Procedure Volume Research Articles

Medicare Reimbursement and Utilization Trends Within Skull Base Surgery

Medicare reimbursements for otolaryngology and neurosurgery procedures have generally declined since 2000. We explore Medicare reimbursement trends for anterior cranial fossa, middle cranial fossa, posterior cranial fossa, pituitary surgery, and skull base reconstruction surgery from 2000-2022. Cross-sectional analysis of the Centers for Medicare and Medicaid Services Physician Fee Schedule was performed from 2000-2022 on approach, resection, and repair of the skull base (Current Procedural Terminology codes 31290-31291, 61546, 61548, 61575-61619, and 62165). Reimbursement data were adjusted for inflation to 2022 U.S. dollars, and annual and total changes calculated. The Centers for Medicare and Medicaid Services Part B National Summary Data File was analyzed for trends in Medicare procedure volume and total payment. Adjusted for inflation since 2000, reimbursements for anterior cranial fossa, middle cranial fossa, posterior cranial fossa, pituitary surgery, and skull base reconstruction codes had an overall decrease of 22.85%, 32.43%, 28.09%, 44.22%, and 38.65%, respectively. Simultaneously, procedure volume increased at an average annual rate of 63.99%, 128.57%, 19.75%, 36.11%, and 12.79%, respectively. While nominal per-service Medicare reimbursement has increased for skull base surgery codes, there has been a downward trend in inflation-adjusted procedural reimbursement. This parallels findings in other otolaryngology and neurosurgery procedures. Despite this, surgical volume in all skull base surgery subfields has increased, indicating increased utility and adoption of these techniques.

Graduating Vascular Surgery Trainee Proficiency in Endovascular and Open Peripheral Revascularization Procedures

Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. While it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared to open peripheral vascular revascularization procedures. Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative (SIMPL OR) application database were collected for all vascular surgery participating institutions from 2018-23. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities. Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n=383 endovascular, 323 open). When controlling for training level and case complexity, there were no differences in autonomy (OR 1.11 [95% CI: 0.62-1.99]) or competency assessment (OR 0.86 [95% CI: 0.46-1.59]) for endovascular, as compared to open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). Predicted probability of competence and autonomy for complex procedures was lower but remained similar between groups (competent:73% endovascular, 70% open; autonomous: 92% endovascular, 92% open). There is no difference in the graduating level of autonomy and competence of endovascular as compared to open peripheral revascularization procedures for vascular surgery trainees. These findings suggest vascular surgery trainees enter independent practice with adequate proficiency to utilize the full scope of techniques to care for patients requiring peripheral revascularization procedures.

TCT-331 Use of Automated Contrast Injector Versus Manifold in Cardiac Catheterization Laboratory Procedures Is Not Associated With Reduced Procedural Contrast Volumes or Rates of Acute Kidney Injury

TCT-331 Use of Automated Contrast Injector Versus Manifold in Cardiac Catheterization Laboratory Procedures Is Not Associated With Reduced Procedural Contrast Volumes or Rates of Acute Kidney Injury

Association between Endoscopist Volume and Interval Cancers after Colonoscopy: Results from the National Colorectal Cancer Screening Program in Korea.

The rate of interval colorectal cancer (iCRC) is now accepted as a key performance indicator of organized colorectal cancer (CRC) screening programs. We aimed to examine the association between endoscopist volumes and the rate of iCRC among individuals with a positive fecal immunochemical test (FIT) within a nationwide population-based CRC screening program. Individuals aged ≥ 50 years who underwent colonoscopy after a positive FIT from January 1, 2019 until December 31, 2020 in the Korean National Cancer Screening Program (KNCSP) were enrolled. We converted the data into per-endoscopist screening results, calculated the iCRC rates per endoscopist, and compared them to the previous year's annual volume that was divided into five groups (V1, 1-9; V2, 10-29; V3, 30-59; V4, 60-119; V5, ≥ 120). A total of 10,412 endoscopists performed 216,907 colonoscopies. Overall, the average rate of iCRC per endoscopist was 8.46 per 1,000 examinations. Compared with the group with the highest volume (V5 group), the rate of iCRC was 2.21 times higher in the V1 group. Similar trends were observed in the other groups (V2: relative risks [RR], 2.15; 95% confidence interval [CI], 1.57 to 2.94; V3: RR, 1.56; 95% CI, 1.15 to 2.13; V4: RR, 1.18; 95% CI, 0.83 to 1.67). The findings emphasize that endoscopists with lower procedure volumes have higher risks of interval cancer being missed or undetected. To maximize the preventative impact of colonoscopy for CRC, this issue should be addressed by monitoring endoscopist volumes and variations in performances.

