Emergency Readmission Research Articles

Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study

PurposeMajor emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery.MethodsThis study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days.ResultsFrom 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission.ConclusionClose to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.

ThTP5.11 The positive impact of our efficient Surgical Assessment Unit use on general surgery emergency readmission rates

Abstract Aim Hospital readmission rates are a general indicator of quality of care, however these rates are currently variable nationally. Lowering these rates will not only alleviate the financial burden of the National Health Service but will improve patient outcomes. Our primary aim was to establish if implementing a senior-led Surgical Assessment Unit would reflect positively on reducing the rates of avoidable emergency readmissions within 30 days of discharge, in our General Surgery department at a district general hospital. Method We compared two 3-month cycles of all General Surgery emergency readmissions in our department within 30 days of discharge from June to August 2022 versus August to October 2021. Data of 361 patients in cycle 2 versus 389 patients in cycle 1 were collected and analysed to determine the readmission rates and to prevent the potential avoidable factors. Results A total of 6.6% of patients were readmitted with various surgical conditions, and the number of extra days of hospital stay totalled to 26 extra days collectively. This is compared to 11%, and 69 days respectively from the previous cycle. The main reasons for readmission were recurrences of the original problem (namely pancreatitis), and post-operative infections. Conclusion Overall, our implemented action plan has reduced the rate of emergency surgical readmissions by 4.4%. However, the main factors for readmissions remained similar. We will continue to provide an efficient use of the Surgical Assessment Unit and senior-led discharge to ensure we minimise the rates of surgical readmissions.

WTP3.3 Percutaneous cholecystostomy: an intervention requiring re-admission and re-intervention?

Abstract Aims A national database study reported a 723% increase in cholecystostomy procedures in England between 2000 and 2019 (Lunevicius, 2022). We aimed to evaluate short and long-term clinical outcomes following percutaneous cholecystostomy for acute cholecystitis (AC) at our centre. Methods A single-centre, retrospective cohort study was conducted utilising data from a tertiary centre database, 2012–2020. Tokyo guidelines were used to grade AC severity. Outcomes were evaluated. Results Seventy-six patients were included. The median age was 76 (IQR 67.5-83.3). The M:F ratio was 1.1:1. Twenty-nine patients (38.2%) had Tokyo Grade 3 AC. The remaining 47 patients (61.8%) had Tokyo Grade 2 AC. Forty-seven patients (61.8%) experienced at least one post-cholecystostomy complication. During index admission, seven patients (9.2%) required admission to ITU, seven patients (9.2%) died, and six (7.9%) required emergency cholecystectomy. The median length of stay was 12 days (IQR 9.33-17.0). Of the 69 patients who were discharged, 23 (33.3%) required emergency readmission due to AC recurrence; 12 of these (17.4%) were readmitted within 30 days. Eleven patients (15.9%) had recurrence of AC whilst the gallbladder catheter remained in-situ, and a further 15 patients (21.7%) had recurrence of AC after catheter removal. Twenty patients (29.0%) required additional percutaneous drainage, of which 11 (15.9%) received repeat cholecystostomy. Twelve patients (17.4%) underwent elective cholecystectomy, with a median interval between PC and elective cholecystectomy of 62.5 days (IQR 20.3-118). Conclusions PC is associated with high post-procedure mortality and morbidity. Clinicians should be discerning in patient selection criteria for PC.

HaEmaturia After Transurethral resection of bladder Tumour (HEATT): A multicentre, regional collaborative analysis of factors associated with emergency re-admission with haematuria following TURBT

Objective: To calculate the re-admission rate with haematuria within 30 days of elective transurethral resection of bladder tumour (TURBT), and identify factors associated with this. Materials and Methods: This was a multicentre, retrospective audit, identifying all adult patients over the age of 16 who underwent elective TURBT between 1 September and 30 November 2019. Data were collected from medical records and operation notes on patient demographics, intra-operative factors and post-operative management. Primary outcome measure was the proportion of patients emergently re-admitted with haematuria. Secondary outcome measures were the re-operation rate for haematuria, and the rate of new acute thrombotic event (TE). Fisher’s exact test was used to calculate p values within subgroups for re-admission rates. Results: 443 patients from 12 hospitals were included. Median age was 75 years (17–99). 15 patients (3.4%) were re-admitted with haematuria. Subgroup analysis demonstrated higher rate of re-admission for pre-existing antithrombotic agents (ATAs) (2.0% vs. 6.1%, p = 0.046), increased for non-Aspirin ATAs (10.5%, p = 0.0015). 52% of non-Aspirin ATAs were restarted within 48 hours of surgery; post-operative plan for restarting was not documented in 22.1%. One patient (0.23%) developed acute TE (pulmonary embolus). Conclusion: Pre-existing use of non-Aspirin ATAs is associated with increased risk of post-TURBT haematuria, with variable practice in post-operative recommencement. Level of evidence: Level 3

