Same-day Admission Research Articles

Opioid use among same-day surgery patients: Prevalence, management and outcomes.

To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes. A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naive patients. Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking.

The Risk of Hypertension After Preoperative Discontinuation of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists in Ambulatory and Same-Day Admission Patients

Twersky, Rebecca S.*; Goel, Vasudha*; Narayan, Preeti*; Weedon, Jeremy† Author Information

Hospitalization before surgery increases risk for postoperative infections

Exposure to a health care facility before surgery may increase risk for postoperative infections. Our objectives were to (1) determine whether the prevalence of postoperative infections was higher among patients who were hospitalized before cardiac surgery, (2) identify risk factors for infection, and (3) evaluate in-hospital outcomes. A total of 32,707 patients underwent cardiac surgery from January 1, 2000, to January 1, 2011. Forty percent (13,107) were hospitalized before their surgery date or were transfers from other health care facilities, and 60% (19,600) were same-day admissions. The primary outcome consisted of a composite infection: pneumonia, sepsis, surgical site infection, and urinary tract infection. The secondary outcome was in-hospital death. The propensity method was used to compare infectious complications and mortality between groups. Overall infectious complications occurred in 2327 patients (7.1%). Overall composite and individual infections decreased over the study period (P for trend <.0001). Among 7814 propensity-matched pairs, 522 infections (6.7%) occurred in the same-day admission group versus 676 (8.7%) in the prior hospitalization group, P<.0001. In-hospital mortality was 1.5% (n=120) for the same-day admission group versus 2.8% (n=221) for the prior hospitalization group (P<.0001). Although the risk of infection decreased over time, the relationship between exposure to a health care facility before surgical intervention and higher infection risk remained substantial. Further investigation into processes of care surrounding infection control is necessary to reduce postoperative infections and associated morbidity.

The Risk of Hypertension after Preoperative Discontinuation of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists in Ambulatory and Same-Day Admission Patients

The continued use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II subtype I receptor antagonists (ARBs) medications in the preoperative period has been reported to be associated with intraoperative hypotension that can be unresponsive to pressor drugs. As a result, several investigators suggested discontinuation of these medications before scheduled surgery but did not report on unintended consequences that might result from discontinuation. We conducted a prospective, single-blind, randomized trial to observe the effect of the medications on preoperative arterial blood pressure recordings in patients presenting for ambulatory and same-day surgery. Six hundred forty-four patients presenting for ambulatory and same-day surgery were enrolled prospectively between 2006 and 2011 and randomly assigned to 2 groups based on continuation or discontinuation of ACEIs and ARBs. An intention-to-treat analysis was performed. The primary outcome was presence of hypertension (HTN) immediately before surgery. Secondary outcomes included surgical cancellations due to HTN, prolongation of hospitalization, adverse clinical events, and HTN in the postoperative period. Data for 526 patients were analyzed. There were 262 patients in the discontinuation group and 264 patients in the continuation group. Discontinuation of ACEIs and ARBs on the day of surgery was not associated with increased prevalence of preoperative HTN (P = 0.775). The upper bound of a 95% confidence interval for the difference in prevalence of Stage 1 and 2 HTN between study arms indicates that discontinuation of study medication is unlikely to be associated with an increase in Stage 1 HTN of >4.8 percentage points and in Stage 2 HTN of no >5.8 percentage points. Discontinuation was not associated with an increase in postoperative HTN, with prolongation of hospitalization or with adverse clinical events. Discontinuing ACEIs and ARBs in patients on the day of surgery did not result in a substantively increased incidence of pre- or postoperative HTN compared with patients who continued these medications on the day of surgery. The results provide an evidentiary basis for the safety of discontinuing ACEIs and ARBs on the day of surgery without increasing adverse hemodynamic outcomes.

