Inpatient Procedures Research Articles

Rise of the robots: implementing robotic surgery into the acute care surgery practice.

Acute Care Surgery (ACS) admissions and procedures are substantially increasing. ACS disproportionally accounts for a majority of morbidity and mortality among surgical patients. Minimally invasive techniques are associated with improved outcomes and shorter hospital length of stay within the ACS population. While laparoscopy is widespread, ACS surgeons have been slower to adopt the use of robotics. We aimed to evaluate the feasibility of incorporating robotic surgery within ACS practice. Robotic General Surgery operations performed by 8 Acute Care Surgeons from 5 local facilities within a large integrated healthcare system were queried over a 15 month period. Patients who underwent emergent, urgent, sub-acute, and elective robotic operations by ACS staff were identified. Demographics collected included age, gender, BMI, and ASA score. Outcomes recorded included procedure classification, total supply and implant charges (TSI), conversion to open, hospital length of stay (LOS), 30 day readmission, and 30 day mortality. Of 200 operations, the most common were Cholecystectomy (43.5%), Inguinal hernia repair (26.0%), Ventral hernia repair (18.0%), Appendectomy (5.0%), and Sigmoid Colectomy (3.5%). The median (± std dev) age was 48 ± 16.66years and BMI was 29.9 ± 8.79kg/m2. 46% of cases were sub-acute (n = 92), 33.5% were elective (n = 67), 14% were emergent (n = 28), and 6.5% were urgent (n = 13). Most patients were ASA 2 (107, 46.1%) or ASA 3 (71, 45.9%). The median (IQR) TSI and LOS were $1,770 (889.50) USD and 0.1 (0.9) days. Forty-one inpatient procedures were performed. Median LOS was 3days and expected LOS was 3.1days (O:E = 0.96). Five patients were readmitted within 30days, and there were no deaths within 30days. Robotic techniques may be safely implemented by ACS surgeons, potentially benefitting both patient and surgeon. LOS was similar between laparoscopic and robotic cases and only two cases required conversion to an open procedure. Next steps include a multi-center prospective trial comparing robotic to laparoscopic cases.

8139 Examining the Association of GLP1-RA or DPP4i with Bullous Skin Diseases in Veterans

Abstract Disclosure: S. Saad-Omer: None. M. Kinaan: None. N. Sami: None. I. Mansi: None. Introduction: Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are Autoimmune Blistering Disorders (AIBDs). GLP-1 Receptor Agonists (GLP1-RA) and Dipeptidyl peptidase 4 inhibitors (DPP4i) have been noted in various case reports and case control studies to be linked with certain AIBDs; however, their overall role in these diseases is not completely understood, despite the exponential increase in use of these medications. This study aims to be the first study to investigate the association of DPP-4 inhibitors and GLP-1 agonists with incidence of AIBD, PV, and BP in a large cohort of American veterans. Methods: This retrospective cohort study of veterans enrolled in the Veterans Health Administration (VHA) used Corporate Data Warehouse (CDW). We extracted data of patients from fiscal years (FY) 2006 to end of FY 2021 who filled either GLP1-RA or DPP4i prescriptions. CDW is a comprehensive data source that encompasses vital status, demographic data, inpatient and outpatient diagnoses and procedure codes, vital signs, laboratory data, and pharmacy fill data. The study groups included: 1) GLP1-RA group: patients who initiated GLP1-RA; and 2) DPP4i group: patients who initiated DPP4i. Our primary outcome was the incidence of AIBDs. We compared baseline characteristics of patients who experienced the outcome and those who did not among GLP1-RA or DDP4i users. We, thereafter, examined factors associated with incidence of AIBD, PV, and BP among GLP1-RA users and DPP4i users. Results: The initial cohort of GLP1-RA or DPP4i users comprised a total of 415,895 patients, from which we excluded 397 (0.095%) patients with prior bullous skin diseases before starting GLP1-RA or DPP4i medications. Overall, a total of 154 patients developed PV/BP disease after initiation of either DPP4i or GLP1-RA. Of these 154 patients, 123 of these patients were on DPP4i and 31 of these patients were on GLP1-RA. The mean age (SD) of PV/BP patients was 72 (11) years compared to an average age of 66 (10) years in patients who did not develop PV/BP. Patients were also found to be predominately white (77.9%). Factors associated with increased risk of BP were use of DPP4i (Odds Ratio [OR] 1.90, 95% confidence interval [95% CI: 1.14-3.47, p=<0.01), and older age (OR: 1.07, 95%CI: 1.04-1.09, p<0.01). Use of GLP1-RA or DPP4i was not associated with PV incidence. (OR: 1.31, 95% CI: 0.65-2.62, p=<0.45). Conclusion: In conclusion, our study supports existing literature that DPP4i use is associated with an increased risk of developing BP. Our data does not find association with GLP-1 agonists nor DPP4 inhibitors in increasing the risk of PV. Presentation: 6/3/2024

