Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS: We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS: 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION: Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.

Acute Kidney Injury in Extracorporeal Membrane Oxygenation Patients: National Analysis of Impact of Age.

BACKGROUND: The aim of this study was to determine epidemiology and outcomes of acute kidney injury (AKI) in patients on extracorporeal membrane oxygenation (ECMO) and to assess if age modifies the effect of AKI on mortality. METHODS: Using National (Nationwide) Inpatient Sample Database for hospitalizations in the USA from 2003 to 2014, we identified adult patients on ECMO support. Using International Classification of Diseases 9th Revision, we assessed the rates of AKI and AKI requiring dialysis (AKI-D) among them and associated survival. We used a multivariable logistic regression to identify risk factors of and differential effect of age on mortality from AKI. RESULTS: AKI was seen in 63.9% of 17,942 ECMO hospitalizations: 21.9% of those with AKI required dialysis. The percentage of those with AKI increased steadily. Mortality was higher in those with AKI, with highest in those with AKI-D (70.8% vs. 61.7%; p < 0.001). While both age and AKI were independent predictors of mortality, age was neither a risk factor for AKI nor did it modify the effect of AKI on mortality. CONCLUSIONS: AKI is common and is increasing among patients on ECMO support. Patients on ECMO have high mortality and AKI is an independent predictor of mortality. Though age is also an independent predictor of mortality in patients on ECMO, it is neither a predictor of AKI nor does not modify the relationship between AKI and mortality.

Common Tenets in Repair of Primary Paraesophageal Hernias: Reducing Tension and Maximizing Length.

Tension-free repair remains the most important principle of surgical management of giant paraesophageal hernias. The axial tension is relieved by generous circumferential mobilization of the esophagus in the mediastinum to the level of subcarina. An esophageal lengthening procedure may be necessary for a true short esophagus. The radial tension is managed by mobilizing the left and right diaphragmatic crus. Adjunctive procedures such as pleurotomy or diaphragmatic relaxation incisions may be needed to further reduce the tension on the repair.

Robotic Versus Video-Assisted Thoracoscopic Surgery Pulmonary Segmentectomy: A Cost Analysis.

OBJECTIVE: Pulmonary segmentectomy using robotic assistance is often perceived as being more expensive than segmentectomy using video-assisted thoracic surgery. The robotic technique allows for meticulous dissection during segmentectomy, potentially leading to fewer parenchymal injuries, fewer air leaks, and shorter length of stay. This study compared pulmonary segmentectomy costs using video-assisted thoracic surgery versus robotic with manual staplers versus robotic with robotic staplers. METHODS: Retrospective analyses were performed evaluating our early experience with robotic pulmonary segmentectomy for 30 months compared with the video-assisted thoracic surgery approach. All 50 anatomical segmentectomies performed since introduction of robotic technique in the practice were included. Twenty-eight procedures were robotic-assisted and 22 were video-assisted thoracic surgery. Procedure-specific evaluation of direct costs was performed, including cost of robotic instruments, staplers, and average length of stay in the hospital. RESULTS: The mean ± SD age was 70 ± 10 years (range = 43-91 years). There were 12 males in the robotic group and eight in the video-assisted thoracic surgery group (P = 0.642). The mean age was 69 years in the robotic group and 71 years in the video-assisted thoracic surgery group (P = 0.367). The median length of stay was 2 (2-4) days in the robotic group (range = 1-9) and 4 (2-5) days in the video-assisted thoracic surgery group (range = 1-20, P = 0.089). The cost of robotic segmentectomy with manual staplers was less than that with robotic staplers. Both robotic techniques cost less than video-assisted thoracic surgery. CONCLUSIONS: In this small series, cost and outcomes in our early experience with robotic-assisted segmentectomy were comparable with our video-assisted thoracic surgery approach with trends toward shorter length of stay and fewer complications. Larger series are needed to validate these results.

Optimizing Anesthesia-Related Waste Disposal in the Operating Room: A Brief Report.

Misappropriation of noncontaminated waste into regulated medical waste (RMW) containers is a source of added expense to health care facilities. The operating room is a significant contributor to RMW waste production. This study sought to determine whether disposing of anesthesia-related waste in standard waste receptacles before patient entry into the operating room would produce a reduction in RMW. A median of 0.35 kg of waste was collected from 51 cases sampled, with a potential annual reduction of 13,800 kg of RMW to the host institution, and a cost savings of $2200.

