Inpatient Surgery Research Articles

Synergistic use of Unplanned Reoperation and Hospital Readmission rates for quality monitoring in pediatric surgical care.

Unplanned reoperation (URO) and unplanned hospital readmission (UHR) are key quality indicators used to assess healthcare quality improvement. The aim of this study was to describe, quantify, analyze and compare both indicators in a Pediatric Surgery Department. An observational study was conducted reviewing the medical records of pediatric patients who underwent unplanned reoperation and unplanned hospital readmission over a six-year period in a pediatric surgical unit. The incidence, indications, and causes of reoperations and readmissions were analyzed. A total of 6,376 surgeries were performed over a six-year period. During this time, there were 37 (0.58%) URO and 20 (0.31%) UHR. There were 23/2,437(0.94%) URO and 14/2,437(0.57%) UHR among emergency surgeries. In contrast, there were 14/3,939(0.35%) URO and 6/3,939(0.15%) UHR among elective surgeries (p < 0.05). Outpatient surgeries had 3/1,639 (0.18%) URO and 1/1,639 (0.06%) UHR compared to inpatient surgeries that had 11/2,300(0.47%) URO and 5/2,300 (0.21%) UHR respectively (p = ns). A total of 1,570 appendectomies were performed during the study period, with 8/1,570(0.5%) patients requiring either a URO or a UHR. The most frequent indication for both URO and UHR were intra-abdominal infections. The main cause of URO was a technical error during surgery (70%), while the main cause of UHR was an error in the medical treatment (35%). In our practice, URO are more frequent than UHR. Emergency surgeries have a higher risk of undergoing an URO or a UHR. Acute appendicitis is the most common diagnosis associated with the need for an URO or a UHR. The majority of unplanned reoperation cases are due to technical errors during surgery.

The Incidence and Risk Factors of Persistent Opioid Use After Surgery—a Retrospective Secondary Data Analysis.

The risk of persistent postoperative opioid use (PPOU) and its association with the type of surgery are still unclear in Germany. We conducted a nationwide retrospective cohort study on the basis of claims data from BARMER, a statutory health insurance carrier in Germany. Opioid-naive adults who did not have cancer and who underwent inpatient surgery in 2018 were included in the study. The operations were divided into 103 categories. PPOU was defined as the prescribing of opioids between postoperative days 1 and 90 and also between postoperative days 91 and 180 after hospital discharge. Patient-associated risk factors in the 12 months before surgery were investigated. 203 327 patients were included. 1.4% had PPOU (95% confidence interval [1.4; 1.5]). There were major differences between operation groups: major amputations and orthopedic procedures carried the greatest risk for the development of PPOU. The type of surgery had a larger effect on the risk of PPOU than pre-existing risk factors (explained variance 22.3% vs. 14.3%). Among such factors, alcohol abuse and pre-existing treatment with antidepressant drugs were associated with the highest risk for PPOU (odds ratios [OR] 1.515 [1.277; 1.797] and 2.131 [1.943; 2.336]). The incidence of PPOU in Germany is low (1.4%). The type of surgery plays an important role in its development.

Abstract 4120469: Racial and ethnic disparities in catheter based interventions vs. open heart surgery in congenital heart disease

Introduction: Transcatheter cardiac interventions have emerged as a viable alternative to open heart surgery for specific congenital heart disease lesions. There is literature to support racial and ethnic disparities in medicine, indicating that patients from racially and ethnically marginalized populations are less likely to receive advanced less invasive procedures. This study seeks to delve into the existence of such inequities between transcatheter and surgical interventions, shedding light on potential inequalities in access and outcomes. Methods: We analyzed California and Florida's State Inpatient and Ambulatory Surgery Databases from 2005 to 2017 to study patients under 18 admitted with diagnosis of atrial septal defect, pulmonary stenosis, aortic stenosis, and ventricular septal defects. Multivariable logistic regression, adjusted for patient characteristics, assessed race and ethnicity's influence on procedure type and in-hospital mortality. We also used log-transformed linear regression to examine associations with length of stay, hospitalization cost, and cost per day. Results: We identified 13,771 records who had open surgeries, and 2,045 records who had CBI. Compared to non-Hispanic White patients, Black patients were significantly more likely to undergo open surgical procedures (adjusted Odds Ratio [aOR] 1.49, p &lt; .001). Additionally, Black, Hispanic, and other race patients had higher risks of in-hospital death (aOR 1.92, p = 0.016 for Black; aOR 1.93, p &lt; 0.01 for Hispanic; aOR 2.37, p &lt; 0.01 for other races). Black and Hispanic patients also experienced longer lengths of stay (Adjusted Means Ratio [aMR] 1.34, p &lt; 0.01 for Black; aMR 1.16, p &lt; 0.01 for Hispanic), and higher costs (aMR 1.12, p = .01 for Black; aMR 1.11, p = .01 for Hispanic), but Black patients had a lower cost per day (aMR 0.96, p = .02). Conclusion: Racial and ethnic gaps persist in pediatric cardiac care, with Black patients facing reduced access to less invasive procedures, higher mortality rates, longer hospital stays, and increased costs compared to non-Hispanic whites. However, the higher costs are likely attributed to longer hospital stays rather than expensive interventions. It is imperative to tackle these disparities to prioritize patient-centered care and streamline resource allocation in healthcare.

