Postdischarge Complications Research Articles

Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital.

The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions. Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk. National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R and c-statistics with cross-validation to estimate predictive discrimination. Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R 9.0%, c-statistic 0.69) and postoperative variables (R 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R 19.6%, c-statistic 0.76). Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

Home Discharge After Primary Elective Total Joint Arthroplasty: Postdischarge Complication Timing and Risk Factor Analysis

BackgroundBundled payment programs for primary total joint arthroplasty (TJA) have identified reducing nonhome discharge as a major area of cost savings. Health care providers must therefore identify, risk stratify, and appropriately care for home-discharged TJA patients. This study aimed to analyze risk factors and timing of postdischarge complications among home-discharged primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and risk stratify them to identify those who would benefit from higher level care. MethodsPatients discharged home after elective primary THA/TKA from 2011 to 2014 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were performed using perioperative variables. ResultsA total of 50,376 and 71,293 home-discharged THA and TKA patients were included for analysis, of which, 1575 THA (3.1%) and 2490 TKA (3.5%) patients suffered postdischarge severe complications or unplanned readmissions. These patients were older, smokers, obese, and functionally dependent (P < .001 for all). In multivariate analysis, severe adverse event predischarge, age, male gender, functional status, and 10 other variables were all associated with ≥1.22 odds of postdischarge severe adverse event or readmission (P < .05). THA and TKA patients with 2, 3, or ≥4 risk factors had 1.43-5.06 times odds of complications within 14 days post discharge and 1.41-3.68 times odds of complications beyond 14 days compared to those with 0 risk factors (P < .001 for all). ConclusionRisk factors can be used to predict which home-discharged TJA patients are at greatest risk of postdischarge complications. Given that this is a growing population, we recommend the development of formal risk-stratification protocols for home-discharged TJA patients.

Hospital-Level Factors Related to 30-Day Readmission Rates.

This study investigates the relationship between inpatient quality of care as measured by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicator (PSI) composite and all-cause, hospital-wide, 30-day readmission rates. Discharge data from 4 statewide databases were analyzed. Linear, repeated-measures regressions were performed to predict hospital-level 30-day readmission rates. The mean readmission rate was 12.9%, and the mean PSI composite ratio was 0.95 among 524 hospitals with 2592 observations. In the hospital-level analysis, the risk-adjusted AHRQ PSI composite was not significantly associated with hospital 30-day readmission rate after controlling for hospital-level characteristics, patient case mix, and sociodemographics. Inpatient quality of care appears to have less influence on hospital readmission rates than do clinical and socioeconomic factors. However, these results suggest that a patient safety composite measure that includes postdischarge complications would provide more information to assist hospitals and communities in understanding the association between quality of care and readmission rates.

A Prospective Randomized Trial of the Effects of Early Enteral Feeding After Radical Cystectomy

To investigate the role of early feeding on recovery after radical cystectomy and urinary diversion. Enhanced recovery protocols have helped to standardize postoperative recovery. This is the first study to directly review the impact of early feeding on recovery in a randomized multi-institutional protocol. From 2011 to 2014, patients at 2 large hospitals were randomized after radical cystectomy to receive access to liquids and then a regular diet on postoperative days 1 and 2 or conventional care with introduction of a liquid diet after return of bowel activity, typically days 3-5. Early ambulation, use of metoclopramide, and no nasogastric tube were standard for all patients. The study was powered to detect a 50% decrease in 90-day complication rate with secondary end points of length of stay, time to bowel activity, and time to diet tolerance. The study was terminated early due to slow accrual (102 of 328). Overall complications for the early vs standard groups were similar (34 vs 31, P = .86). Immediate inpatient and postdischarge complication rates were also similar (P = .63 and P = .44). Length of stay was not different (8.74 days vs 9.69 days, P = .43). Rates of ileus (27% vs 41%, P = .21) and return of bowel function (4.67 days vs 4.09 days, P = .62) were the same in arms. Although this prospective randomized study did not meet the accrual target, early introduction of diet was well tolerated and did not show a negative or positive difference in any outcomes. Enhanced recovery protocols standardize postoperative care and early feeding is a well-tolerated addition.

