Nationwide Analysis Of Outcomes Research Articles

Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors.

The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.

130. Times Have Changed: A Nationwide Analysis of Outcomes and Costs Associated with Early vs. Late Free Flap Reconstruction following Lower Extremity Trauma in 698 Patients

130. Times Have Changed: A Nationwide Analysis of Outcomes and Costs Associated with Early vs. Late Free Flap Reconstruction following Lower Extremity Trauma in 698 Patients

D2. Times Have Changed: A Nationwide Analysis of Outcomes and Costs Associated with Early vs. Late Free Flap Reconstruction following Lower Extremity Trauma in 698 Patients

PURPOSE: For over 35 years the Godina Principle has governed the timing of free flap reconstruction (FFR) after lower extremity (LE) trauma. We aim to reevaluate the timing of LE FFR within 72 hours of injury. METHODS: The Nationwide Readmission Database (2015-2019) was queried for all admissions with acute LE trauma who received FFR. The association between flap timing and complications, readmissions, and costs was analyzed using risk-adjusted analyses. RESULTS: A total of 698 patients undergoing FFR after LE trauma were identified. Timing of FFR was stratified by immediate (0-72 hours), delayed (72 hours-10 days), and late (10+ days). Delay of FFR was not associated with increased risk of amputation or 30-day readmissions for surgical complications, surgical site infection (SSI), or any other complications. Delayed FFR was associated with higher predicted length of stay (LOS) (2.9 days, P=0.048) after FFR but not increased cost (P=0.628). Late FFR was also associated with increased LOS post FFR (6.11 days, P=0.032) but cost was again similar (P=0.641). CONCLUSION: Delay of FFR does not appear to increase risk of amputation, surgical complications, SSI, readmissions, or costs. Despite increased LOS, patients can benefit from FFR regardless of transfer delays to microsurgery-capable centers. Patients who previously were not considered candidates, may now be well-suited for FFR, resulting in improved psyche, quality of life, and societal re-integration.

Nationwide Analysis of Outcomes after Resuscitative Endovascular Balloon Occlusion of the Aorta: Is There a Need for Age-Specific Considerations?

Nationwide Analysis of Outcomes after Resuscitative Endovascular Balloon Occlusion of the Aorta: Is There a Need for Age-Specific Considerations?

Fragmentation of Care Is Associated with Poor Outcomes in Geriatric Trauma: A Nationwide Analysis of Outcomes and Predictors

Fragmentation of Care Is Associated with Poor Outcomes in Geriatric Trauma: A Nationwide Analysis of Outcomes and Predictors

A nationwide analysis of outcomes and healthcare utilization in HIV versus non-HIV patients with colon cancer.

3550 Background: The incidence and mortality of Colon cancer (CC) is reportedly similar in HIV and non-HIV populations with same screening guidelines. The pathogenesis of HIV-CC may be multifactorial; related to chronic inflammation from AIDS colopathy, 2-fold increase in risk of polyps, smoking, elevation in proinflammatory cytokines, decrease in adiponectin, activation of b-catenin signaling pathway all of which may promote neoplastic growth of colonic mucosa. With increasing survival in HIV due to effective antiretroviral therapy, non-AIDS defining cancers are rising as population ages. We attempted to compare demographics and outcomes of HIV and non-HIV-CC patients in a national database. Methods: Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) was queried to identify all HIV and non-HIV-CC admissions. The groups were compared for socio-demographic differences, medical comorbidities, inpatient mortality, length of stay (LOS) and hospital charges (THC). Secondary outcomes studied included rates of sepsis, septic shock (SS), Anemia, transfusions, GI bleeding, colostomy rates, Acute Kidney Injury (AKI) and protein energy malnutrition (PEM). Statistics were performed using t-test, univariate and multinomial logistic regression. Results: A total 895 HIV-CC and 514,840 non-HIV-CC admissions were identified. HIV-CC were younger (mean age 56.3 vs 67.3 years, p &lt; 0.001) with 76% &lt; 65 years old compared to 40% in non-HIV-CC. HIV-CC were more likely male (75.4% vs 50.5%, p &lt; 0.001), African Americans (AA) (43% vs 14%, p &lt; 0.001) and Hispanic (19% vs 9%, p &lt; 0.001), were more likely from lowest income quartile zip codes (44% vs 28%, p &lt; 0.001) from the Northeast region of US (27% vs 19%, p &lt; 0.001) and on Medicaid (30% vs 10%, p &lt; 0.001). HIV-CC had significantly lower rates of medical comorbidities (hypertension, diabetes, obesity, dyslipidemia, heart failure, all p &lt; 0.05) compared to non-HIV-CC. The odds of adjusted inpatient mortality were significantly lower in HIV-CC (aOR = 0.46 CI = 0.24-0.87, p = 0.018), however HIV-CC had longer mean LOS (8.17 vs 6.66 days, p &lt; 0.01) and higher mean THC ($88,305 vs $76,317, p = 0.051). Cancer pain and PEM were significantly higher in the HIV-CC group, but other secondary outcomes were similar. Conclusions: HIV-CC patients were significantly younger and minorities with significantly lower all-cause mortality compared to non-HIV-CC. The lower mortality may be explained by younger age, treatment of teaching hospitals for HIV-CC and lower incidence of medical comorbidities which may be driving mortality higher in non-HIV-CC. However, healthcare utilization of HIV-CC was higher with over $10 million in extra charges in 3 years compared to non-HIV-CC. The young age of HIV-CC compared to non-HIV suggests a need for studies to evaluate the role of starting colon-cancer screening at a younger age in the HIV population.