The trends and outcomes of inflammatory bowel disease surgery during the COVID-19 pandemic: A retrospective propensity score-matched analysis from a multi-institutional research network.

The coronavirus disease 2019 (COVID-19) pandemic has affected the management of inflammatory bowel disease (IBD) patients. Elective operations and surveillance endoscopies were postponed for IBD patients to preserve healthcare resources and to prevent the spread of COVID-19. This study aimed to describe the trends and outcomes of IBD surgery during the pandemic. This was a retrospective propensity score-matched analysis using data extracted from TriNetX, a multi-institutional research database. IBD patients admitted for surgery were identified between March 2019 to February 2020 (prepandemic) and March 2020 to February 2023 (pandemic). The monthly volume of IBD surgical procedures was compared during the pandemic to the prepandemic period. After matching, the risk of adverse outcomes following IBD surgery was compared between the 3 years of the pandemic compared to the prepandemic cohort. There was a reduction in both elective and emergency IBD operations during the pandemic. These trends were not significant. After matching, the risks of returning to theaters and hospital readmission were comparable across the 3 years of the pandemic. In the first and second years of the pandemic, elective patients were at a greater risk of mortality (risk ratio [RR], 2; 95% confidence interval [CI], 1.160-3.448 and RR, 1.778; 95% CI, 1.003-3.150, respectively) and the emergency cohort had a higher risk of critical care admission (RR, 1.759; 95% CI, 1.126-2.747 and RR, 1.742; 95% CI, 1.131-2.682, respectively). Our study highlights the impact of the COVID-19 pandemic on the management of IBD patients undergoing surgery. These results provide insights into the management of IBD surgery during times of crisis and can help guide decision-making and resource allocation for IBD patients requiring surgical intervention.

Bilateral penetrating corneal transplantation in a patient with keratoconus and Stormorken Syndrome: a clinical case

Introduction. Keratoconus is a progressive corneal disease that results in thinning, curvature change, and refractive alterations, significantly impairing. visual acuity, even to the point of light perception. In advance stages, corneal transplantation may be necessary. Purpose. This publication aims to analyze a clinical case of corneal transplantation in a patient with keratoconus and Stormorken Syndrome, a rare genetic disorder caused by mutations in the STIM1 gene leading to calcium channelopathies. Case description. Patient Z., a 24-year-old male diagnosed with Stormorken Syndrome in childhood, was referred to the Moscow City Ophthalmological Centre. Comprehensive evaluations, including biomicroscopy, keratopachimetry, and ultrasound eye examination, confirmed keratoconus in both eyes. The patient underwent bilaterial penetrating keratoplasty due to disease progression. Postoperatively, visual acuity was 0.8 in the right eye, and 0.7 in the left eye. Additional clinical observations including bilateral myositis (resistant to medication), hypoinflammation, thrombocytopenia, dyslexia, and proximal muscles weakness, of the consistent with Stormorken Syndrome. Genetical testing confirmed a pathogenic STMI1 mutation. Conclusion. Despite the high volume of keratoplasty procedures at our clinic, this case is noteworthy. The currrent literature lacks reports on penetrating keratoplasty using native donor material in patients with Stormorken Syndrome, highlighting the uniqueness of this case.

Tertiary Care Center Trends in Colonic Stent Placement over the Past Decade.