National Costs for Cardiovascular-related Hospitalizations and Inpatient Procedures in the United States, 2016-2021

The current economic burden of cardiovascular-related hospitalizations grouped by diagnoses and procedures in the U.S. has not been well characterized. The objective was to identify current trends in cardiovascular-related hospitalizations, procedural utilization, and health care costs, using the most recent 6 years of hospitalization data. A retrospective analysis of discharge data from the National Inpatient Sample (NIS) database was conducted to determine trends in cardiovascular-related hospitalizations, costs, and procedures for each year from 2016 to the most recent available dataset, 2021. Total cardiovascular-related costs were adjusted to and reported in 2023 dollars. In 2021, there were 4,687,370 cardiovascular-related hospitalizations at a cost of $108 billion. Heart failure hospitalizations accounted for the highest costs at $18.5 billion, followed by Non-ST-Elevation Myocardial Infarction at $11.2 billion, and stroke at $10.9 billion. Significant upward trends in costs from 2016 to 2021 were observed for heart failure, stroke, atrial fibrillation, ST-elevation myocardial infarction, chest pain, hypertensive emergency, ventricular tachycardia, aortic dissection, sudden cardiac death, pericarditis, supraventricular tachycardia, and pulmonary heart disease. Over the 6 observational years, total costs increased by over $10 billion, representing a 10 percent increase. However, the increases were not linear, as there was a significant increase of 6.5% from 2018 to 2019, then a dip of over 7% from 2019 to 2020, followed by a rise of about 6% from 2020 to 2021. By 2030, total CV-related costs are projected to reach $131.3 billion. For all years, coronary procedures were the most performed, followed by ECMO, non-bypass peripheral vascular surgery, pacemaker placement, and CABG. Both TAVR and MitraClip procedures demonstrated significant upward trends from 2016 to 2021. Overall, from the years 2016 to 2021, cardiovascular-related hospitalizations, costs, and procedures demonstrated upward trends. In conclusion, cardiovascular disease remains a high burden in the hospital setting with tremendous health care costs.

Sinunasal surgery as outpatient procedure with special consideration of nasal packing - Position paper of the German Society of Otorhinolaryngology, Head and Neck Surgery, the working group Rhinology / Rhinosurgery (ARHIN) of the German Society of Otorhinolaryngology, Head and Neck Surgery and German Professional Association of Otorhinolaryngologists

Currently, there is an intensive discussion on advancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. Development of a checklist to stratify sinunasal procedures into in- or outpatient procedures with consideration of current scientific literature and risk factors. After comprehensive assessment of the literature and analysis of specific risk factors, a list of sinunasal procedures is presented, which should be performed as inpatient procedures. We present a checklist for in- and outpatient sinunasal procedures, which considers social, medical and surgical factors as well as the use of nasal packing materials. Furthermore, a checklist is added to assess, whether patients are ready for discharge after a planned outpatient procedure.