Procedural volume and survival after lung transplantation in the United States: the need to look beyond volume in the establishment of quality metrics.

BACKGROUND: We sought to evaluate the effect of center volume on patient survival. METHODS: We performed a retrospective analysis on nationwide data from the Scientific Registry of Transplant Recipients provided by United Network for Organ Sharing pertaining to lung transplantation (LT) recipients transplanted between 2005 and 2013. Centers were categorized into 4 groups based on their annual volume as follows: less than 20, 20 to 29, 30 to 39, and greater than or equal to 40 LTs. Baseline characteristics were compared and Kaplan-Meier analysis was used to estimate survival. RESULTS: A total of 13,506 adult recipients underwent LT during the study period. Of these, 2,491 (18.4%) patients were transplanted in centers with volume less than 20, 2,562 (19.0%) in centers with volume 20 to 29, 2,998 (22.2%) in centers with volume 30 to 39, and 5,455(40.4%) in centers with volume greater than or equal to 40. Survival was poorest in the lowest volume centers (1-year 81.4% vs 85.5% and 5-year 49.7% vs 56.5%, respectively). CONCLUSIONS: Post-LT survival in low volume centers is significantly lower than in high volume centers but the explanatory power of volume as a predictor of survival is low.

Lung Transplantation in Patients with High Lung Allocation Scores in the US: Evidence for the Need to Evaluate Score Specific Outcomes.

Objective. The lung allocation score (LAS) resulted in a lung transplantation (LT) selection process guided by clinical acuity. We sought to evaluate the relationship between LAS and outcomes. Methods. We analyzed Scientific Registry of Transplant Recipient (SRTR) data pertaining to recipients between 2005 and 2012. We stratified them into quartiles based on LAS and compared survival and predictors of mortality. Results. We identified 10,304 consecutive patients, comprising 2,576 in each LAS quartile (quartile 1 (26.3-35.5), quartile 2 (35.6-39.3), quartile 3 (39.4-48.6), and quartile 4 (48.7-95.7)). Survival after 30 days (96.9% versus 96.8% versus 96.0% versus 94.8%), 90 days (94.6% versus 93.7% versus 93.3% versus 90.9%), 1 year (87.2% versus 85.0% versus 84.8% versus 80.9%), and 5 years (55.4% versus 54.5% versus 52.5% versus 48.8%) was higher in the lower groups. There was a significantly higher 5-year mortality in the highest LAS group (HR 1.13, p = 0.030, HR 1.17, p = 0.01, and HR 1.17, p = 0.02) comparing quartiles 2, 3, and 4, respectively, to quartile 1. Conclusion. Overall, outcomes in recipients with higher LAS are worse than those in patients with lower LAS. These data should inform more individualized evidence-based discussion during pretransplant counseling.

Risk factors associated with lung retransplantation: evaluation of a nationwide registry over a quarter century.

BACKGROUND: The relative paucity of donors heightens the debate and scrutiny surrounding retransplantation. To date, risk factors associated with retransplantation are poorly characterized in the literature. We sought to identify those risk factors that may independently serve to predict lung retransplantation. METHODS: We performed a retrospective evaluation of the United Network for Organ Sharing data over 25 years from 1987 to 2012. Competing risk analysis was used to evaluate the cohort for cumulative incidence of retransplantation. Recipient-related, donor-related, and transplant-related characteristics were assessed using Cox regression to identify risk factors associated with lung retransplantation. RESULTS: We identified 23,180 adult lung transplant recipients, of which 791 (3.4%) had also undergone retransplantation. Factors associated with lung retransplantation at 1 year included recipient age (hazard ratio [HR], 0.97; p=0.005), admission to the intensive care unit (HR, 2.89; p=0.002), donor age (HR, 1.02; p=0.004), and bilateral lung transplantation (HR, 0.41; p<0.001). Moreover, predictors of 5-year risk of retransplantation included recipient age (HR, 0.95; p<0.001), intensive care unit hospitalization (HR, 1.87; p=0.005), and bilateral lung transplant (HR, 0.46; p<0.001), as well as recipient body mass index of 25 to 29 kg/m2 (HR, 1.29; p=0.04) and a diagnosis of chronic obstructive pulmonary disease (HR, 0.68; p=0.008). CONCLUSIONS: We identified factors associated with retransplantation that may afford a better prediction of graft failure and need for retransplantation. These may further serve to better guide donor selection and assist in the development and validation of a risk-scoring model to further guide preoperative counseling.