Non-home Discharge Research Articles

Racial Disparities in Utilization and Outcomes of Cervical Disc Arthroplasty

Study Design: Retrospective study. Objective: We examined racial disparities in (1) cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) utilization and (2) CDA in-hospital outcomes. Summary of Background Data: ACDF and CDA are established treatments for cervical disc disease. While CDA may offer certain advantages over ACDF, its utilization patterns have not been comprehensively explored. Methods: This study of 2012 to 2019 discharges from the National Inpatient Sample included White, Black, and Hispanic patients aged 18 years and older who underwent elective ACDF or CDA. Patient demographics, comorbidities, cervical spine diagnoses, and hospital characteristics were extracted. Survey-weighted logistic regression modeled the adjusted association between race and CDA (vs. ACDF) utilization; an interaction between race and year examined temporal changes in disparities. For CDA outcomes, multivariable logistic regression was used for binary outcomes (nonhome discharge, combined complications, and dysphagia) and linear regression for length of stay. Results: The cohort included 712,355 weighted procedures (97.6% ACDF; 84.2% White, 9.7% Black, 6.1% Hispanic). CDA utilization increased from 1.0% of the procedures in 2012 to 3.8% in 2019. Black and Hispanic patients had significantly lower odds than White patients of receiving CDA versus ACDF (OR=0.77, 95% CI: 0.66–0.89, P=0.001; OR=0.80, 95% CI: 0.69–0.93, P=0.003) respectively. There was no statistically significant interaction between race and discharge year (P=0.50). For in-hospital CDA-specific outcomes, Black (vs. White) patients were more likely to experience dysphagia (OR=2.70, 95% CI: 1.53–4.78, P=0.001) and combined complications (OR=3.10, 95% CI: 1.91–5.05, P <0.001). There were no significant differences in any CDA outcome for Hispanic versus White patients. Conclusions: This study revealed decreased utilization of CDA versus ACDF in minority patients, a pattern that persisted over time despite overall increasing CDA utilization. In addition, a higher burden of dysphagia and combined complications following CDA in Black patients warrants further examination. Level of Evidence: III

Assessment of the five factor modified frailty index in predicting postoperative complications and non-home discharge in patients undergoing interval cytoreductive surgery for ovarian cancer

Assessment of the five factor modified frailty index in predicting postoperative complications and non-home discharge in patients undergoing interval cytoreductive surgery for ovarian cancer

Incidence, predictors and outcomes of non-home discharge following transcatheter aortic valve implantation: a multicentre Australian experience. The NHD TAVI study

Abstract Background Patients undergoing transcatheter aortic valve implantation (TAVI) commonly experience non-home discharge (NHD), a phenomenon associated with increased health-care expenditure and possibly poorer outcomes. Despite its relevance to patients, post-TAVI NHD remains poorly explored in the literature. Purpose To characterise the incidence and predictors of NHD following TAVI, understand its impact on quality of life, and identify the proportion of patients that require long-term residential care following initial NHD. Methods Retrospective analysis of prospectively collected data of 2229 patients undergoing TAVI from 2010–2023 included in an Australian TAVI Registry. Results Median age was 82 (IQR: 78-86) years and 41% were female. 257 (11.5%) patients were not discharged home following TAVI, with incidence falling over time (R2=0.636, p<0.001). Multivariable logistic regression modelling for NHD prediction was developed with excellent calibration and discrimination (C-Statistic 0.835). Independent predictors of NHD were post-procedural stroke (adjusted odds ratio [aOR] 11.1), procedure at a private hospital (aOR 3.0), living alone (aOR 2.4), vascular access site complications (aOR 2.1), frailty (aOR 1.9), age>80 (aOR 1.8), hypoalbuminemia (aOR 1.8), NYHA III-IV (aOR 1.7) and hospital length of stay (aOR 1.1) (all p<0.05). NHD was not associated with mortality at 30-days and less than one percent of all patients required longer-term residential care. Conclusion While common following TAVI, NHD does not predict short-term mortality and most patients successfully return home within 30-days. When used appropriately, NHD may serve as a brief and effective method of optimising functional status without compromising long-term independence.Predictors of Non Home Discharge

Symptoms of Anxiety and Depression (SAD) in patients undergoing transcatheter aortic valve implantation. A multicentre Australian experience: The SAD-TAVI Study

