Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

BACKGROUND: The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS: The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS: Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS: After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians.

BACKGROUND: Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population. METHODS: Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes. RESULTS: Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200). CONCLUSION: Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

Factors Associated With High Resource Use in Elective Adult Cardiac Surgery From 2005 to 2016.

BACKGROUND: Lack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations. METHODS: Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU. RESULTS: An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (N = 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU. CONCLUSIONS: In this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.

Racial disparities in surgical management and outcomes of acute limb ischemia in the United States.

BACKGROUND: Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking. METHODS: The 2012-2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization. RESULTS: Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06-1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17-1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73-0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74-0.99). The nonwhite group incurred increased adjusted index hospitalization costs (ß: +$4,810, 95% confidence interval 3,280-6,350), length of stay (ß: + 1.09 days, 95% confidence interval 0.70-1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06-1.26). CONCLUSION: Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider-specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

BACKGROUND: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. METHODS: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. RESULTS: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40). CONCLUSIONS: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting.

BACKGROUND: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression. RESULTS: Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001). CONCLUSIONS: Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis.

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as Frail. Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, P < .001) and in-hospital mortality (4% vs. 2%, P < .001). Frailty was also associated with increased cumulative costs of care ($39 417 vs. $27 244, P < .001). After risk adjustment, frailty remained an independent predictor of readmission (Adjusted odds ratio [AOR] 1.18, CI 1.14-1.23), in-hospital mortality (AOR 1.48, CI 1.34-1.65), and incremental costs (+$7 646, CI $6927-$8365). Frailty is an independent marker of worse outcomes following minor foot amputation, and may be utilized to direct quality improvement efforts.

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting.

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Trauma patients returning to the emergency department after discharge.

BACKGROUND: While readmission rates of trauma patients are well described, little has been reported on rates of re-presentation to the emergency department (ED) after discharge. This study aimed to determine rates and contributing factors of re-presentation of trauma patients to the ED. METHODS: One-year retrospective analysis of discharged adult trauma patients at a county-funded safety-net level one trauma center. RESULTS: Of 1416 trauma patients, 195 (13.8%) re-presented to the ED within 30 days. Of those that re-presented, 47 (24.1%) were re-admitted (3.3% overall). The most common reasons for re-presentation were pain control and wound complications. Patients with Medicare (AOR 2.6, 95% CI 1.3 to 5.2) or other government insurance (AOR 2.5, 95% CI 1.6 to 4.1) were more likely to re-present than patients with private insurance. CONCLUSION: A considerable number of trauma patients re-presented to the ED after discharge for reasons that did not require hospitalization. Discharge planning for certain vulnerable groups should emphasize wound care, pain control and scheduled follow-up to decrease the reliance on the ED.

National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US.

BACKGROUND: Gun violence remains a major burden on the US healthcare system, with annual cost exceeding $170 billion. Literature on the national trends in cost and survival of gun violence victims requiring operative interventions is lacking. STUDY DESIGN: All adults admitted with a diagnosis of gunshot wound requiring operative intervention were identified using the 2005-2016 National Inpatient Sample. The ICD Injury Severity Score, a validated prediction tool, was used to quantify the extent of traumatic injuries. Survey-weighted methodology was used to provide national estimates. Hospitalizations exceeding the 66th percentile of annual cost were considered as high-cost tertile. Multivariable logistic regressions with stepwise forward selection were used to identify factors associated with mortality and high-cost tertile. RESULTS: During the study period, 262,098 admissions met inclusion criteria with a significant increase in annual frequency and decrease in ICD Injury Severity Scores. A decline in mortality (8.6% to 7.6%; parametric test of trend = 0.03) was accompanied by increasing mean cost ($25,900 to $33,000; nonparametric test of trend < 0.001). After adjusting for patient and hospital characteristics, head and neck (adjusted odds ratio 31.2; 95% CI, 11.0 to 88.4; p < 0.001), vascular operations (adjusted odds ratio 24.5; 95% CI, 19.2 to 31.1; p < 0.001), and gastrointestinal (adjusted odds ratio 27.8; 95% CI, 17.2 to 44.8; p < 0.001) were independently associated with high-cost tertile designation compared with patients who did not undergo these operations. CONCLUSIONS: During the past decade, the increase in gun violence and severity has resulted in higher cost. Operations involving selected surgical treatments incurred higher in-hospital cost. Given the profound economic and social impact of surgically treated gunshot wounds, policy and public health efforts to reduce gun violence are imperative.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (ß: $2,398, P < .001). CONCLUSION: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017.

BACKGROUND: Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS: We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS: Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS: Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

National trends in postoperative infections across surgical specialties.

