=1.04, 0.76-1.42 for Medicaid), but private insurance was associated with lower mortality (OR=0.84, 0.71-0.99). When comparing those patients with insurance to those without, there was no difference in total hospital charges in adjusted analysis. Conclusions: Mortality following injury is not independently associated with lack of insurance, but rather affected by pre-injury factors and injury severity. Private insurance was associated with better outcome, although public insurance was equivalent to no insurance. In our trauma center hospital resource allocation does not seem to be affected by insurance status.

Development of a Safe and Pragmatic Awake Craniotomy Program at Maine Medical Center

Awake craniotomy offers an excellent means of performing intraoperative mapping and optimizing surgical resection of brain tumors. Awake craniotomy relies on a strong collaboration between anesthesiologists, neurosurgeons, and operating room staff. The authors recently introduced awake craniotomy for tumor resection at the Maine Medical Center and propose that it can be performed safely, effectively, and efficiently in a high-volume community hospital. We describe a practical approach to performing awake craniotomy involving streamlined anesthetic protocols and simplified intraoperative testing parameters in a carefully selected group of patients. Our first 25 patients are retrospectively reviewed with particular attention to the anesthetic protocol, the extent of resection, the operative time, post-operative complications, the length of hospitalization, and their functional status at follow-up. The authors established an anesthetic protocol based primarily on midazolam, fentanyl, propofol, and local anesthetic. The authors note that all but one patient was able to tolerate the awake procedure. Gross total resection was achieved in nearly 80% of patients with a glial tumor. Operative time was short, averaging 159 minutes of entire anesthesia care. Length of stay averaged 3.7 days. Persistent new post-operative deficits were noted in 2 of 25 patients. There was no substantial difference in total hospital charges for patients undergoing awake craniotomy when compared to a matched historical control. With attention focused on patient selection and a streamlined anesthetic protocol, the authors were able to successfully implement an awake craniotomy protocol in a community setting with satisfying results, including low operative morbidity, short operative times, low anesthetic complications, and excellent patient tolerance.

Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients’ outcome and cost-effectiveness

Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness. A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System. Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03). Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.

Outcomes of Laparoscopic versus Open Appendectomy

Controversy remains regarding which approach is better, laparoscopic appendectomy (LA) or open appendectomy (OA). A 5-year retrospective review of patients undergoing appendectomy was performed to compare the outcomes of LA and OA using standard statistical methods (P < 0.05). LA was performed in 207 and OA in 100 patients (conversion 6.7%). Females underwent LA more frequently than males (81.7% vs 51.9%; P = 0.0001). LA patients were older (30.2 years vs 25.7 years; P = 0.03), with no differences in body mass index (BMI) (27.9 kg/m2 vs 25.5 kg/m2; P = 0.06) or operative times (51.1 minutes vs 51.5 minutes; P = 0.84). LA patients required less analgesics (19.2 mg vs 31.5 mg; P = 0.01), and shorter hospital stays (27.2 hours vs 53.1 hours; P = 0.0001). Operating room charges were higher for LA (3839 dollars vs 2528 dollars; P = 0.0001), with no difference in total hospital charges (8801 dollars vs 9147 dollars; P = 0.14). Complications between LA and OA were similar (3.6% vs 8%; P = 0.12). Converted patients were older, required more analgesia, and had higher morbidity, length of stay, and hospital charges. LA is the procedure of choice for appendicitis regardless of age, sex, BMI, or degree of appendiceal inflammation. LA is as safe and quick to perform as OA with lower analgesic requirements, length of stay, and no difference in total charges.