Abstract Background Symptoms of anxiety and/or depression (SAD) commonly co-exist in severe aortic stenosis, associated with increased morbidity and mortality following transcatheter aortic valve implantation (TAVI). Despite this, mental health remains under-researched in the TAVI literature. Purpose To characterise the prevalence of SAD in those undergoing TAVI and identify patient phenotypes at highest risk of these symptoms. We also aimed to examine how SAD evolve following TAVI and establish factors predictive of improvement and regression in mental health. Methods Retrospective review of prospectively collected data from patients undergoing TAVI between 2018 and 2023 included in an Australian TAVI registry. Results Of 1279 patients, median age was 82 (IQR 77, 87), 41% were female and median STS score was 3.9 (2.3, 5.9). 353 (28%) patients reported moderate or worse SAD at baseline. Of this group, 260 (74%) had complete resolution in symptoms within 30-days. Body Mass Index<25 (adjusted odds ratio [aOR] 3.4, p<0.001), vascular site complications (aOR 3.4, p=0.029) and non-home discharge (aOR 2.4, p=0.036) independently predicted failed improvement in SAD. Onset of new SAD was uncommon, present in only 72 (8%) patients. Non-home discharge (19% vs 8%, p=0.006) and a composite endpoint of stroke, acute myocardial infarction, and heart-failure readmission (11% vs 4%, p=0.012) were more prevalent in this cohort. Conclusion Symptoms of anxiety and depression are common but under recognised in severe aortic stenosis. TAVI is highly effective at improving these symptoms. Regular screening for mental health should be adopted as a standard of care in TAVI.Evolution of SAD Following TAVI

Transcatheter versus surgical aortic valve replacement in patients younger than 65 years: analysis from the national inpatient sample database

Abstract Background Data on the relative utilization and outcomes of transcatheter aortic valve replacement (TAVR) versus surgical AVR (SAVR) in patients <65 years are limited. Purpose To compare the relative utilization and outcomes of TAVR versus SAVR in patients <65 years in the United States. Methods We queried the National Inpatient Sample (2016-2020) to identify patients <65 years hospitalized for isolated AVR. In-hospital outcomes of TAVR versus SAVR were compared using multivariable regression and propensity-matching analyses. Results Of 74,155 patients aged <65 years hospitalized for isolated AVR, 17,300 (23.3%) underwent isolated TAVR, and 56,855 (76.7%) underwent isolated SAVR. From 2016-2020, the use of TAVR increased, while the use of SAVR decreased in patients <65 years (both ptrend<0.01). Factors independently associated with TAVR selection in patients <65 years included female sex, congestive heart failure, pulmonary disease, renal failure, liver disease, cancer, and prior revascularization. Factors independently associated with SAVR selection included bicuspid aortic valve. After adjustment for baseline characteristics, TAVR was associated with lower odds of in-hospital mortality (adjusted odds ratio [aOR] 0.61, 95% confidence interval [CI] 0.38-0.97), stroke (aOR 0.58, 95% CI 0.38-0.90), acute kidney injury (aOR 0.41, 95% CI 0.34-0.49), and major bleeding (aOR 0.62, 95% CI 0.38-0.96), and higher vascular complications compared with SAVR (aOR 2.39, 95% CI 1.75-3.24). Length of stay was shorter and nonhome discharges were lower with TAVR (all p<0.01). Similar findings were observed in the propensity-matched cohort. Conclusions This nationwide observational analysis showed that TAVR is a feasible treatment option for patients <65 years with lower in-hospital mortality and resource utilization compared with SAVR.Central Illustration

Transcatheter vs. surgical aortic valve replacement in patients with aortic stenosis and cardiogenic shock.

Patients with aortic stenosis (AS) and cardiogenic shock (CS) are an extremely high-risk population with a poor prognosis in the absence of definitive therapy. We aimed to compare the outcomes of transcatheter aortic valve replacement (TAVR) with those of surgical aortic valve replacement (SAVR) in patients with AS-CS. We queried the Nationwide Readmission Database (2016-21) to identify patients hospitalized for AS-CS who underwent isolated TAVR or SAVR. In-hospital outcomes of TAVR vs. SAVR were compared using multivariable regression and propensity-matching analyses. Ninety-day readmissions were compared using a Cox proportional hazards regression model. A total of 16 161 patients were hospitalized for AS-CS, of whom 6470 (40.0%) underwent isolated TAVR and 9691 (60.0%) underwent isolated SAVR. From 2016 through 2021, the proportion of TAVR increased from 29.5 to 46.5% and the proportion of SAVR correspondingly decreased in AS-CS (Ptrend < 0.01). After adjustment for baseline characteristics, TAVR was associated with lower odds of stroke [adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.47-0.84], acute kidney injury (aOR 0.80, 95% CI 0.69-0.93), and major bleeding (aOR 0.54, 95% CI 0.40-0.71) and higher odds of vascular complications (aOR 1.56, 95% CI 1.23-1.97) compared with SAVR. In-hospital mortality, myocardial infarction, permanent pacemaker placement, and 90-day all-cause and heart failure readmissions showed similar rates between TAVR and SAVR. However, hospital length of stay was shorter and total costs and non-home discharges were lower with TAVR than with SAVR. This nationwide observational analysis showed that TAVR is increasingly performed in patients with AS-CS and is associated with similar rates of in-hospital mortality and 90-day readmissions but lower rates of in-hospital complications and resource utilization compared with SAVR.

