University HealthSystem Consortium Database Research Articles

Tackling the economic burden of postsurgical complications: would perioperative goal-directed fluid therapy help?

IntroductionPay-for-performance programs and economic constraints call for solutions to improve the quality of health care without increasing costs. Many studies have shown decreased morbidity in major surgery when perioperative goal directed fluid therapy (GDFT) is used. We assessed the clinical and economic burden of postsurgical complications in the University HealthSystem Consortium (UHC) in order to predict potential savings with GDFT.MethodsData from adults who had a major surgical procedure in 2011 were screened in the UHC database. Thirteen post-surgical complications were tabulated. In-hospital mortality, hospital length of stay and costs from patients with and without complications were compared. The risk ratios reported by the most recent meta-analysis were used to estimate the potential reduction in post-surgical morbidity with GDFT. Potential cost-savings were calculated from the actual and anticipated morbidity rates.ResultsA total of 75,140 patients met the search criteria, and 8,421 patients developed one or more post-surgical complications (morbidity rate 11.2%). In patients with and without complications, in-hospital mortality was 12.4% and 1.4% (P <0.001), mean hospital length of stay was 20.5 ± 20.1 days and 8.1 ± 7.1 days (P <0.001) and mean direct costs were $47,284 ± 49,170 and $17,408 ± 15,612 (P <0.001), respectively. With GDFT, morbidity rate was projected to decrease to 8.0 - 9.3%, yielding gross costs savings of $43 M - $73 M for the study population or $569 - $970 per patient.ConclusionPostsurgical complications have a dramatic impact (+172%) on costs. Potential costs savings resulting from GDFT are substantial. Perioperative GDFT may be recommended not only to improve quality of care but also to decrease costs.

Hospital readmissions: necessary evil or preventable target for quality improvement.

To evaluate readmission rates and associated factors to identify potentially preventable readmissions. The decision to penalize hospitals for readmissions is compelling health care systems to develop processes to minimize readmissions. Research to identify preventable readmissions is critical to achieve these goals. We performed a retrospective review of University HealthSystem Consortium database for cancer patients hospitalized from January 2010 to September 2013. Outcome measures were 7-, 14-, and 30-day readmission rates and readmission diagnoses. Hospital and disease characteristics were evaluated to evaluate relationships with readmission. A total of 2,517,886 patients were hospitalized for cancer treatment. Readmission rates at 7, 14, and 30 days were 2.2%, 3.7%, and 5.6%, respectively. Despite concern that premature hospital discharge may be associated with increased readmissions, a shorter initial length of stay predicted lower readmission rates. Furthermore, high-volume centers and designated cancer centers had higher readmission rates. Evaluating institutional data (N = 2517 patients) demonstrated that factors associated with higher readmission rates include discharge from a medical service, site of malignancy, and emergency primary admission. When examining readmission within 7 days for surgical services, the most common readmission diagnoses were infectious causes (46.3%), nausea/vomiting/dehydration (26.8%), and pain (6.1%). A minority of patients after hospitalization for cancer-related therapy are readmitted with potentially preventable conditions such as nausea, vomiting, dehydration, and pain. However, most factors associated with readmission cannot be modified. In addition, high-volume centers and designated cancer centers have higher readmission rates, which may indicate that readmission rates may not be an appropriate marker for quality improvement.

Clostridium difficile Infection After Colorectal Surgery: A Rare but Costly Complication