Private and public patients in public hospitals in Australia

IntroductionThe nature of the private–public mix in health insurance and in health care is a major issue in most health systems. ObjectiveTo compare the hospitalization characteristics of private and public patients hospitalized in public hospitals. MethodsWe focused on planned, overnight and same-day admissions, discharged during 2004–2005 from the public New South Wales hospitals, and run fixed-effects regressions in order to identify the effect of accommodation status (private/public) on the hospitalization characteristics. ResultsPrivate patients have one third less waiting days than public patients, and they are assigned higher urgency of admission. Length of stay and length of visit are both unrelated to the accommodation status, however, private patients tend to have more hours in ICU and more procedures performed during the hospitalization. In-hospital mortality and the number of transfers (wards) are not affected by the accommodation status. ConclusionsPrivate patients are treated differently than public patients in public hospitals, reinforcing the private health insurance-related inequity in inpatient care identified by others. Two health policy issues emerge from the findings: the role of private health insurance in the Australian socialized medicine system, and in particular, in the public hospitals; and the way public hospitals are reimbursed for private patients.

Do outlier inpatients experience more emergency calls in hospital? An observational cohort study

To determine the effect of spending time as an outlier (ie, an inpatient who spends time away from his or her "home" ward) on the frequency of emergency calls for patients admitted to a tertiary referral hospital. Observational cohort study of all patients admitted to a university-affiliated tertiary referral hospital in Melbourne, Victoria, between 1 July 2009 and 30 November 2011. The number of emergency calls per hospital admission, with reference to location within the hospital. There were 58,158 admissions during the study period. The median age of admitted patients was 61 years, 55% were male, and the inhospital mortality was 1.40%. In 11,034 admissions (18.97%), patients spent time as outliers. Inhospital mortality was 2.57% in the outlier group versus 1.12% in the non-outlier group (P < 0.001). After adjusting for age, same-day admission, 10-year predicted mortality, interhospital transfer and high-risk clinical units, outlier status was associated with a 53% increase in emergency calls (P < 0.001). This study found a strong association between time spent away from a patient's home ward and the number of emergency calls. We postulate that outlier patients are at risk as they may have therapeutic and monitoring needs that are only available on their home ward. With increasing pressure to move patients out of the emergency department, the number of outlier patients may increase.

An innovative case management

PURPOSE/OBJECTIVES This article identifies the necessity of a registered nurse case manager gatekeeper in the postanesthesia care unit (PACU) at Mayo Clinic Hospital, Phoenix, AZ. The Centers for Medicare & Medicaid Services have mandated certain criteria regarding the status of same-day postprocedure surgery hospital admissions that must be adhered to in order to receive appropriate reimbursement for surgical procedures. The changes in reimbursement for surgical procedures have become more challenging. To receive optimal reimbursement for surgical procedures, Mayo Clinic Hospital initiated a case management position in the PACU to ensure compliance with the Centers for Medicare & Medicaid Services requirements. This article discusses how the case management role was developed using the Medicare inpatient-only list status determination to achieve a positive financial outcome. PRIMARY PRACTICE SETTING cute care hospitals that perform surgical procedures. FINDINGS AND CONCLUSIONS In 2010, Mayo Clinic Hospital sustained a loss of $357,128 from incorrect status determinations and orders. In 2011, the PACU registered nurse case manager gatekeeper program achieved a savings of $1 million. The estimated savings for 2012 through the end of November is approximately $1.6 million. IMPLICATIONS FOR CASE MANAGEMENT This article addresses the following:

Surgery Cancelation on the Day of Surgery in Same-Day Admission in a Finnish Hospital