Associations Between Patients' Primary Language and Outcomes and Patient Engagement Process Metrics for Total Joint Arthroplasty.

Previous research has indicated language-based disparities in outcomes after total hip and knee arthroplasty. In this study, we examined the relationship between primary spoken language and outcomes and patient engagement process metrics in a multihospital academic health system. This retrospective cohort study included patients who underwent elective primary total hip or knee arthroplasty in 2018 to 2022. Primary language was categorized as English, Spanish, and Other. Associations were examined between language and perioperative outcomes (same-day discharge, extended hospital length of stay, nonhome discharge, 30-day hospital returns, 90-day readmissions, and 90-day combined complications), and engagement-related metrics (preoperative joint class attendance and patient-reported outcome measure [PROM] completion). We report adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Among 8,220 patients (7.9% Spanish and 5.1% Other non-English), we found no notable associations between language and same-day discharge, nonhome discharge, 30-day hospital returns, 90-day readmissions, or 90-day complications. Other (versus English) language was significantly associated with decreased odds of extended length of stay (OR 0.49, 95% CI, 0.32 to 0.76, P = 0.001). In patient engagement, Other (versus English) language was associated with significantly decreased odds of preoperative class attendance (OR 0.72, 95% CI, 0.54 to 0.95, P = 0.02). Spanish (versus English) primary language was significantly associated with decreased odds of preoperative and 1-year PROM completion (OR 0.34 to 0.75, P ≤ 0.001), and Other (versus English) primary language was significantly associated with decreased odds of preoperative PROM completion (OR 0.59, 95% CI, 0.47 to 0.73, P < 0.001). Our findings highlight language-based disparities in patient engagement metrics but comparable outcomes. Differences in findings compared with past literature may be related to institution-specific language-related support systems. There is a need for additional resources to support patients' active participation in their care, regardless of their primary spoken language.

Association between patient-reported frailty and nonhome discharge among older patients with acute stroke: A prospective study.

To investigate the association between prestroke frailty and nonhome discharge, prolonged length of stay as well as functional outcomes. Prospective observational study. Single urban teaching hospital in Guangzhou, China. Consecutive sample of 271 older patients admitted with acute stroke. N/A. A five-item FRAIL scale (0∼5 points) and the stroke severity at onset were measured. The primary outcome of interest was nonhome discharge, with secondary outcomes including prolonged length of stay and worse short-term prognosis. Multivariable logistic regression adjusting for confounding factors was used to determine the association between patient-reported frailty and nonhome discharge, prolonged length of stay, worse short-term prognosis. The population had a median age of 68 [interquartile range (IQR), 64∼74)]years, with 50 individuals (18.5%) identified as frail. After adjusting for age, sex, Barthel index, National Institutes of Health Stroke Scale, and Mini-Mental Status Exam score at admission, patients with self-reported frailty were significantly likely to experience nonhome discharge (Odds Ratio [OR] = 4.788; 95% confidence interval [CI] = 1.272∼18.017; p = .021), prolonged length of stay (OR = 4.76; 95% CI = 1.80∼12.56; p = .002), mRS scores at 30 days (OR = 6.72;95% CI = 1.79∼25.20; p = .005) and three months postdischarge and three-month (OR = 8.94; 95% CI = 2.10∼38.08; p = .003). In older adults with stroke, frailty is associated with nonhome discharge, prolonged length of stay, and worse short-term prognosis, regardless of the stroke severity, cognition, and Barthel index score at admission. FRAIL scale can be used as a practical screening tool in acute care setting by multidisciplinary team in supporting discharge process.