Season-dependent characteristics of shock-related injuries in the Arctic zone of the Arkhangelsk region

Relevance. Studying the dynamics of injury rates, injury types and severity, as well as the treatment quality across various country regions, in particular the Arctic, is a prerequisite for managerial, healthcare, and strategic efficiency prior to and during hospital stay, taking into account the climate, geography, social and economic characteristics of every Russian Federation constituent.The objective is to analyse shock-related injuries in the Arctic zone of the Arkhangelsk region to understand season-related injury dynamics.Methods. Retrospective case series description parameters were used to study 140 patients with traumatic shock admitted to the Arkhangelsk Regional Clinical Hospital (ARCH) - a tier 1 trauma center. The analysed medical registration records included patient ambulance record and token (form 114/u), inpatient medical record (form 003/u), surgery logbook (form 008/u), patient radiographs, CT and nuclear MRI reports, as well as laboratory results. The study was conducted in accordance with ethical standards of the Declaration of Helsinki and European Community Directives (8/906 EC) and was approved by the local ethics committee of the Northern State Medical University of the Russian Ministry of Healthcare, Arkhangelsk (protocol no. 02/4-15 dated 04/08/2015). Statistical application package STATA ver.12 was used for statistical data processing.Results and discussion. The research demonstrated that the incidence of shock trauma is 4 times higher in men than in women. The vast majority of the injured are of working age. Seasonal distribution analysis per type of injuries and shock severity, including due to alcohol abuse, was carried out. The number of shock injuries is highest in winter, mainly due to road accidents which constitute 75.6 % of all injuries in winter. Throughout the year, over 50 % of shock injuries are combined injuries, that outperform isolated and multiple injuries in number. In particular, numerous combined injuries occur in winter with a responsible for almost 60 % among all other injuries. The majority the injured with shock-related trauma presented with stage 2 shock (49.3 %), whereas stage 1 and stage 3 shock was diagnosed in 27.9 % and in 21.4 % respectively. In winter, one in four patients with a shock-related injury presented with stage 3 shock. Alcohol-associated shock injuries are more numerous in summer (35.3 %), showing almost the same incidence as road traffic, domestic, and street injuries.Conclusion. The analysis of various types of injuries and season-related incidence of shock injuries in the Arctic territory of the Arkhangelsk region provides evidence to justify preventive measures to reduce the injury rates. Intensified efforts are required to minimise road traffic accidents in winter and combat alcohol abuse responsible for most injuries in summer. Since the vast majority of shock injuries occur in winter, in cold months ambulances must be equipped with local heating facilities, such as evacuation thermal bags with autonomous electric heating, thermal blankets, infusion warmers for blood transfusion and infusion sets.

A Comparison Study of 90-day Readmission and Emergency Department Visitation after Outpatient versus Inpatient Pediatric Pollicization Surgery

A Comparison Study of 90-day Readmission and Emergency Department Visitation after Outpatient versus Inpatient Pediatric Pollicization Surgery

Reply to Editorial Comment on “Comparative Outcomes of Day-Case Percutaneous Nephrolithotomy Versus Conventional Inpatient Surgery: A Systematic Review and Meta-Analysis”

Reply to Editorial Comment on “Comparative Outcomes of Day-Case Percutaneous Nephrolithotomy Versus Conventional Inpatient Surgery: A Systematic Review and Meta-Analysis”

Critical care unit bed availability and postoperative outcomes: a multinational cohort study.

Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes. This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis. A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710). Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.

Association between cardiac consultation and outcomes in patients with perioperative myocardial infarction/injury

Abstract Introduction Perioperative cardiac complications are a frequent occurrence and can lead to high short- and long-term mortality rates after major noncardiac surgery. No single intervention has yet demonstrated its effectiveness in treating perioperative myocardial infarction/injury (PMI). In this large prospective multicentre study, we aimed to evaluate the association between postoperative cardiac consultation and major adverse cardiac event (MACE) and all-cause death within 365 days in patients with PMI after undergoing major noncardiac surgery. Methods We prospectively included consecutive patients undergoing major inpatient noncardiac surgery at two hospitals who were eligible for the institutional active PMI surveillance and response programme. For this analysis, only patients with PMI who were directly transferred to the regular ward following surgery were included. In the case of a PMI, the standardised structured institutional response included assessing the patient for possible symptoms, recording a 12-lead ECG and a cardiac consultation. The specific scope of the PMI workup and management was determined by the attending clinical cardiologist following an institutional flowchart. Our primary endpoint was the occurrence of MACE (defined as a composite of cardiovascular death, MI, AHF, and life-threatening arrhythmia) within 365 days, excluding the initial PMI. All-cause death after 365 days was the secondary endpoint. Multivariable Cox proportional hazard models were used to evaluate the association of cardiac consultation with MACE and all-cause death after 365 days. Results During the period between October 2014 and September 2019, the BASEL-PMI study programme enrolled 14294 patients. After the exclusion of patients without PMI, with a postoperative ICU stay, multiple inclusion, or palliative setting 1048 patients remained. Among those, 434 patients received postoperative cardiac consultation (41.4%). Patients had a median age of 77 years and 44.8% were female. After adjustment, patients who received a postoperative cardiac consultation had a lower risk of having MACE after 365 days (adjusted hazard ratio [aHR] = 0.54, 95% confidence interval [CI] 0.37 - 0.79, p-value = 0.001) and a lower risk of death of any cause after 365 days (aHR = 0.66, 95%CI 0.44 - 1.00, p-value = 0.048). Conclusion In a large multicentre prospective cohort study, postoperative cardiac consultation in patients with PMI was associated with a reduced risk of MACE and all-cause death after 365 days.Kaplan-Meier curve for MACE

Usefulness of preoperative NT-proBNP for prediction of acute heart failure, perioperative myocardial infarction/injury and mortality after non-cardiac surgery

Abstract Background Predicting cardiac complications after non-cardiac surgery is challenging. Purpose to determine the predictive accuracy of N-Terminal Pro–B-Type Natriuretic Peptide (NT-proBNP) and, to assess the utility of existing NT-proBNP cutoffs of the 2021 ESC Guidelines for the diagnosis of acute and chronic heart failure for prediction of postoperative acute heart failure (pAHF), perioperative myocardial infarction/injury (PMI) and mortality following non-cardiac surgery. Methods we prospectively determined preoperative NT-proBNP concentrations in consecutive patients at high cardiac risk undergoing inpatient non-cardiac surgery. Uni- and multivariable regression models were constructed to test the association between NT-proBNP concentrations and the outcomes (pAHF, PMI, 30-day and one-year mortality), using NT-proBNP as a continuous variable. We further stratified NT-proBNP into 5 categories according to guidelines (&amp;lt;125 pg/ml, 125 to 299pg/ml, 300 to 900 pg/ml, 901 to 1800pg/ml and &amp;gt;1800 pg/ml). Receiver operating characteristic curves were constructed to determine the predictive value of NT-proBNP. Results Among the 2,334 cases included, pAHF occurred in 83 (3.6%), PMI in 381 (17%), 45 (2.5%) patients died within 30 days and 179 (10%) within one year. After adjusting for confounders, NT-proBNP concentrations were independent predictors of pAHF (adjusted hazard ratio [aHR] 1.8 [95%CI, 1.5-2.1], p&amp;lt;0.001), PMI (aHR 1.3 [95%CI, 1.2-1.4],p&amp;lt;0.001) and 30 day/one year mortality (aHR 1.6[95%CI, 1.3-2.0], p&amp;lt;0.001)/aHR 1.5 [95%CI 1.4-1.7], p&amp;lt;0.001). By quintiles, higher the NT-proBNP levels were strongly associated with adverse outcome (Figure). Accuracy of preoperative NT-proBNP for prediction of pAHF was excellent (area under the curve [AUC] 0.825) and better than accuracy of the Revised Cardiac Risk Index score (AUC 0.692, p&amp;lt;0.001), whereas accuracy of NT-proBNP for prediction of PMI (AUC 0.654) and mortality (AUC 0.787) was only moderate. Conclusion NT-proBNP concentrations are independent predictors of pAHF, PMI and short and long-term mortality following non-cardiac surgery. Stratifying NT-proBNP concentrations using current recommended cut-offs could help to further determine the magnitude of the risk, mainly of pAHF.