Survey on the use of nasal tamponades in sinunasal surgery

Currently, there is an intensive discussion about enhancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. We performed a Germany-wide survey among otorhinolaryngologists regarding the use of nasal packing materials in sinonasal surgery. Additionally, we asked for any complication in relation to nasal packing. In 85,6% nasal packing was used for septal and turbinate surgery at least occasionally, in 44,2% always. In sinus surgery these numbers are 94,1% and 49%, respectively. Non-resorbable nasal packing materials were predominantly used.Most frequent complications were bleeding with nasal packing in situ (> 50% of respondents) and posterior dislocation (24% of respondents), requiring emergency treatment. Death was listed in 5 patients. One patient suffered from permanent brain damage due to hypoxia. Application of non-resorbable nasal packing materials with occlusion of the nasal cavity carry a substantial risk of complications, which necessitate emergency treatment, thus requiring inpatient care.

Day-case laparoscopic cholecystectomy in the management of gallbladder disease: a literature review.

Day-case laparoscopic cholecystectomy (DCLC) has gained traction globally due to its benefits, including shorter hospital stays, reduced costs, and enhanced patient experience. While concerns about patient safety, particularly related to bleeding and bile duct injury persist, the literature supports the efficacy and advantages of DCLC highlighting the need for its wider adoption in healthcare settings to optimise resources and improve patient outcomes. This was a literature review that aims to assess the feasibility and safety of day-case laparoscopic cholecystectomy for symptomatic gallstone patients, focusing on incidence and aetiology of unexpected admissions and readmissions, as well as conversion-to-open rates. PubMed was searched for all studies focusing on DCLC between 2014 and 2024. The timeframe was specifically selected to identify recent trends and practices in this evolving field. By focusing on this specific period, the review aims to provide a comprehensive analysis of current practices, emerging trends, and the evolving standard of care in this area. This review highlights that the main causes of unexpected admission post DCLC were postoperative nausea, vomiting, and pain, while the implementation of anaesthetic pathways notably increased day-case rates. Studies addressing complication rates postoperatively consistently found no significant difference between day-case and in-patient procedures. DCLC for symptomatic gallstone patients is supported by research as safe and effective, with high success rates and patient satisfaction. Studies show minimal complications and acceptable readmission rates, suggesting that DCLC can be the standard approach for selective patients, improving outcomes and healthcare efficiency.

Priority areas for outcomes improvement among older adults undergoing inpatient general surgery inclusive of geriatric-pertinent complications.

Comprehensive studies on priority areas for improving geriatric surgery outcomes, inclusive of geriatric-pertinent data, are limited. The ACS NSQIP geriatric database (2014-2018) was used to abstract older adults (≥65years) undergoing inpatient general surgery procedures. Thirty-day complication, functional decline, and mortality rates were analyzed, with a focus on two geriatric-pertinent complications: delirium and new/worsening pressure ulcers. There were 9062 patients; 41.9% were ≥75years. Mean age was 73.9years. The majority of patients were female (54.0%), White (77.7%), and had independent functional status before surgery (94.0%). Overall 30-day complication, functional decline, and mortality rates were 33.6%, 34.5%, and 3.5%, respectively; failure to the rescue rate was 9.7%. Including geriatric-pertinent complications increased the overall complication rate by 20.4%. Delirium emerged as the leading complication (11.9%), followed by bleeding (11.1%), and wound-related complications (10.1%); these three accounted for 53.7% of complications. Delirium and pressure ulcers were associated with a >50% rate of postoperative functional decline (52.0% and 71.4%, respectively); pressure ulcers were also notable for a 25.5% failure to the rescue rate. Both were also among complications most likely to occur following the 3 most common procedures (colorectal surgery, pancreatic resections, and exploratory laparotomy), which overall accounted for approximately 79.6% of complications, 73.4% of patients experiencing functional decline, and 82.3% of mortality. Delirium is the leading complication among older adults undergoing inpatient surgery. Overall, a small number of complications and procedure groups account for most surgical morbidity and mortality among older adults and thus constitute priority areas for outcomes improvement.

A cross-sectional study assessing the role of interventional radiology services in regional and remote Australia.

