Thirty-day Readmission Research Articles

Outcomes for High-Risk Surgical Procedures Across High- and Low-Competition Hospital Markets

Maintaining competition among hospitals is increasingly seen as important to achieving high-quality outcomes. Whether or not there is an association between hospital market competition and outcomes after high-risk surgery is unknown. To evaluate whether there is an association between hospital market competition and outcomes after high-risk surgery. We performed a retrospective study of Medicare beneficiaries who received care in US hospitals. Participants were 65 years and older who electively underwent 1 of 10 high-risk surgical procedures from 2015 to 2018: carotid endarterectomy, mitral valve repair, open aortic aneurysm repair, lung resection, esophagectomy, pancreatectomy, rectal resection, hip replacement, knee replacement, and bariatric surgery. Hospitals were categorized into high-competition and low-competition markets based on the hospital market Herfindahl-Hirschman index. Comparisons of 30-day mortality and 30-day readmissions were risk-adjusted using a multivariate logistic regression model adjusting for patient factors (age, sex, comorbidities, and dual eligibility), year of procedure, and hospital characteristics (nurse ratio and teaching status). Data were analyzed from May 2022 to March 2023. Thirty-day postoperative mortality and readmissions. A total of 2 242 438 Medicare beneficiaries were included in the study. The mean (SD) age of the cohort was 74.1 (6.4) years, 1 328 946 were women (59.3%), and 913 492 were men (40.7%). When examined by procedure, compared with low-competition hospitals, high-competition market hospitals demonstrated higher 30-day mortality for 2 of 10 procedures (mitral valve repair: odds ratio [OR], 1.11; 95% CI, 1.07-1.14; and carotid endarterectomy: OR, 1.06; 95% CI, 1.03-1.09) and no difference for 5 of 10 procedures (open aortic aneurysm repair, bariatric surgery, esophagectomy, knee replacement, and hip replacement; ranging from OR, 0.97; 95% CI, 0.94-1.00, for hip replacement to OR, 1.09; 95% CI, 0.94-1.26, for bariatric surgery). High-competition hospitals also demonstrated 30-day readmissions that were higher for 5 of 10 procedures (open aortic aneurysm repair, knee replacement, mitral valve repair, rectal resection, and carotid endarterectomy; ranging from OR, 1.01; 95% CI, 1.00-1.02, for knee replacement to OR, 1.05; 95% CI, 1.02-1.08, for rectal resection) and no difference for 3 procedures (bariatric surgery: OR, 1.03; 95% CI, 0.99-1.07; esophagectomy: OR, 1.02; 95% CI, 0.99-1.06; and pancreatectomy: OR, 1.00; 95% CI, 0.99-1.01). Hospitals in high-competition compared with low-competition markets cared for patients who were older (mean [SD] age of 74.4 [6.6] years vs 74.0 [6.2] years, respectively; P < .001), were more likely to be racial and ethnic minority individuals (77 322/450 404 [17.3%] vs 23 328/444 900 [5.6%], respectively; P < .001), and had more comorbidities (≥2 Elixhauser comorbidities, 302 415/450 404 [67.1%] vs 284 355/444 900 [63.9%], respectively; P < .001). This study found that hospital market competition was not consistently associated with improved outcomes after high-risk surgery. Efforts to maintain hospital market competition may not achieve better postoperative outcomes.

A validation study of the high acuity readmission risk pediatric screen (HARRPS) tool©: Predicting readmission risk within the pediatric population