USING THE CAPABILITY, OPPORTUNITY, AND MOTIVATION MODEL OF BEHAVIOUR (COM-B) TO IMPLEMENT A PATHWAY TO REDUCE 30-DAY ELECTIVE EMERGENCY ADMISSIONS

AbstractIntroduction30-day emergency readmission is an indicator of treatment related complication once discharged, resulting in readmission. A board-approved quality improvement pathway was introduced to reduce elective re-admissions.MethodThe pathway involved telephone and email contact details provision to patients for any non-life threatening medical assistance, allowing for initial nurse led management of all issues. A new clinic room available 7 days, and same day ultrasound scanning for DVT studies were introduced. A capability, opportunity and behavior model of change was implemented.Readmission rates before and six months after implementation were collected from Model Hospital. A database used to document patient communications was interrogated for patient outcomes.ResultsPrior to implementation, readmission rates following elective primary total knee replacement (TKR) at the 1st business quarter of 2021 (April – June 2021), was 8.7%, (benchmark 3.8%). Following implementation, readmission rates decreased to 4.1% (October – December 2021). 54% of patients making contact were managed with telephone advice. 15% of patients required face-to-face clinic. 32% of those required a same day scan to exclude DVT (1/4).20 out of 684 TKRs performed following protocol introduction were re-admitted within 30 days. Readmissions were 41% surgical, 29% medical. 52% were unaware of the newly implemented protocol. Further improvements have been made to the protocol based on these findings.Implementation of a suitable pathway can significantly reduce re-admission rates in our center and could be used to reduce readmission rates in other national elective treatment centers.

Varying Degree of Overlap Following the Critical Steps of Lumbar Fusion and Short-term Outcomes.

Retrospective cohort. The present study analyzes the impact of end-overlap on short-term outcomes after single-level, posterior lumbar fusions. Few studies have evaluated how "end-overlap" (i.e., surgical overlap after the critical elements of spinal procedures, such as during wound closure) influences surgical outcomes. Retrospective analysis was performed on 3563 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a 6-year period at a multi-hospital university health system. Exclusion criteria included revision surgery, missing key health information, significantly elevated body mass index (>70), non-elective operations, non-general anesthesia, and unclean wounds. Outcomes included 30-day emergency department visit, readmission, reoperation, morbidity, and mortality. Univariate analysis was carried out on the sample population, then limited to patients with end-overlap. Subsequently, patients with the least end-overlap were exact-matched to patients with the most. Matching was performed based on key demographic variables-including sex and comorbid status-and attending surgeon, and then outcomes were compared between exact-matched cohorts. Among the entire sample population, no significant associations were found between the degree of end-overlap and short-term adverse events. Limited to cases with any end-overlap, increasing overlap was associated with increased 30-day emergency department visits ( P =0.049) but no other adverse outcomes. After controlling for confounding variables in the demographic-matched and demographic/surgeon-matched analyses, no differences in outcomes were observed between exact-matched cohorts. The degree of overlap after the critical steps of single-level lumbar fusion did not predict adverse short-term outcomes. This suggests that end-overlap is a safe practice within this surgical population.

