Similar Readmission Rates Research Articles

Coronary computed tomography angiography vs.standard of care for evaluation of NSTE-ACS: a systematic review and meta-analysis

Abstract Background Non-ST elevation acute coronary syndrome (NSTE-ACS) is one of the common cardiac emergencies that pose a diagnostic challenge, especially in the absence of EKG changes or elevation in cardiac markers. Coronary computed tomography angiography (CT) has an established role in the evaluation of stable chest pain with ESC giving it class I recommendation. The role of CCTA in the management of NSTE-ACS is less clear. Purpose To evaluate the hypothesis of CT efficacy in identifying and managing patients with NSTE-ACS in comparison to the standard of care (SOC). Methods We searched MEDLINE, EMBASE, and Cochrane Central for randomized controlled trials (RCT) that compared initial CT utilization vs SOC in patients presenting with acute chest pain with suspected or confirmed NSTE-ACS. SOC arm included initial evaluation and triaging by treating physician including but not limited to clinical observation, serial cardiac markers, stress testing, and invasive coronary angiography (ICA). Studies with follow-up data of 1 month or more were included. Outcomes evaluated were incidence of rehospitalization/ER visits post index visit, referral to ICA, and presence of significant lesion during ICA requiring revascularization. Results A total of 6,862 patients (3,663 in the CT arm and 3,199 in the SOC) were analyzed from 13 RCTs. No statistically significant difference was noted between two intervention arms with regards to repeat hospital visits [Odds ratio (OR): 1.02; 95% CI: 0.85–1.24; P=0.82; I2=0%], and referral to ICA (OR: 1.32: 95% CI: 0.95–1.83; P=0.10; I2=66). CT was however more likely to uncover significant lesions requiring revascularization compared to SOC arm (OR: 1.77; 95% CI: 1.32–2.37; P=0.0001; I2=23%]. Conclusion Our meta-analysis showed that in patients with suspected NSTE-ACS, CT is associated with similar rates of ICA referral and re-admissions albeit being more likely to uncover hemodynamically significant lesions that require revascularization. These findings are consistent with the finding of the recently published VERDICT trial that showed comparable efficacy between coronary CT and ICA. Further studies evaluating the long term cardiovascular outcomes are warranted. Funding Acknowledgement Type of funding sources: None.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

Abstract Background Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (MI). However, type 2 MI is common in contemporary practice with scarce data regarding sex-based differences of clinical outcomes and resource utilization. Purpose To examine the association of sex category with clinical outcomes and resource utilization in hospitalizations with type 2 MI. Methods The Nationwide Readmission Database 2018 was queried for hospitalizations within the United States with type 2 MI using The International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code I21.A1. Comorbidities and outcomes were identified using the corresponding ICD-10 codes. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with type 2 MI. Results A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with type 2 MI were more likely to be older (72.8 years vs. 69.7 years; P<0.001), admitted on the weekend (26.5% vs. 25.9%; P=0.02), and have a higher prevalence of chronic pulmonary disease (35.6% vs. 32.0%; P<0.001), obesity (17.9% vs. 15.7%; P<0.001), neurological disorders (22.9% vs. 22.3%; P=0.02), deficiency anemias (7.5% vs. 6.6%; P<0.001), and hypothyroidism (22.1% vs. 10.1%; P<0.001) compared to males with type 2 MI. Female with type 2 MI was associated with lower in-hospital mortality, shorter LOS, less hospital costs, and increased nursing home discharge compared to males with type 2 MI. Females and males with type 2 MI had similar rates of 30-day all-cause readmission [Table 1]. Conclusion Among type 2 MI hospitalizations, females have lower in-hospital mortality, less hospitalization cost, shorter LOS, but increased rates of nursing home discharge compared to males. Thirty-day all-cause readmission was similar between males and females with type 2 MI. Funding Acknowledgement Type of funding sources: None.

Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis

To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. Continuous infusion of dexmedetomidine and ketamine. The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine+ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine+ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.

Enhanced recovery Pathways in gynecologic surgery: Are they safe and effective in the elderly?