BackgroundThe initial research study of the High Acuity Readmission Risk Pediatric Screen (HARRPS) Tool © focused on using retrospective data to apply weighted values to the questions within the tool, identify overall risk score, and attribute risk categories (low, moderate, high risk) to the overall risk score. This study focused on validating the data from the initial study, as well as cross examining the need to include admission diagnosis within the tool. MethodStudy was a single-centered, retrospective chart review study using a different subset of patients from the initial study. Pediatric patients with thirty-day readmissions were compared to pediatric patients without a thirty-day readmission over a twelve-month period. Utilized same statistical software and methodology from initial study to identify if readmission risk probability could be replicated with a different population. ResultsThe initial study performed in 2018 demonstrated a c-statistic score/ area under the curve (AUC) of 0.68 [95% CI: 0.67, 0.69]. In addition, the initial study demonstrated as risk score increases, the probability of readmission gradually increased until a patient had a risk score of seven or greater, at which point readmission risk plateaued. This resulted in low, moderate, and high readmission risk categories. The current study performed using data from 2019 demonstrated an improved c-statistic score / AUC of 0.83 [95% CI: 0.80, 0.87] with admission diagnosis included, and a c-statistic score / AUC of 0.80 [95% CI: 0.76, 0.83] without the admission diagnosis included. The analysis of overall risk score demonstrated a substantial difference in how to interpret final readmission risk scores. Both the initial study and validation study were consistent in demonstrating a risk score of three or less was associated with low readmission risk. However, in the validation study, there was no substantial difference between moderate or high risk, leading to updating the tool from 3 risk categories into 2 risk categories of low risk and at risk of readmission. ConclusionBased on the finding from the validation study, the admission diagnosis was removed from the HARRPS Tool© as the difference in c-statistic score was nominal, and the risk categories were changed from three categories (low, moderate, high risk) to two categories of low risk (score 0–2) and at risk of readmission for a score of 3+. The ability of the HARRPS Tool© to predict readmission risk preforms best with a c-statistic = 0.80, outperforming the following tools: LACE (0.65), LACE -SDH (0.67), LACE + (0.61), Epic's readmission risk model (0.69), and SQLAPE ® (0.71) (Ryan, et al., 2021; Hwang, et al., 2021).

Thirty-Day Readmission Among Patients With Uncomplicated Choledocholithiasis: A Nationwide Readmission Database Analysis.

We aimed to determine the rate of 30-day hospital readmissions of uncomplicated choledocholithiasis and its impact on mortality and health care use in the United States. Nonelective admissions for adults with uncomplicated choledocholithiasis were selected from the Nationwide Readmission Database 2016-2018. The primary outcome was the all-cause 30-day readmission rate. Secondary outcomes were reasons for readmission, readmission mortality rate, procedures, and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. The 30-day rate of readmission was 9.3%. Biliary and pancreatic disorders and postprocedural complications accounted for 36.6% and 10.3% of readmission, respectively. The mortality rate among patients readmitted to the hospital was higher than that for index admissions (2.0% vs. 0.4%, P <0.01). Readmitted patients were less likely to receive endoscopic retrograde cholangiopancreatography (61% vs. 69%, P <0.01) and laparoscopic cholecystectomy (12.5% vs. 26%, P <0.01) during the index admissions. A total of 42,150 hospital days was associated with readmission, and the total health care in-hospital economic burden was $112 million (in costs) and $470 million (in charges). Independent predictors of readmission were male sex, Medicare (compared with private) insurance, higher Elixhauser Comorbidity Index score, no endoscopic retrograde cholangiopancreatography or laparoscopic cholecystectomy, postprocedural complications of the digestive system, hemodynamic or respiratory support, urban hospitals, and lower hospital volume of uncomplicated choledocholithiasis. The uncomplicated choledocholithiasis 30-day readmission rate is 9.3%. Readmission was associated with higher mortality, morbidity, and resource use. Multiple independent predictors of readmission were identified.

Thirty-Day Unplanned Hospital Readmissions in Patients With Cancer and the Impact of Social Determinants of Health: A Machine Learning Approach.

Develop a cancer-specific machine learning (ML) model that accurately predicts 30-day unplanned readmissions in patients with solid tumors. The initial cohort included patients 18 years or older diagnosed with a solid tumor. Two distinct cohorts were generated: one with and one without detailed social determinants of health (SDOHs) data. For each cohort, data were temporally partitioned in 70% (training), 20% (validation), and 10% (testing). Tree-based ML models were developed and validated on each cohort. The metrics used to evaluate the model's performance were receiver operating characteristic curve (ROC), area under the ROC curve, precision, recall (R), accuracy, and area under the precision-recall curve. We included 13,717 patients in this study in two cohorts (5,059 without SDOH data and 8,658 with SDOH data). Unplanned 30-day readmission occurred in 21.3% of the cases overall. The five main non-SDOH factors most highly associated with an unplanned 30-day readmission (R, 0.74; IQR, 0.58-0.76) were: number of previous unplanned readmissions; higher Charlson comorbidity score; nonelective index admission; discharge to anywhere other than home, hospice, or nursing facility; and higher anion gap during the admission. Neighborhood crime index, neighborhood median home values, annual income, neighborhood median household income, and wealth index were the main five SDOH factors important for predicting a high risk for an unplanned hospital readmission (R, 0.66; IQR, 0.56-0.72). The models were not directly comparable. Key drivers of unplanned readmissions in patients with cancer are complex and involve both clinical factors and SDOH. We developed a cancer-specific ML model that with reasonable accuracy identified patients with cancer at high risk for an unplanned hospital readmission.