Preoperative Osteoporosis Is Associated with Increased Healthcare Utilization and Compromised Pain and Function Improvement after Primary Total Hip Arthroplasty: A Prospective Cohort Analysis

Osteoporosis (OP) has been linked to complications after total hip arthroplasty (THA), but its impact on healthcare utilization and patient-reported outcomes remains unclear. This study aimed to evaluate the association between: 1) pre-THA OP and healthcare utilization as well as patient-reported pain and function outcome measures; and 2) Dual Energy X-ray Absorptiometry (DEXA) scan-based T-scores and the aforementioned outcomes. A retrospective analysis of prospectively collected data of primary THA (2015 to 2018) was performed (n = 5,321) from a validated academic institutional database of a large North American tertiary health care system; of which 4,074 (76.6%) completed one-year follow-up. Outcomes included prolonged length of stay [LOS] > 3 days, discharge disposition, 90-day readmission, and one-year reoperation, as well as Hip Disability and Osteoarthritis Outcome Score (HOOS]) Pain, HOOS-function (PS), and minimal clinically important difference thresholds (MCID), and satisfaction. The prevalence of OP pre-THA was 56.9%, of which 39.8% were not prescribed OP medications and 15.3% had a DEXA scan. Compared to those who did not have OP, those who had OP were independently associated with higher odds of prolonged LOS, non-home discharge, 90-day readmission, and 1-year reoperation (P < 0.005). Furthermore, they had significantly higher odds of failing to achieve MCID (odds ratio (OR): 1.41 (95% confidence interval (CI): 1.06 to 1.89)) for HOOS-PS and satisfaction (OR: 1.5 (95% CI: 1.16 to 1.93)) at 1-year. Higher T-scores were associated with lower odds of prolonged LOS, non-home discharge, failure to achieve MCID in HOOS-Pain, and HOOS-PS. Over half of patients had OP, however, only 15.3% of patients had a DEXA scan prior to THA. Patients who had OP were at higher risk of prolonged LOS, non-home discharge, 90-day readmission, and one-year reoperation in addition to poor pain/function improvement and dissatisfaction one year after THA.

Do Obese Patients Have Worse Outcomes in Adult Spinal Deformity Surgeries? A Meta-Analysis.

Meta-Analysis. This meta-analysis evaluates the difference in surgical outcomes between obese and non-obese patients undergoing adult spinal deformity (ASD) corrective surgery. ASD encompasses a wide range of debilitating spinal abnormalities. Concurrently, obesity is on the rise globally and has been shown to influence the outcomes of ASD management. The relationship between obesity and surgical outcomes in ASD has been the focus of recent studies, yielding various results. We conducted a comprehensive search of PubMed, Cochrane, and Google Scholar (page 1-20) through June of 2024. The surgical outcomes assessed included post-operative complications, revision rates, wound infections, thromboembolic events, implant-related complications, and non-home discharge. Surgical parameters such as operative time, length of stay (LOS), and estimated blood loss (EBL), as well as functional outcomes like the Oswestry Disability Index (ODI) and pain scores were analyzed. Nine studies met inclusion criteria. Non-obese patients exhibited a lower rate of implant-related complications (OR=0.25; 95% CI: 0.12-0.52, P=0.0002) and non-home discharge (OR=0.52; 95% CI: 0.32-0.84, P=0.007). Additionally, non-obese patients had reduced LOS (MD=-0.29; 95% CI: -0.53 - -0.05, P=0.02) and EBL (SMD=-0.68; 95% CI: -1.19 - -0.18, P=0.008). No statistically significant differences were observed for the remaining outcomes. Non-obese patients undergoing ASD corrective surgery are associated with fewer implant-related complications, a lower EBL, shorter LOS, and a higher likelihood of being discharged home compared to their obese counterparts.

Robotic versus open pancreaticoduodenectomy in octogenarians: a comparative propensity score analysis of perioperative outcomes

IntroductionCompared to open pancreaticoduodenectomies (OPD), the robotic (RPD) approach improves the rate of complication and the length of stay. However, it remains unknown if these benefits persist in octogenarians, who are at higher risk for perioperative morbidity and mortality. MethodsA retrospective analysis of the ACS-NSQIP database was performed to identify patients aged 80 years or older who underwent PD for pancreatic adenocarcinoma between 2015 and 2021. Patients who underwent RPD or OPD were compared using inversed probability weighting of the propensity score to control for known confounding variables. Outcomes assessed include operative time, length of stay (LOS), non-home discharge, major complications, unplanned readmission, return to the operating room (OR), mortality, and clinically relevant postoperative pancreatic fistula (CRPOPF). ResultsOf 30,751 patients undergoing PD, 1720 were 80 or older. One thousand six hundred twenty-five patients (94 %) underwent OPD, and 95 (6 %) underwent RPD. RPD was significantly associated with a reduced incidence of major complications (32.6 % vs. 45.6 % in OPD; p < 0.01) and a lower rate of non-home discharge (24.7 % vs. 34.3 % in OPD; p < 0.05). However, RPD was associated with a longer operative time (438 min vs. 342 min for OPD; p < 0.0001). There was no difference in other assessed outcomes between the two groups. ConclusionRPD may reduce major postoperative complications and non-home discharges compared to the open approach for octogenarians.

