Preexisting Opioid Use Disorder and Outcomes After Lower Extremity Arthroplasty: A Multistate Analysis, 2007-2014.

OBJECTIVE: The aim of this study was to examine the association of preexisting opioid use disorder and postoperative outcomes in patients undergoing total hip or knee arthroplasty (THA and TKA, respectively) in the overall population and in the Medicare-only population. METHODS: This retrospective cohort study examined data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007-2014 from California, Florida, New York, Maryland, and Kentucky. We compared patients with and without opioid use disorders on unadjusted rates and calculated adjusted odds ratios (aORs) of in-hospital mortality, postoperative complications, length of stay, and 30-day and 90-day readmission status; analyses were repeated in a subgroup of Medicare insurance patients only. SUBJECTS: After applying our exclusion criteria, our study included 1,422,210 adult patients undergoing lower extremity arthroplasties, including 818,931 Medicare insurance patients. In our study, 0.4% of THA patients and 0.3% of TKA patients had present-on-admission opioid use disorder. RESULTS: Opioid use disorder patients were at higher risk for in-hospital mortality (aOR = 3.10), 30- and 90-day readmissions (aORs = 1.81, 1.81), and pulmonary and infectious complications (aORs = 1.25, 1.96). CONCLUSIONS: Present-on-admission opioid use disorder was a risk factor for worse postoperative outcomes and increased health care utilization in the lower extremity arthroplasty population. Opioid use disorder is a potentially modifiable risk factor for mortality, postoperative complications, and health care utilization, especially in the at-risk Medicare population.

Sickle Cell Disease is Associated with Increased Morbidity, Resource Utilization, and Readmissions after Common Abdominal Surgeries: A Multistate Analysis, 2007-2014.

INTRODUCTION: Sickle cell disease (SCD), the most commonly inherited hemoglobinopathy in the United States, increases the likelihood of postoperative complications, resulting in higher costs and readmissions. We used a retrospective cohort study to explore SCD's influence on postoperative complications and readmissions after cholecystectomy, appendectomy, and hysterectomy. METHODS: We used an administrative database's 2007-2014 data from California, Florida, New York, Maryland, and Kentucky. RESULTS: 1,934,562 patients aged ≥18 years were included. Compared to non-SCD patients, SCD patients experienced worse outcomes: increased odds of blood transfusion and major and minor complications, higher adjusted odds of 30- and 90-day readmissions, longer length of stay, and higher total hospital charges. CONCLUSION: Sickle cell disease patients are at high risk for poor outcomes based on their demographic characteristics. Therefore, perioperative physicians including hematologists, anesthesiologists, and surgeons need to take this knowledge into consideration for management and counselling of SCD patients on the risks of surgery and recovery.

Medicaid insurance status predicts postoperative mortality after total knee arthroplasty in state inpatient databases.

Aim: Medicaid versus private primary insurance status may predict in-hospital mortality and morbidity after total knee arthroplasty (TKA). Materials & methods: Regression models were used to test our hypothesis in patients in the State Inpatient Database (SID) from five states who underwent primary TKA from January 2007 to December 2014. Results: Medicaid patients had greater odds of in-hospital mortality (odds ratio [OR]: 1.73; 95% CI: 1.01-2.95), greater odds of any postoperative complications (OR: 1.25; 95% CI: 1.18-1.33), experience longer lengths of stay (OR: 1.09; 95% CI: 1.08-1.10) and higher total charges (OR: 1.03; 95% CI: 1.02-1.04). Conclusion: Medicaid insurance status is associated with higher in-hospital mortality and morbidity in patients after TKA compared with private insurance.

Pre-existing opioid use disorder and postoperative outcomes after appendectomy or cholecystectomy: A multi-state analysis, 2007-2014.

INTRODUCTION AND OBJECTIVES: Opioid use disorder has become increasingly prevalent in recent years. Previous studies have shown that patients with opioid use disorder undergoing orthopedic, elective abdominopelvic, and cardiac procedures have poorer postoperative outcomes. The aim of this study was to examine the effect of pre-existing opioid use disorder on postoperative outcomes including in-hospital mortality, hospital length of stay (LOS), hospital readmission, and postoperative complications in patients undergoing appendectomy or cholecystectomy. METHODS: The authors used administrative data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007-2014 from California, Florida, Kentucky, Maryland, and New York. The authors compared unadjusted rates of in-hospital mortality, postoperative complications, LOS, and 30-day and 90-day readmission status. The authors calculated the adjusted odds ratio (OR) for their outcomes using logistic regression models. RESULTS: In all, 488,981 appendectomy patients and 790,491 cholecystectomy patients aged ≥ 18 years were included in the analysis. Appendectomy (OR 2.26) but not cholecystectomy patients with opioid use disorder had statistically significant adjusted odds of in-hospital death. Patients with opioid use disorder (overall reported, and by each procedure separately) had higher adjusted odds of postoperative complication (OR 1.46), 30-day readmission (OR 1.80), 90-day readmission (OR 1.98), and longer LOS (OR 1.37). CONCLUSIONS: The authors found higher unadjusted rates and adjusted ORs of in-patient mortality, hospital readmission, and postoperative complications in patients with opioid use disorder undergoing common abdominal surgeries. The authors' study shows that opioid use disorder is a risk factor for poorer postoperative outcomes in this surgical patient population.