It is estimated that 8% of hospitalised patients require treatment from Interventional Radiology (IR). However, little is known about the potential impact of IR on regional and remote Australians, including Indigenous patients. This study aimed to assess treatments performed by IRs on regional/remote patients to predict future IR workforce and governance needs. Single-centre cross-sectional study at a tertiary Victorian hospital. Patients were identified when they had an advanced IR treatment between 1 January 2022 and 2024. Basic procedures such as biopsy and drain insertion were not included. The primary outcome was the type and volume of IR treatments performed on patients who were transferred from a regional or remote home location for treatment. Of 3485 advanced IR interventions, 908 procedures (26.0%) from patients who lived in a regional or remote location were included with 36.5% female, of mean age 55.6 years (SD 17.9). 1.4% identified as Indigenous which is similar to the Indigenous population incidence in Victoria of 1.0%. Of this group, 350 (38.5%) were either a day procedure, overnight elective admission, or simple inpatient procedure which could have been performed in a regional centre, which included 1.1% Indigenous patients. There is an unmet need for IR services in regional and remote Australia, with many patients being transferred to our metropolitan centre for treatment that could be performed in regional IR hubs. This data will be important to drive government and hospital planning including capital infrastructure, workforce modelling and future recognition of IR as a new specialty in Australia.

Health system resilience during the COVID-19 pandemic: A comparative analysis of disruptions in care from 32 countries.

To quantify disruptions in hospitalization and ambulatory care throughout the coronavirus disease 2019 (COVID-19) pandemic for 32 countries, and examine associations of health system characteristics and COVID-19 response strategies on disruptions. We utilized aggregated inpatient hospitalization and surgical procedure data from the Organization for Economic Co-operation and Development Health Database from 2010 to 2021. Covariate data were extracted from the Organization for Economic Co-operation and Development Health Database, World Health Organization, and Oxford COVID-19 Government Response Tracker. This is a descriptive study using time-series analyses to quantify the annual effect of the COVID-19 pandemic on non-COVID-19 hospitalizations for 20 diagnostic categories and 15 surgical procedures. We compared expected hospitalizations had the pandemic never occurred in 2020-2021, estimated using autoregressive integrated moving average modeling with data from 2010 to 2019, with observed hospitalizations. Observed-to-expected ratios and missed hospitalizations were computed as measures of COVID-19 impact. Mixed linear models were employed to examine associations between hospitalization observed-to-expected ratios and covariates. The COVID-19 pandemic was associated with 16,300,000 (95% uncertainty interval 14,700,000-17,900,000; 18.0% [16.5%-19.4%]) missed hospitalizations in 2020. Diseases of the respiratory (-2,030,000 [-2,300,000 to -1,780,000]), circulatory (-1,680,000 [-1,960,000 to -1,410,000]), and musculoskeletal (-1,480,000 [-1,720,000 to -1,260,000]) systems contributed most to the declines. In 2021, there were an additional 14,700,000 (95% uncertainty interval 13,100,000-16,400,000; 16.3% [14.9%-17.9%]) missed hospitalizations. Total healthcare workers per capita (β = 1.02 [95% CI 1.00, 1.04]) and insurance coverage (β = 1.05 [1.02, 1.09]) were associated with fewer missed hospitalizations. Stringency index (β = 0.98 [0.98, 0.99]) and excess all-cause deaths (β = 0.98 [0.96, 0.99]) were associated with more missed hospitalizations. There was marked cross-country variability in disruptions to hospitalizations and ambulatory care. Certain health system characteristics appeared to be more protective, such as insurance coverage, and number of inputs including healthcare workforce and beds. Substantial disruptions in health services associated with the coronavirus disease 2019 pandemic have placed a renewed interest in health system resilience. While there is a growing body of evidence documenting disruptions in services, there are limited comparative assessments across diverse countries with different health system designs, preparedness levels, and public health responses. Learning and adapting from health system-specific gaps and challenges highlighted by the pandemic will be critical for improving resilience. All countries experienced disruptions to hospitalizations and surgical procedures with a combined total of 30 million missed hospitalizations and 4 million missed surgical procedures in 2020-2021, but there was marked cross-country heterogeneity in disruptions. Countries with greater baseline healthcare workers, insurance coverage, and hospital beds had disproportionately lower disruptions in care. National health planning discussions may need to balance health system resiliency and efficiency to avert preventable morbidity and mortality.