Surgery cancelations cause inappropriate use of hospital resources and additional financial and psychological stress to patients. Cancelation rates have been described to be even more than 10% of scheduled cases. Preoperative anesthesia evaluation clinics have been initialized to decrease cancelation rates. At Hyvinkää hospital, 95% of elective surgical patients are admitted on the morning of operation, and only 25% of these patients visit preoperative anesthesia evaluation clinic prior to surgery. Cancelation rate in Finnish hospitals has not been described. We studied retrospectively 12,205 scheduled elective same-day admission surgical cases at Helsinki and Uusimaa Hospital District, Hyvinkää hospital for a period of 2 years. Obstetric cases, emergency cases, and a few inpatient cases were excluded. A case was considered as canceled if surgery was canceled after the finalization of operation room schedule for the next day. Cancelation rates among different specialties and reasons for cancelation were analyzed. A total of 12,205 surgeries were scheduled during the study period, and 551 (4.5%) of these were canceled. The highest cancelation rate was in hand surgery, with 8.2% of scheduled cases, followed by orthopedic surgery with 5.4%, and pediatric surgery with 5.1% cancelation rate. Endocrinology had no cancelations, and breast, urology, and vein surgery also had less than 2% of canceled cases. Patient-related issues caused 72.4% of cancelations, and operation no longer being necessary caused 26% of all cancelations. Day of surgery cancelation rate was low in same-day admission, although it varied between specialties. Specialties having explicit surgery indications had fewer cancelations than specialties having surgery indications based on more subjective diagnostic. Process improvements need to be considered continuously to further decrease cancelation rate.

A Peri-Operative Audit of the Paediatric Cochlear Implantation Programme at the Singapore General Hospital

Introduction: Paediatric cochlear implantation has become an established procedure for treating irreversible hearing loss. The aim of this survey was to review the peri-operative anaesthetic management of this programme since its inception. Methods: We conducted a retrospective clinical audit of 184 paediatric (age &lt;12) cochlear implantation cases by reviewing clinical records. The surgery was performed by the same surgeon at the Singapore General Hospital (SGH) from 1997 to 2010. Results: A total of 184 procedures (including five bilateral cases) were performed on 173 patients. The average age (mean [standard deviation, range]) at the time of surgery was 3.7 (±2.6, 0.7–11) years. The mean duration of the unilateral and bilateral implantation procedures were 3.2 (±1.0, 1.2–6.5) hours and 4.7 (±0.8, 4–6) hours respectively. Inhalational anaesthesia (66.3%) was the most popular choice for induction. 15 (8.1%) patients required additional analgesia in the post-anaesthetic care unit. In the ward, 14 patients (7.6%) required stronger analgesia in addition to paracetamol. Peak paracetamol requirement (22.9 [±16.6] mg/kg) was on the first postoperative day. Nausea and vomiting was reported in 19 (10.3%) procedures. The correlation between increasing age and post-operative nausea and vomiting was statistically significant (p&lt;0.05) as was the association between age and analgesic requirements. The average duration of hospital stay was 3.2 (±1.0, 1–6) days. Mean age at time of surgery as well as duration of unilateral implantation procedures decreased over time. A trend towards same day admission (SDA) was also noted. Conclusion: Cochlear implantation in paediatric patients is a relatively safe procedure involving few complications.

An Innovative Case Management Gatekeeper Model for Medicare Surgeries

This article identifies the necessity of a registered nurse case manager gatekeeper in the postanesthesia care unit (PACU) at Mayo Clinic Hospital, Phoenix, AZ. The Centers for Medicare & Medicaid Services have mandated certain criteria regarding the status of same-day postprocedure surgery hospital admissions that must be adhered to in order to receive appropriate reimbursement for surgical procedures. The changes in reimbursement for surgical procedures have become more challenging. To receive optimal reimbursement for surgical procedures, Mayo Clinic Hospital initiated a case management position in the PACU to ensure compliance with the Centers for Medicare & Medicaid Services requirements. This article discusses how the case management role was developed using the Medicare inpatient-only list status determination to achieve a positive financial outcome. cute care hospitals that perform surgical procedures. In 2010, Mayo Clinic Hospital sustained a loss of $357,128 from incorrect status determinations and orders. In 2011, the PACU registered nurse case manager gatekeeper program achieved a savings of $1 million. The estimated savings for 2012 through the end of November is approximately $1.6 million. This article addresses the following:

Trends in elective knee arthroscopies in a population‐based cohort, 2000–2009

To assess the use of elective knee arthroscopy procedures for all adults 20 years and older, and for adults with a concomitant diagnosis of osteoarthritis (OA) in Victoria. Retrospective, longitudinal cohort study of 807 030 elective orthopaedic admissions using routinely collected public and private hospital data from 1 July 2000 to 30 June 2009. Trends in rates of elective knee arthroscopy in the time period (defined as a statistically significant change in the incident rate ratio for each financial year with respect to the reference year). Subgroup analyses were undertaken for patients with an associated diagnosis of OA. There were 190 881 admissions for 159 528 patients having an elective knee arthroscopic procedure. There was a significant decrease in arthroscopic procedures from the 2000-01 financial year, after adjusting for growth in elective orthopaedic volume and relevant patient and hospital characteristics. The trend did not apply to patients with osteoarthritis of the knee. A significant shift in the use of multiday procedures undertaken in high volume, public hospital settings to same-day admissions in the private sector was also identified. The overall rate of elective knee arthroscopy in Victorian hospitals has decreased. There has been no sustained reduction in arthroscopy use for people with a concomitant diagnosis of OA, despite published evidence questioning the effectiveness of the procedures.

Is the benefit of intraoperative sentinel lymph node biopsy (SLNB) analysis using one-step nucleic-acid amplification (OSNA) negated by the need for further breast surgery?

Is the benefit of intraoperative sentinel lymph node biopsy (SLNB) analysis using one-step nucleic-acid amplification (OSNA) negated by the need for further breast surgery?

Pressure Ulcer Prevalence and Risk Factors During Prolonged Surgical Procedures

Pressure ulcer formation related to positioning while in the OR increases the length of hospital stay and hospital costs, but there is little evidence documenting how positioning devices used in the OR influence pressure ulcer development when examined with traditional risk factors. The aim of this prospective cohort study was to identify the prevalence of and risk factors associated with pressure ulcer development among patients undergoing surgical procedures lasting longer than three hours. Participants included all adult same-day admission patients scheduled for a three-hour surgical procedure during an eight-month period (N = 258). Data were gathered preoperatively, intraoperatively, and postoperatively on pressure ulcer risk factors. Bivariate analyses indicated that the type of positioning (ie, heels elevated) (χ 2 = 7.897, P = .048), OR bed surface (ie, foam table pad) (χ 2 = 15.848, P = .000), skin assessment in the postanesthesia care unit (χ 2 = 41.652, P = .000), and male gender (χ 2 = 6.984, P = .030) were associated with pressure ulcer development. Logistic regression analyses indicated that the use of a foam pad (β = 2.691, P = .024) and a lower day-one Braden score (β = .244, P = .003) were predictive of pressure ulcers.

Coding Hospital Evaluation and Management Services for the Noncritical Patient

When to report hospital observation services, hospital inpatient services, and observation or inpatient care same-day admission and discharge services 99217--99239