ObjectiveTo compare perioperative outcomes of the elderly versus non-elderly patients on ERPs undergoing laparotomy for gynecologic surgery. MethodsFrom January 2016 to June 2017, patients undergoing elective laparotomies for gynecologic surgery were enrolled in a perioperative ERP protocol. Outcomes were compared between the elderly (age ≥ 70 years) and the non-elderly (age ≤ 69 years). Primary outcomes were length of stay and perioperative complication rates. Comparisons were performed using chi-squared tests or Fisher’s exact tests for categorical data and Student’s t-test or Wilcoxon rank-sum tests for continuous variables, with p < 0.05 for significance. ResultsOne hundred eighty-nine patients were enrolled in the study, including 16 patients ≥ 70 years old. The median age was 75 years for the elderly and 45 years for the non-elderly. Elderly patients were more likely to have more complex surgery and longer operative times (absolute median difference of 39 min). Despite the increasing complexity of surgical procedures for elderly patients, there were no statistically significant differences in serious inpatient complications (Clavien-Dindo score 3A or greater), pain and nausea scores, 30-day complications and readmission rates. Elderly patients had a longer median length of stay compared to non-elderly patients by one day (p < 0.001), however, this was not statistically significant on multivariate analysis. ConclusionIn our series, elderly patients on the ERP had similar rates of complications and readmission when compared to non-elderly patients, despite undergoing more complex surgeries. This suggests that ERP may be feasible and safe in the elderly population undergoing elective gynecologic laparotomy.

Significance of Hospital Size in Outcomes of Single-Level Elective Anterior Cervical Discectomy and Fusion: A Nationwide Readmissions Database Analysis

To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size. A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression. The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P= 0.537). Length of stay increased significantly with hospital size (P < 0.001), and small hospitals had the lowest charges (P < 0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes. Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates.

Kidney Transplantation From Hepatitis C Viremic Deceased Donors to Aviremic Recipients in a Real-world Setting.

Background.Transplantation of hepatitis C viremic (HCV+) deceased donor kidney transplants (DDKT) into aviremic (HCV–) recipients is a strategy to increase organ utilization. However, there are concerns around inferior recipient outcomes due to delayed initiation of direct-acting antiviral (DAA) therapy and sustained HCV replication when implemented outside of a research setting.Methods.This was a retrospective single-center matched cohort study of DDKT recipients of HCV+ donors (cases) who were matched 1:1 to recipients of HCV– donors (comparators) by age, gender, race, presence of diabetes, kidney donor profile index, and calculated panel-reactive antibody. Data were analyzed using summary statistics, t-tests, and chi-square tests for between-group comparisons, and linear mixed-effects models for longitudinal data.Results.Each group consisted of 50 recipients with no significant differences in baseline characteristics. The 6-mo longitudinal trajectory of serum creatinine and estimated glomerular filtration rate did not differ between groups. All recipients had similar rates of acute rejection and readmissions (all P > 0.05). One case lost the allograft 151 d posttransplant because of acute rejection, and 1 comparator died on postoperative day 7 from cardiac arrest. HCV+ recipients initiated DAA on average 29 ± 11 d posttransplant. Ninety-eight percent achieved sustained virologic response at 4 and 12 wks with the first course of therapy; 1 patient had persistent HCV infection and was cured with a second course of DAA.Conclusions.Aviremic recipients of HCV+ DDKT with delayed DAA initiation posttransplant had similar short-term outcomes compared with matched recipient comparators of HCV– donors.

Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia.

To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.

P115. Analysis of 90-day readmissions across hospital size: Risk factors for readmission in single level anterior cervical discectomy and fusion

P115. Analysis of 90-day readmissions across hospital size: Risk factors for readmission in single level anterior cervical discectomy and fusion

The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes.

The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH). The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear. Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates. Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P <0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P =0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients. Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis.

Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures. The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant. The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001). SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure. III.

Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion.

Hospitals seek to reduce costs and improve patient outcomes by decreasing length of stay (LOS), 30-day all-cause readmissions, and preventable complications. We evaluated hospital-reported outcome measures for elective single-level anterior cervical discectomy and fusions (ACDFs) between tertiary (TH) and community hospitals (CH) to determine location-based differences in complications, LOS, and overall costs. Patients undergoing elective single-level ACDF in a 1-year period were retrospectively reviewed from a physician-driven database from a single medical system consisting of 1 TH and 4 CHs. Adult patients who underwent elective single-level ACDF were included. Patients with trauma, tumor, prior cervical surgery, and infection were excluded. Outcomes measures included all-cause 30-day readmissions, preventable complications, LOS, and hospital costs. A total of 301 patients (60 TH, 241 CH) were included. CHs had longer LOS (1.25 ± 0.50 versus 1.08 ± 0.28 days, P = .01). There were no differences in complication and readmission rates between hospital settings. CH, orthopaedic subspecialty, female sex, and myelopathy were predictors for longer LOS. Overall, costs at the TH were significantly higher than at CHs ($17 171 versus $11 737; Δ$ = 5434 ± 3996; P < .0001). For CHs, the total costs of drugs, rooms, supplies, and therapy were significantly higher than at the TH. TH status, orthopaedic subspecialty, and myelopathy were associated with higher costs. Patients undergoing single-level ACDFs at CHs had longer LOS, but similar complications and readmission rates as those at the TH. However, cost of ACDF was 1.5 times greater in the TH. To improve patient outcomes, optimize value, and reduce hospital costs, modifiable factors for elective ACDFs should be evaluated. 3.