Impact of an automated peri-procedural digital health intervention on rates of emergency department visits and readmissions

BackgroundProviding timely peri-procedural education, reminders, and check-ins can improve patient adherence and clinical outcomes. We sought to retrospectively evaluate the impact of a peri-procedural digital health tool on emergency department (ED) visits and readmissions. MethodsA digital health tool for peri-procedural care engaged patients at scheduled intervals, resulting in an overall engagement score. Multivariate models determined predictors of tool engagement and post-procedural 30- and 90-day rehospitalizations and ED visits. Results11,737 unique completed procedures were analyzed from 10,438 patients. Patients of Black and Latinx race/ethnicity (vs White), those with Medicare and Medicaid insurance (vs commercial), and those with non-activated patient portals (vs activated) were less likely to engage. After adjustment for confounders, higher engagement with the tool was associated with lower rates of 30-day hospitalizations (OR 0.64), 90-day hospitalizations (OR 0.65), and 90-day ED visits (OR 0.77). ConclusionsHighly engaged patients had fewer 30-day and 90-day ED visit and readmissions, even after adjustment for key confounders. Engagement, and thus the resulting benefits, were not equitably distributed.

Early postoperative telehealth visit protocol implementation reduces emergency department utilization following benign foregut procedures.

Emergency department (ED) visits and readmissions following benign foregut surgery (BFS) represent a burden on patients and the health care system. The objective of this study was to identify differences in ED visits and readmissions before and after implementation of an early postoperative telehealth visit protocol for BFS. We hypothesized that utilization of telehealth visits would be associated with reduced post-operative ED and hospital utilization. An early postoperative telehealth protocol was initiated in 2020 at an academic medical center to provide a video conference within the first postoperative week. Consecutive elective BFS including fundoplication, Linx, paraesophageal hernia repair, and Heller myotomy performed between 2018 and 2022 were included. Outcomes included ED visits and 30-day readmission. Bivariate analyses were performed using Chi-squared testing for categorical variables. The association between telehealth visits and outcomes were evaluated using multivariable logistic regression. 616 patients underwent BFS during the study period. 310 (50.3%) were performed prior to the implementation of telehealth visits and 306 (49.7%) were after. 241 patients in the telehealth visit group (78.8%) completed their telehealth visit. A total of 34 patients (5.5%) had ED visits without readmission while 38 patients (6.2%) were readmitted within the first 30days. The most common cause of ED visits and readmissions included pain (n = 18, 25%) and nausea/vomiting (n = 12, 16%). There was a significant reduction in ED visits without admission following telehealth visit implementation (7.4% vs 3.6%; OR 2.20, 95% CI 1.04-4.65, p = 0.04). There was no difference in readmission rates (6.1% versus 6.5%; OR 0.89, 95% CI 0.46-1.73, p = 0.73). The telehealth cohort had significantly lower ED visits for pain (31% vs 16.7%, p = 0.04) and nausea/vomiting (23.8% vs 6.7%, p = 0.02). Early telehealth follow-up was associated with a significant decrease in ED visits following BFS. The majority of this was attributable to a reduction in ED visits for pain, nausea, and vomiting. These results provide a possible avenue for improving quality and cost-effectiveness within this patient population.

Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction

Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time. To examine the association of head and neck cancer resection and reconstruction interventions with operative time. This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022. The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning. The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time. A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time. The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

RETRACTED: Discharge of postoperative patients with an opioid prescription is associated with increased persistent opioid use, healthcare expenditures and mortality: a retrospective cohort study

BackgroundThe risk factors for persistent opioid use after surgical discharge and the association between opioid prescription at discharge and postoperative emergency department visits, readmission, and mortality are unclear. MethodsThis population-based retrospective cohort study involved opioid-naive patients who underwent surgical procedures from January 1, 2000 to November 30, 2020. The data source was Hong Kong Hospital Authority Clinical Management System electronic health record. The primary outcome was the incidence of new persistent opioid use. Other study outcomes included 30-day emergency department visits, 30-day readmission, and 30-day all-cause mortality. Multivariable logistic regression models were used to estimate the association between opioid prescription at discharge and persistent opioid use, emergency department visits, readmission, and all-cause mortality. ResultsOver a median follow-up of 1 month with 36 104 person-years, 438 128 patients (opioid prescription: 32 932, no opioid prescription: 405 196) who underwent surgical procedures were analysed, of whom 15 112 (3.45%) had persistent opioid use after discharge. Prescribing opioids on discharge was associated with increased risks of developing persistent opioid use (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 2.19–2.40, P<0.001), 30-day emergency department visits (OR: 1.28, 95% CI: 1.23–1.33, P<0.001), 30-day readmission (OR: 1.17, 95% CI: 1.13–1.20, P<0.001), and 30-day all-cause mortality (OR: 1.68, 95% CI: 1.53–1.86, P<0.001). ConclusionsIn this large cohort of patients undergoing surgery, an opioid prescription on discharge was associated with a higher chance of persistent opioid use and increased risks of postoperative emergency department visits, readmission, and mortality. Minimising opioid prescriptions on discharge could improve perioperative patient outcomes.