Effect of tranexamic acid in vascular surgery- a sub-study of the POISE-3 randomized clinical trial

Abstract Background/Introduction In the POISE-3 trial involving patients undergoing noncardiac surgery, tranexamic acid (TXA) reduced the incidence of the composite outcome of life-threatening bleeding, major bleeding, or bleeding into a critical organ at 30 days. Bleeding is a major issue in vascular surgery. However, TXA use may be limited due to concerns about its safety in this high-risk population. With 1,399 participants in POISE-3 undergoing vascular surgery, this is the largest trial assessing TXA's efficacy in this population. Purpose In this post hoc subgroup analysis, we aimed to investigate the interaction between surgery type (vascular/non-vascular) and the effects of TXA vs placebo on bleeding and cardiovascular (CV) safety outcomes in the POISE-3 population. Methods: Eligible patients were ≥45 years, undergoing inpatient noncardiac surgery, and at risk for bleeding and CV complications. Patients were randomised (1:1) to TXA 1 gm IV bolus at start and end of surgery (total 2 gm) or placebo. We used Cox proportional hazards models incorporating tests for interaction to analyse time to the first occurrence of the composite bleeding outcome, and the CV safety outcome (composite of myocardial injury after noncardiac surgery, non-hemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism) at 30 days. Estimates of hazard ratios (HR) with 95% confidence intervals (CI) were calculated for each subgroup with the interaction P value. Results 9,468 of 9535 (99.3%) POISE-3 patients are included in this analysis; 1399 of whom underwent vascular surgery (699 TXA, 700 placebo). Majority (89.8%) of the vascular surgeries were aorto-iliac, peripheral vascular and extracranial surgeries. In the vascular surgery group, 12.6% of patients receiving TXA experienced the composite bleeding outcome versus 14.7% with placebo (HR 0.85, 95% CI 0.64-1.13). For non-vascular surgery patients, these rates were 8.6% with TXA and 11.3% with placebo (HR 0.74, 95% CI 0.65-0.86), with an interaction P value of 0.42. In vascular surgery patients, the CV safety outcome occurred in 20.2% with TXA versus 18.1% with placebo (HR 1.12, 95% CI 0.88-1.42). In the non-vascular surgery group, both TXA and placebo arms showed a 13.1% incidence rate (HR 1.00, 95% CI 0.89-1.13), with an interaction P value of 0.43. Conclusion In vascular surgery patients, there were higher rates of bleeding and cardiovascular events compared to those undergoing non-vascular surgeries; however, there was no significant interaction between the effects of TXA and the type of surgery. The overall POISE-3 trial provides the best estimate of effect with TXA for all patients including those undergoing vascular surgery. The main limitation is that this subgroup analysis was not pre-specified.

Effects of the COVID-19 pandemic on inpatient dermatosurgery in Germany : Retrospective evaluation of the surgical cases from nine dermatology clinics

Currently, only little data is available on the impact of the COVID-19 pandemic on inpatient dermatosurgical care in German dermatological clinics. Aretrospective analysis of all dermatosurgical cases that were treated in inpatient setting in nine German dermatological clinics in four federal states in 2019, 2020 and 2021 was performed. The diagnoses were recorded using the ICD-10codes. In addition, demographic data such as age, gender and the length of inpatient stay were analysed. In 2019, 2020 and 2021, a total of 10,739, 9185 and 9828 dermatosurgical inpatients were treated respectively. Thus, the reduction of inpatient dermatosurgical cases was 14.5% in 2020 and 8.5% in 2021 compared to 2019. Inpatient surgical treatment of melanoma decreased by 10.1% of cases in 2020. This decrease was only 1.4% in 2021 compared to 2019. The number of inpatient surgeries performed for benign lesions such as melanocytic nevi or viral warts reduced sharply in both pandemic years. Our data show for the first time how inpatient care for the entire spectrum of dermatosurgical diseases developed during the COVID-19 pandemic in Germany. After the initial marked decline in inpatient dermatosurgical cases in 2020, there was less difference in 2021 compared to 2019. This trend can be interpreted as an indication that there is still astrong need for inpatient dermatosurgical care that cannot yet be met on an outpatient basis.