Robot-assisted partial cystectomy: perioperative outcomes and early oncological efficacy.

To report on patients undergoing robot-assisted partial cystectomy (RAPC), focusing on perioperative outcomes over a range of clinical, anatomical and pathological variables, as well as the overall oncological efficacy of this approach. We retrospectively reviewed all patients who underwent RAPC by a single surgeon between 2005 and 2015. We identified 29 patients who underwent surgery for definitive management of a primary bladder tumour. Clinicopathological data and perioperative variables were recorded. Continuous variables were compared using the Student's t-test. Prediction of perioperative outcomes for those undergoing RAPC for intra-diverticular neoplasms was done using univariate logistic regression. Survival was estimated using the Kaplan-Meier method. The median (interquartile range) patient age was 75 (65-81) years, 18 patients (62.1%) had an American Society of Anesthesiologists classification of ≥3, and 10 patients (34.5%) had a history of prior abdominal surgery. The median estimated blood loss (EBL) was 50 mL and the median length of stay (LOS) was 1 day. Two patients (6.9%) had a perioperative complication and five (17.9%) a post-discharge complication at ≤90 days, all of which were minor. The positive surgical margin rate was 3.6% and in those with muscle-invasive disease a median of 12 lymph nodes were removed. Neither the size of diverticulum nor the need for ureteric re-implantation was predictive of LOS, EBL, or complication (P > 0.05). We did not encounter any wound, port site, or unusual recurrence patterns to suggest the technical factors of a robotic approach influenced oncological outcomes. The 5-year overall and recurrence-free survival rates were 79% and 68%, respectively. RAPC confers the ability to achieve favourable outcomes with low morbidity and reduced hospital stays. Oncological efficacy compares favourably with the published literature. For experienced surgeons, this may represent the optimal surgical approach for organ-preserving bladder surgery.

Is Outpatient Arthroplasty as Safe as Fast-Track Inpatient Arthroplasty? A Propensity Score Matched Analysis

BackgroundIn the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient total joint arthroplasty is attractive provided the incidence of costly complications is comparable to contemporary “fast-track” inpatient pathways. MethodsAll patients undergoing total hip arthroplasty or total knee arthroplasty between 2011 and 2013 were selected from the American College of Surgeons–National Surgical Quality Improvement Program database. A propensity score was used to match 1476 fast-track (≤2 day length of stay) inpatients with 492 outpatients (3:1 ratio). Thirty-day complication, reoperation, and readmission rates were compared, both during and after hospitalization. Logistic regression was used to calculate propensity score adjusted odds ratios. ResultsAfter matching, outpatients had higher rates of medical complication (anytime, 10.0% vs 6.7%, P = .018; post discharge, 6.3% vs 1.1%, P < .001). Most complications were bleeding requiring transfusion, which occurred at similar rates after surgery but at higher rates post discharge in outpatients (anytime, 7.5% outpatients vs 5.6% inpatients, P = .113; post discharge, 4.1% outpatients vs 0.1% inpatients, P < .001). There was no difference in readmission rate (2.4% outpatient vs 2.0% inpatient, P = .589). ConclusionOutpatients experience higher rates of post-discharge complications, which may countermand cost savings. Surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post-discharge medical complications to include blood management strategies.

Readmissions After Colectomy: The Upstate New York Surgical Quality Initiative Experience.

