Emergency Department Visit Rates After Ambulatory Surgery.

This cohort study compares the rates of emergency department visits after cholecystectomy, transurethral resection of the prostate, and knee arthroplasty at freestanding ambulatory surgery centers vs hospital-owned surgery centers.

Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty.

Importance: In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown. Objectives: To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs. Design, Setting, and Participants: This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022. Main Outcomes and Measures: Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared. Results: A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001). Conclusions: This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research.

Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals.

BACKGROUND: Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay. METHODS: We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay. RESULTS: We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001). CONCLUSION: Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.

Readmission risk and costs of firearm injuries in the United States, 2010-2015.

BACKGROUND: In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms. METHODS: We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs. RESULTS: Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%. CONCLUSIONS: From 2010-2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this.

Retinoic acid and BMP4 cooperate with p63 to alter chromatin dynamics during surface epithelial commitment.

Human embryonic stem cell (hESC) differentiation promises advances in regenerative medicine1-3, yet conversion of hESCs into transplantable cells or tissues remains poorly understood. Using our keratinocyte differentiation system, we employ a multi-dimensional genomics approach to interrogate the contributions of inductive morphogens retinoic acid and bone morphogenetic protein 4 (BMP4) and the epidermal master regulator p63 (encoded by TP63)4,5 during surface ectoderm commitment. In contrast to other master regulators6-9, p63 effects major transcriptional changes only after morphogens alter chromatin accessibility, establishing an epigenetic landscape for p63 to modify. p63 distally closes chromatin accessibility and promotes accumulation of H3K27me3 (trimethylated histone H3 lysine 27). Cohesin HiChIP10 visualizations of chromosome conformation show that p63 and the morphogens contribute to dynamic long-range chromatin interactions, as illustrated by TFAP2C regulation11. Our study demonstrates the unexpected dependency of p63 on morphogenetic signaling and provides novel insights into how a master regulator can specify diverse transcriptional programs based on the chromatin landscape induced by exposure to specific morphogens.

Full-Thickness Chemical Burn From Trifluoroacetic Acid: A Case Report and Review of the Literature.

Trifluoroacetic acid (TFA) burns are an ill-defined entity due to a lack of reported sizable burns from this chemical. In this case report of the largest reported burn from TFA, we demonstrate that TFA causes extensive, progressive full-thickness tissue injury that may initially appear superficial. Trifluoroacetic acid does not seem to involve the systemic toxicities that result from hydrofluoric acid burns, and there is no role for calcium gluconate in acute management based on this case. Operative intervention should be staged because wound beds may initially seem healthy yet demonstrate continued necrosis.

Self-inflicted gunshot wounds: readmission patterns.

BACKGROUND: Self-inflicted gunshot wounds (SI-GSWs) are often fatal, but roughly 20% of individuals survive. What happens to survivors after the initial hospitalization is unknown. We hypothesized that the SI-GSW survivors are frequently readmitted and that the pattern of readmission is different from that of the survivors of non-GSW self-harm (SH). METHODS: We conducted a retrospective cohort analysis using the 2013 and 2014 Nationwide Readmission Database. Patients with any diagnosis indicating deliberate SH in the first 6 months of the year were included. This group was divided into those who had SI-GSW as their mechanism and those who did not. Weighted numbers are reported. RESULTS: A total of 1987 patients were admitted for SI-GSW in the study period. Many (n = 506, 26%) experienced at least one readmission in 6 months. When compared with non-GSW SH patients, readmission rates were not statistically different (26% versus 26%, P = 0.60). However, readmissions for repeat SH were lower for the SI-GSW cohort (3% versus 7%, P = 0.004). Readmission for the SI-GSW cohort less frequently had a primary diagnosis of psychiatric illness (28% versus 57%, P < 0.001). In multivariate analysis, there was no difference in odds ratios (OR) of all-cause readmission between the two groups. SI-GSW was associated with a lower OR of repeat SH readmission compared with non-GSW SH (OR 0.65, P = 0.039). CONCLUSIONS: Readmissions after an SI-GSW are frequent, highlighting the burden of this injury beyond the index hospitalization. There are differences in readmission patterns for SI-GSW patients versus non-GSW SH patients, and this suggests that prevention and follow-up strategies may differ between the two groups.

Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury.

BACKGROUND: Traumatic injuries result in a significant disruption to patients' lives, including their ability to work, which may place patients at risk of losing insurance coverage. Our objective was to evaluate the impact of injury on insurance status. We hypothesized that trauma patients with ongoing health needs experience changes in coverage. METHODS: We used the Nationwide Readmission Database (2013-2014), a nationally representative sample of readmissions in the United States. We included patients aged 27 years to 64 years admitted with any diagnosis of trauma with at least one readmission within 6 months. Patients on Medicare and with missing payer information were excluded. The primary outcome was payer status. RESULTS: 57,281 patients met inclusion criteria, 11,006 (19%) changed insurance payer at readmission. Of these, 21% (n = 2,288) became uninsured, 25% (n = 2,773) gained coverage, and 54% (n = 5,945) switched insurance. Medicaid and Medicare gained the largest fraction of patients (from 16% to 30% and 0% to 18%, respectively), with a decrease in private payer coverage (37% to 17%). In multivariate analysis, patients who were younger (27-35 years vs. 56-64 years; odds ratio [OR], 1.30; p < 0.001); lived in a zip code with average income in the lowest quartile (vs. the highest quartile; OR, 1.37; p < 0.001); and had three or more comorbidities (vs. none; OR, 1.61; p < 0.001) were more likely to experience a change in insurance. CONCLUSION: Approximately one fifth of trauma patients who are readmitted within 6 months of their injury experience a change in insurance coverage. Most switch between insurers, but nearly a quarter lose their insurance. The government adopts a large fraction of these patients, indicating a growing reliance on government programs like Medicaid. Trauma patients face challenges after injury, and a change in insurance may add to this burden. Future policy and quality improvement initiatives should consider addressing this challenge. LEVEL OF EVIDENCE: Epidemiologic, level III.

Drug-induced pulmonary arterial hypertension: a primer for clinicians and scientists.

Drug-induced pulmonary arterial hypertension (D-PAH) is a form of World Health Organization Group 1 pulmonary hypertension (PH) defined by severe small vessel loss and obstructive vasculopathy, which leads to progressive right heart failure and death. To date, 16 different compounds have been associated with D-PAH, including anorexigens, recreational stimulants, and more recently, several Food and Drug Administration-approved medications. Although the clinical manifestation, pathology, and hemodynamic profile of D-PAH are indistinguishable from other forms of pulmonary arterial hypertension, its clinical course can be unpredictable and to some degree dependent on removal of the offending agent. Because only a subset of individuals develop D-PAH, it is probable that genetic susceptibilities play a role in the pathogenesis, but the characterization of the genetic factors responsible for these susceptibilities remains rudimentary. Besides aggressive treatment with PH-specific therapies, the major challenge in the management of D-PAH remains the early identification of compounds capable of injuring the pulmonary circulation in susceptible individuals. The implementation of pharmacovigilance, precision medicine strategies, and global warning systems will help facilitate the identification of high-risk drugs and incentivize regulatory strategies to prevent further outbreaks of D-PAH. The goal for this review is to inform clinicians and scientists of the prevalence of D-PAH and to highlight the growing number of common drugs that have been associated with the disease.

National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy.

IMPORTANCE: Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood. OBJECTIVE: To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy. DESIGN, SETTING, AND PARTICIPANTS: The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported. EXPOSURES: Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy. MAIN OUTCOMES AND MEASURES: All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate. RESULTS: A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission. CONCLUSIONS AND RELEVANCE: This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.