BackgroundThe incidence and virulence of Clostridium difficile infection (CDI) are on the rise. The characteristics of patients who develop CDI following colorectal resection have been infrequently studied. Materials and MethodsWe utilized the University HealthSystem Consortium database to identify adult patients undergoing colorectal surgery between 2008 and 2012. We examined the patient-related risk factors for CDI and 30-day outcomes related to its occurrence. ResultsA total of 84,648 patients met our inclusion criteria, of which the average age was 60 years and 50 % were female. CDI occurred in 1,266 (1.5 %) patients during the years under study. The strongest predictors of CDI were emergent procedure, inflammatory bowel disease (IBD), and major/extreme APR-DRG severity of illness score. CDI was associated with a higher rate of complications, intensive care unit (ICU) admission, longer preoperative inpatient stay, 30-day readmission rate, and death within 30 days compared to non-CDI patients. Cost of the index stay was, on average, $14,130 higher for CDI patients compared with non-CDI patients. ConclusionEmergent procedures, higher severity of illness, and inflammatory bowel disease are significant risk factors for postoperative CDI in patients undergoing colorectal surgery. Once established, CDI is associated with worse outcomes and higher costs. The poor outcomes of these patients and increased costs highlight the importance of prevention strategies targeting high-risk patients.

Use of Elderly Allografts in Liver Transplantation.

Purpose: Use of liver allografts from elderly donors has increased due to organ shortage and increased life expectancy of the general population. The aim of this study is to evaluate the current utilization of elderly donors in the United States, patterns of recipient selection, and their outcomes. Methods: Using a linkage between the Scientific Registry of Transplant Recipients and University HealthSystem Consortium databases, we identified 12,445 liver transplant (LT) recipients between January 2007 and December 2011. Recipients were divided into two cohorts based on the donor age: ≥ 70 years (n= 540) and < 60 years (n= 10,473). A stepwise cox regression evaluated the impact of elderly donors on graft survival after adjusting for transplant related factors. Results: Elderly donors accounted for 4.3% of donors used in the five-year period. Compared to younger donors, elderly donors were more likely to be females (53.9% vs. 39.0%, P<0.001), shared regionally or nationally (46.4% vs. 28.5%, P<0.001), and used at high volume centers (48.5% vs. 32.2%, P<0.001). The top three centers using elderly donors accounted for 1/3 of all elderly donors, and resided in Regions 7 and 9. The comparison between the two recipient cohorts showed that recipients of elderly donors were older (> 60 years: 47.8% vs. 29.1%, P<0.001), less likely to be on dialysis (2.6% vs. 8.1%, P<0.001), or inpatient at time of LT (16.9% vs. 21.7%, P=0.03), and had lower MELD score (>28: 13.2% vs. 23.0%, P<0.001). Both recipient groups had similar perioperative mortality, readmission rates, and long-term patient survival. Recipients of elderly donors were associated with increased graft loss (p<0.001). In the multivariate analysis, elderly donors were associated with increased risk of graft failure only when adjusted for recipient characteristics (HR 1.32, 95% CI 1.11-1.56) or center and regional factors (HR 1.23; 95% CI 1.04-1.46) individually; however, in the adjusted analysis including all these factors together, elderly donors did not carry increased risk of graft failure. Conclusions: Currently, the use of elderly liver allografts is limited to selected recipients (older age, less severe disease) by high volume centers in regions of high wait list mortality. Adjusted analysis of graft survival confirms that the use of elderly donors in appropriately selected recipients and centers results in acceptable graft survival.

Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations

Hypothermia occurs in as many as 7% of elective colorectal operations and is an underestimated risk factor for complications and death. Rewarming of hypothermic patients alone is not sufficient to prevent such adverse events. We investigated the outcomes of patients who became hypothermic (<35°C) after elective operations and compared them with closely matched, nonhypothermic operative patients to better define the impact of hypothermia on surgical outcomes, as well as to identify independent risk factors for hypothermia. We queried the University HealthSystem Consortium (UHC) database for elective operative patients who became unintentionally hypothermic from October 2008 to March 2012, and identified 707 patients. Exclusion criteria were deliberate hypothermia, age <18 years, or death on day of admission. Separately, to validate the accuracy of hypothermia coding, we reviewed the hospital charts of all University of Louisville Hospital patients with hypothermia whose data were submitted to UHC. All patients from UHC with a code for hypothermia were indeed unintentionally hypothermic. Hypothermic patients undergoing elective operations experienced a 4-fold increase in mortality (17.0% vs 4.0%; P < .001) and a doubled complication rate (26.3% vs 13.9%; P < .001), in which sepsis and stroke increased the most. Several independent risk factors for hypothermia were amenable to preoperative improvement: anemia, chronic renal impairment, and unintended weight loss. Severity of illness on admission, age >65 years, male sex, and neurologic disorders also were risk factors. Hypothermia is associated with an increased rate of mortality and complications. Preventive treatment of these risk factors before operation and aggressive warming measures in the "at risk" population may decrease hypothermia-related morbidity and mortality in elective operations. Randomized-controlled trials should be conducted to evaluate the impact of aggressive warming measures in the at-risk population.