Hospital readmissions remain a major medical and financial concern to the healthcare system and have become an area of interest in health outcomes performance metrics. There is a pressing need to identify process measures that may help reduce readmissions. Our aim was to assess the patient characteristics and surgical factors associated with 30-day readmissions for colorectal surgery in Upstate New York. This was a retrospective cohort study. The study included colectomy cases abstracted for the National Surgical Quality Improvement Program in the Upstate New York Surgical Quality Initiative from June 2013 to June 2014. The study consists of 630 colectomies. Patients with a length of stay >30 days or who died during the index admission were excluded. Readmission within 30 days of surgery was the main outcome measure. Of 630 colectomy patients, 76 patients (12%) were readmitted within 30 days of surgery. Major and minor complications were associated with 30-day postoperative readmission (OR = 2.99 (95% CI, 1.70-5.28) and OR = 2.19 (95% CI, 1.09-4.43)) but excluded from final analysis because they included both predischarge and postdischarge complications. Risk factors independently associated with 30-day postoperative readmission included diabetes mellitus (OR = 1.94 (95% CI, 1.02-3.67)), smoker within the past year (OR = 2.01 (95% CI, 1.12-3.60)), no scheduled follow-up (OR = 2.20 (95% CI, 1.25-3.86)), and ileostomy formation (OR = 1.97 (95% CI, 1.03-3.77)). Limitations include the retrospective design and only 30 days of postoperative follow-up. Consistent with national trends, 1 in 8 patients in the Upstate New York Surgical Quality Initiative program was readmitted within 30 days after colorectal surgery. This study identified several risk factors that may act as tangible targets for intervention, including preoperative smoking cessation programs, optimization of diabetic management, mandatory scheduled follow-up appointments on discharge, and ostomy care pathways.

Complication timing impacts 30-d mortality after hepatectomy

BackgroundTo date, no study has specifically focused on the timing of complications after hepatectomy relative to patient outcomes. We sought to investigate the effect of complication timing on 30-d mortality. Materials and methodsA total of 3064 patients who underwent hepatic resection in 2014 were identified from American College of Surgeons National Surgical Quality Improvement Program database. Cox regression analysis was performed to determine the association of complication timing with 30-d mortality. ResultsMedian patient age was 60 y (interquartile range, 50-68). Among all patients who experienced a complication, 16.6% had only a postdischarge complication. Wound disruption (64%) and surgical site infection (58.1%) occurred frequently after discharge. Organ space surgical site infection occurred at a later time after surgery among patients who underwent minimally invasive surgery (minimally invasive surgery, 16 d versus open 10 d; P = 0.008). Among 47 (1.5%) patients who died within 30 d from surgery, 21.3% of deaths occurred postdischarge. After adjusting for competing risk factors, patients who had experienced a postdischarge complication demonstrated an increased risk of 30-d mortality (referent, predischarge, hazard ratio 2.96, 95% confidence intervals 1.07-8.17; P = 0.04). ConclusionsPostdischarge complications occurred less frequently after hepatectomy than predischarge complications; however, late complications were associated with a three-fold increased risk of mortality.

Interleukin-12 serum level has prognostic value in patients with ST-segment elevation myocardial infarction

ObjectivesThe study aimed to evaluate whether serum inflammatory markers have prognostic value in patients with ST-segment elevation myocardial infarction (STEMI). BackgroundThe role of cytokine-driven inflammation in the development of postdischarge complications after STEMI is obscured. MethodsWe recruited 214 patients who were admitted within 24 h of STEMI onset to our Institute. IL-1α, -6, -8, -10, -12, TNF-α, and CRP serum levels were measured on the 10–14th day after STEMI onset. ResultsSerum levels of IL-12, TNF-α, and CRP were significantly higher in patients with 3 affected coronary arteries compared to those with 1 affected coronary artery. However, only Killip class II–IV at admission and IL-12 serum level ≥90.0 pg/mL were defined as statistically significant predictors of adverse outcome after 1 year of follow-up. ConclusionIL-12 serum level may be suggested as a candidate prognostic marker if measured 10–14 days after STEMI onset.

Timely Post-discharge Telephone Follow-Up is a Useful Tool in Identifying Post-discharge Complications Patients After Congenital Heart Surgery.