Implementation of a perioperative-enhanced recovery protocol in patients undergoing open gastrectomy for gastric cancer.

The purpose of this study was to compare surgical outcomes before and after implementation of an enhanced recovery protocol (ERP) in gastrectomy for gastric cancer. We included patients who underwent open gastrectomy for gastric cancer before (January 2016 to September 2018) or after (October 2018 to September 2020) ERP implementation. The primary outcome was the postoperative length of stay (LOS). Secondary outcomes included 90-day readmission rates and Clavien-Dindo grade ≥ 3 complications. One hundred patients underwent gastrectomy before (pre-ERP group) and 52 underwent gastrectomy after (ERP group) protocol implementation. Demographic and clinicopathologic characteristics were similar. The median (interquartile range) postoperative LOS was shorter in the ERP group (7.0 days [6.0-8.0] vs. 8.0 days [7.0-11.0];p < 0.001). The ERP group had similar rates of readmission (33% vs. 24%; p = 0.34) and grade ≥ 3 complications (19% vs. 19%; p = 1.0) compared to the pre-ERP group, but experienced lower rates of surgical wound complications (0% vs. 19%; p < 0.001). Rates of other complications were similar. Implementation of an ERP in patients undergoing open gastrectomy for gastric cancer is feasible and safe and has the potential to decrease postoperative LOS without increasing complication rates.

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review.

Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources. The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges. The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome. Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery. In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.

TaTME: Present and Future Perspectives?

AbstractTransanal total mesorectal excision (TaTME) is a new procedure developed to overcome the specific difficulties posed by rectal surgery, especially in narrow pelvis, male, and obese patients, and can be used in benign and malignant pathologies. The advantages are especially important in rectal cancer, as they could potentially result in a more precise distal dissection, lower rate of positive circumferential resection margins, and increase the rate of sphincter-sparing procedures. The indications for TaTME are currently expanding, despite not yet being standardized. Training programs are increasing day by day, to improve the learning curve related to this difficult technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates compared with open/laparoscopic approach. Oncological results have shown that TaTME is associated with better quality mesorectal excision and safer distal resection margin. In this work, we review the evolution of TaTME, surgical technique, development, applicability, current situation, and implementation, as well as future perspectives for colorectal cancer and other pathologies. While satisfactory short-term results have been reported, it is a new technique, and long-term results and definitive results from controlled trials are pending. As evidence of safety and feasibility accumulates, training programs structured to standardize teaching, training, and safe expansion will aid the safe spread of TaTME.

Comparison of Perioperative Outcomes for Radical Nephrectomy Based on Surgical Approach for Masses Greater Than 10 cm.

Introduction and Objective: Robot-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN), but there are concerns over costs and objective benefit. In the setting of very large renal masses (>10 cm), comparison between techniques is limited and it is unclear whether a robotic approach confers any perioperative benefit over LRN or open radical nephrectomy (ORN). In this study, perioperative outcomes of RRN, LRN, and ORN for very large renal masses are compared. Methods: Using the National Cancer Database, patients were identified who underwent radical nephrectomy for kidney tumors >10 cm diagnosed from 2010 to 2015. Patients were analyzed according to surgical approach. Perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30- and 90-day mortality were compared among cohorts. Results: A total of 9288 patients met inclusion criteria (RRN = 842, LRN = 2326, ORN = 6120). Compared with ORN, recipients of RRN or LRN had similar rates of 30-day readmission and 30- and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days ±0.19; p < 0.0001) and LRN (-1.40 days ±0.12; p < 0.0001) compared with ORN. LRN had a higher rate of conversion to open compared with RRN (odds ratio 1.48; 95% confidence interval 1.10-1.98; p = 0.0087). Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, whereas ORN use decreased from 75% to 59.6%. Conclusions: Minimally invasive approaches are increasingly utilized in very large renal masses. RRN has lower rates of conversion to open but produces comparable perioperative outcomes to LRN. Minimally invasive approaches have a shorter length of inpatient stay but otherwise report similar surgical margin status, readmission rates, and mortality rates compared with ORN.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BackgroundSex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes. MethodsThe Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI. ResultsA total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88–0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] −0.28; 95% CI −0.38–0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI −1916.04–1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05–1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97–1.04; P = 0.841). ConclusionAmong T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Comparison Between Veteran and Non-Veteran Populations With Clinical Stage I Non-small Cell Lung Cancer Undergoing Surgery.