Risk-Specific Training Cohorts to Address Class Imbalance in Surgical Risk Prediction.

Machine learning tools are increasingly deployed for risk prediction and clinical decision support in surgery. Class imbalance adversely impacts predictive performance, especially for low-incidence complications. To evaluate risk-prediction model performance when trained on risk-specific cohorts. This cross-sectional study performed from February 2024 to July 2024 deployed a deep learning model, which generated risk scores for common postoperative complications. A total of 109 445 inpatient operations performed at 2 University of Florida Health hospitals from June 1, 2014, to May 5, 2021 were examined. The model was trained de novo on separate cohorts for high-risk, medium-risk, and low-risk Common Procedure Terminology codes defined empirically by incidence of 5 postoperative complications: (1) in-hospital mortality; (2) prolonged intensive care unit (ICU) stay (≥48 hours); (3) prolonged mechanical ventilation (≥48 hours); (4) sepsis; and (5) acute kidney injury (AKI). Low-risk and high-risk cutoffs for complications were defined by the lower-third and upper-third prevalence in the dataset, except for mortality, cutoffs for which were set at 1% or less and greater than 3%, respectively. Model performance metrics were assessed for each risk-specific cohort alongside the baseline model. Metrics included area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), F1 scores, and accuracy for each model. A total of 109 445 inpatient operations were examined among patients treated at 2 University of Florida Health hospitals in Gainesville (77 921 procedures [71.2%]) and Jacksonville (31 524 procedures [28.8%]). Median (IQR) patient age was 58 (43-68) years, and median (IQR) Charlson Comorbidity Index score was 2 (0-4). Among 109 445 operations, 55 646 patients were male (50.8%), and 66 495 patients (60.8%) underwent a nonemergent, inpatient operation. Training on the high-risk cohort had variable impact on AUROC, but significantly improved AUPRC (as assessed by nonoverlapping 95% confidence intervals) for predicting mortality (0.53; 95% CI, 0.43-0.64), AKI (0.61; 95% CI, 0.58-0.65), and prolonged ICU stay (0.91; 95% CI, 0.89-0.92). It also significantly improved F1 score for mortality (0.42; 95% CI, 0.36-0.49), prolonged mechanical ventilation (0.55; 95% CI, 0.52-0.58), sepsis (0.46; 95% CI, 0.43-0.49), and AKI (0.57; 95% CI, 0.54-0.59). After controlling for baseline model performance on high-risk cohorts, AUPRC increased significantly for in-hospital mortality only (0.53; 95% CI, 0.42-0.65 vs 0.29; 95% CI, 0.21-0.40). In this cross-sectional study, by training separate models using a priori knowledge for procedure-specific risk classes, improved performance in standard evaluation metrics was observed, especially for low-prevalence complications like in-hospital mortality. Used cautiously, this approach may represent an optimal training strategy for surgical risk-prediction models.

Incidence and risks of excessive distension absorption in hysteroscopic surgery using 5% mannitol solution: a retrospective descriptive study