An initial experience with 85 consecutive robotic-assisted rectal dissections: improved operating times and lower costs with experience.

Data are limited about the robotic platform in rectal dissections, and its use may be perceived as prohibitively expensive or difficult to learn. We report our experience with the initial robotic-assisted rectal dissections performed by a single surgeon, assessing learning curve and cost. Following IRB approval, a retrospective chart review was conducted of the first 85 robotic-assisted rectal dissections performed by a single surgeon between 9/1/2010 and 12/31/2012. Patient demographic, clinicopathologic, procedure, and outcome data were gathered. Cost data were obtained from the University HealthSystem Consortium (UHC) database. The first 43 cases (Time 1) were compared to the next 42 cases (Time 2) using multivariate linear and logistic regression models. Indications for surgery were cancer for 51 patients (60 %), inflammatory bowel disease for 18 (21 %), and rectal prolapse for 16 (19 %). The most common procedures were low anterior resection (n = 25, 29 %) and abdominoperineal resection (n = 21, 25 %). The patient body mass index (BMI) was statistically different between the two patient groups (Time 1, 26.1 kg/m(2) vs. Time 2, 29.4 kg/m(2), p = 0.02). Complication and conversion rates did not differ between the groups. Mean operating time was significantly shorter for Time 2 (267 min vs. 224 min, p = 0.049) and remained significant in multivariate analysis. Though not reaching statistical significance, the mean observed direct hospital cost decreased ($17,349 for Time 1 vs. $13,680 for Time 2, p = 0.2). The observed/expected cost ratio significantly decreased (1.47 for Time 1 vs. 1.05 for Time 2, p = 0.007) but did not remain statistically significant in multivariate analyses. Over the series, we demonstrated a significant improvement in operating times. Though not statistically significant, direct hospital costs trended down over time. Studies of larger patient groups are needed to confirm these findings and to correlate them with procedure volume to better define the learning curve process.

Bariatric surgery in the elderly: 2009–2013

BackgroundAmple evidence supports the safety and effectiveness of bariatric surgery in the general adult population but more information is needed in patients age 60 years and older (elderly). We previously examined the outcome of bariatric surgery performed in the elderly between 1999 and 2005 using the University HealthSystem Consortium (UHC) Clinical Database. The aim of this study was to analyze contemporary outcomes of bariatric surgery in the elderly and to compare them to previous data from 1999–2005. MethodsUsing International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the UHC database for all elderly (age >60 yr) and adult nonelderly (age 19–60 yr) patients who underwent bariatric surgery for the treatment of morbid obesity between 2009 and 2013. Outcome measures, such as patient characteristics, LOS, morbidity, and observed-to-expected (risk-adjusted) mortality ratio were compared between elderly and nonelderly patients. ResultsBariatric surgery in the elderly made up 2.7% of all bariatric operations in 1999–2005. This represents an increase to 10.1% of all bariatric operations in 2009–2013. In-hospital mortality was .30% for the nonelderly and .70% for the elderly in 1999–2005, whereas contemporary in-hospital mortality has decreased to .11% for the nonelderly and .05% for the elderly. ConclusionOur results show that the number of bariatric procedures performed in the elderly is increasing and now represents 10% of all bariatric operations performed at academic centers. In-hospital mortality in bariatric surgery in the elderly has improved so much that it is now even better than in-hospital mortality in the nonelderly in 1999–2005.