Single-staged retromuscular abdominal wall reconstruction with mesh at the time of ostomy reversal: are we crossing the line? An ACHQC Analysis.

The most appropriate method of reconstructing the abdominal wall at the site of a simultaneous stoma takedown is controversial. The contaminatedfield, concomitant GI procedure being performed and presence of aherniaallcomplicate decision-making. We sought to describe the surgical approaches, mesh type and outcomes of concomitant abdominal wall reconstruction during stoma takedown in a large hernia registry. All patients who underwent stoma takedown with simultaneous hernia repair with retromuscular mesh placement from January 2014 to May 2022 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Patients were stratified by mesh type including permanent synthetic (PS), resorbable synthetic (RS) and biologic mesh. Association of mesh type with 30-day wound events and other complications and1-year outcomes were evaluated. There were 368 patients who met inclusion criteria.Eighty-nine patients had ileostomies, 276 colostomies and 3hadboth. Two hundred and seventy-nine (75.8%) patients received PS mesh, 46 (12.5%)biologic, and 43 (11.7%)RS. Seventy percent (259/368)had a parastomal hernia,75% (285/368) had a midline incisional hernia, and 48% (178/368) had both. All groups had similar preoperative comorbidities and the majority had atransversus abdominus release. All mesh groups had similar thirty-day SSI (13.2-14.3%), SSO (10.5-17.8%) and SSOPI (7.9-14.1%), p = 0.6. Three patients with PS mesh developed infected synthetic mesh and one PS mesh required excision. Four patients with PS developed an enterocutaneous fistula. Of these, only one patient was recorded as having both an enterocutaneous fistula and mesh infection. Thirty-day reoperation and readmission weresimilar across all mesh groups.Recurrence at 1-year was similar betweenmesh groups. Quality of life measured using HerQLes scores were higher at one year compared to baseline in all groups indicating improvement in hernia-specific quality of life. Early complication rates associated with simultaneous stoma takedown and abdominal wall reconstruction are significant, regardless of mesh type utilized. Concomitant surgery should be weighed heavily and tailored to individual patients.

Hospital Discharge and Readmissions Before and During the COVID-19 Pandemic for California Acute Stroke Inpatients

BackgroundAcute stroke therapy and rehabilitation declined during the COVID-19 pandemic. We characterized changes in acute stroke disposition and readmissions during the pandemic. MethodsWe used the California State Inpatient Database in this retrospective observational study of ischemic and hemorrhagic stroke. We compared discharge disposition across a pre-pandemic period (January 2019 to February 2020) to a pandemic period (March to December 2020) using cumulative incidence functions (CIF), and re-admission rates using chi-squared. ResultsThere were 63,120 and 40,003 stroke hospitalizations in the pre-pandemic and pandemic periods, respectively. Pre-pandemic, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, there were more home discharges [51%, subdistribution hazard ratio 1.17, 95% CI 1.15-1.19], decreased SNF discharges [17%, subdistribution hazard ratio 0.70, 95% CI 0.68-0.72], and acute rehabilitation discharges were unchanged [CIF, p<0.001]. Home discharges increased with increasing age, with an increase of 8.2% for those ≥85 years. SNF discharges decreased in a similar distribution by age. Thirty-day readmission rates were 12.7 per 100 hospitalizations pre-pandemic compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. Home discharge readmission rates were unchanged between periods. Readmission rates for discharges to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation decreased (11.3 vs. 10.1 per 100 hospitalizations, p=0.034). ConclusionsDuring the pandemic a greater proportion of patients were discharged home, with no change in readmission rates. Research is needed to evaluate the impact on quality and financing of post-hospital stroke care.

Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock

Recent studies have produced inconsistent findings regarding the outcomes of the percutaneous microaxial left ventricular assist device (LVAD) during acute myocardial infarction with cardiogenic shock (AMICS). To compare the percutaneous microaxial LVAD vs alternative treatments among patients presenting with AMICS using observational analyses of administrative data. This comparative effectiveness research study used Medicare fee-for-service claims of patients admitted with AMICS undergoing percutaneous coronary intervention from October 1, 2015, through December 31, 2019. Treatment strategies were compared using (1) inverse probability of treatment weighting to estimate the effect of different baseline treatments in the overall population; (2) instrumental variable analysis to determine the effectiveness of the percutaneous microaxial LVAD among patients whose treatment was influenced by cross-sectional institutional practice patterns; (3) an instrumented difference-in-differences analysis to determine the effectiveness of treatment among patients whose treatment was influenced by longitudinal changes in institutional practice patterns; and (4) a grace period approach to determine the effectiveness of initiating the percutaneous microaxial LVAD within 2 days of percutaneous coronary intervention. Analysis took place between March 2021 and December 2022. Percutaneous microaxial LVAD vs alternative treatments (including medical therapy and intra-aortic balloon pump). Thirty-day all-cause mortality and readmissions. Of 23 478 patients, 14 264 (60.8%) were male and the mean (SD) age was 73.9 (9.8) years. In the inverse probability of treatment weighting analysis and grace period approaches, treatment with percutaneous microaxial LVAD was associated with a higher risk-adjusted 30-day mortality (risk difference, 14.9%; 95% CI, 12.9%-17.0%). However, patients receiving the percutaneous microaxial LVAD had a higher frequency of factors associated with severe illness, suggesting possible confounding by measures of illness severity not available in the data. In the instrumental variable analysis, 30-day mortality was also higher with percutaneous microaxial LVAD, but patient and hospital characteristics differed across levels of the instrumental variable, suggesting possible confounding by unmeasured variables (risk difference, 13.5%; 95% CI, 3.9%-23.2%). In the instrumented difference-in-differences analysis, the association between the percutaneous microaxial LVAD and mortality was imprecise, and differences in trends in characteristics between hospitals with different percutaneous microaxial LVAD use suggested potential assumption violations. In observational analyses comparing the percutaneous microaxial LVAD to alternative treatments among patients with AMICS, the percutaneous microaxial LVAD was associated with worse outcomes in some analyses, while in other analyses, the association was too imprecise to draw meaningful conclusions. However, the distribution of patient and institutional characteristics between treatment groups or groups defined by institutional differences in treatment use, including changes in use over time, combined with clinical knowledge of illness severity factors not captured in the data, suggested violations of key assumptions that are needed for valid causal inference with different observational analyses. Randomized clinical trials of mechanical support devices will allow valid comparisons across candidate treatment strategies and help resolve ongoing controversies.

Independent Predictors and Causes of Thirty-Day Gastrointestinal Readmissions Following COVID-19-Related Hospitalizations: Analysis of the National Readmission Database.

The coronavirus disease 2019 (COVID-19) pandemic led to significant mortality and morbidity in the United States. The burden of COVID-19 was not limited to the respiratory tract alone but had significant extrapulmonary manifestations. We decided to examine the causes, predictors, and outcomes of gastrointestinal (GI)-related causes of 30-day readmission following index COVID-19 hospitalization. We used the National Readmission Database (NRD) from 2020 to identify hospitalizations among adults with principal diagnosis of COVID-19. We identified GI-related hospitalizations within 30 days of index admission after excluding elective and traumatic admissions. We identified the top causes of GI-related readmission, and the outcomes of these hospitalizations. We used a multivariate Cox regression analysis to identify the independent predictors of readmission. Among 1,024,492 index hospitalizations with a primary diagnosis of COVID-19 in the 2020 NRD database, 644,903 were included in the 30-day readmission study. Of these 3,276 (0.5%) were readmitted in 30 days due to primary GI causes. The top five causes of readmissions we identified in this study were GI bleeding, intestinal obstruction, acute diverticulitis, acute pancreatitis, and acute cholecystitis. Multivariate Cox regression analysis done adjusting for confounders showed that renal failure, alcohol abuse, and peptic ulcer disease were associated with increased odds of 30-day readmission from GI-related causes. GI manifestations of COVID-19 are not uncommon and remain an important cause of readmission. Targeted interventions addressing the modifiable predictors of readmission identified will be beneficial in reducing the burden on already limited healthcare resources.