Symptoms of Anxiety and Depression in Patients Undergoing Transcatheter Aortic Valve Implantation – The SAD-TAVI Study

Symptoms of anxiety and/or depression (SAD) commonly co-exist in severe aortic stenosis (AS). In patients undergoing transcatheter aortic valve implantation (TAVI), these symptoms are associated with increased morbidity and mortality. Despite this, mental health remains under-researched in the TAVI literature. Drawing from the largest registry in Australia, we aimed to characterise the prevalence of SAD in TAVI patients. We also aimed to identify patient phenotypes at highest risk of these symptoms, examine how they evolve following TAVI and establish factors predictive of improvement and regression in mental health. 1279 patients undergoing TAVI between 2018 and 2023 included in a multi-centre Australian registry were analysed. Median age was 82 (IQR 77, 87), 41% female and median STS score 3.9 (2.3, 5.9). 353 (28%) patients reported moderate or worse SAD at baseline. Of this group, 260 (74%) had complete resolution in symptoms within 30-days. Body Mass Index<25 (adjusted odds ratio [aOR] 3.4, p<0.001), vascular site complications (aOR 3.4, p=0.029) and non-home discharge (aOR 2.4, p=0.036) independently predicted persistence of SAD. Only 72 (8%) patients developed new-onset SAD at 30-days following TAVI. Non-home discharge (aOR 2.12, p=0.025) and a composite cardiovascular endpoint including stroke, acute myocardial infarction, and heart-failure readmission (aOR 2.55, p=0.028) were independent predictors of new-onset SAD. In conclusion, symptoms of anxiety and depression are common but under recognised in aortic stenosis. TAVI is highly effective at improving these symptoms and regular screening for mental health should be considered in the management of all TAVI patients.

The Utility of Neighborhood Social Vulnerability Indices in Predicting Nonhome Discharge Disposition Following Revision Total Joint Arthroplasty: A Comparison Study

BackgroundIdentifying risk factors associated with non-home discharge (NHD) following revision hip and knee total joint arthroplasty (TJA) could reduce the rate of preventable discharge to rehabilitation or skilled nursing facilities. Neighborhood-level deprivation indices are becoming an increasingly important measure of socioeconomic disadvantage as these indices consider multiple social determinants of health. This study aimed to compare the utility of widely used neighborhood social vulnerability indices in predicting NHD following revision TJA patients. MethodsThis study included 1,043 consecutive patients who underwent revision TJA at a single tertiary health system. There were three multivariate logistic regression analyses with the outcome of NHD performed using the area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) while controlling for other demographic variables. Neighborhood-level indices were included in the analysis as continuous variables and categorical quartiles, with the lowest quartile representing the least deprived neighborhoods of the patient cohort. The strength of the association of significant indices was measured. ResultsPatients in the highest ADI and SDI quartiles demonstrated higher odds of NHD compared to the cohort with the lowest quartile (ADI OR [odds ratio] = 1.93, 95% CI [confidence interval] = 1.23 to 3.03, P = 0.005; SDI OR = 1.86, 95% CI = 1.18 to 2.91, P = 0.007). Discharge disposition was more strongly associated with ADI than SDI (0.68 versus 0.26). Age, ASA status, and alcohol use were independent determinants of discharge disposition. No significant association was seen between SVI and discharge disposition. ConclusionArea-level indices can be utilized to identify patients at higher risk of NHD following revision TJA. This study highlights the important differences between these indices' utility when evaluating their effects on clinical outcomes in this patient population. The findings shed light on the potential of integrating these tools into policy development, clinical preoperative programs, and research to better understand and address the health disparities in arthroplasty outcomes.