Predictors for Perioperative Outcomes following Total Laryngectomy: A University HealthSystem Consortium Discharge Database Study

The University HealthSystem Consortium (UHC) database collects discharge information on patients treated at academic health centers throughout the United States. We sought to use this database to identify outcome predictors for patients undergoing total laryngectomy. A secondary end point was to assess the validity of the UHC's predictive risk mortality model in this cohort of patients. Retrospective review. Academic medical centers (tertiary referral centers) and their affiliate hospitals in the United States. Using the UHC discharge database, we retrieved and analyzed data for 4648 patients undergoing total laryngectomy who were discharged between October 2007 and January 2011 from all of the member institutions. Demographics, comorbidities, institutional data, and outcomes were retrieved. The length of stay and overall costs were significantly higher among female patients (P < .0001), while age was a predictor of intensive care unit stay (P = .014). The overall complication rate was higher among Asians (P = .019) and in patients with anemia and diabetes compared with other comorbidities. The average institutional case load was 1.92 cases/mo; we found an inverse correlation (R = -0.47) between the institutional case load and length of stay (P < .0001). The UHC admit mortality risk estimator was found to be an accurate predictor not only of mortality (P < .0002) but also of intensive care unit admission and complication rate (P < .0001). This study provides an overview of laryngectomy outcomes in a contemporary cohort of patients treated at academic health centers. UHC admit mortality risk is an excellent outcome predictor and a valuable tool for risk stratification in these patients.

Racial disparities in the use of blood transfusion in major surgery.

BackgroundRacial disparities in healthcare in the United States are widespread and have been well documented. However, it is unknown whether racial disparities exist in the use of blood transfusion for patients undergoing major surgery.MethodsWe used the University HealthSystem Consortium database (2009-2011) to examine racial disparities in perioperative red blood cells (RBCs) transfusion in patients undergoing coronary artery bypass surgery (CABG), total hip replacement (THR), and colectomy. We estimated multivariable logistic regressions to examine whether black patients are more likely than white patients to receive perioperative RBC transfusion, and to investigate potential sources of racial disparities.ResultsAfter adjusting for patient-level factors, black patients were more likely to receive RBC transfusions for CABG (AOR = 1.41, 95% CI: [1.13, 1.76], p = 0.002) and THR (AOR = 1.39, 95% CI: [1.20, 1.62], p < 0.001), but not for colectomy (AOR = 1.08, 95% CI: [0.90, 1.30], p = 0.40). Black-white disparities in blood transfusion persisted after controlling for patient insurance and hospital effects (CABG: AOR = 1.42, 95% CI: [1.30, 1.56], p < 0.001; THR: AOR = 1.43, 95% CI: [1.29, 1.58], p < 0.001).ConclusionsWe detected racial disparities in the use of blood transfusion for CABG and THR (black patients tended to receive more transfusions compared with whites), but not for colectomy. Reporting racial disparities in contemporary transfusion practices may help reduce potentially unnecessary blood transfusions in minority patients.

Costs of Outpatient Thyroid Surgery from the University HealthSystem Consortium (UHC) Database

To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers. Cross-sectional analysis of a national database. The University HealthSystem Consortium (UHC) data collected from discharge summaries. Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy. During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P < .0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation. Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.

Specialties performing paracentesis procedures at university hospitals: Implications for training and certification

Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear. To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs. Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals. Patients with liver disease who underwent inpatient paracentesis procedures. We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral. There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001). Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.