ObjectiveTo clarify the incidence of excessive distension absorption in hysteroscopic surgery using 5% mannitol solution, evaluate the associated risks, and help to establish a safe fluid deficit threshold for such complication.DesignRetrospective descriptive study.SettingAcademic medical center.PatientsTen thousand six hundred ninety-three patients underwent inpatient hysteroscopic surgery with 5% mannitol perfusion using a monopolar electrosurgical instrument from Jan. 2015 to Sep. 2020.Intervention(s)None. This study has been approved by the Ethics Committee of Sun Yat-sen Memorial Hospital.Measurements and main resultsA fluid deficit of more than 1000 mL was defined as the diagnostic criteria for excessive distension absorption. The overall incidence of excessive distension absorption in this study was 0.46% (49/10693). The incidence was 2.57% (16/623) for transcervical resection of fibroid (TCRF), 2.36% (9/381) for retained products of conception (RPOC) removal, 1.20% (6/501) for hysteroscopic uterine septum resection (HSR), 0.48% (4/828) for transcervical resection of the endometrium (TCRE), and 0.53% (14/2621) for transcervical resections of adhesion (TCRA). Excessive distension absorption could occur within seven minutes in HSR. Among the patients diagnosed with excessive distension absorption, 30.77% (12/39) exhibited signs or symptoms related to circulation overload with a fluid deficit under 2500 mL, and 10.26% (4/39) developed pulmonary edema.ConclusionExcessive distension absorption could happen in all kinds hysteroscopic surgical treatment including RPOC removal and TCRA which were rarely reported. The overall incidence of excessive distension absorption could be low. But it would be five times higher in certain procedures such as TCRF, RPOC removal and TCRA. Resection using a needle electrode in HSR and TCRA may contribute to the short time development of excessive distension absorption. 30.77% of the patients could not tolerate the fluid deficit of less than 2500 mL which was set as a threshold for isotonic distending media and presented with circulation overload related signs or symptoms.

Outpatient Upper Extremity Fracture Surgery Is Associated with Increased Post-operative Emergency Department Visits.

This study aimed to determine if outpatient upper extremity fracture surgery was associated with increased post-operative ED visits and identify related risk factors. Design: Retrospective cohort. This multi-center study was conducted within a single academic institution, encompassing two level 1, two level 2, and one level 3 trauma center. All patients >18 years of age that underwent upper extremity fracture surgery from 2015-2021 were included. Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a p<0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90-days. A total of 6,315 patients with an average age of 51±19 years were identified of which 52% were female and 65% had outpatient surgery. Post-operatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increasing to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (OR:1.5, p=0.030), tobacco use (OR:2.1, p<0.001), higher Elixhauser Comorbidity scores (OR:1.2, p<0.001), non-White race (OR:1.9, p<0.001) elbow fractures (OR:1.8, p=0.016), and hand fractures (OR: 1.6, p=0.046) were associated with 30-day ED visits. Outpatient surgery was associated with increased rate of 30-day ED visits. Patients that smoke, had increased number of comorbidities or were non-White presented to the ED more frequently. III.

Editorial Comment on “Comparative Outcomes of Day-case Percutaneous Nephrolithotomy Versus Conventional Inpatient Surgery: A Systematic Review and Meta-analysis”

Editorial Comment on “Comparative Outcomes of Day-case Percutaneous Nephrolithotomy Versus Conventional Inpatient Surgery: A Systematic Review and Meta-analysis”

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.

Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

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.

Promoting health information system in guiding decisions for improving performance: an intervention study at the Research Institute of Ophthalmology, Giza, Egypt.

This study aims to design and test a platform of key performance indicators (KPIs) and indices emphasizing achievements and improvement and helping decision-making. An operations research study was designed to analyze data from the Hospital Management Information System (HMIS) from July 2017 to June 2018 at the Research Institute of Ophthalmology (RIO), Giza, Egypt. The HMIS data were submitted to reform covering parameters in service delivery and corresponding indicators and indices. Data were grouped into four themes: human resources and outpatient, inpatient, and surgical operations. A total of 14 performance indicators were deployed to four specific indices and total performance indices and applied to six teams of ophthalmologists at RIO. The decision matrices were deliberated to demonstrate achievements and provide recommendations for subsequent improvements. Throughout 1 year, six teams of ophthalmologists (n = 222) at RIO provided the following services: outpatient (n = 116,043), inpatient (n = 8,081), and surgical operations (n = 9,174). Teams 2, 1, and 6 were the top teams in the total performance index. Team 4 had plunges in the outpatient index, and Team 5 faced limitations in the inpatient index. The study provided a model for upgrading the performance of the management information system (MIS) in health organizations. The KPIs and indices were used not only for documenting successful models of efficient service delivery but also as examples of limitations for further support and interventions.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) for benign ovarian cysts is safe and feasible in same-day discharge: a retrospective cohort study

BackgroundAdvances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established.ObjectiveThis study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes.Materials and methodsThe study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient’s demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson’s chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method’s quick recovery nature.ResultsUpon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185–0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158–0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071–679.859, P = 0.045).ConclusionIn this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.