The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC). Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population. We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB). The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001). Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.

Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery

BackgroundEnhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. MethodsWe queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. ResultsTwo hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. ConclusionOverall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

Quality of care and outcomes in internal medicine patients bedspaced to noninternal medicine units.

Hospital overcrowding has led to a practice known as bedspacing (in which admitted patients are placed on a different specialty's inpatient ward), yet little is known about the impact of this practice on healthcare quality.We investigated whether hospital outcome measures differ between bedspaced general internal medicine (GIM) patients vs nonbedspaced patients.Our retrospective study included patients admitted to GIM wards at 2 academic hospitals (2012–2014), comparing bedspaced to nonbedspaced patients, and identifying adverse events from the hospital's Electronic Patient Record.We compared these groups with respect to actual length of stay vs the expected length of stay (% ELOS), which is defined as length of stay (LOS) divided by expected length of stay (ELOS), 30-day readmission, adverse events (falls, medication-related incidents, equipment-related incidents, first treatment related incidents, laboratory-related incidents, and operative/invasive events), and in-hospital mortality.There were 22,519 patients analyzed with 15,985 (71%) discharged from a medical ward and 6534 (29%) discharged from a non-medical ward. Bedspaced patients had shorter lengths of stay (4.1 vs 6.2 days, P < .001) and expected lengths of stay (ELOS) (6.1 vs 6.4 days, P < .001). Bedspaced patients had a lower percentage of ELOS (% ELOS) than nonbedspaced patients (70% vs 91%, P < .001), similar readmission rates (9.8 vs 10.3 events per 100 patients, P = .24), lower in-hospital mortality rates (2.6 vs 3.3 events per 100 patients, P = .003) and fewer adverse events (0.20 vs 0.60 events per 100 patient days, P < .01).Bedspacing of patients is common. Patients who are bedspaced to off-service wards have better outcomes. This may relate to preferential allocation practices.

Implementation of a nonopioid protocol following robot-assisted radical cystectomy with intracorporeal urinary diversion

PurposeThe implementation of robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for management of patients with muscle-invasive or high-risk noninvasive bladder cancer has increased in utilization over the last decade. Here, we seek to describe institutional opioid prescription and utilization patterns following implementation of a nonopioid (NOP) perioperative pain management protocol in patients who received RARC with ICUD. Materials and methodsThe records of all patients who underwent RARC that utilized a NOP perioperative pain management protocol at a single academic institution from 2016 to 2020 were retrospectively reviewed. Descriptive statistical analyses were performed. For comparison, we included 74 consecutive patients who received the same NOP protocol with extracorporeal urinary diversion (ECUD). ResultsA total of 116 patients who received ICUD were included in our analysis. The median operation time for the ICUD group was 305 minutes (interquartile range [IQR]: 262–352). 12.1% (n = 14) of patients who underwent ICUD required narcotics during inpatient hospitalization. For these patients, the median morphine milligram equivalent requirement was 52.0 (IQR: 7.62–157). Additionally, only 12.1% (n = 14) of patients were prescribed opioids postoperatively at discharge. We identified that within 6 months of surgery only 5 (4.3%) patients required a second narcotic prescription. Furthermore, of patients who did not use mu-opioid blockers, a minority experienced postoperative ileus (15.7%, n = 16). 30- and 90-day all Clavien complication rates for patients were 44.8% (n = 52) and 49.1% (n = 57), respectively. Nineteen (16.4%) patients were readmitted within 30 days of discharge, of which none were pain related. When compared to ECUD, patients who received ICUD experienced similar complication and readmission rates. ConclusionsThe implementation of a NOP protocol for patients undergoing RARC with ICUD allows for both decreased postoperative narcotic use and reduced need for narcotic prescriptions at discharge with acceptable complication and readmission rates.