319 PAYMENTS FOR OUTPATIENT UROLOGIC CARE IN NON-HOSPITAL-BASED SETTINGS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness1 Apr 2011319 PAYMENTS FOR OUTPATIENT UROLOGIC CARE IN NON-HOSPITAL-BASED SETTINGS John M. Hollingsworth, Julie C. Lai, Christopher S. Saigal, Christopher P. Filson, Brent K. Hollenbeck, and Urologic Diseases in America Projectc John M. HollingsworthJohn M. Hollingsworth Ann Arbor, MI More articles by this author , Julie C. LaiJulie C. Lai Santa Monica, CA More articles by this author , Christopher S. SaigalChristopher S. Saigal Los Angeles, CA More articles by this author , Christopher P. FilsonChristopher P. Filson Ann Arbor, MI More articles by this author , Brent K. HollenbeckBrent K. Hollenbeck Ann Arbor, MI More articles by this author , and Urologic Diseases in America Projectc More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2638AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The delivery of outpatient urologic care within a hospital infrastructure that is designed and maintained for inpatient care may have important implications for payers. Motivated by this, we compared payments made for common urologic procedures that can be performed in multiple ambulatory settings. METHODS Using a 5% random sample of Medicare beneficiaries (1998–2006), we identified elderly adults who underwent one of 20 urologic procedures. First, we determined where each procedure was performed: a hospital outpatient department (HOPD), an ambulatory surgery center (ASC), or a physician office (PO). We then measured payments made between the index date and 30 days post procedure. Finally, we used multivariable linear regression to examine the association between log-transformed payments and the type of ambulatory setting. RESULTS Eight-five percent of the procedures examined were performed in a PO. With the exception of minimally invasive surgical therapies (MIST) for prostate enlargement, median total payments for each procedure type were substantially lower in ASCs and POs versus HOPDs (Table). Across ambulatory settings, same-day admissions and readmissions within 30 days were the largest drivers of median total payments. Even after adjustment for patient demographics, geographic region, and disease severity, log-transformed payments were lower for procedures performed in a PO versus a HOPD (P<0.001). Median Total Payments in U.S. Dollars (25th, 75th percentile) Procedure Type HOPD ASC PO Endoscopic bladder procedures 799(472,1595) 617(412,1373) 197(146,270) Prostate biopsy 1948(490,1254) 1347(482,960) 317(164,272) Urodynamic procedures 1318(843,2187) 1158(673,1864) 351(74,244) Endoscopic urethral procedures 1201(816,1747) 1086(714,1612) 335(202,462) Endoscopic ureteral procedures 1884(1194,3513) 1843(1072,3577) 291(200,538) Urethral dilation/catheter placement 683(264,1210) 255(146,480) 77(55,125) Shockwave lithotripsy 3940(3010,6960) 3178(2863,4038) 822(721,1682) MIST for prostate enlargement 2912(2414,3602) 3094(2479,4179) 3549(3138,3999) CONCLUSIONS These data support payment policies that encourage the provision of outpatient urologic care in less resource-intensive settings. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e129-e130 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information John M. Hollingsworth Ann Arbor, MI More articles by this author Julie C. Lai Santa Monica, CA More articles by this author Christopher S. Saigal Los Angeles, CA More articles by this author Christopher P. Filson Ann Arbor, MI More articles by this author Brent K. Hollenbeck Ann Arbor, MI More articles by this author Urologic Diseases in America Projectc More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

40 DO SHORT-TERM OUTCOMES FOLLOWING COMMON UROLOGIC PROCEDURES VARY BY THE AMBULATORY CARE SETTING WHERE THEY WERE PERFORMED?