Thirty-Day readmissions among COVID-19 patients hospitalized during the early pandemic in the United States: Insights from the Nationwide Readmissions Database

BackgroundHospital readmissions are core indicators of the quality of health care provision. ObjectiveTo understand factors associated with 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database. MethodsThis retrospective study characterized the 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database. ResultsThe 30-day, all-cause hospital readmission rate in this population was 3.2%. We found the most common diagnoses at readmission to be sepsis, acute kidney injury, and pneumonia. Chronic alcoholic liver cirrhosis and congestive heart failure were prominent predictors of readmission among patients with COVID-19. Moreover, we found that younger patients and patients from economically disadvantaged backgrounds were at higher risk of 30-day readmission. Acute complications during index hospitalization, including acute coronary syndrome, congestive heart failure, acute kidney injury, mechanical ventilation, and renal replacement therapy, also increased the risk of 30-day readmission for patients with COVID-19. ConclusionBased on the results of our study, we advise clinicians to promptly recognize patients with COVID-19 who are at high risk of readmission, and to subsequently manage their underlying comorbidities, to institute timely discharge planning, and to allocate resources to underprivileged patients in order to decrease the risk of 30-day hospital readmissions.

Timing and Outcomes of Precoronary Artery Bypass Grafting Carotid Endarterectomy

The Society for Vascular Surgery Clinical Practice Guidelines suggests the timing of carotid endarterectomy (CEA) in patients with symptomatic or bilateral severe asymptomatic carotid stenosis needing coronary artery bypass grafting (CABG) be performed either with preoperative CEA or concomitantly with CABG. The optimal timing of CEA in patients with high grade unilateral stenosis, however, has been controversial due to equivocal and/or scarce data. This study examines our experience with pre-CABG CEA and timing in this patient population. This is a single-center retrospective review of all patients who underwent CEA before or during CABG between January 2010 and January 2021. All patients receiving CEA were anesthetized by a dedicated cardiac anesthesiologist. Patients were compared based on timing of CEA in relation to CABG: concomitant (CABG day 0 from CEA) and nonconcomitant (CABG day 1-30 after CEA). The nonconcomitant cohort was substratified into hyperacute (CABG within 48 hours), acute (CABG within 2 weeks), and subacute (CABG within 30 days). Demographics and status of carotid disease were collated. Primary outcomes included stroke, defined as new neurologic deficit, myocardial infarction (MI), 30-day readmission, and 30-day mortality. A total of 39 patients were identified in the study population. Of these, 9 (23%) patients underwent CEA and CABG concomitantly, with 30 receiving nonconcomitant CEA (hyperacute [9, 23%]; acute [16, 41%]; subacute [5, 13%]). Baseline demographics and comorbidities were similar between groups. The degree of internal carotid artery stenosis, presence of high-grade contralateral stenosis, and symptomatic carotid presentation did not impact perioperative outcomes. One stroke occurred after a concomitant CEA/CABG that was a bi-hemispheric event believed to be due to cannulating a highly diseased ascending aorta. One patient in the concomitant cohort developed postoperative MI, cardiogenic shock, and subsequent death (Table I). There was no observed stroke, MI, or death in the nonconcomitant cohort. Thirty-day readmission and mortality were similar between all groups (Tables I and II). However, when comparing aggregate stoke/MI (Table I), a statistically significant difference was observed in favor of the nonconcomitant cohort (P = .007). Careful consideration is needed when determining appropriate timing for coronary revascularization in patients with carotid disease. These data suggest that nonconcomitant, preoperative CEA can be performed safely by a dedicated cardiac anesthesiologist before CABG. Concomitant CEA/CABG, as reflected in these data, carries an added procedural risk of stroke and a potentially poor cardiac outcome. Further study is warranted to elucidate the role of timing in perioperative outcomes for patients requiring CEA and CABG.Table IPerioperative outcomes for patients undergoing coronary artery bypass grafting (CABG) within 30 days of carotid endarterectomy (CEA)Concomitant CABG (n = 9)Nonconcomitant CABG (n = 30)P valuePostoperative events (MI, NS), No. (%)2 (22.2)0 (0).007a30-day readmission, No. (%)1 (11.1)3 (10).9330-day mortality, No. (%)1 (11.1)0 (0).07MI, Myocardial infarction; NS, neurologic symptoms. Open table in a new tab Table IIPerioperative outcomes for patients undergoing coronary artery bypass grafting (CABG) within 30 days of carotid endarterectomy (CEA), with the nonconcomitant CEA/CABG cohort substratified by timingConcomitant CABG (n = 9)Hyperacute CABG (n = 9)Acute CABG (n = 16)Subacute CABG (n = 5)P valuePostoperative events (MI, NS), No. (%)2 (11.1)0 (0)0 (0)0 (0).3530-day readmission, No. (%)1 (11.1)0 (0)1 (6.3)2 (40).1130-day mortality, No. (%)1 (11.1)0 (0)0 (0)0 (0).35MI, Myocardial infarction; NS, neurologic symptoms. Open table in a new tab