Sickle cell disease and readmissions rates after lower extremity arthroplasty: a multistate analysis 2007-2014.

AIM: To compare readmission rates between patients with sickle cell disease (SCD) and non-sickle cell disease undergoing total hip and knee arthroplasty (THA and TKA). METHODS: Identified adult patients who underwent THA or TKA from 2007 to 2014 in California, Florida, New York, Maryland and Kentucky using a multistate database. Outcomes were 30- and 90-day readmission rates, mortality, complications, length of stay and hospital charges. Logistic regression models were used for analysis. RESULTS: Compared with non-sickle cell disease patients following TKA and THA, SCD patients had higher odds of 30- (odds ratio [OR]: 3.79) and 90-day readmissions (OR: 4.15), mortality (OR: 6.54), more complications, longer length of stay, and higher total charges. CONCLUSION: Following TKA and THA, SCD is associated with higher readmissions and worse outcomes.

The Disparity of Care and Outcomes for Medicaid Patients Undergoing Colectomy.

BACKGROUND: Colectomies are one of the most common surgeries in the United States with about 275,000 performed annually. Studies have shown that insurance status is an independent risk factor for worse surgical outcomes. This study aims to analyze the effect of insurance on health outcomes of patients undergoing colectomy procedures. METHODS: We examined hospital discharge data from the State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, from 2009 to 2014 in California, Florida, New York, Maryland, and Kentucky. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), total hospital charges, and 30- and 90-d readmissions. RESULTS: A total of 444,877 patients were included in the analysis. Bivariate analysis showed that open surgeries were more common in Medicaid patients (50.5%), whereas robotic and laparoscopic surgeries were more common in private insurance holders (50.4% and 21.7%, respectively). In the adjusted multivariate models, when compared with private insurance patients, Medicaid patients had the highest odds ratio (OR) for mortality (OR, 1.96; 95% confidence interval [CI], 1.78-2.15), complication rates (OR, 1.43; 95% CI, 1.38-1.49), 30-d readmission (OR, 1.47; 95% CI, 1.40-1.55), 90-d readmission (OR, 1.44; 95% CI, 1.37-1.51), longer LOS (coefficient, 1.26; 95% CI, 1.24-1.28), and higher total hospital charges (coefficient, 1.15; 95% CI, 1.13-1.17). CONCLUSIONS: We identified Medicaid insurance status as a predictor of open colectomies and of higher mortality, LOS, complications, readmission rates, and charges after colectomy. Further research and initiatives are necessary to meet the specific needs of patients with different payer types.

Racial/Ethnic and Socioeconomic Disparities in Total Knee Arthroplasty 30- and 90-Day Readmissions: A Multi-Payer and Multistate Analysis, 2007-2014.

Previous studies have addressed racial/ethnic and socioeconomic disparities in total knee arthroplasty (TKA) within the Medicare population. However, there is limited research examining these disparities across racial/ethnic and socioeconomic groups in the general population. This study used administrative data from the State Inpatient Databases from the Healthcare Cost and Utilization Project for the years 2007-2014 from California (2007-2011 only), Florida, New York, and Maryland (2012-2014 only). In all, 739,857 TKA readmission-eligible patients aged ≥8 years were included in the analysis. Black patients and patients with Medicaid had a higher likelihood of 30- and 90-day readmissions compared to white patients and patients with private insurance, respectively. Patients living in higher median income areas and patients treated at higher volume hospitals had lower likelihoods of 30- and 90-day readmissions compared to patients in the lowest median income quartile and patients treated at the lowest volume hospitals, respectively. These results confirmed racial/ethnic and socioeconomic disparities in TKA readmissions across 4 geographically diverse states, identified public insurance status as the salient factor across subpopulations, and raise awareness of the existence of these disparities outside of the Medicare population.

The Disparities of Coronary Artery Bypass Grafting Surgery Outcomes by Insurance Status: A Retrospective Cohort Study, 2007-2014.