Drivers of Variation in Opioid Prescribing after Common Surgical Procedures in a Large Multihospital Healthcare System.

Misuse of prescription opioids is a well-established contributor to the US opioid epidemic. The primary objective of this study was to identify which level of care delivery (ie patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures. Electronic health record data from a large multihospital healthcare system were used in conjunction with random-effect models to examine variation in opioid prescribing practices after similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation. Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5 mg oxycodone tablets after surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic Black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider. Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.

Benchmarking commercial healthcare claims data.

Commercial healthcare claims datasets represent a sample of the US population that is biased along socioeconomic/demographic lines; depending on the target population of interest, results derived from these datasets may not generalize. Rigorous comparisons of claims-derived results to ground-truth data that quantify this bias are lacking. (1) To quantify the extent and variation of the bias associated with commercial healthcare claims data with respect to different target populations; (2) To evaluate how socioeconomic/demographic factors may explain the magnitude of the bias. This is a retrospective observational study. Healthcare claims data come from the Merative™ MarketScan® Commercial Database; reference data for comparison come from the State Inpatient Databases (SID) and the US Census. We considered three target populations, aged 18-64 years: (1) all Americans; (2) Americans with health insurance; (3) Americans with commercial health insurance. We analyzed inpatient discharge records of patients aged 18-64 years, occurring between 01/01/2019 to 12/31/2019 in five states: California, Iowa, Maryland, Massachusetts, and New Jersey. We estimated rates of the 250 most common inpatient procedures, using claims data and using reference data for each target population, and we compared the two estimates. The average rate of inpatient discharges per 100 person-years was 5.39 in the claims data (95% CI: [5.37, 5.40]) and 7.003 (95% CI: [7.002, 7.004]) in the reference data for all Americans, corresponding to a 23.1% underestimate from claims. We found large variation in the extent of relative bias across inpatient procedures, including 22.8% of procedures that were underestimated by more than a factor of 2. There was a significant relationship between socioeconomic/demographic factors and the magnitude of bias: procedures that disproportionately occur in disadvantaged neighborhoods were more underestimated in claims data (R 2 51.6%, p < 0.001). When the target population was restricted to commercially insured Americans, the bias decreased substantially (3.2% of procedures were biased by more than factor of 2), but some variation across procedures remained. Naïve use of healthcare claims data to derive estimates for the underlying US population can be severely biased. The extent of bias is at least partially explained by neighborhood-level socioeconomic factors.

Routine Urology Consultation and Follow-up After Pediatric Blunt Renal Trauma is Likely Unnecessary

IntroductionThis study examines the outcomes of high-grade renal trauma in pediatric patients and evaluates the intervention rate. In our hospital, we routinely consult urology on all high-grade injuries. We anticipated minimal intervention, casting doubt on the need for routine urology consultation and follow-up. MethodsWe conducted a retrospective review at a single pediatric trauma center from January 2018 to June 2023, focusing on patients with severe (grade III-V) renal injuries. Data collected included demographics, trauma-related variables, hospital course, interventions, and follow-up. When the grade was not readily available in the electronic medical record, we had a board-certified pediatric radiologist review the imaging and provide the grade. Follow-up was included only if it was with a pediatric urologist. ResultsThere were 92 patients that met our inclusion criteria. Of these, 47 were grade III, 32 were grade IV, and 13 were grade V. Six (6.5%) patients required inpatient renal stent procedures. Follow-up occurred in 55/92 (60%) patients with a pediatric urologist. Follow-up by grade is as follows: 22/47 (47%) grade III, 22/32 (69%) grade IV, and 11/13 (85%) grade V. Overall 5.8% of patients required antihypertensive medications and this was more likely as injury grade increased. All stents were removed outpatient and there were 3 (3.3%) additional outpatient interventions, all in patients that were symptomatic. ConclusionGiven the low prevalence of interventions after discharge, routine consultation and follow-up with urology is likely unnecessary in the absence of an inpatient urologic procedure during the index hospitalization. Patients with high-grade injuries should instead follow up with a trauma clinic or general provider with urology follow-up based on symptoms. Type of StudyRetrospective Review. Level of EvidenceLevel III.

