Rates and Risk Factors for Unplanned Emergency Department Utilization and Hospital Readmission Following Bariatric Surgery.

OBJECTIVE: To identify unplanned emergency resource utilization in the perioperative period following bariatric surgery. SUMMARY OF BACKGROUND DATA: Avoidable emergency department (ED) utilization and hospital readmissions pose a significant economic burden to our healthcare system. The extent of this problem is poorly studied in the bariatric literature. METHODS: Using New York statewide longitudinal administrative data, 38,776 patients, who underwent primary bariatric surgery from 2010 to 2013, were analyzed. Multiple logistic regression models analyzed all variables with P < 0.05 on univariate models. RESULTS: The 30-day unplanned ED utilization rate was 11.3% and 30-day hospital readmission rate was 5.3%. ED visits resulted in an inpatient admission 34.9% of the time. In total, 17.5% had 2 or more 30-day unplanned ED presentations. Patients presenting to the ED were more likely to be black, have pulmonary disease, be insured by the Centers for Medicaid and Medicare Services, travel further distances for index procedure, and have a surgical procedure other than gastric banding. In total, 46.7% presented to a nonindex hospital and 32.5% were admitted. Patients presenting to a nonindex hospital were significantly less likely to be admitted than those presenting to an index hospital. CONCLUSIONS: Unplanned perioperative healthcare utilization is a significant burden incurred by the bariatric population. A clear opportunity is identified for improvement in healthcare delivery-particularly for high-risk and high-frequency utilizers. Presentation to nonindex hospitals has important implications to the accuracy of current patient safety and quality outcomes measures. System measures designed to capture all unplanned resource utilization, not just those to index hospitals, are crucial for accurate evaluation.

Population-Based Analysis of Hematologic Malignancy Referrals to a Comprehensive Cancer Center, Referrals for Blood and Marrow Transplantation, and Participation in Clinical Trial, Survey, and Biospecimen Research by Race.

Racial and ethnic disparities have been reported in clinical trial/research participation, utilization of autologous and allogeneic blood and marrow transplantation (BMT), and availability of allogeneic donors. We performed a population-based cohort study to investigate adult hematologic malignancy referrals to a US tertiary cancer center, utilization of BMT, and participation in clinical trial, survey, and biospecimen research by race. US Census Data and the New York State Public Access Cancer Epidemiology Database identified the racial distribution of the general population and new hematologic malignancy cases in the primary catchment area. From 2005 to 2011, 1106 patients aged 18 to 75 years were referred for BMT consultation; although the rate of BMT among hematologic malignancy referrals did not differ by race, the reasons for not receiving a BMT did. Participation in biospecimen research did not vary by race; however, African Americans and other minorities were significantly less likely to participate in survey research than European Americans. Although rates of hematologic malignancy referrals and use of BMT for minorities appear to be low (<10%), they closely reflect the race distribution of all hematologic malignancy cases and the western New York population. African Americans are equally likely as other races to participate in biospecimen banking, but further study is needed to understand reasons for lower participation in survey research.

Predicting potentially preventable hospital readmissions following bariatric surgery.

BACKGROUND: Using hospital readmissions as a quality of care measure predicates that some readmissions were preventable. OBJECTIVES: This study identifies predictors of potentially preventable readmissions (PPR) within 30 days of bariatric surgery discharge. SETTING: New York State acute care hospitals. METHODS: Adult inpatient surgical discharges, during 2012, with a principal diagnosis of overweight or obesity and a principal procedure for bariatric surgery were identified. Logistic regression was used to evaluate surgical approach, sex, age, race/ethnicity, payor, body mass index, complications and co-morbidities recorded during the surgical admission. RESULTS: There were 10,448 surgeries studied for readmission of which 552 were followed by a PPR, for a statewide rate of 5.3 per 100 surgeries. Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) was the most common surgical approach (46.0%), then Sleeve Gastrectomy (SG) (41.3%), Laparoscopic Adjustable Gastric Band (LAGB) (8.1%), and Open Roux-en-Y Gastric Bypass (RYGB) (4.6%). RYGB had the highest PPR rate (8.8), followed by LRYGB (6.1), SG (4.3) and LAGB (3.3). Compared to LAGB, the odds of a PPR in patients with RYGB, LRYGB, and SG increased by 2.4 fold, 1.8 fold and 1.2 fold respectively. Black, non-Hispanic patients were at a greater risk of PPR (odds-ratio 2.0, P<.0001) compared to White, non-Hispanic patients while the risk of a PPR increased by 2-fold in patients with a surgical complication. CONCLUSIONS: Taking all patient risk factors into account, the most significant predictors of a PPR were surgical approach, race and the presence of a surgical complication.