Non-Home Discharge is an Independent Risk Factor for Readmission Following Primary Total Shoulder Arthroplasty

Utilization of total shoulder arthroplasty (TSA) in the United States has increased substantially within the last two decades and this trend is expected to continue. As TSA volume has continued to increase, healthcare policy has shifted towards an emphasis on value-based care. Therefore, it is important to understand variables that may increase TSA costs, including readmission rates. Patients discharged to home healthcare (HHC) or post-acute care (PAC) facilities have demonstrated increased readmission rates following TSA. However, few studies have directly compared HHC to PAC facilities and routine home discharge while accounting for pertinent demographics. The purpose of this study was to compare 180-day readmission rates between routine home discharge, HHC, and PAC facility groups following primary TSA. The Nationwide Readmissions Database was queried from 2010 to 2020 to identify all patients that underwent primary TSA. Readmission rates were compared between routine home discharge, HHC, and PAC facility groups. Binary logistic regression identified independent risk factors for readmission within 180 days. From 2010 to 2020 a total of 171,898 patients underwent TSA. 71% were routinely discharged home, 21% were discharged to HHC, and 8% were discharged to a PAC facility. After adjusting for income, insurance, obesity status, age, Charlson Comorbidity index, and gender, discharge to a PAC facility was independently predictive of readmission within 180 days following TSA (OR: 1.69, 95% CI 1.59-1.79, p<0.001). Patients discharged to a PAC facility after TSA had higher readmission rates compared to HHC and routine home discharge that persisted even after controlling for relevant demographics. Clinicians should be cognizant of the risks and benefits of different discharge methods and consider home discharges for suitable candidates. Understanding risk factors that increase healthcare expenditures has significant utility for institutions in the era of bundled care. However, it is important that alternative payment models do not disincentivize orthopedic surgeons from providing care to medically complex patients.

Impact of frailty on outcomes of patients undergoing elective endovascular thoraco-abdominal aortic aneurysm repair.

Frailty and it score assessment by the Clinical Frailty Scale (CFS) have been recently proposed in surgery to overcome chronological age and major comorbidities as predictor tools of the surgical risks. We aim to evaluate the impact of frailty on outcomes of patients undergoing TAAA endovascular repair and whether CFS may be used as screening tool in the preoperative work-up and peri-operative risk stratification. REtrospective analysis of 76 patients (61 male, 74.9±6.9 years) undergoing elective branched-EVAR. Patients were divided in Group A (CFS<5) and Group B (CFS≥5). Post-operative morbidity, access-site related-complications, ICU- and in-hospital length-of-stay, reintervention rate, surgery- and all-causes related mortality were evaluated. Fifty-four patients (71.1%) were classified as CFS<5, whereas twenty-two as CFS≥5. Demographics and comorbidities were homogeneous regardless of CFS class. No differences in term of MAE and of access-site related-complication but a greater perioperative and early mortality rate in the group of frail patients was noted (P=0.009, OR 11.8, 95% CI 1.35-3.58; P=0.019, respectively), as a longer hospitalization (P=0.007) and more frequent non-home discharge. Mid-term aneurysm- and all-causes related mortality was similar in both groups. Frailty seems to be associated with worse perioperative outcomes. CFS is a reliable tool to quantify the degree of disability due to frailty and to better assess the risks and benefits of endovascular TAAA repair. Frailty is not equated with inoperability but indicate the need for a tailored approach for the more vulnerable patients. Larger studies and a widespread use of frailty screening methods are needed to confirm its efficacy in the prediction of outcomes after endovascular interventions.

Machine learning model outperforms the ACS Risk Calculator in predicting non-home discharge following primary total knee arthroplasty.

Despite the increase in outpatient total knee arthroplasty (TKA) procedures, many patients are still discharged to non-home locations following index surgery. The ability to accurately predict non-home discharge (NHD) following TKAs has the potential to promote a reduction in associated adverse events and excess healthcare costs. This study aimed to evaluate whether a machine learning (ML) model could outperform the American College of Surgeons (ACS) Risk Calculator in predicting NHD following TKA, using the same set of clinical variables. We hypothesised that the ML model would outperform the ACS Risk Calculator. Data from 365,240 patients who underwent a primary TKA between 2013 and 2020 were extracted from the ACS-National Surgical Quality Improvement Program database and used to develop an artificial neural network (ANN) to predict discharge disposition following primary TKA. The ANN and ACS calculator were assessed and compared using discrimination, calibration and decision curve analysis. Age (>68 years), BMI (>35.5 kg/m2) and ASA Class (≥2) were found to be the most important variables in predicting NHD following TKA. When compared to the ACS calculator, the ANN model demonstrated a significantly superior ability to distinguish the area under the receiver operating characteristic curve (AUC) among NHD patients and provided probability predictions well aligned with the true outcomes (AUCANN = 0.69, AUCACS = 0.50, p = 0.002, slopeANN = 0.85, slopeACS = 4.46, interceptANN = 0.04, and interceptACS = 0.06). Our findings support the hypothesis that machine learning models outperform the ACS Risk Calculator in predicting non-home discharge after TKA, even when constrained to the same clinical variables. Our findings underscore the potential benefits of integrating machine learning models into clinical practice for improving preoperative patient risk identification, optimisation, counselling and clinical decision-making. III.