Colonic endoluminal stent placement is a commonly utilized and effective endoscopic approach for the management of malignant large bowel obstruction and is an emerging approach for the management of some benign etiologies of large bowel obstruction. However, recent studies evaluating the evolution of clinical scenarios and patient populations for which stenting is performed in real-world practice are lacking. We assessed colonic stent utilization patterns in a tertiary care academic medical center over the past 10 years. We analyzed the demographics and patient and procedure characteristics of the initial (first half of study period) and latter (second half of the study period) procedures to assess trends over time using standard descriptive statistics. Our analysis was notable due to its provision of some novel insights. The frequency of colonic stent placement procedures increased significantly over time by comparison of the procedure volume for the initial 5-year interval (22 colonic stent procedures) relative to the latter 5-year interval (49 colonic stent procedures) (p = 0.03). The median age of patients who underwent colonic stent placement was significantly lower in the latter 5 years, compared with the initial 5 years of the study period (mean of 81.41 vs. 58.73 years, respectively, p < 0.001). The increased diversity of indications for colonic stent placement was also noted over time. Our data highlight the evolution of colonic stent placement in tertiary care practice over time and are notable for some interesting trends, including the increased utilization of colonic stent placement over time, the broadening of indications for colonic stent placement to include benign indications, and lower patient age at the time of colonic stent placement over time. These findings will help inform the clinical practice of colonic stent placement and provide a foundation to guide future research on the topic.

Characteristics of High-Quality Multi-Hospital Health Systems Performing Major Cancer Surgery

Objective: To identify characteristics associated with high- and low-quality multi-hospital systems for major cancer surgery Background: Although multi-hospital health systems provide most inpatient healthcare in the US, our understanding of how these systems can optimize surgical quality among their hospitals remains limited. Identifying the structural characteristics (e.g., number of hospitals, procedural volume, geographic dispersion) that distinguish high- and low-quality systems may inform actionable strategies to improve surgical quality. Methods: We conducted a retrospective cross-sectional observational study of 270,491 Medicare beneficiaries (2016-2020) undergoing major cancer surgery at a multi-hospital health system. Systems were classified into quartiles of quality based on risk- and reliability-adjusted rates of 30-day mortality using a hierarchical multivariable logistical regression model to adjust for patient, procedural, and hospital factors. Results: The adjusted 30-day operative mortality rate in the highest- versus lowest-quality quartile of systems was 1.7% versus 3.1%,(P&lt;0.001). High-quality systems had fewer hospitals per system (median [IQR], number of system hospitals, 5 [3-11] vs. 12 [8-30];P&lt;0.001), with each performing more procedures per hospital (median [IQR] annual procedure volume, 104 [52-218] vs. 45 [22-90];P&lt;0.001). High-quality systems were also more geographically concentrated (median [IQR] maximum distance between hospitals, 62 [19-194] vs. 321 [91-1125] miles;P&lt;0.001). Furthermore, high-quality systems demonstrated less variation in quality between hospitals (mean [SD] within-system absolute variation in mortality, 0.8% [0.3%] vs. 2.6% [1.0%];P&lt;0.001). Conclusions: The highest-quality multi-hospital systems had fewer, more geographically concentrated hospitals, with each performing more procedures per hospital. Among the highest-quality systems, diverse system phenotypes were represented, suggesting the potential to overcome structural limitations and achieve high quality.

Clinical Outcomes in Relation to Total Hospital Surgical and Transcatheter Aortic Valve Replacement Volumes.

There is a paucity of data regarding the relationship between overall hospital volumes for total aortic valve replacement (AVR; transcatheter AVR [TAVR] or surgical AVR [SAVR]) and patient outcomes. We queried the 2019 Nationwide Readmission Database for patients undergoing AVR. Based on procedural volumes of TAVR or SAVR, we classified hospitals as high (≥50th percentile) or low (<50th percentile) volume centers and categorized hospitals as high TAVR/high SAVR, high TAVR/low SAVR, high SAVR/low TAVR, and low TAVR/low SAVR. Multivariable regression models were employed. The main study outcomes were in-hospital mortality and 30-day readmission after total AVR. Our final analysis included 72 123 patients undergoing AVR at 400 hospitals across the United States. The median (interquartile range) hospital procedural volumes for total AVR, TAVR, and SAVR were 137 (86-210), 82 (50-127), and 56 (31-87) procedures, respectively. There was an inverse correlation between hospital procedural volumes of AVR, TAVR, or SAVR and in-hospital mortality after total AVR but not with 30-day readmission. Using high TAVR/high SAVR hospitals as reference, there was higher in-hospital mortality after total AVR among low TAVR/low SAVR hospitals (adjusted odds ratio [OR], 1.29 [95% CI, 1.07-1.56]) but similar in-hospital mortality among high TAVR/low SAVR hospitals and low TAVR/high SAVR volumes. There was no difference in 30-day readmission rates after total AVR among the 4 hospital categories. Nationwide data revealed that in-hospital mortality after total AVR (SAVR or TAVR) is inversely related to hospital total volumes of AVR. Patients with aortic stenosis have better outcomes if they are managed among experienced centers with high case volumes of both TAVR and SAVR.