High early mortality after percutaneous liver biopsy in metastatic cancer: national analysis

ObjectiveThe study aimed to assess outcomes in patients undergoing liver biopsy for metastatic cancer, focusing on mortality rates and chemotherapy following their biopsy.MethodsHospital Episode Statistics data from 2010 to 2019...

Efficacy and safety of office-based diode laser ablation for recurrent low-grade non-muscle-invasive bladder cancer under local anaesthesia: A pilot study

ABSTRACT Introduction Low-grade tumors account for approximately 50% of non-muscle invasive bladder cancer (NMIBC) with recurrence rates between 46% and 62%. Management of NMIBC recurrence typically involves transurethral resection of bladder tumor (TURBT) under general or regional anesthesia, which carries perioperative risks and considerable healthcare costs due to repeated procedures. Therefore, less invasive treatments such as office-based laser ablation, which aim to manage recurrences and reduce inpatient procedures without compromising oncological control, are needed. Objectives This study aims to assess the efficacy and safety of office-based diode laser ablation for treating recurrent NMIBC under local anesthesia and to evaluate the influence of tumor size on treatment outcomes. Methods A retrospective analysis was conducted on patients with recurrent low-grade NMIBC who underwent office-based diode transurethral laser ablation (TULA) under local anesthesia between 2021 and 2022. Results A total of 30 patients were included, with a mean age of 55 (±12) years. The mean original tumor size was 2.82 (±2.59) cm The mean recurrent tumor size was 1.15 (±0.88) cm, with a median of two recurrent tumors (range 1–20). The recurrence rate post-ablation for the entire cohort was 70%, with a median post-ablation recurrence duration of 5 months. The recurrence rate post-TULA was significantly higher in patients with an ablated tumor size of more than 1 cm compared to those with a tumor size of less than 1 cm (86.6% vs. 53.3%, p = 0.046). None of the patients experienced tumor progression, with a median follow-up duration of 12 months. Patients tolerated the procedure well, reporting only mild pain, and there were no complications greater than grade 1 on the Clavien-Dindo classification. Conclusion Office-based diode laser ablation is a safe, effective, and well-tolerated alternative for treating recurrent low-grade NMIBC with a low volume, less than 1 cm, under local anesthesia.

Plasmapheresis in ANCA-Associated Vasculitis with Active Kidney Involvement in the United States (2016-2020): A Cross-Sectional Study.

Plasmapheresis is currently recommended when antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presents with severe kidney and/or lung involvement. This cross-sectional study aimed at describing characteristics of hospitalized patients diagnosed with AAV with severe kidney involvement undergoing plasmapheresis in the US. We defined the study population as adults hospitalized for active kidney involvement with a new diagnosis of AAV (by subtype or unspecified). We established the cohort from the 2016-2020 National Inpatient Sample by ICD-10-CM codes. In this cross-sectional study, we described demographic and clinical characteristics, associated inpatient procedures, lengths of stay, hospital costs, and disposition at discharge comparing patients treated and not treated with plasmapheresis. We identified a total of 975 cases of hospitalized AAV with acute kidney involvement in the US treated by plasmapheresis over the 5-year period. Demographic characteristics of patients who received plasmapheresis were similar to those in patients who did not (n=5670). There were no regional differences in the proportion of patients who received plasmapheresis; however, plasmapheresis was deployed more frequently among patients admitted to urban teaching hospitals relative to rural and non-teaching hospitals. Cases treated with plasmapheresis were more likely to have had acute kidney injury (AKI) (96% vs. 90%, p=0.0007), AKI requiring dialysis (52% vs 16%, p<0.001), hypoxia (40% vs. 16%, p<0.0001), and respiratory failure requiring mechanical ventilation (13% vs. 3%, p=0.0003). During 2016-2020, plasmapheresis was deployed in approximately 20% of patients being admitted for AAV and acute kidney involvement in the US. As standards of care and practice evolve, the role of plasmapheresis in the management of AAV with acute kidney involvement will require further study.