Comparing the safety and efficacy of red blood cell transfusion dose in hematopoietic stem cell transplant patients: single versus double unit transfusions

Until recently, the national standard practice for blood transfusions in bone marrow transplant patients was two units of red blood cells (RBCs) per transfusion episode. This practice was called into question due to safety concerns, suggesting that one unit of RBCs per transfusion episode may be an equivalent or even safer and less costly practice (assuming factors such as amount of bleeding and hemoglobin level are equal). Following a thorough review of existing blood management practices and review of the literature, our academic medical center changed practice to routinely transfuse one unit of RBCs per low hemoglobin (7-8 g/dL) episode if certain clinical criteria were met. Following IRB approval, a retrospective medical record review began to evaluate this practice change among two groups of hematology-oncology patient populations (allogeneic and autologous bone marrow transplant). Patient records from these two groups of patients are being evaluated before and after the practice change (one vs two units of RBCs/transfusion) looking at average units of blood products transfused per patient, impact on length of stay, and estimate of nursing time costs. The project is expected to generate new knowledge regarding safe blood management practices in hematology oncology patients. The project is using the hematology oncology inpatient unit log of admissions and discharges to identify adult allogeneic and autologous bone marrow transplant patients who received a blood transfusion for a hemoglobin of 7-8g/dl and hematocrit above 21%; and were not actively bleeding, septic, experiencing a major infection, or pregnant. Patient data are being obtained from the University HealthSystem Consortium (UHC) database. 400 cases are being enrolled, 200 from pre-practice change (7-1-2009 to 6-30-2011) and 200 from post-practice change (9-1-2011 to 8-31-2013). A two-month gap was purposefully included between the two time periods to allow for full transition to the new practice standard of one unit of RBCs/transfusions. Data thus far suggests a reduction in red blood cell utilization at an average of 1.3 units per hospital discharge. Based on these utilization trends, we are estimating a cost savings of at least $1300 per month just in purchase cost ($200 per RBC unit X 1.3 units per discharge X an average of 5 patients/month). Additionally, we are estimating a savings in nursing hours of approximately 13 hours per month (2 hours per RBC transfusion X 1.3 units per discharge X an average of 5 patients/month). Preliminary project findings indicate promise for the standard practice of transfusing one unit of RBCs per low hemoglobin episode for allogeneic bone marrow transplant and autologous bone marrow transplant patients. After data collection is complete, formal statistics will be completed to compare the mean number of RBC units between the practice of routinely transfusing 1 RBC unit and the practice of routinely transfusing 2 RBC units, as well as comparing length of stay and costs. Early conclusions suggest the goal of improving the safety of blood transfusions and preserving a precious resource might be achieved with this important practice change for two groups of oncology patients. These results will inform other practice settings to improve their use of blood management products for oncology patients and promote patient safety and cost-effective practices. Use of the UHC database as a meaningful resource for practice improvement projects and research studies will be highlighted. Continued evaluation and ongoing improvement of blood management practices at the project site will be discussed with suggestions for other settings and practices. This will help improve the safety of blood transfusions. It could guide future studies with baseline information from this transfusion practice change. Other oncology areas could adopt a similar practice change, educate patients and clinicians on safe transfusion practices.

The Risk of Uterine Malignancy Is Linearly Associated With Body Mass Index in a Cohort of US Women

Objective We sought to quantify the relationship of uterine malignancy with body mass index (BMI). Study Design The University HealthSystem Consortium database was queried to identify all women undergoing total hysterectomy with a recorded BMI in the overweight and obese categories. Least squares regression was applied to evaluate the association between increasing BMI and the proportion of women with a diagnosis of uterine malignancy. Multivariate binary logistic regression was performed to adjust for other known risk factors including age, race, and other comorbidities. Results There were 6905 women who met inclusion criteria; 1891 (27.4%) of these had uterine malignancy. There is a linear relationship (y = 0.015x - 0.23, R 2 = 0.92) of the probability of uterine malignancy vs BMI. After adjusting for other risk factors, we found that each 1-U increase in BMI was significantly, independently associated with an 11% increase in the proportion of patients diagnosed with uterine malignancy (odds ratio, 1.11; 95% confidence interval, 1.09–1.13; P Conclusion In a population of women undergoing hysterectomy, we observed a linear increase in the frequency of uterine cancer associated with increasing BMI. This finding suggests that even relatively modest weight gain may significantly raise cancer risk. In the United States, the mean BMI for women is 26.5 kg/m 2 and it is estimated that more than half of US women have a BMI within the study's range. Our results could, therefore, be relevant to a majority of the population. The findings could increase popular acceptance of weight management as a key component of general health maintenance and, possibly, as an additional approach to cancer risk reduction.

Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

BackgroundMorbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group. MethodsDischarge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed. ResultsA total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure. ConclusionsOn the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.

Costs of Outpatient Thyroid Surgery from the University Heathcare Consortium

Objectives: Compare the cost of outpatient and inpatient thyroidectomy at US academic medical centers. Methods: Discharge data were collected from the first quarter of 2009 through the fourth quarter of 2012 from the University Health System Consortium (UHC) on over 50,000 patients. The UHC database, compiled from over 100 academic health centers and their 200 affiliated hospitals, was searched based on diagnosis codes for outpatient and inpatient thyroid procedures. The Agency for Healthcare and Research Quality (AHRQ) chronic conditions were collected in addition to demographic, length of stay (LOS), and cost data. Comparisons were made between inpatient and outpatient thyroidectomy stratified by number of chronic conditions. Results: The cost of outpatient thyroidectomy was consistently less than that for inpatient thyroidectomy. More outpatient thyroidectomies were performed on patients with 0 or 1 chronic condition, while more inpatient thyroidectomies were performed on patients with 2 or greater chronic conditions. When stratifying by number of chronic conditions, the cost of outpatient thyroidectomy remained stable independent of the number of additional conditions. However, the cost of inpatient thyroidectomy rose linearly with an increased number of chronic conditions. Conclusions: Outpatient thyroid surgery is associated with less cost when compared with inpatient thyroid surgery, and the difference in cost rises with number of chronic conditions present. The transition to outpatient thyroid surgery may provide significant cost-savings, particularly in those patients with chronic conditions. However, certain chronic conditions may preclude patients from undergoing outpatient surgery.

The risk of uterine malignancy is linearly associated with body mass index in a cohort of US women

We sought to quantify the relationship of uterine malignancy with body mass index (BMI). The University HealthSystem Consortium database was queried to identify all women undergoing total hysterectomy with a recorded BMI in the overweight and obese categories. Least squares regression was applied to evaluate the association between increasing BMI and the proportion of women with a diagnosis of uterine malignancy. Multivariate binary logistic regression was performed to adjust for other known risk factors including age, race, and other comorbidities. There were 6905 women who met inclusion criteria; 1891 (27.4%) of these had uterine malignancy. There is a linear relationship (y = 0.015x - 0.23, R(2) = 0.92) of the probability of uterine malignancy vs BMI. After adjusting for other risk factors, we found that each 1-U increase in BMI was significantly, independently associated with an 11% increase in the proportion of patients diagnosed with uterine malignancy (odds ratio, 1.11; 95% confidence interval, 1.09-1.13; P < .001). In a population of women undergoing hysterectomy, we observed a linear increase in the frequency of uterine cancer associated with increasing BMI. This finding suggests that even relatively modest weight gain may significantly raise cancer risk. In the United States, the mean BMI for women is 26.5 kg/m(2) and it is estimated that more than half of US women have a BMI within the study's range. Our results could, therefore, be relevant to a majority of the population. The findings could increase popular acceptance of weight management as a key component of general health maintenance and, possibly, as an additional approach to cancer risk reduction.