The objective of this study was to evaluate the effect of structured post-discharge telephone follow-up (TFU) on the time to the first postoperative clinic visit and early unplanned hospital readmissions in patients after congenital heart surgery. Structured phone calls delivered by senior surgical practitioners were made 1-4days post-discharge. Demographics and clinical outcomes of pediatric patients receiving a TFU from 2012 to 2014 were assessed. In total, 196 phone calls were made in 165 patients. Thirty-four health problems were identified in 32 (19%) patients (15 infants, 9 children, 8 neonates). Sixty-nine percent (n=22) of the patients with problems identified at TFU were males. Fifty-three percent (n=17) of the patients with problems identified at TFU were RACHS 2. Most of the problems (53%) were identified in middle-class economic families. Gastrointestinal and incision site complications were the most common problems identified. Eighteen (56%) patients had adjustments of medications. Six (19%) TFUs resulted in earlier than scheduled post-op clinic visits. Overall incidence of unplanned readmissions was 16% and similar between the patients that had problems during TFU (13%) and patients that did not have problems identified at TFU (18%; p=0.50). Our study demonstrates the potential impact of the timely and structured post-discharge TFU in identifying post-discharge complications and modifying discharge instructions. When TFU identifies a problem, the interventions may be successful in preventing readmissions before first postoperative clinic visit. TFUs may be helpful, as a supplement standard of care with specific focus on patients <1year of age to help identify adverse events that could otherwise escalate.

Drivers of readmissions in vascular surgery patients

Postoperative readmissions are frequent in vascular surgery patients, but it is not clear which factors are the main drivers of readmissions. Specifically, the relative contributions of patient comorbidities vs those of operative factors and postoperative complications are unknown. We sought to study the multiple potential drivers of readmission and to create a model for predicting the risk of readmission in vascular patients. The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program data set was queried for unplanned readmissions in 86,238 vascular patients. Multivariable forward selection logistic regression analysis was used to model the relative contributions of patient comorbidities, operative factors, and postoperative complications for readmission. The unplanned readmission rate was 9.3%. The preoperative model based on patient demographics and comorbidities predicted readmission risk with a low C index of .67; the top five predictors of readmission were American Society of Anesthesiologists class, preoperative open wound, inpatient operation, dialysis dependence, and diabetes mellitus. The postoperative model using operative factors and postoperative complications predicted readmission risk better (C index, .78); postoperative complications were the most significant predictor of readmission, overpowering patient comorbidities. Importantly, postoperative complications identified before discharge from the hospital were not a strong predictor of readmission as the model using predischarge postoperative complications had a similar C index to our preoperative model (.68). However, the inclusion of complications identified after discharge from the hospital appreciably improved the predictive power of the model (C index, .78). The top five predictors of readmission in the final model based on patient comorbidities and postoperative complications were postdischarge deep space infection, superficial surgical site infection, pneumonia, myocardial infection, and sepsis. Readmissions in vascular surgery patients are mainly driven by postoperative complications identified after discharge. Thus, efforts to reduce vascular readmissions focusing on inpatient hospital data may prove ineffective. Our study suggests that interventions to reduce vascular readmissions should focus on prompt identification of modifiable postdischarge complications.