Outcomes of Thirty-Day Readmission in Patients With Heart Failure on Index Hospitalization Undergoing Transcatheter Edge-to-Edge Mitral Repair: Insights from the United States Nationwide Readmission Database

Outcomes of Thirty-Day Readmission in Patients With Heart Failure on Index Hospitalization Undergoing Transcatheter Edge-to-Edge Mitral Repair: Insights from the United States Nationwide Readmission Database

What Is the Effect of Resident Involvement on Short-Term Outcomes after Distal Radius Fracture Surgery?

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic).

Transition from standard robotic prostatectomy to Retzius-sparing prostatectomy: feasibility and early outcomes.

Retzius-sparing robotic-assisted radical prostatectomy (rsRARP) has gained popularity due to superior early continence outcomes compared to standard robotic prostatectomy (sRARP). We evaluate the results of a single surgeon who transitioned from sRARP to rsRARP and compare oncologic and functional outcomes. We retrospectively reviewed all prostatectomies performed by a single surgeon between June 2018 and October 2020. Perioperative, oncologic, and functional data were collected and analyzed. Patients who underwent sRARP were compared with those who underwent rsRARP. Both groups contained 37 consecutive patients each. Preoperative patient characteristics and biopsy results were similar between the two groups. Perioperative outcomes were significant for longer operative room time and higher proportion of T3 tumors in the rsRARP group. Thirty-day complication and readmission rates were similar between groups. There was no difference in early oncologic outcomes, including positive surgical margin rate, biochemical recurrence, and need for adjuvant or salvage treatments. The time to urinary continence and immediate continence rate was superior in the rsRARP group. The Retzius-sparing approach can be safely adopted by surgeons experienced in sRARP without compromising early oncologic outcomes and with the benefit of improved early continence recovery.

PO-03-163 CONCOMITANT LAAO AND ATRIAL FIBRILLATION ABLATION VS. A STAGED APPROACH: INSIGHTS FROM THE NATIONWIDE READMISSIONS DATABASE

Percutaneous left atrial appendage occlusion (LAAO) is increasingly performed in patients with atrial fibrillation (AF). It is sometimes combined with catheter ablation (CA), either in a concomitant procedure or a staged approach. To compare the safety, efficacy, and costs of concomitant LAAO and CA versus a staged approach. The Nationwide Readmissions Database (NRD) is a nationally representative sample of all US hospitalizations, containing longitudinal patient data on almost half of all hospitalizations. The 2019 NRD was used to identify patients who underwent CA and LAAO from January to November 2019. Only patients who underwent CA and LAAO on the same date were included in the concomitant group; patients who underwent CA and LAAO on different dates or hospitalizations were included in the short-interval staged (SIS) group (within 6 months). In the SIS group, comorbidities were obtained from the first staged admission; outcomes were pooled from both procedures. Analysis accounted for the complex survey design of the NRD. Per NRD data reporting guidelines, any variable with n<10 was not reported. Out of the 25,392 patients who underwent LAAO during the study period, 191 patients underwent a concomitant procedure, and 392 patients underwent a SIS procedure. In the SIS group, mean time between the procedures was 92.4 ± 5.2 days, and LAAO was performed first in 52.3%. Patients in the concomitant group were significantly less likely to have heart failure (41.8% vs 56.5%, p=0.044), chronic obstructive pulmonary disease (11.1% vs 32.2%, p<0.01), fluid/electrolyte disorders, (<10 vs 17.5%, p=0.01), pulmonary circulation disorders (14.4% vs <10, p<0.01), and total Elixhauser comorbidities (4.1 ± 0.2 vs. 5.3 ± 0.2, p<0.01). Thirty-day readmissions (5.8% vs 4.3%, p<0.01), major bleeding (7.2% vs 19.3%, p=0.014), total length of stay (LOS) (1.8 ± 0.2 vs. 7.1± 0.6, p<0.01), and total charges ($184,566 ± $20,430 vs. $303,812± $18,308) were all significantly less in the concomitant group. After multivariate adjustment, 30-day readmissions, LOS, and total cost remained significantly different (Figure 1). Concomitant and SIS CA and LAAO procedures are performed infrequently. Patients undergoing concomitant procedures are healthier with less cardiopulmonary and overall comorbidities. After multivariate adjustment, concomitant procedures were associated with less 30-day readmissions, shorter LOS, and less total charges.