Hospital admissions greater than 30 days following bariatric surgery: patient and procedure matter.

INTRODUCTION: Assessment of hospital admission in the 30-day period following bariatric surgery likely underestimates true hospital utilization. The purpose of this study is to assess hospital admissions for 2 years following bariatric surgery to identify potential differences by patient and procedure. METHODS: New York State Planning and Research Cooperative System (SPARCS) longitudinal administrative data were used to identify 22,139 adult patients who underwent a primary bariatric surgery from 2006 to 2008. Bariatric operations included laparoscopic gastric banding (LGB), laparoscopic Roux-en-y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy (LSG). Patients were followed for 2 years after surgery to identify all-cause hospital admissions. Statistical correlation between postoperative hospital admission and patient demographics, comorbid conditions, and bariatric procedure was performed. RESULTS: Of the 22,139 patients, 5,718 (26 %) patients were admitted within 2 years of surgery for a total of 9,502 admissions. Thirty-day admission rate was 5 %. The number of admissions per patient ranged from 1 to 22. Assessing the number of admissions per patient demonstrated that 3,741 (17 %) patients had one, 1,575 (7 %) had 2-3, and 402 (2 %) patients had greater than 4 admissions. LSG had both the highest admission rate and percentage of patients with >4 admissions, followed by RYGB and then LGB (p < 0.001). Risk factors for admission included black race, female gender, age > 50, Medicaid/Medicare as payer, congestive heart failure, pulmonary disease, diabetes, rheumatoid arthritis, history of substance abuse, and psychoses/depression. CONCLUSION: One out of four bariatric patients will be admitted to the hospital within 2 years of surgery. While most patients are admitted only once, a subset of patients requiring numerous hospital admissions was identified. LSG is associated with both the highest rate as well as highest frequency of hospital admissions. Several patient factors were also identified that significantly increased admission risk. Consideration and attention to these factors are necessary for operative planning, preoperative patient education, and postoperative monitoring.

Comparison of tissue metal concentrations in Zucker lean, Zucker obese, and Zucker diabetic fatty rats and the effects of chromium supplementation on tissue metal concentrations.

Diabetes results in several metabolic changes, including alterations in the transport, distribution, excretion, and accumulation of metals. While changes have been examined in several rat models of insulin resistance and diabetes, the metal ion concentrations in the tissues of Zucker lean, Zucker obese (an insulin resistance and early stage diabetes model), and Zucker diabetic fatty (ZDF, a type 2 diabetes model) have not previously been examined in detail. The concentration of Cu, Zn, Fe, Mg, and Ca were examined in the liver, kidney, heart and spleen, and Cr concentration in the liver and kidney of these rats were examined. Zucker obese rats have a reduction in the concentration of Cu, Zn, Fe, Mg in the liver compared to ZDF and/or lean Zucker rats, presumably as a result of the increased fat content of the liver of the obese rats. ZDF rats have increased concentrations of kidney Cu compared to the lean rats, while kidney Ca concentrations are increased in the Zucker obese rats. Spleen Fe concentrations are decreased in Zucker obese rats compared to the lean rats. No effects on metal concentrations in the heart were observed between the lean, obese, and ZDF rats, and no effects on Cr concentrations were identified. Cr(III) complexes have previously been shown to have beneficial effects on the signs of insulin resistance in Zucker obese and ZDF rats. The effects of daily gavage administration of chromium picolinate ([Cr(pic)(3)]) (1 mg Cr/kg body mass), CrCl(3) (1 mg Cr/kg body mass), and Cr3 ([Cr(3)O(propionate)(6)(H(2)O)(3)](+)) (33 µg and 1 mg Cr/kg body mass) on metal concentrations in these tissues were examined. Treatment with CrCl(3) and Cr3, but not [Cr(pic)(3)], at 1 mg Cr/kg resulted in a statistically significant accumulation of Cr in the kidney of lean and obese but not ZDF rats but resulted in lowering the elevated levels of kidney Cu in ZDF rats, suggesting a beneficial effect on this symptom of type 2 diabetes.