Utility of routine intraoperative cholangiogram during cholecystectomy in children: A nationwide analysis of outcomes and readmissions

PurposeThis study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization. MethodsThe Nationwide Readmissions Database 2010–2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ2 analysis or Mann-Whitney U were used for statistical analysis with p < 0.05 set as significant. Results34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13–17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%.The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p < 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p < 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates. ConclusionThis nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries. Type of StudyRetrospective Comparative Study. Level of EvidenceLevel III.

S0056 A Nationwide Analysis of Outcomes in a Depressed Patient With Pancreatitis

S0056 A Nationwide Analysis of Outcomes in a Depressed Patient With Pancreatitis

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility

BackgroundMost studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. MethodsUsing a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. ResultsOf 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. ConclusionsThe survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes

Subarachnoid hemorrhage (SAH) is the most morbid sequela of intracranial aneurysms. Although mortality from SAH has been declining, opioid use in the United States has surged, and neurosurgeons are increasingly tasked with operating on patients with opioid use disorders (OUDs). There is a deficit in the literature regarding how OUDs affect SAH outcomes, particularly transient cerebral ischemic (TCI) events. The objective of this study was to investigate the influence of clinically diagnosed OUDs on the outcomes after acute SAH, with a specific focus on the rate of symptomatic TCI. Patients with and without a diagnosed OUD who underwent either microsurgical clipping or endovascular coiling for SAH were queried from the 2012-2014 National Inpatient Sample using International Classification of Disease codes. The primary outcome was the rate of TCI after SAH treatment. A total of 25,330 patients were included, 310 of whom (1.22%) also carried a diagnosis of OUD. Univariate and multivariate regression showed that patients with OUD faced significantly increased odds of TCI (P= 0.044) compared with patients without OUD. OUD status was not associated with increased odds of other adverse outcomes, including overall complication, in-hospital mortality, poor outcome by a validated National Inpatient Sample SAH Outcome Measure, nonhome discharge, or extended hospitalization. Patients with OUD face significantly higher odds of symptomatic TCI events producing clinical deficits during hospitalization for acute SAH. These findings suggest usefulness in screening patients for OUD to identify individuals who may benefit from a higher level of clinical scrutiny for post-SAH TCI.

A Nationwide Analysis of Outcomes of COPD Exacerbations Between Urban vs Rural Hospitals

A Nationwide Analysis of Outcomes of COPD Exacerbations Between Urban vs Rural Hospitals