BACKGROUND: Despite the introduction of several measures to reduce incidence, postoperative infections have been reported to increase. We aimed to assess trends in the incidence and impact of postoperative infections using a recent national cohort. METHODS: Patients undergoing the most commonly performed elective inpatient procedures in 9 surgical specialties were identified from the 2006 to 2014 National Inpatient Sample. Diagnostic coding was utilized to identify patients with postoperative infections. To adjust for patient and operative differences in assessing outcomes, an inverse probability of treatment weighing protocol was used. RESULTS: Of an estimated 23,696,588 patients, 1,213,182 (5.1%) developed postoperative infections. Skin and soft tissue operations had the highest burden (12.9%) and endocrine the lowest (1.3%). During the study period, we found decreasing incidence, case fatality, and incremental cost of postoperative infections. Infection was associated with increased in-hospital mortality (1.4 vs 0.4%, P < .001), duration of stay (7.6 vs 3.7 days, P < .001), and costs ($27,597 vs $17,985, P < .001). Annually, postoperative infections led to an average incremental cost burden exceeding $700 million in the United States alone. CONCLUSION: During the study period there was a substantial decrease in the burden of postoperative infections. Despite encouraging trends, postoperative infections continue to serve as a suitable quality improvement target, particularly in specialties with a high burden of infections.

National trends and outcomes in timing of ERCP in patients with cholangitis.

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Impact of interhospital transfer on clinical outcomes and resource use after cardiac operations: Insights from a national cohort.

BACKGROUND: Interhospital transfer is a common clinical practice that has been associated with poor patient outcomes in small series. We aimed to evaluate the impact of transfer status on cardiac surgery patients in a national cohort. METHODS: Patients undergoing nonelective coronary artery bypass grafting, valve replacement or repair, or a combination were identified using the 2010 to 2017 Nationwide Readmissions Database. Patients were stratified by transfer status and outcomes were evaluated using adjusted multivariable linear and logistic models. RESULTS: Of an estimated 1,023,315 patients, 170,319 (16.6%) were transfers. Transfer was independently associated with increased complications, index hospitalization duration of stay, costs, early (30 day), and intermediate (31-90 day) readmission. Among transferred patients, transfer to a high-volume center predicted reduced odds of mortality (adjusted odds ratio: 0.64, P < .001). Additionally, transfers were less likely to be readmitted back to the index hospital (80.7% vs 44.9%, P < .001). CONCLUSION: Transfer status is a significant independent predictor of increased complications, length of stay, cost, and readmission among nonelective cardiac surgery patients. Notably, transfer to higher volume facilities appears to increase odds of survival. Our findings are important when considering the risks involved in the management of transferred patients.

Impact of center volume on outcomes of surgical repair for type A acute aortic dissections.

BACKGROUND: Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS: Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS: An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION: The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States.

INTRODUCTION: Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy. MATERIAL AND METHODS: We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality. RESULTS: Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01). CONCLUSIONS: Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.

The impact of obesity on outcomes in patients receiving extracorporeal life support.

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010-2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.

Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support.

BACKGROUND: The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS: The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS: Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION: Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.

National Analysis of Coronary Artery Bypass Grafting in Autoimmune Connective Tissue Disease.

BACKGROUND: Autoimmune connective tissue diseases (CTDs) are associated with accelerated atherosclerosis and inflammation, while often requiring immunosuppression. Large-scale outcomes of coronary artery bypass graft (CABG) surgery in this population have not been reported thus far. This study characterized trends in use of CABG in patients with CTDs and the impact of the disease on mortality, in-hospital complications, length of stay, and costs. METHODS: The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing isolated CABG. The CTDs cohort included rheumatoid arthritis, lupus erythematosus, and antiphospholipid syndrome (APLS), among others. Hierarchical multivariable logistic models were used to calculate the independent impact of CTDs on clinical outcomes and costs. RESULTS: Of an estimated 2,101,591 patients, 41,567 (1.8%) were diagnosed with CTDs (rheumatoid arthritis, 58%; systemic lupus erythematosus, 12%; APLS, 11%) Although the overall annual use of CABG decreased, the proportion of patients with CTDs receiving the operation significantly increased. After adjusting for patient and hospital characteristics, CTDs were not associated with increased mortality (adjusted odds ratio [AOR], 0.91; P = .34) but were protective against cardiovascular (AOR, 0.92; P < .003), neurologic (AOR, 0.81; P = .01), and infectious (AOR, 0.80; P = .01) complications. The diagnosis of CTDs was also predictive of reduced length of hospital stay (ß-coefficient = -0.40; P < .001) and costs (ß-coefficient, -$1200; P = .01). On subgroup analysis patients with APLS had significantly increased odds of mortality (AOR, 1.5) and increased renal (AOR, 1.3), infectious (AOR, 1.7), and thromboembolic (AOR, 4.3) complications (all P < .05). CONCLUSIONS: CABG in patients with CTDs provides acceptable outcomes and paradoxically improved resource use. However CABG in patients with APLS warrants careful consideration given inferior outcomes.