Effect of Health Insurance on Inpatient Health Service Utilization among Households Affected by Non-Communicable Diseases in Busia County, Kenya

Background: Non-Communicable Diseases (NCDs) are increasingly becoming important agents of illness and premature deaths globally, killing up to 41 million people annually, most of which occur in LMICs. In Kenya, major NCDs are cardio-vascular diseases, chronic respiratory diseases, cancers and diabetes. They account for 50% of all inpatient morbidities and 39% of all hospital mortalities. Patients afflicted with NCDs go through expensive treatment regiments, restraining them from utilizing available care. NCDs deepen inequality and are major drivers of unending poverty. World leaders resolved to deal with the devastating consequences of NCDs as a developmental challenge under SDGs. Kenya successively reformed its National Health Insurer to include a package that address the blight of NCDs and transform it into a primary enabler for achieving UHC. There is however, evidence suggesting that enrolment in health insurance (HI) does not necessarily guarantee inpatient utilization of NCDs care. This study examined the effect of HI on inpatient health service utilization among households with NCDs. Methods: A quasi experimental design was conducted among eligible households with HI cover and those without, involving a representative sample of 350 households. Interviewers conducted interviews at baseline and after one year among household heads. Results: Utilization of Inpatient NCDs care improved 1.256 (95% CI= 0.965-1.634), times more among insured households, (P=0.04). Conclusion: HI improves inpatient utilization of NCDs care. To accelerate progress towards UHC, national government should expand HI program to all counties, improve awareness of cover package entitlements and remove payment preconditions for inpatient procedures. County government to ensure health systems at primary level are well equipped to tackle inpatient NCDs care needs.

Preoperative vs Postoperative Opioid Prescriptions and Prolonged Opioid Refills Among US Youths

High-risk practices, including dispensing an opioid prescription before surgery when not recommended, remain poorly characterized among US youths and may contribute to new persistent opioid use. To characterize changes in preoperative, postoperative, and refill opioid prescriptions up to 180 days after surgery. This retrospective cohort study was performed using national claims data to determine opioid prescribing practices among a cohort of opioid-naive youths aged 11 to 20 years undergoing 22 inpatient and outpatient surgical procedures between 2015 and 2020. Statistical analysis was performed from June 2023 to April 2024. The primary outcome was the percentage of initial opioid prescriptions filled up to 14 days prior to vs 7 days after a procedure. Secondary outcomes included the likelihood of a refill up to 180 days after surgery, including refills at 91 to 180 days, as a proxy for new persistent opioid use, and the opioid quantity dispensed in the initial and refill prescriptions in morphine milligram equivalents (MME). Exposures included patient and prescriber characteristics. Multivariable logistic regression models were used to estimate the association between prescription timing and prolonged refills. Among 100 026 opioid-naive youths (median [IQR] age, 16.0 [14.0-18.0] years) undergoing a surgical procedure, 46 951 (46.9%) filled an initial prescription, of which 7587 (16.2%) were dispensed 1 to 14 days before surgery. The mean quantity dispensed was 227 (95% CI, 225-229) MME; 6467 youths (13.8%) filled a second prescription (mean MME, 239 [95% CI, 231-246]) up to 30 days after surgery, and 1216 (3.0%) refilled a prescription 91 to 180 days after surgery. Preoperative prescriptions, increasing age, and procedures not typically associated with severe pain were most strongly associated with new persistent opioid use. In this retrospective study of youths undergoing surgical procedures, of which, many are typically not painful enough to require opioid use, opioid dispensing declined, but approximately 1 in 6 prescriptions were filled before surgery, and 1 in 33 adolescents filled prescriptions 91 to 180 days after surgery, consistent with new persistent opioid use. These findings should be addressed by policymakers and communicated by professional societies to clinicians who prescribe opioids.

National Trends of Inpatient Radiation Cystitis: 2016-2019.