Reducing Length of Hospital Stay Following Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective treatment for severe aortic stenosis across the spectrum of surgical risk cohorts. Subsequently, the dramatic increase in procedural volume worldwide has placed significant financial and logistical pressures on healthcare institutions, particularly regarding hospital length of stay (LOS), which can adversely affect patient flow. In this review article, we discuss different peri-procedural strategies developed to reduce LOS and facilitate early discharge after TAVI.

Procedural volume is linearly associated with mortality, major complications, and readmissions in patients undergoing malignant brain tumor resection.

Improved outcomes have been noted in patients undergoing malignant brain tumor resection at high-volume centers. Studies have arbitrarily chosen high-volume dichotomous cutoffs and have not evaluated volume-outcome associations at specific institutional procedural volumes. We sought to establish the continuous association of volume with patient outcomes and identify cutoffs significantly associated with mortality, major complications, and readmissions. We hypothesized that a linear volume-outcome relationship can estimate likelihood of adverse outcomes when comparing any two volumes. The patient cohort was identified with ICD-10 coding in the Nationwide Readmissions Database(NRD). The association of volume and mortality, major complications, and 30-/90-day readmissions were evaluated in multivariate analyses. Volume was used as a continuous variable with two/three-piece splines, with various knot positions to reflect the best model performance, based on the Quasi Information Criterion(QIC). From 2016 to 2018, 34,486 patients with malignant brain tumors underwent resection. When volume was analyzed as a continuous variable, mortality risk decreased at a steady rate of OR 0.988 per each additional procedure increase for hospitals with 1-65 cases/year(95% CI 0.982-0.993, p < 0.0001). Risk of major complications decreased from 1 to 41 cases/year(OR 0.983, 95% CI 0.979-0.988, p < 0.0001), 30-day readmissions from 1 to 24 cases/year(OR 0.987, 95% CI 0.979-0.995, p = 0.001) and 90-day readmissions from 1 to 23 cases/year(OR 0.989, 95% CI 0.983-0.995, p = 0.0003) and 24-349 cases/year(OR 0.9994, 95% CI 0.999-1, p = 0.01). In multivariate analyses, institutional procedural volume remains linearly associated with mortality, major complications, and 30-/90-day readmission up to specific cutoffs. The resulting linear association can be used to calculate relative likelihood of adverse outcomes between any two volumes.

SP2.8 - The undifferentiated general surgical take over 10 years: emergency operating

Abstract Aims The aim of this study is to further understand the specific pressures on the department’s operating theatres and capacity, and to identify areas in which we could adapt to facilitate these demands, by reviewing the undifferentiated general surgical admissions in a District General Hospital in July 2013 and July 2023. Methods All patients seen by the emergency general surgical team in July 2013 and July 2023 were identified retrospectively. Data was gathered using electronic notes, to analyse admissions and surgeries within 30 days. Patients were excluded if there was insufficient information available. Results 26% (n=102/395) of all patients treated by emergency general surgical teams in July 2013 had surgery within 30 days. This proportion reduced to 23% (134/594) in July 2023, however overall volume has increased by 31%. The proportion of procedures performed on the day of admission has decreased from 10% to 7%. 3% of procedures were performed under local anaesthetic both in 2013 and 2023. Wait from admission to surgery has decreased from 2.84 days (+/-0.6, p=0.02) in 2013, to 1.9 days in 2023 (+/-0.83, p=0.02). Conclusions Although volume of procedures within the same 31-day period has increased throughout the 10 years, the proportion of patients that proceed to intervention has reduced marginally. This is reflected in the increasingly busy emergency operating lists throughout the country, with little change in resources to account for increasing volume. The rising proportion of patients managed conservatively may represent improving medical management of conditions, or more pragmatic management of frail patients.