Thirty-Day Unplanned Readmissions Following Elective and Acute Percutaneous Coronary Intervention.

Prior studies have reported a high rate of unplanned readmissions following acute percutaneous coronary intervention (PCI). Data outside the USA comparing 30-day unplanned readmissions following elective PCI to those who undergo acute PCI remain limited. Patients who underwent a PCI procedure in Australia and New Zealand between 2010 and 2015 were included. We determined the rates, causes and predictors of 30-day unplanned readmissions, as well as rates of repeat revascularisation procedures, for patients who underwent an elective or acute PCI. Predictors of readmissions were identified using logistic regression. A total of 199,686 PCI encounters were included, of which 74,890 (37.5%) were elective and 124,796 (62.5%) were acute procedures. Overall, 10.6% of patients had at least one unplanned readmission within 30 days of discharge with lower rates following elective PCI (7.0%) compared to acute PCI (12.7%) (p<0.01). Non-specific chest pain was the commonest cause of readmission after elective and acute PCI, accounting for 20.7% and 21.5% of readmission diagnoses, respectively. Readmissions for acute myocardial infarction (13.0% vs 4.6%, p<0.01) and heart failure (6.5% vs 3.3%, p<0.01) were higher following acute PCI compared to elective PCI. Among readmitted patients, 16.7% had a coronary catheterisation, 12.2% had a PCI and 0.7% had coronary artery bypass surgery. Multivariable predictors of 30-day unplanned readmission included female sex and comorbidities such as heart failure, metastatic disease, chronic lung disease and renal failure (p<0.0001 for all). Unplanned readmissions following elective or acute PCI are high. Clinical and quality-control measures are required to prevent avoidable readmissions in both settings.

A-48 | Thirty-Day Readmission Rates, Predicators, and Causes of Readmission of Acute Coronary Syndrome Patients With Co-Diagnosis of Chronic Kidney Disease who Underwent Left Heart Catheterization During Index Admission: National Readmission Database of 2018

Left heart catheterization (LHC) for acute coronary syndrome (ACS) is a widely performed procedure. This is challenging to some extent in patients with chronic kidney disease (CKD) especially after receiving intravenous (IV) contrast. We aimed to analyze the rates, predictors and causes of readmission after LHC in ACS patients with co-morbid CKD. The National Readmission Database for 2018 was queried to identify hospitalized adults with ACS and co-diagnosis of CKD who received IV contrast during LHC with exclusion of elective and traumatic admissions. Multivariate logistic and linear regression analysis were used to adjust for possible confounders. A total of 78,168 hospitalizations with ACS and CKD who underwent LHC with 73,603 discharged alive. Within 30-days from discharge, 12,632 (17.2%) were readmitted. Congestive heart failure (CHF) with CKD stage 1-4 (15.5%), non-ST segment elevation myocardial infarction (7.7%), and Sepsis (4.6%) were most common causes of readmissions. Independent predictors of readmission included female sex (aOR 1.16, 95% CI: 1.09 - 1.24, P<0.001), discharge against medical advice (aOR 1.70, 95% CI: 1.23-2.35, P<0.001), CHF (aOR 1.45, 95% CI: 1.35-1.56, P<0.001). Figure 1 shows the Forrest plot of multivariate analysis of independent factors associated with readmissions. Predictors of readmission after LHC included female sex, discharge to skilled facility or against medical advice, anemia, hemodialysis, diabetes mellitus, CHF, acute kidney injury, and COPD. Modifiable factors need to be addressed to prevent such a high rate of readmissions.