Patterns of Outpatient Follow-up Visits After Hospitalizations for Acute Bronchiolitis

This cohort study examines the associations of posthospitalization follow-up with emergency department visits, readmissions, and use of nonrecommended medications among children with bronchiolitis.

Long-term disease interactions amongst surgical patients: a population cohort study

BackgroundThe average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described. MethodsWe included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations. ResultsWe identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9–4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0–3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs. ConclusionOne in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.

Comparison of outcomes for patients with and without a serious mental illness presenting to hospital for chronic obstruction pulmonary disease: retrospective observational study using administrative data.

There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons. To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD). This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18-74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified. Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI. Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12-1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34-1.69, P ≤ 0.001) but not with in-hospital mortality. Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.

Patient emergency health-care use before hospital admission for COVID-19 and long-term outcomes in Scotland: a national cohort study

It is unclear what effect the pattern of health-care use before admission to hospital with COVID-19 (index admission) has on the long-term outcomes for patients. We sought to describe mortality and emergency readmission to hospital after discharge following the index admission (index discharge), and to assess associations between these outcomes and patterns of health-care use before such admissions. We did a national, retrospective, complete cohort study by extracting data from several national databases and linking the databases for all adult patients admitted to hospital in Scotland with COVID-19. We used latent class trajectory modelling to identify distinct clusters of patients on the basis of their emergency admissions to hospital in the 2 years before the index admission. The primary outcomes were mortality and emergency readmission up to 1 year after index admission. We used multivariable regression models to explore associations between these outcomes and patient demographics, vaccination status, level of care received in hospital, and previous emergency hospital use. Between March 1, 2020, and Oct 25, 2021, 33 580 patients were admitted to hospital with COVID-19 in Scotland. Overall, the Kaplan-Meier estimate of mortality within 1 year of index admission was 29·6% (95% CI 29·1-30·2). The cumulative incidence of emergency hospital readmission within 30 days of index discharge was 14·4% (95% CI 14·0-14·8), with the number increasing to 35·6% (34·9-36·3) patients at 1 year. Among the 33 580 patients, we identified four distinct patterns of previous emergency hospital use: no admissions (n=18 772 [55·9%]); minimal admissions (n=12 057 [35·9%]); recently high admissions (n=1931 [5·8%]), and persistently high admissions (n=820 [2·4%]). Patients with recently or persistently high admissions were older, more multimorbid, and more likely to have hospital-acquired COVID-19 than patients with no or minimal admissions. People in the minimal, recently high, and persistently high admissions groups had an increased risk of mortality and hospital readmission compared with those in the no admissions group. Compared with the no admissions group, mortality was highest in the recently high admissions group (post-hospital mortality HR 2·70 [95% CI 2·35-2·81]; p<0·0001) and the risk of readmission was highest in the persistently high admissions group (3·23 [2·89-3·61]; p<0·0001). Long-term mortality and readmission rates for patients hospitalised with COVID-19 were high; within 1 year, one in three patients had died and a third had been readmitted as an emergency. Patterns of hospital use before index admission were strongly predictive of mortality and readmission risk, independent of age, pre-existing comorbidities, and COVID-19 vaccination status. This increasingly precise identification of individuals at high risk of poor outcomes from COVID-19 will enable targeted support. Chief Scientist Office Scotland, UK National Institute for Health Research, and UK Research and Innovation.

Heart Failure Emergency Readmission Prediction Using Stacking Machine Learning Model.

Heart failure is a devastating disease that has high mortality rates and a negative impact on quality of life. Heart failure patients often experience emergency readmission after an initial episode, often due to inadequate management. A timely diagnosis and treatment of underlying issues can significantly reduce the risk of emergency readmissions. The purpose of this project was to predict emergency readmissions of discharged heart failure patients using classical machine learning (ML) models based on Electronic Health Record (EHR) data. The dataset used for this study consisted of 166 clinical biomarkers from 2008 patient records. Three feature selection techniques were studied along with 13 classical ML models using five-fold cross-validation. A stacking ML model was trained using the predictions of the three best-performing models for final classification. The stacking ML model provided an accuracy, precision, recall, specificity, F1-score, and area under the curve (AUC) of 89.41%, 90.10%, 89.41%, 87.83%, 89.28%, and 0.881, respectively. This indicates the effectiveness of the proposed model in predicting emergency readmissions. The healthcare providers can intervene pro-actively to reduce emergency hospital readmission risk and improve patient outcomes and decrease healthcare costs using the proposed model.