Nationwide analysis of outcomes of bowel preparation in colorectal surgery

Nationwide analysis of outcomes of bowel preparation in colorectal surgery

Combining Safety and Trainee Education in Surgical Oncology: We All Win

This timely article by Castleberry et al. brings focus to safety concerns in performing large and complex operations in cancer patients. The authors reviewed de-identified data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (PUFs) to study the overall 30-day postoperative mortality and morbidity rates and failure-torescue rate in patients undergoing oncologic operations for colorectal, hepatopancreaticobiliary, and gastroesophageal primary cancers. The primary purpose of the study was to assess the impact of surgical trainee involvement on riskadjusted 30-day morbidity and mortality in patients undergoing these procedures. The risk-adjusted results showed a 6.2 % (27.2 vs. 21 %) higher morbidity with trainee involvement but a 0.2 % (1.9 vs. 2.1 %) lower 30-day mortality rate and a 1.7 % (5.9 vs. 7.6 %) lower failure-to-rescue rate with trainee involvement. These absolute differences are small but were statistically significant due to the large study population of 77,862 patients. It is interesting that these differences were consistent across all types of oncologic procedures performed. There are many limitations of this data: only NSQIP participating hospitals were included, only 30-day mortality was recorded (there is not an insignificant number of patients undergoing hepatopancreaticobiliary and gastroesophageal procedures who may have delayed mortality between postoperative days 30–90). The reason for trainee involvement or no involvement was not recorded. The total number of trainees in a given operation was not recorded, and only the most senior PGY trainee who was present was recorded. Overall, this study suggests that trainee involvement does not worsen (and may even improve) perioperative mortality in patients undergoing complex oncologic procedures but may lead to a modest increase in postoperative morbidity. Another recent study on trainee involvement in open versus laparoscopic partial colectomy, also using ACS-NSQIP data, had similar results. These are encouraging studies as we go forward in our surgical teaching and training. We now place patient safety very appropriately as one of our top quality standards in patient care and the transparent involvement of trainees in the care of these patients in our teaching hospitals will be essential going forward. The ‘‘cost’’ of surgical resident and fellow training cannot be at the expense of poorer patient outcomes. It will be very interesting to see if future studies from these NSQIP hospitals (or other teaching hospitals) will be able to analyze longitudinal data and report any differences in cancer recurrence and cancer-specific survival with trainee involvement. The dynamics of how we teach in the operating room are rapidly expanding and changing. The high cost of medical care, the focus on reducing medical errors, and the ACGMEmandated resident work hour restrictions have brought out some of the best and most creative new approaches to teaching and learning from surgical educators. Surgical simulators allow all levels of residents to complete virtually and repetitively many of the essential steps in complex procedures before ever performing the actual surgeries. Instead of only one trainee performing and staying for an entire operation, many programs now encourage junior residents to observe and perform parts of operations (i.e., placing videoendoscopic ports or performing a laparotomy This article is an editorial about ‘‘Resident Education in the Era of Patient Safety: A nationwide analysis of outcomes and complications in resident-assisted oncologic surgery.’’ by Anthony Castleberry et al. available at doi: 10.1245/s10434-013-3079-2.

Resident Education in the Era of Patient Safety: A Nationwide Analysis of Outcomes and Complications in Resident-Assisted Oncologic Surgery

Complex, oncologic surgery is an important component of resident education. Our objective was to evaluate the impact of resident participation in oncologic procedures on overall 30-day morbidity and mortality. A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. Colorectal, hepatopancreaticobiliary, and gastroesophageal oncology procedures were included. Multivariate logistic regression was used to assess the impact of trainee involvement on 30-day morbidity and mortality after adjusting for potential confounders. A total of 77,862 patients were included for analysis, 53,885 (69.2%) involving surgical trainees and 23,977 (30.8%) without trainees. The overall 30-day morbidity was significantly higher in the trainee group [27.2 vs. 21%, adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.15-1.24, p < 0.0001)]; however, there was significantly lower 30-day postoperative mortality in the trainee group (1.9 vs. 2.1%, AOR 0.87, 95% CI 0.77-0.98, p = 0.02) and significantly lower failure-to-rescue rate (defined as mortality rate among patients suffering one or more postoperative complications) (5.9 vs. 7.6%, AOR 0.79, 95% CI 0.68-0.90, p = 0.001). The overall 30-day morbidity was highest in the PGY 5 level (29%) compared to 24% for PGY 1 or 2 and 23% for PGY 3 (AOR per level increase 1.05, 95% CI 1.03-1.07, p < 0.0001). Trainee participation in complex, oncologic surgery is associated with significantly higher rates of 30-day postoperative complications in NSQIP-participating hospitals; however, this effect is countered by overall lower 30-day mortality and improved rescue rate in preventing death among patients suffering complications.