The Impact of the COVID-19 Pandemic on Case Volume and Wait Times of Elective Hand Procedures: A Retrospective Chart Review Study.

Introduction: The COVID-19 pandemic has decreased the number of surgeries performed in North America. The purpose of this study was to compare the number of elective hand surgeries performed during the pandemic to a corresponding pre-pandemic time period and to quantify the impact to the surgical backlog in hand surgery. Methods: Patient health records for individuals who underwent surgical management of carpal tunnel syndrome (CTS), Dupuytren's disease (DD) or stenosing tenosynovitis (time periods: March 11, 2018 to July 1, 2019 [pre-pandemic] and March 11, 2020 to July 1, 2021 [pandemic]) were retrieved from two academic institutions. The primary outcome was number of surgeries performed in each time period. Secondary outcomes included wait times for each time period; and variables as predictors of wait times, including a) age; b) gender; c) socioeconomic status; d) geographic location; and, e) comorbidities. Results: Seven-hundred-and-fifteen cases were included (447 CTR cases, 135 fasciotomy/subtotal palmar fasciectomy cases and 133 pulley release/tendon release cases). Two-hundred-and-sixty-four elective hand procedures were performed during the COVID-19 time period, compared to 451 in the pre-pandemic time period (n = 187 surgeries, 41.5%). Mean surgical wait times decreased for CTS and DD and increased for stenosing tenosynovitis during the pandemic compared to the corresponding pre-pandemic time period. No association or variation in wait times was found in regard to the aforementioned variables. Conclusions: During the pandemic, a decreased total number of elective hand surgeries were performed when compared to the corresponding pre-pandemic period. This contributes to a backlog of elective surgical procedures.

Elbow arthroplasty utilization in 2060: projections of primary and revision elbow arthroplasty in the United States in the next 40 years

BackgroundIn the past decade the prevalence of end stage inflammatory elbow arthritis has declined with consequential changes in indications and utilization of total elbow arthroplasty (TEA). Current literature lacks future projections for the utilization of TEA. This aim of this study is to review the trends in utilization of TEA in last two decades and determine the projections of utilization for TEA (primary and revision) through 2060. MethodsThis analysis utilized the publicly available 2000-2019 data from the CMS Medicare Part-B National Summary. Procedure volumes including TEA, and revision TEA, were determined using current procedural terminology (CPT) codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Using these volumes log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average (ARIMA) models were applied to generate projections from 2020-2060. The Poisson model was chosen to display the data based on error analysis and prior literature. ResultsThe projected annual growth rate from 2020 to 2060 for primary and revision TEA are 1.03% growth (95% CI 0.82% - 1.25%) and 5.17% growth (95% CI 3.02%-6.97%), respectively. By 2060, the demand for primary TEA and revision TEA is projected to be 2084 procedures (95% FI 1995 – 2174) and 3161 procedure (95% FI 3052 – 3272), respectively. The procedure volume for revision TEA is estimated to outnumber primary TEA by year 2050. ConclusionThe overall procedural volume of primary TEA, and revision TEA continues to be low. Although it is estimated that the incidence of primary and revision TEA will continue to increase in next 40 years, the utilization trends only show mild increase, which is five times higher for revision TEA compared to primary TEA.

Adapting the WHO hand hygiene ‘reminders in the workplace’ to improve acceptability for healthcare workers in maternity settings worldwide: a mixed methods study

IntroductionHand hygiene is key in preventing healthcare-associated infections, but it is challenging in maternity settings due to high patient turnover, frequent emergencies and volume of aseptic procedures. We sought to...

Examining the Impact of a GI Hospitalist Model on the Outcomes of Double-Balloon Enteroscopy: A Single-Center Retrospective Study.