Early clinical outcomes and medical complications following long segment fusion for adult spinal deformity with and without three column osteotomy

BackgroundSurgical treatment of adult spinal deformity (ASD) commonly involves long-segment fusion with or without three column osteotomies (3CO) to provide satisfactory correction of sagittal and coronal balance. While some clinical studies have implicated 3CO as a driver of high surgical complication rates, these prior investigations are limited by small sample size. Herein, we compare early outcomes and adverse events in patients undergoing long segment posterior spinal fusion for ASD with and without 3CO. MethodsA multicenter administrative database was queried for patients undergoing elective posterior spinal fusion for ASD. Patients were stratified based upon long segment fusion with and without 3CO. Preoperative patient demographics, procedural characteristics, hospitalization events, and postoperative complication rates were evaluated. Student's t-test and Fisher's exact test were utilized where appropriate to compare differences between the two groups for continuous and categorical variables. Results340 cases met the inclusion criteria, of which 156 involved 3CO. Patients who required 3CO had a lower rate of preoperative diabetes (22.3 % vs 10.3 %, p = 0.003), higher rates of non-home discharge (26.2 % vs 57.1 %, p < 0.001), longer operation time (245.62 ± 9.45 vs. 434.40 ± 11.65, p < 0.001), and longer length of stay (4.17 ± 0.66 vs. 7.76 ± 0.83, p < 0.001). In terms of complications, 3CO patients had higher rates of deep surgical site infection (0 % vs 3.2 %, p = 0.02), reintubation (0 % vs 4.5 %, p = 0.004), inability to wean off ventilator (0 % vs 2.6 %, p = 0.04), and perioperative blood transfusion (20.1 % vs 76.3 %, p < 0.001). ConclusionsIn this retrospective analysis, posterior 3CO was frequently undertaken but associated with higher risk for postoperative adverse events following spinal deformity correction.

Concurrent and predictive validity of the Global Leadership Initiative on Malnutrition criteria for adult patients in convalescent rehabilitation wards

Background & aimsThe Global Leadership Initiative on Malnutrition (GLIM) criteria has been recognised as major diagnostic criteria for malnutrition in adults worldwide; however, its validity in rehabilitation settings remains unclear. This study investigated the concurrent and predictive validity of the GLIM criteria for adult patients in convalescent rehabilitation wards. MethodsThis retrospective cohort study was conducted using pre-established datasets from convalescent rehabilitation wards in a hospital. The inclusion criteria were adults aged ≥18 years admitted to the wards between November 2018 and October 2020 who were available for body composition assessment. Malnutrition diagnoses were determined by registered dietitians (RDs) using the GLIM criteria. The Subjective Global Assessment (SGA) was performed by another RD and used for the malnutrition reference standard. The GLIM criteria sensitivity and specificity were examined for SGA. The odds ratios and hazard ratios of GLIM-defined malnutrition for the total score of the Functional Independence Measure (tFIM) effectiveness and non-home discharge were calculated using univariable and multivariable logistic regression analyses and Cox proportional hazard models. ResultsData from 723 patients were extracted from the dataset. GLIM-defined malnutrition was confirmed in 207 (28.6%) patients, 87 (12.0%) with moderate malnutrition and 120 (16.6%) with severe malnutrition. The SGA graded 146 (20.2%) patients with moderate malnutrition (grade B) and 86 (11.9%) with severe malnutrition (grade C). The GLIM criteria (malnutrition/ no malnutrition) had fair sensitivity (76.7%, 95% confidence interval [CI]: 70.7–82.0%) and good specificity (94.1%, 95% CI: 91.6–96.0%), indicating acceptable concurrent validity. GLIM-defined moderate malnutrition had poorer sensitivity than severe malnutrition (42.5% vs 81.4%). Logistic regression analyses revealed no evidence for the association between GLIM-defined malnutrition and poor tFIM effectiveness (adjusted odds ratio [AOR]: 1.09, 95% CI: 0.71–1.69) and non-home discharge (AOR: 1.19, 95% CI: 0.76–1.84). The Cox proportional hazard analyses also showed no effect of malnutrition on outcomes. ConclusionThe GLIM criteria had fair sensitivity and good specificity, indicating acceptable criteria for diagnosing malnutrition in rehabilitation settings. However, its predictive validity for functional recovery and discharge outcomes was insufficient.