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes1 Apr 201140 DO SHORT-TERM OUTCOMES FOLLOWING COMMON UROLOGIC PROCEDURES VARY BY THE AMBULATORY CARE SETTING WHERE THEY WERE PERFORMED? John M. Hollingsworth, Julie C. Lai, Christopher S. Saigal, Christopher P. Filson, Brent K. Hollenbeck, and Urologic Diseases in America Project, Los Angeles, CA John M. HollingsworthJohn M. Hollingsworth Ann Arbor, MI More articles by this author , Julie C. LaiJulie C. Lai Santa Monica, CA More articles by this author , Christopher S. SaigalChristopher S. Saigal Los Angeles, CA More articles by this author , Christopher P. FilsonChristopher P. Filson Ann Arbor, MI More articles by this author , Brent K. HollenbeckBrent K. Hollenbeck Ann Arbor, MI More articles by this author , and Urologic Diseases in America Project, Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.103AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The savings achieved by payers from steering urologic procedures to ambulatory surgery centers (ASCs) and physician offices (POs) may be wholly mitigated if the quality of care at these less resource-intense facilities is not comparable to that of hospital outpatient departments (HOPDs). Motivated by this concern, we assessed short-term outcomes for patients across ambulatory care settings. METHODS Using a 5% random sample of Medicare beneficiaries (1998–2006), we identified elderly adults who underwent one of 20 common outpatient urologic procedures. Through appropriate place-of-service and revenue codes, we determined the facility type at which each procedure was performed (i.e., HOPD, ASC, or PO). We then measured the incidence of same-day admissions, as well as the frequency of hospitalization, complications, and death within 30 days of the index date. Finally, we fit multivariable logistic regression models to evaluate the association between an event occurrence and the ambulatory setting where care was delivered. RESULTS Over the study period, the proportion of procedures performed at ASCs remained relatively stable. However, there was a substantial increase in frequency PO-based procedures, reflecting a shift in care away from HOPDs. While patients treated in a PO (versus a HOPD) had lower odds of experiencing an adverse event (OR, 0.90; 95% CI, 0.81–0.99), the predicted probability of any adverse event was exceedingly low irrespective of the ambulatory care setting (Figure). CONCLUSIONS These data indicate a shift in outpatient urologic care to the PO. Insofar as the care provided in these facilities is less expensive, this trend represents delivery of higher value care for payers. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e16-e17 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information John M. Hollingsworth Ann Arbor, MI More articles by this author Julie C. Lai Santa Monica, CA More articles by this author Christopher S. Saigal Los Angeles, CA More articles by this author Christopher P. Filson Ann Arbor, MI More articles by this author Brent K. Hollenbeck Ann Arbor, MI More articles by this author Urologic Diseases in America Project, Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Does speed matter? The impact of operative time on outcome in laparoscopic surgery

Controversy exists concerning the importance of operative time on patient outcomes. It is unclear whether faster is better or haste makes waste or similarly whether slower procedures represent a safe, meticulous approach or inexperienced dawdling. The objective of the present study was to determine the effect of operative time on 30-day outcomes in laparoscopic surgery. Patients who underwent laparoscopic general surgery procedures (colectomy, cholecystectomy, Nissen fundoplication, inguinal hernia, and gastric bypass) from the ACS-NSQIP 2005-2008 participant use file were identified. Exclusion criteria were defined a priori to identify same-day admission, elective procedures. Operative time was divided into deciles and summary statistics were analyzed. Univariate analyses using a Cochran-Armitage test for trend were completed. The effect of operative time on 30-day morbidity was further analyzed for each procedure type using multivariate regression controlling for case complexity and additional patient factors. Patients within the highest deciles were excluded to reduce outlier effect. A total of 76,748 elective general surgical patients who underwent laparoscopic procedures were analyzed. Univariate analyses of deciles of operative time demonstrated a statistically significant trend (p<0.0001) toward increasing odds of complications with increasing operative time for laparoscopic colectomy (n=10,135), cholecystectomy (n=37,407), Nissen fundoplication (n=4,934), and gastric bypass (n=17,842). The trend was not found to be significant for laparoscopic inguinal hernia repair (n=6,430; p=0.14). Multivariate modeling revealed the effect of operative time to remain significant after controlling for additional patient factors. Increasing operative time was associated with increased odds of complications and, therefore, it appears that speed may matter in laparoscopic surgery. These analyses are limited in their inability to adjust for all patient factors, potential confounders, and case complexities. Additional hierarchical multivariate analyses at the surgeon level would be important to examine this relationship further.