PD10-09 HEALTH CARE DISPARITIES AND POST DISCHARGE COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III1 Apr 2016PD10-09 HEALTH CARE DISPARITIES AND POST DISCHARGE COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY David M. Golombos, Padraic O'Malley, Patrick Lewicki, Bashir Al Hussein Al Awamlh, Daniel P. Nguyen, Igor Inoyatov, and Douglas S. Scherr David M. GolombosDavid M. Golombos More articles by this author , Padraic O'MalleyPadraic O'Malley More articles by this author , Patrick LewickiPatrick Lewicki More articles by this author , Bashir Al Hussein Al AwamlhBashir Al Hussein Al Awamlh More articles by this author , Daniel P. NguyenDaniel P. Nguyen More articles by this author , Igor InoyatovIgor Inoyatov More articles by this author , and Douglas S. ScherrDouglas S. Scherr More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2917AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Health disparities linked to socioeconomic status (SES) have demonstrated association with patient outcomes and complications. We hypothesized that in a diverse urban population, lower SES would be associated with peri-operative morbidity and post-discharge complications after radical cystectomy. METHODS IRB approved, retrospective chart review was performed on 383 non-metastatic patients who underwent definitive radical cystectomy at a single tertiary care center between 2001-2014. Along with selected clinical and pathologic parameters traditionally used for pre-operative risk stratification, potential social determinants of health, such as median household income and rates of completed high school education were gathered using patient zip codes and US Census data. Post-operative complications were defined using the standardized Clavien-Dindo classification. After dividing patients into tertiles based on SES parameters, potential differences were assessed using Wilcox rank-sum testing. Multivariable logistic regression was then performed to identify predictors of complication. A p=0.05 was considered as significant. RESULTS After 20 international patients were excluded, 363 patients were analyzed. Patients with the lowest education levels were at higher risk for any complication within 90 days (P=0.004). Both low level of education (p=0.038) and low household median income (p=0.037) increased patient risk of post-discharge complication within 90 days. On multivariable logistic regression, education level (OR, 0.64 [95% CI, 0.46-0.89] p=0.007), household income (OR, 0.64 [95% CI, 0.19-0.92] p=0.031), and length of stay (OR, 1.13 [95% CI, 1.08-1.19] p=<0.001) were significantly associated with any complication. ASA classification approached, but did not achieve significance (p=0.072). Furthermore, education level (OR, 0.64 [95% CI, 0.46-0.89] p=0.008) and household income (OR, 0.42 [95% CI,0.19-0.96] p=0.039) were associated with post-discharge 90 day complication, with ASA classification (p=0.07) and nodal involvement (p=0.08) approaching significance. CONCLUSIONS Patients with lower socioeconomic status, indicated by lower median household income and education level, appear to be at increased risk of post-operative complication after radical cystectomy, especially once discharged from the hospital. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e242 Advertisement Copyright & Permissions© 2016MetricsAuthor Information David M. Golombos More articles by this author Padraic O'Malley More articles by this author Patrick Lewicki More articles by this author Bashir Al Hussein Al Awamlh More articles by this author Daniel P. Nguyen More articles by this author Igor Inoyatov More articles by this author Douglas S. Scherr More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pediatric appendicitis and need for antibiotics at time of discharge: Does route of administration matter?

IntroductionFollowing complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics. MethodsWe performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10–10/14. We compared outcomes including ED and hospital readmission rates, and development of postoperative complications, between those children who were discharged on IV antibiotics and those discharged on PO antibiotics. Results325 children were discharged with antibiotics following appendectomy (n=291 PO antibiotics group; n=34 IV group). On both univariate and multivariate analysis, rate of each complication did not differ between the two groups including inpatient readmission (5% PO vs. 6% IV; p=0.8), ED readmission (10% vs. 11%; p=0.8), postdischarge complications related to the operation (10% vs. 15%; p=0.4), or abscess development post-discharge (4% vs. 3%; p=1). ConclusionsAmong children with complicated appendicitis who are discharged home with ongoing antibiotic therapy, our data demonstrate no differences in outcomes between those children who receive IV and PO antibiotics. Further data, collected in a prospective fashion, are needed to clarify the role of IV and PO antibiotics among children with perforated appendicitis.

Relation of Atrial Fibrillation in Acute Myocardial Infarction to In-Hospital Complications and Early Hospital Readmission

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and contributes to high rates of in-hospital adverse events. However, there are few contemporary studies examining rates of AF in the contemporary era of AMI or the impact of new-onset AF on key in-hospital and postdischarge outcomes. We examined trends in AF in 6,384 residents of Worcester, Massachusetts, who were hospitalized with confirmed AMI during 7 biennial periods between 1999 and 2011. Multivariate logistic regression analysis was used to examine associations between occurrence of AF and various in-hospital and postdischarge complications. The overall incidence of AF complicating AMI was 10.8%. Rates of new-onset AF increased from 1999 to 2003 (9.8% to 13.2%), and decreased thereafter. In multivariable adjusted models, patients developing new-onset AF after AMI were at a higher risk for in-hospital stroke (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.6 to 4.1), heart failure (OR 2.0, 95% CI 1.7 to 2.4), cardiogenic shock (OR 3.7, 95% CI 2.8 to 4.9), and death (OR 2.3, 95% CI 1.9 to 3.0) than patients without AF. Development of AF during hospitalization for AMI was associated with higher rates of readmission within 30 days after discharge (21.7% vs 16.0%), but no significant difference was noted in earlypostdischarge 30-day all-cause mortality rates (8.3% vs 5.1%). In conclusion, new-onset AF after AMI is strongly related to in-hospital complications of AMI and higher short-term readmission rates.