Excess risk of Clostridium difficile infection in ovarian cancer is related to exposure to broad-spectrum antibiotics

The purpose of the study was to determine if a diagnosis of ovarian cancer is independently associated with an increased risk of Clostridium difficile infection (CDI). The University HealthSystem Consortium database was queried to perform a retrospective cohort study of women with and without ovarian cancer who were diagnosed with CDI. Inpatients undergoing total hysterectomy from 2008 to 2012 were studied. Ovarian cancer patients were compared to non-ovarian cancer patients to evaluate relative risk (RR) of CDI. Adjustment was made for known or suspected CDI risk factors to determine RR of CDI independent of these variables. In this study, 115,203 patients were included. CDI was reported in 0.80 % of ovarian cancer patients and in 0.31 % of non-ovarian cancer patients (RR = 2.50; 95 % confidence interval (CI) = 2.02 to 3.35). Stratification by age, presence of other comorbidities, or administration of antineoplastic drugs did not significantly modify the elevated risk associated with ovarian cancer. Significantly increased risk in ovarian cancer patients was no longer observed after controlling for broad-spectrum antibiotic administration (RR = 1.28, 95 % CI = 0.39 to 4.13). Compared to non-ovarian cancer patients, ovarian cancer patients were more frequently treated with broad-spectrum antibiotics, had a 39 % longer mean duration of therapy, and had 2.5-fold greater mean total exposure to broad-spectrum antibiotics. After adjustment for antibiotic use, ovarian cancer patients are not at excess risk of CDI. Additional studies are needed to understand the patterns of broad-spectrum antibiotic prescription for ovarian cancer patients leading to increased exposure. If feasible, reduction of this exposure may decrease morbidity in this population.

Risk factors for in-hospital mortality and prolonged length of stay in older patients with solid tumor malignancies

Hospitalized adult patients with cancer and with major comorbidities have higher mortality rates and longer duration of hospitalization. There is limited understanding of risk factors that contribute to prolonged hospitalization and mortality in older patients with solid tumors. Risk factors associated with in-hospital mortality and prolonged length of stay (LOS) in older patients with cancer were investigated in a retrospective cohort study. Data from the University HealthSystem Consortium database included 386,377 patients age ≥ 65 years with solid tumors hospitalized between 1995 and 2003 at 133 U.S. academic medical centers. The overall mortality rate was 7.3%. Mortality in older patients with cancer was strongly associated with longer LOS. Almost twice as many deaths were observed among those with LOS ≥ 10 days (p<0.0001). Nearly 38% of older cancer patients who died in hospital had potentially curable disease. Primary central nervous system malignancies were most strongly associated with in-hospital mortality (OR=1.81; 1.59-2.07), followed by esophageal (OR=1.74; 1.54-1.97) and lung cancer (OR=1.57; 1.43-1.72). Male gender, African-American race, and Hispanic and Asian race/ethnicity were associated with increased risk of mortality (p<0.0001). Additional risk factors included metastatic disease, infection, neutropenia, renal, lung, hepatic, cerebrovascular disease, arterial/venous thromboembolism, heart failure, and red blood cell transfusion. Risk factors for prolonged LOS included gastric cancer, infection, venous thromboembolism and red blood cell transfusion. Prolonged LOS was strongly associated with mortality. Risk factors such as infection, neutropenia and red blood cell transfusion, when modified, could potentially reduce rates of prolonged LOS and mortality in older patients with cancer.