Effect of COVID-19 pandemic on outcomes in intracerebral hemorrhage.

Patients with severe intracerebral hemorrhage (ICH) often suffer from impaired capacity and rely on surrogates for decision-making. Restrictions on visitors within healthcare facilities during the pandemic may have impacted care and disposition for patient with ICH. We investigated outcomes of ICH patients during the COVID-19 pandemic compared to a pre-pandemic period. We conducted a retrospective review of ICH patients from two sources: (1) University of Rochester Get With the Guidelines database and (2) the California State Inpatient Database (SID). Patients were divided into 2019-2020 pre-pandemic and 2020 pandemic groups. We compared mortality, discharge, and comfort care/hospice. Using single-center data, we compared 30-day readmissions and follow-up functional status. The single-center cohort included 230 patients (n = 122 pre-pandemic, n = 108 pandemic group), and the California SID included 17,534 patients (n = 10,537 pre-pandemic, n = 6,997 pandemic group). Inpatient mortality was no different before or during the pandemic in either cohort. Length of stay was unchanged. During the pandemic, more patients were discharged to hospice in the California SID (8.4% vs. 5.9%, p<0.001). Use of comfort care was similar before and during the pandemic in the single center data. Survivors in both datasets were more likely to be discharged home vs. facility during the pandemic. Thirty-day readmissions and follow-up functional status in the single-center cohort were similar between groups. Using a large database, we identified more ICH patients discharged to hospice during the COVID-19 pandemic and, among survivors, more patients were discharged home rather than healthcare facility discharge during the pandemic.

PC6. A Nationally Validated Risk Assessment Score for Predicting Unplanned Readmissions in Hand Surgery

PURPOSE: To present a validated model that reliably predicts unplanned readmission after upper extremity/hand surgery. METHODS: A total of 83,409 hand surgery patients were identified using the 2012-2019 ACS-NSQIP databases. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the principal hand surgery. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression with backward variable selection on the testing sample. Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based New Risk Score (NRS) predictive of readmission. The NRS was then tested on the original sample and validated on NSQIP patients who had undergone hand surgery in 2020 (n = 15,247). The NRS was compared to two other widely used risk scores with receiver operating characteristics (ROC) analysis. RESULTS: The rate of 30-day unplanned readmission in the 2020 cohort was 1.1%. Independent risk factors included female gender, emergent case, diabetes, dyspnea, underweight BMI, ASA Class 5, smoking, hypertension, dialysis dependence, wound infection, chronic steroid use, weight loss, transfusion prior to surgery, and SIRS/sepsis (all P < 0.05). ROC analysis of the validation (2020) cohort rendered an area under the curve of 0.754, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.686 and 0.704, respectively. CONCLUSION: We present a validated risk stratification tool for unplanned readmissions following hand surgery. Future studies should determine if implementation of this NRS optimizes safety and reduces readmission rates in hand surgery patients.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020).

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

Mortality and Hospital Readmission Rates for Heart Failure Among Patients of Middle Eastern Ancestry Compared to Non-Middle Eastern Whites in Southeast Michigan.

Outcomes after hospital admission for heart failure are likely affected by cultural and ethnic factors. We obtained data from a large health system in Southeast Michigan on all patients admitted for heart failure from 2008 to 2015. Middle Eastern patients were identified through self-identification and a surname algorithm. Multivariate linear, logistic, and Cox regression models were used to evaluate length of stay and readmission rates compared to Caucasian patients. Mortality data was collected from the National Death Index. 7,784 white and 642 Middle Eastern patients were identified. Middle Eastern patients were younger, had higher rates of comorbid conditions, and had a greater mean hospital length of stay (7.96 vs 7.03days, p = 0.015). Middle Eastern patients had similar thirty-day hospital readmission risk (4.25% vs 4.47%, p = 0.370) but greater ninety-day readmission risk (9.01% vs 8.35%, p = 0.043); after controlling for covariates these differences were not significant. Middle Eastern patients had lower mortality risk (HR = 0.79, p = 0.003). After a hospital admission for heart failure, Middle Eastern patients had longer hospital lengths of stay, similar risk of hospital readmission, but lower all-cause mortality.