Postdischarge complications following nonoperative management of blunt splenic injury

BackgroundNonoperative management (NOM) is the standard of care in majority of blunt splenic injuries. However, little is known about the postdischarge complications. MethodsPatients admitted for blunt splenic injury were identified in the California State Inpatient Database (2007 to 2011). We examined patterns and risk factors for postdischarge complications among these patients. ResultsIn total, 2,704 (61.45%) patients had NOM without splenic artery embolization (SAE) and 257 (5.84%) had NOM with adjunct SAE. Thirty-day readmission rate was higher in those who had adjunct SAE (12.84% vs 7.36%, P = .002). Subsequent operations during readmission were seen in 18.10% of readmitted patients and 38.10% of all patients were readmitted at nonindex hospitals. Major diagnoses on readmission were spleen injury (36.2%) and respiratory complications (9.05%). Adjunct SAE was an independent risk factor for readmission (adjusted odds ratio 1.82, 95% confidence interval 1.19 to 2.78). ConclusionsNearly one fifth of readmitted patients initially managed nonoperatively required an operative intervention. Improving predischarge assessments and postdischarge follow-up may reduce readmissions among these patients.

Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem

ObjectivesTo determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines. MethodsPatients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups. ResultsA total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics. ConclusionsDespite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

Implantable cardioverter-defibrillator harm in young patients with inherited arrhythmia syndromes: A systematic review and meta-analysis of inappropriate shocks and complications

Implantable cardioverter-defibrillators (ICDs) are implanted with the intention to prolong life in selected patients with inherited arrhythmia syndromes, but ICD implantation is also associated with inappropriate shocks and complications. We aimed to quantify the rate of inappropriate shocks and other ICD-related complications to be able to weigh benefit and harm in these patients. We performed a systematic review and meta-analysis of inappropriate shock and/or other ICD-related complication rates, including ICD-related mortality, in patients with inherited arrhythmia syndromes, that is, arrhythmogenic right ventricular cardiomyopathy/dysplasia, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, hypertrophic cardiomyopathy, dilated cardiomyopathy due to a mutation in the lamin A/C gene, long QT syndrome, and short QT syndrome. We searched MEDLINE and EMBASE from inception to May 30, 2014. Of 2471 unique citations, 63 studies comprising 4916 patients with inherited arrhythmia syndromes (mean age of 39 ± 15 years) were included. Inappropriate shocks occurred in 20% of patients (crude annual rate of 4.7% per year), with a significantly higher rate in studies published before 2008 (6.1% per year vs 4.1% per year). Moreover, 22% experienced ICD-related complications (4.4% per year) and there was a 0.5% ICD-related mortality (0.08% per year). ICD implantation carries a significant risk of inappropriate shocks and inhospital and postdischarge complications in relatively young patients with inherited arrhythmia syndromes. These data can be used to better inform patients and physicians about the expected risk of adverse ICD events and thereby facilitate shared decision making.