Factors associated with nonhome discharge after endovascular aneurysm repair

ObjectiveThis study aims to identify preoperative factors associated with nonhome discharge (NHD) after endovascular aneurysm repair (EVAR). NHD has implications for patient care, readmission, and long-term mortality; nevertheless, the existing literature lacks information regarding factors associated with NHD for patients undergoing EVAR. In contrast, our study assesses preoperative factors associated with NHD for this population by using national data from the Vascular Quality Initiative. MethodsWe identified adult patients who underwent elective EVAR in the Vascular Quality Initiative (2003-2022) and excluded those who were not living at home preoperatively. Multivariable logistic regression was used to identify preoperative factors associated with NHD. Kaplan-Meier methods and Cox-regression analyses were used to assess the impact of NHD on 5-year survival as a secondary outcome. ResultsWe included 61,792 patients, of which 3155 (5.1%) had NHD. NHD patients were more likely to be older (79 years [interquartile range, 73-18 years] vs 73 years [interquartile range, 67-79 years]), female (33.7% vs 18.2%; P < .001), non-White (16.0% vs 11.7%; P < .001), and have more comorbidities. NHD patients had higher rates of postoperative complications (acute kidney injury, 11.9% vs 2.0% [P < .001]; myocardial infarction, 3.8% vs 0.5% [P < .001]; and in-hospital reintervention, 4.7% vs 0.5% [P = .033]). Multivariable analysis revealed many preoperative characteristics were associated with higher odds of NHD: most notably, age (per additional decade: odds ratio [OR], 2.15; 95% confidence interval [CI], 2.03-2.28; P < .001), female sex (OR, 1.79; 95% CI, 1.63-1.95; P < .001) and aneurysm diameter >65 mm (OR, 2.18; 95% CI, 1.98-2.39; P < .001), along with potentially modifiable factors, including anemia, chronic obstructive pulmonary disease, chronic heart failure, weight, and diabetes. In contrast, aspirin, statin, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocekr use were associated with lower odds of NHD. NHD was associated with higher hazards of 5-year mortality, even after adjusting for confounders (40% vs 14%; adjusted hazard ratio, 2.13; 95% CI, 1.86-2.44; P < .001). ConclusionsSeveral factors were associated with higher odds of NHD after elective EVAR, including nonmodifiable factors such as female sex and larger aortic diameter, and potentially modifiable factors such as anemia, chronic obstructive pulmonary disease, chronic heart failure, body mass index, and diabetes. Special attention should be given to populations with nonmodifiable factors, and efforts at optimizing medical conditions with higher NHD likelihood seems appropriate to improve patient outcomes and quality of life after EVAR.

A Novel Preoperative Risk Score to Identify Patients at High Risk for Nonhome Discharge after Elective Open Abdominal Aortic Aneurysm Repair

Non-home discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its impact on patients. For home-dwelling patients undergoing elective surgery, the need for postoperative NHD can have meaningful implications on quality of life, long-term outcomes, and healthcare spending. Understanding post-surgical NHD risk is essential to preoperative counseling and shared decision making. This is particularly true for the treatment of abdominal aortic aneurysms as the postoperative course can vary between open and endovascular surgery. We aimed to identify independent predictors of NHD following elective open abdominal aortic aneurysm repair (OAR), and to create a clinically useful preoperative risk score. Elective OAR cases were queried from the SVS Vascular Quality Initiative from years 2013-2022. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. Overall, 8,274 patients were included and 1,502 (18.2%) required NHD. At baseline, patients who required NHD were more likely to be ≥ 80 years old (23.6% vs. 6.5%), female (35.9% vs. 23.1%), not independently ambulatory (14.6% vs. 4.3%), anemic (24.4% vs. 13.9%), have COPD (41.6% vs. 30.7%), ASA class ≥ 4 (41.0% vs. 32.5%), and a supraceliac proximal clamp (9.8% vs. 5.7%; all P<0.05). Multivariable analysis in the development group identified the following independent predictors of NHD: age ≥ 80 years, not independently ambulatory, proximal clamp location, hypogastric artery occlusion, anemia (Hb <12 g/dL), chronic obstructive pulmonary disease, female sex, hypertension, and American Society of Anesthesiologists class ≥ 4. These were then used to create a 14-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-4 points; n=4,966) with an NHD rate of 9.9%, moderate risk (5-6 points; n=2,442) with an NHD rate of 25.5%, and high risk (≥ 7 points; n=886) with an NHD rate of 44.6%. The risk score had good predictive ability with c-statistic=0.73 for model development and c-statistic=0.72 in the validation dataset. This novel risk score can predict NHD following elective OAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.