Estimating the acute health effects of coarse particulate matter accounting for exposure measurement error

In air pollution epidemiology, there is a growing interest in estimating the health effects of coarse particulate matter (PM) with aerodynamic diameter between 2.5 and 10 μm. Coarse PM concentrations can exhibit considerable spatial heterogeneity because the particles travel shorter distances and do not remain suspended in the atmosphere for an extended period of time. In this paper, we develop a modeling approach for estimating the short-term effects of air pollution in time series analysis when the ambient concentrations vary spatially within the study region. Specifically, our approach quantifies the error in the exposure variable by characterizing, on any given day, the disagreement in ambient concentrations measured across monitoring stations. This is accomplished by viewing monitor-level measurements as error-prone repeated measurements of the unobserved population average exposure. Inference is carried out in a Bayesian framework to fully account for uncertainty in the estimation of model parameters. Finally, by using different exposure indicators, we investigate the sensitivity of the association between coarse PM and daily hospital admissions based on a recent national multisite time series analysis. Among Medicare enrollees from 59 US counties between the period 1999 and 2005, we find a consistent positive association between coarse PM and same-day admission for cardiovascular diseases.

Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and efficacy of postoperative administration supported by recent trials of new oral anticoagulants.

In European countries, low-molecular-weight heparin is generally initiated preoperatively for thromboprophylaxis in hip or knee replacement surgery. The objective of this review is to compare pre- and postoperative thromboprophylaxis strategies using available evidence, and discuss the challenges and issues that arise. Surgery is the first step in the process of thrombus formation, but thrombosis is not an instant process and the formation and growth of the thrombus can take several days or weeks. Hence, it may be possible to stop this process if thromboprophylaxis is initiated after surgery. Meta-analyses or systematic reviews comparing pre- and postoperative initiation of therapy have found no consistent differences in efficacy and similar safety (bleeding rates) between the two strategies. The recently available oral anticoagulant dabigatran etexilate provides thromboprophylaxis when administered postoperatively and is as safe as preoperative enoxaparin. Further support for the use of postoperative oral thromboprophylaxis in hip or knee replacement surgery has been provided by the phase III clinical trials of rivaroxaban and apixaban versus preoperative enoxaparin. Postoperative thromboprophylaxis offers the opportunity to change management practices in Europe. As postoperative initiation may have a clinical benefit in some settings (e.g. for neuraxial anesthesia) and practical advantages (e.g. allowing same-day admission), it is a worthwhile thromboprophylactic strategy for hip or knee replacement surgery.

Distributed Lag Analyses of Daily Hospital Admissions and Source-Apportioned Fine Particle Air Pollution

BackgroundPast time-series studies of the health effects of fine particulate matter [aerodynamic diameter ≤ 2.5 μm (PM2.5)] have used chemically nonspecific PM2.5 mass. However, PM2.5 is known to vary in chemical composition with source, and health impacts may vary accordingly.ObjectiveWe tested the association between source-specific daily PM2.5 mass and hospital admissions in a time-series investigation that considered both single-lag and distributed-lag models.MethodsDaily PM2.5 speciation measurements collected in midtown Manhattan were analyzed via positive matrix factorization source apportionment. Daily and distributed-lag generalized linear models of Medicare respiratory and cardiovascular hospital admissions during 2001–2002 considered PM2.5 mass and PM2.5 from five sources: transported sulfate, residual oil, traffic, steel metal works, and soil.ResultsSource-related PM2.5 (specifically steel and traffic) was significantly associated with hospital admissions but not with total PM2.5 mass. Steel metal works–related PM2.5 was associated with respiratory admissions for multiple-lag days, especially during the cleanup efforts at the World Trade Center. Traffic-related PM2.5 was consistently associated with same-day cardiovascular admissions across disease-specific subcategories. PM2.5 constituents associated with each source (e.g., elemental carbon with traffic) were likewise associated with admissions in a consistent manner. Mean effects of distributed-lag models were significantly greater than were maximum single-day effect models for both steel- and traffic-related PM2.5.ConclusionsPast analyses that have considered only PM2.5 mass or only maximum single-day lag effects have likely underestimated PM2.5 health effects by not considering source-specific and distributed-lag effects. Differing lag structures and disease specificity observed for steel-related versus traffic-related PM2.5 raise the possibility of distinct mechanistic pathways of health effects for particles of differing chemical composition.