Drivers of Readmissions in Vascular Surgery Patients

Readmissions are frequent in vascular surgery patients, but it is not clear which factors are the drivers of readmissions. Specifically, the relative contributions of patient comorbidities vs postoperative complications are unknown. We sought to study the potential drivers of readmission and create a model for predicting the risk of readmission in vascular patients. The 2012 to 2013 American College of Surgeons National Quality Improvement Program data set was queried for unplanned readmissions in vascular patients. Bivariable and multivariable risk adjustment analyses were used to model the relative contributions of patient comorbidities, operative factors, and postoperative complications for readmission. The unplanned readmission rate was 9.3%. The preoperative model based on patient comorbidities predicted readmission risk with a low C index of 0.666; the top five predictors were American Society of Anesthesiologists class, preoperative open wound, inpatient operation, dialysis dependence, and diabetes mellitus. The postoperative model that included postoperative complications predicted readmission risk better (C index, 0.778); postoperative complications were the most significant predictor of readmission, overpowering patient comorbidities. Importantly, postoperative complications identified prior to discharge from the hospital were not a strong predictor of readmission because the model using predischarge postoperative complications had a similar C index to our preoperative model (0.681). However, the inclusion of complications identified after discharge appreciably improved the predictive power of the model (C index, 0.778). The top five predictors of readmission in the final model based on comorbidities and postoperative complications were postdischarge deep space infection, superficial wound infection, pneumonia, myocardial infection, and sepsis. Readmissions in vascular surgery patients are mainly driven by postoperative complications identified after discharge. Thus, efforts to reduce vascular readmissions based on inpatient data may prove ineffective. Our study suggests interventions to reduce vascular readmissions should focus on prompt identification of modifiable postdischarge complications.

Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis

Little is reported about postdischarge complications after bariatric surgery. We sought to identify the rates of postdischarge complications, associated risk factors, and their influence on early hospital readmission. Using the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) (2005-2013), we identified patients ≥18 years of age who underwent a bariatric operation with a primary diagnosis of morbid/severe obesity and a body mass index ≥35. The incidence of postdischarge complication was the primary outcome, and hospital readmission was the secondary outcome. The association between postdischarge complications and various patient factors was explored by the use of multivariable logistic regression. A total of 113,898 patients were identified with an overall postdischarge complication rate of 3.2% within 30 days of operation. The rates decreased from 2005 to 2006 (4.6%) to 2013 (3.0%) (P < .001). On average, postdischarge complications occurred 10 days postoperatively, with wound infection (49.4%), reoperation (30.7%), urinary tract infection (16.9%), shock/sepsis (12.4%), and organ space surgical-site infection (11.0%) being the most common. Patients undergoing open gastric bypass had the greatest postdischarge complication rate of 8.5%. Of those patients experiencing postdischarge complications, 51.6% were readmitted. The overall readmission rate was 4.9%. The factors associated most strongly with increased odds of postdischarge complications were body mass index ≥ 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time. Postdischarge complications after bariatric surgery represent a substantial source of patient morbidity and hospital readmissions. The majority of postdischarge complications are infection-related, including surgical-site infections and catheter-associated urinary tract infections. Adopting and implementing standardized pre- and postoperative strategies to decrease perioperative infection may help to decrease the rate of postdischarge complications and associated readmissions and enhance overall quality of care.

Complications and mortality following surgery for oral cavity cancer: analysis of 408 cases.

To analyze the postoperative complications and mortality for oral cavity cancers, their time course, and to identify modifiable risk factors associated with their occurrence. Retrospective cohort study. Patients undergoing surgery for oral cavity cancer were identified in the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File (2005-2010). Overall and disease-specific complication and mortality data were analyzed using chi-square and multivariate regression analysis. There were 408 cases identified. The overall 30-day complication and mortality rates were 20.3% and 1.0%, respectively. The most common adverse events were reoperation (9.6%), infectious (6.6%), and respiratory (5.1%) complications. Twenty patients (4.9%) experienced postdischarge complications. Fifty-two percent of postdischarge wound dehiscences and 67% of postdischarge surgical-site infections occurred by postdischarge day 7, and 91% of all postdischarge complications occurred by postdischarge day 14. Smoking was independently associated with respiratory (odds ratio [OR] 3.59, P = .008) and surgical site complications (OR 5.13, P =.004). Neck dissection was independently associated with respiratory (OR 6.17, P = .001), surgical site (OR 6.30, P = .003), and infectious (OR 3.83, P = .003) complications. Current smokers and those undergoing neck dissection are at high risk of postoperative complications after oral cavity cancer surgery. Less than 5% of patients experienced postdischarge complications, nearly all of which occurred by postdischarge day 14. Most early postdischarge complications occurred at the surgical site. In order to mitigate postdischarge complications and their sequelae, early clinical follow-up should be sought for high-risk patients. 4.