Save the Perineum! A Protocol to Reduce Perineal Trauma

Purpose for the Program Perineal trauma, including a third‐degree or fourth‐degree laceration, is a serious adverse outcome of a vaginal delivery, which can lead to chronic pain, urinary or bowel disturbances, and sexual dysfunction. The third‐degree and fourth‐degree laceration rate at this large university hospital was noted to be in the high range based on the University Health System Consortium database. The Obstetric Quality and Safety Committee identified the rate of third‐degree and fourth‐degree lacerations and charged a multidisciplinary team composed of physicians, nurses, and nurse–midwives to investigate potential causes that could be addressed to make positive improvements on the issue. Proposed Change To implement a perineal safety bundle for management of the second stage of labor. There are practices with some evidence thought to decrease perineal trauma; however, the team was not confident that one particular change alone would affect the rate of third‐degree and fourth‐degree lacerations. Therefore, a bundle was created composed of the following: (a) “Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b) use of warm packs to the perineum applied every 30 minutes during the second stage of labor; (c) change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d) foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e) avoidance of manual perineal stretching during the second stage of labor. Implementation, Outcomes, and Evaluation Nurses, physicians, and residents were educated about the bundle protocol. Physicians were given the option to opt‐in or opt‐out of the bundle. The protocol used during this 6‐month time frame concluded in January 2013. Data on differences between use of the bundle versus nonuse will be compared with third‐degree and fourth‐degree laceration rates. Implications for Nursing Practice The implementation of evidence‐based practice related to the second stage of labor is a process. Varied techniques of leg holding positions, perineal massage and manipulation, and passive management of the “labor down” phase have been thought to add to the perineal trauma and use of operative vaginal delivery techniques. Introduction of the bundle has provided direction to the nursing and medical staff in use of evidence‐based practice. Perineal trauma, including a third‐degree or fourth‐degree laceration, is a serious adverse outcome of a vaginal delivery, which can lead to chronic pain, urinary or bowel disturbances, and sexual dysfunction. The third‐degree and fourth‐degree laceration rate at this large university hospital was noted to be in the high range based on the University Health System Consortium database. The Obstetric Quality and Safety Committee identified the rate of third‐degree and fourth‐degree lacerations and charged a multidisciplinary team composed of physicians, nurses, and nurse–midwives to investigate potential causes that could be addressed to make positive improvements on the issue. To implement a perineal safety bundle for management of the second stage of labor. There are practices with some evidence thought to decrease perineal trauma; however, the team was not confident that one particular change alone would affect the rate of third‐degree and fourth‐degree lacerations. Therefore, a bundle was created composed of the following: (a) “Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b) use of warm packs to the perineum applied every 30 minutes during the second stage of labor; (c) change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d) foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e) avoidance of manual perineal stretching during the second stage of labor. Nurses, physicians, and residents were educated about the bundle protocol. Physicians were given the option to opt‐in or opt‐out of the bundle. The protocol used during this 6‐month time frame concluded in January 2013. Data on differences between use of the bundle versus nonuse will be compared with third‐degree and fourth‐degree laceration rates. The implementation of evidence‐based practice related to the second stage of labor is a process. Varied techniques of leg holding positions, perineal massage and manipulation, and passive management of the “labor down” phase have been thought to add to the perineal trauma and use of operative vaginal delivery techniques. Introduction of the bundle has provided direction to the nursing and medical staff in use of evidence‐based practice.

Creating a risk of readmission (ROR) score for gynecologic oncology (GO) patient.

6636 Background: The annual cost of 30 day hospital readmissions in the US is $16 billion. The objectives of this study are to determine factors associated with readmission among GO patients, and to create a risk score to identify populations at the highest risk of readmission. Methods: The University HealthSystem Consortium database was queried to identify readmissions among GO patients from 1/1/08 through 9/30/12. Risk factors for 30 day readmission were determined by univariate and multivariate analysis. For each risk factor found to be independently associated with readmission, the low risk group was scored 0 and the high risk group scored 1. The ROR score is the sum of the individual scores. Probability of readmission was calculated for each ROR score. Results: Overall, the readmission rate for GO patients was 4.5%. Vulvar cancer, medical MSDRG, urgent or emergent admission, length of stay &gt; 4 days, and coverage by a public payer (during 1st admission) each was independently associated with readmission. Probability of readmission increases significantly with increasing risk score. Patients with a ROR score of 0 or 1 have a readmission rate of 3.9% (95% CI 3.7% to 4.1%); patients with a ROR score of &gt;1 have a readmission rate of 10.7% (95% CI 10.1% to 11.2%). Conclusions: Specific risk factors and composite risk score are associated with 30 day readmission rate among GO patients. The patient specific ROR score may be used to target transitions of care interventions aimed at reducing readmissions. [Table: see text] [Table: see text]