Unanticipated costs associated with interscalene nerve catheters for shoulder surgery.

Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of ongoing care or complications. Pulmonary complications can lead to unexpected admissions and emergency department visits. The purpose of the study was to identify unplanned hospital admissions or emergency department visits related to regional anesthesia after shoulder surgery and determine the additional associated costs. A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single, large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients, whereas 160 patients had a single-shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at 1, 2, 7, and 14 days following surgery. All emergency department visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care. Of the 1728 patients who had CIB, 10 patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency department visit or readmission. The average age of the 10 patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days, with 1 patient requiring admission to the intensive care unit. The average cost of admission to the hospital or visit to the emergency department was $6849 (range, $1988-$19,483). These costs were primarily related to chest radiographs and electrocardiogram (9/10), chest computed tomography (CT) with contrast (3/10), and head CT (2/10). Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency department workup may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.

Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health

BackgroundThe risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6–12 months post-injury. MethodsTrauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6–12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups. ResultsOf 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores. ConclusionsInjury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.

Open vs Robotic Radical Cystectomy Outcomes at a Single Institution: A Retrospective Review of 152 Patients

Introduction: Robotic radical cystectomy is becoming increasingly used over the traditional open approach; however, the potential advantages remain an area of active investigation, with several studies to date finding overall comparable outcomes. We sought to add to the existing body of work by performing a retrospective review of open vs robotic radical cystectomies performed at our institution. Methods: All patients who underwent radical cystectomy for urothelial cancer with curative intent at New York University (Manhattan and Long Island sites) were included. Surgical dates spanned between October 2017 and March 2022. Individual patient charts were reviewed in Epic for data extraction. Results: A total of 152 patients were included in the final analysis including 71 robotic and 81 open radical cystectomies. Estimated blood loss and the number of perioperative blood transfusions were significantly lower in the robotic cohort, whereas operative times were significantly longer. The median length of stay was 5 days in the robotic cohort vs 6 days in the open cohort; this only reached statistical significance for the ileal conduit subgroup. However, 90-day mortality, return to emergency department, readmissions, and complication rates were not significantly different. Oncologic outcomes were also similar, aside from an increase in lymph node count among the robotic cohort. Conclusions: In the hands of experienced surgeons, a robotic surgical approach did not confer major benefits in perioperative morbidity and mortality, although it did achieve similar oncologic efficacy, led to fewer blood transfusions, and led to a shorter length of stay in patients who underwent ileal conduits diversions.

The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression.

Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.

Comparison of Different Modeling Approaches for Prescription Opioid Use and Its Association With Adverse Events.

Previous research linking opioid prescribing to adverse drug events has failed to properly account for the time-varying nature of opioid exposure. This study aimed to explore how the risk of opioid-related emergency department visits, readmissions, or deaths (composite outcome) varies with opioid dose and duration, comparing different novel modeling techniques. A prospective cohort of 1,511 hospitalized patients discharged from 2 McGill-affiliated hospitals in Montreal, 2014-2016, was followed from the first postdischarge opioid dispensation until 1 year after discharge. Marginal structural Cox proportional hazards models and their flexible extensions were used to explore the association between time-varying opioid use and the composite outcome. Weighted cumulative exposure models assessed cumulative effects of past use and explored how its impact depends on the recency of exposure. The patient mean age was 69.6 (standard deviation= 14.9) years; 57.7% were male. In marginal structural model analyses, current opioid use was associated with a 71% increase in the hazard of opioid-related adverse events (adjusted hazard ratio = 1.71, 95% confidence interval: 1.21, 2.43). The weighted cumulative exposure results suggested that the risk cumulates over the previous 50 days of opioid consumption. Flexible modeling techniques helped assess how the risk of opioid-related adverse events may be associated with time-varying opioid exposures while accounting for nonlinear relationships and the recency of past use.