A GI hospitalist (GIH) is a physician who practices in the inpatient setting performing consultations and endoscopic procedures. Obscure small bowel bleeding is a common inpatient diagnosis that is difficult to manage and associated with longer hospitalizations. Having an onsite GIH physician with expertise in video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) has the potential to improve patient outcomes. This study will be the first to explore how implementing a GIH model and providing a GIH with training in DBE can affect the outcomes of patients with small bowel pathology. We performed a retrospective study of patients who received an inpatient DBE at an academic medical center before and after initiation of a GIH model and credentialing of a GIH in DBE. We compared outcomes, including procedure volumes, diagnostic and therapeutic yields, procedure duration, time to procedure, and length of stay. There was a 46.5% increase in the number of DBEs performed by the GIH. The diagnostic yield increased from 56.3 to 74.0% (OR 2.2, 95% CI 1.2-4.2), and the proportion of DBEs with a therapeutic intervention increased from 38.0 to 65.4% (OR 3.1, 95% CI 1.4-7.0). The total procedure time increased from 77.8 to 96.4min (p < 0.05) with a GIH. Having a GIH perform inpatient DBEs was associated with an increased number of procedures, duration of procedures, diagnostic yield, and therapeutic interventions. The onsite presence of a GIH with competency in DBE improves the care of hospitalized patients with small bowel pathology.

Impact of hospital volume and facility characteristics on postoperative outcomes after hepatectomy: A mediation analysis

BackgroundThe impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy. MethodsData on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue. ResultsThe analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue. ConclusionsHospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection.

Wrist and Hand Arthroscopy Procedure Volume Is Low Among Graduating Orthopaedic Surgery Residents

Wrist and Hand Arthroscopy Procedure Volume Is Low Among Graduating Orthopaedic Surgery Residents

Characteristics of Patients Undergoing Fetal Potassium Chloride Injection at a Single Center Over Time.

Changes in the U.S. laws, particularly the Dobbs decision in 2022, altered access to abortions. Fetal potassium chloride (KCl) injections can be used for second- and third-trimester abortions. This descriptive study aims to present the characteristics of patients who received KCl injections in a state with protective laws (Colorado), including pre- and post-Dobbs. Patients undergoing KCl injection at our institution between January 2014 and December 2023 were included. Records were reviewed for demographic data, parity, and procedure details. Distance traveled and area deprivation index (ADI) were determined based on residence data. Group differences pre- and post-Dobbs were analyzed using Chi-squared and Mann-Whitney U tests. Subanalyses were performed to compare in-state and out-of-state (OOS) patients. One hundred and nineteen patients were included: 56 pre-Dobbs and 63 post-Dobbs, representing a 6.4-fold increase in volume post-Dobbs. Patients were from 10 states of residence pre-Dobbs and 17 post-Dobbs. Median distance traveled significantly increased post-Dobbs, 29.8 versus 383.9 miles (p = 0.004). The maximum distance traveled was 855 miles pre-Dobbs and 1,201 miles post-Dobbs. ADI did not vary pre- or post-Dobbs. Singleton procedures increased post-Dobbs for all patients. There was no change in gestational duration at the time of procedure across any comparison. Procedure volume and distance traveled increased for both in-state and OOS patients with minimal change in patient characteristics pre- and post-Dobbs. Our data indicate an increased need for these procedures, even in a state with protective laws.

Smaller Hospital Size is Associated With Higher Mortality in Stanford Type A Aortic Dissection.

Stanford Type A Aortic Dissection (TAAD) is associated with high in-hospital mortality and the need for immediate surgical intervention. Larger hospital size may be associated with better patient care and surgical outcomes. This study aimed to examine the effect of hospital size on TAAD outcomes. Patients who underwent TAAD repair were identified in National Inpatient Sample (NIS) from Q4 2015-2020. NIS stratifies hospital size into small, medium, and large based on the number of hospital beds, geographical location, and the teaching status of the hospitals. Patients admitted to small/medium and large hospitals were stratified into two cohorts. Multivariable logistic regressions were performed to compare in-hospital outcomes, adjusted for demographics, comorbidity, primary payer status, and hospital characteristics including procedural volume. There were 1106 and 3752 TAAD admitted to small/medium and large hospitals, respectively. Among patients admitted to small/medium hospitals, there was higher mortality (17.27% vs 14.37%, aOR = 1.32, P < 0.01), but shorter length of stay (P < 0.01) and lower cost (P = 0.03) compared to larger hospitals. There was no difference in morbidities. Marked higher mortality is associated with admission to smaller hospitals among patients with TAAD, which may in turn decrease the average hospital stay and cost. Given that a significant percentage of patients are already being transferred out of the initial hospital and small/medium hospital is associated with higher mortality, centralization of care in centers of excellence may decrease the high mortality associated with TAAD.