Radiation cystitis with hematuria (RCH) is a potentially devastating complication after pelvic radiation. The cumulative incidence of RCH is debated, and certain severe manifestations may require hospital admission. We aimed to evaluate demographics and outcomes of patients hospitalized for RCH. We performed a retrospective review of hospitalized patients with a primary or secondary diagnosis of RCH from 2016 to 2019 using the National Inpatient Sample. Our unit of analysis was inpatient encounters. Our primary outcome was inpatient mortality. Secondary outcomes included need for inpatient procedures, transfusion, length of stay (LOS), and cost of admission. We then performed multivariate analysis using either a logistic or linear regression to identify predictors of mortality and LOS. Cost was analyzed using a generalized linear model controlling for LOS. We identified 21,320 weighted cases of hospitalized patients with RCH. The average patient age was 75.4 years, with 84.7% male and 69.3% White. The median LOS was 4 days, and the median cost was $8767. The inpatient mortality rate was 1.3%. The only significant predictor for mortality was older age. The only significant predictor of both higher cost and longer LOS was an Elixhauser Comorbidity Score ≥ 3. RCH represents a significant burden to patients and the health care system, and we observed an increasing number of hospitalized patients over time. Additional research is needed to identify underlying causes of RCH and effective treatments for this sometimes-severe complication of pelvic radiation.

Perioperative Primary Care Utilization and Postoperative Readmission, Emergency Department Use, and Mortality in Older Surgical Patients.

Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients. Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes). Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure. Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission.

Perioperative Patient-Initiated Communication in Gender-Affirming Mastectomy.

Background: Gender-affirming mastectomy (GAM) improves the psychosocial functioning and quality of life of transgender and non-binary (TGNB) individuals. However, the perioperative period is often marked by emotional stress, concerns about surgical outcomes, and physical discomfort. While inpatient procedures provide multiple opportunities to engage with and educate patients, outpatient surgeries, such as GAM, pose a unique challenge as patients are followed for <24 h postoperatively. Given the heightened emotional and psychological distress related to gender dysphoria TGNB individuals often experience, addressing these gaps can significantly improve outcomes. This study aims to characterize patient and surgical characteristics associated with patient-initiated communication (PIC) frequency in this population. Methods: A single-center retrospective review of TGNB patients undergoing GAM from February 2018 to November 2022 was conducted. Demographics, surgical characteristics, and frequency of and reasons for perioperative PIC (30 days before and after surgery) were recorded. The primary outcome was the incidence of perioperative PIC. The secondary outcomes included (1) the rationale for PIC and (2) patient and surgical characteristics associated with PIC. Results: A total of 352 patients were included. Of these, 285 (74.6%) initiated communication in the perioperative period, totaling 659 PICs. The median age was 25.0 (interquartile range [IQR]: 9.0) years. The median body mass index (BMI) was 28.5 (IQR: 8.5) kg/m2. The mean number of PICs was 0.7 ± 1.3 preoperatively and 1.3 ± 1.7 postoperatively (p < 0.001). The most frequent preoperative PIC subjects were administrative issues (AI; n = 66, 30.7%), preoperative requirements (n = 43, 20.0%), and cost and insurance (n = 33, 15.0%). The most frequent postoperative PIC subjects were wound care (n = 77, 17.3%), AI (n = 70, 15.0%), activity restrictions (n = 60, 13.5%), drainage (n = 56, 12.6%), and swelling (n = 37, 8.3%). Collectively, older patients (β = 0.234, p = 0.001), those with a history of major depressive disorder or generalized anxiety disorder (2.4 ± 3.0 vs. 1.7 ± 1.9; p = 0.019), and those without postoperative drains (n = 16/17, 94.1% vs. n = 236/334, 70.7%; p = 0.025) engaged in higher levels of PIC. There were no significant associations between other patient characteristics, perioperative details, or complications and PIC frequency. Conclusions: Perioperative PIC is prevalent among the majority of GAM patients at our institution, with age, psychiatric diagnosis, and postoperative drain use identified as significant predictors. To mitigate PIC frequency, it is crucial to ensure adequate support staffing and provide comprehensive postoperative instructions, particularly concerning activity restrictions and drainage management. These interventions may reduce PICs in high-volume centers. Further research should investigate targeted interventions to further support TGNB patients during the perioperative period.