BACKGROUND: Coronary artery bypass grafting (CABG) surgery is the gold standard treatment for complex coronary artery disease. Social determinants of health, including primary payer status, are disproportionately associated with adverse outcomes following surgical operations. We sought to examine associations between insurance status, in particular having Medicaid public insurance, and postoperative outcomes following isolated CABG surgeries. METHODS: A retrospective review was performed using Florida, California, New York, Maryland, and Kentucky State Inpatient Databases (2007-2014) for isolated CABG patients ≥ 18 years. Multivariate regression for postsurgical inpatient mortality, postsurgical complications, 30- and 90-day readmission rates, total charges, and length of stay yielded adjusted odds ratios (ORs) reported for outcomes by insurance status. RESULTS: Among 312,018 individuals, patients with Medicaid insurance and those designated as Uninsured incurred increased adjusted ORs of postsurgical inpatient mortality (56 and 64%, respectively) compared to Private Insurance. Additionally, Medicaid had the highest adjusted OR for 30-day readmission (OR 1.52, 95% CI 1.45-1.59), 90-day readmission (OR 1.53, 95% CI 1.47-1.59), postsurgical complications (OR 1.10, 95% CI 1.07-1.14) including pulmonary and infectious complications, postoperative length of stay, and total hospital charges (2016 dollars). CONCLUSIONS: Medicaid insurance, compared to Private Insurance, is significantly associated with worse outcomes after isolated CABG. Our results demonstrate that Medicaid as a patient's primary insurance payer is an independent predictor of perioperative risks. Further research may help explain the reasons for the differences in payer groups.

Coronary artery bypass graft readmission rates and risk factors - A retrospective cohort study.

BACKGROUND: Hospital readmissions contribute substantially to the overall healthcare cost. Coronary artery bypass graft (CABG) is of particular interest due to its relatively high short-term readmission rates and mean hospital charges. METHODS: A retrospective review was performed on 2007-2011 data from California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project. All patients ≥18 years of age who underwent isolated CABG and met inclusion/exclusion criteria were included. Insurance status was categorized by Medicaid, Medicare, Private Insurance, Uninsured, and Other. Primary outcomes were unadjusted rates and adjusted odds of readmission at 30- and 90-days. Secondary outcomes included diagnosis at readmission. RESULTS: A total of 177,229 were included in the analyses after assessing for exclusion criteria. Overall 30-day readmission rate was 16.1%; rates were highest within Medicare (18.4%) and Medicaid (20.2%) groups and lowest in the private insurance group (11.7%; p < 0.0001). Similarly, 90-day rates were highest in Medicare (27.3%) and Medicaid (29.8%) groups and lowest in the private insurance group (17.6%), with an overall 90-day rate of 24.0% (p < 0.0001). The most common 30-day readmission diagnoses were atrial fibrillation (26.7%), pleural effusion (22.5%), and wound infection (17.7%). Medicare patients had the highest proportion of readmissions with atrial fibrillation (31.7%) and pleural effusions (23.3%), while Medicaid patients had the highest proportion of readmissions with wound infections (21.8%). Similar results were found at 90 days. Risk factors for readmission included non-private insurance, age, female sex, non-white race, low median household income, non-routine discharge, length of stay, and certain comorbidities and complications. CONCLUSIONS: CABG readmission rates remain high and are associated with insurance status and racial and socioeconomic markers. Further investigation is necessary to better delineate the underlying factors that relate racial and socioeconomic disparities to CABG readmissions. Understanding these factors will be key to improving healthcare outcomes and expenditure.

Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status.

BACKGROUND: Total hip replacements (THRs) are the sixth most common surgical procedure performed in the USA. Readmission rates are estimated at between 4.0 and 10.9%, and mean costs are between $10,000 and $19,000. Readmissions are influenced by the quality of care received. We sought to examine differences in readmissions by insurance payer, race and ethnicity, and income status. METHODS: We analyzed all THRs from 2007 to 2011 in California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Primary outcomes were readmission at 30 and 90 days after THR. Descriptive statistics were calculated, and multivariate logistic regression analysis was used to estimate adjusted odds ratio (OR) for readmissions. Statistical significance was evaluated at the < 0.05 alpha level. RESULTS: A total of 274,851 patients were included in the analyses. At 30 days (90 days), 5.6% (10.2%) patients had been readmitted. Multivariate logistic regression analysis showed that patients insured by Medicaid (OR 1.23, 95%CI 1.17-1.29) and Medicare (OR 1.58, 95%CI 1.44-1.73) had increased odds of 30-day readmission, as did patients living in areas with lower incomes, Black patients, and patients treated at lower volume hospitals. Ninety-day readmissions showed similar significant results. CONCLUSIONS: The present study has shown that patients on public insurance, Black patients, and patients who live in areas with lower median incomes have higher odds of readmission. Future research should focus on further identifying racial and socioeconomic disparities in readmission after THR with an eye towards implementing strategies to ameliorate these differences.

Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York.

STUDY OBJECTIVE: To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements. DESIGN: Retrospective cohort study. SETTING: Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. PATIENTS: 295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51). INTERVENTIONS: Patients underwent total hip replacement. MEASUREMENTS: Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data. MAIN RESULTS: Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS. CONCLUSIONS: We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.

Discharge Against Medical Advice of Elderly Inpatients in the United States.

Discharge against medical advice (DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on DAMA in this subgroup. The National Inpatient Sample (2003-2013 for trends, 2013 for multivariable analysis, n = 29,290,852) was used to describe trends in DAMA in elderly inpatients, to study diagnosis codes associated with admission, and to assess factors associated with DAMA using multivariable logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported for risk factors of interest. Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups. From 2003 to 2013, rates increased in individuals aged 18 to 64 (from 1.44% to 1.78%) and in those aged 65 and older (from 0.37% to 0.42% (both P < .001). In both age groups, individuals admitted for mental illness had the highest risk of DAMA. Factors associated with higher adjusted odds of DAMA were generally similar between age groups, although risk of DAMA was higher in elderly adults than in those aged 18 to 64 for blacks (OR 1.65, 95% CI 1.49-1.82 vs OR 1.16, 95% CI 1.12-1.20), Hispanics (OR 1.58, 95% CI 1.41-1.77 vs OR 0.83, 95% CI 0.79-0.87), and those in the lowest income quartile (OR 1.57, 95% CI 1.43-1.72 vs OR 1.12, 95% CI 1.08-1.17), suggesting that race/ethnicity and poverty are more pronounced as risk factors for DAMA in elderly inpatients.

Conversion-to-open in laparoscopic appendectomy: A cohort analysis of risk factors and outcomes.

BACKGROUND: Identifying risk factors for conversion from laparoscopic to open appendectomy could select patients who may benefit from primary open appendectomy. We aimed to develop a predictive scoring model for conversion from laparoscopic to open based on pre-operative patient characteristics. METHODS: A retrospective review of the State Inpatient Database (2007-2011) was performed using derivation (N = 71,617) and validation (N = 143,235) cohorts of adults ≥ 18 years with acute appendicitis treated by laparoscopic-only (LA), conversion from laparoscopic to open (CA), or primary open (OA) appendectomy. Pre-operative variables independently associated with CA were identified and reported as odds ratios (OR) with 95% confidence intervals (CI). A weighted integer-based scoring model to predict CA was designed based on pre-operative variable ORs, and complications between operative subgroups were compared. RESULTS: Independent predictors of CA in the derivation cohort were age ≥40 (OR 1.67; CI 1.55-1.80), male sex (OR 1.25; CI 1.17-1.34), black race (OR 1.46; CI 1.28-1.66), diabetes (OR 1.47; CI 1.31-1.65), obesity (OR 1.56; CI 1.40-1.74), and acute appendicitis with abscess or peritonitis (OR 7.00; CI 6.51-7.53). In the validation cohort, the CA predictive scoring model had an optimal cutoff score of 4 (range 0-9). The risk of conversion-to-open was ≤5% for a score <4, compared to 10-25% for a score ≥4. On composite outcomes analysis controlling for all pre-operative variables, CA had a higher likelihood of infectious/inflammatory (OR 1.44; CI 1.31-1.58), hematologic (OR 1.31; CI 1.17-1.46), and renal (OR 1.22; CI 1.06-1.39) complications compared to OA. Additionally, CA had a higher likelihood of infectious/inflammatory, respiratory, cardiovascular, hematologic, and renal complications compared to LA. CONCLUSIONS: CA patients have an unfavorable complication profile compared to OA. The predictors identified in this scoring model could help select for patients who may benefit from primary open appendectomy.

Variability in length of stay after uncomplicated pulmonary lobectomy: is length of stay a quality metric or a patient metric?†.

OBJECTIVES: Previous studies have identified predictors of prolonged length of stay (LOS) following pulmonary lobectomy. LOS is typically described to have a direct relationship to postoperative complications. We sought to determine the LOS and factors associated with variability after uncomplicated pulmonary lobectomy. METHODS: Analysing the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality database, we reviewed lobectomies performed (2009-11) on patients in California, Florida and New York. LOS and comorbidities were identified. Multivariable regression analysis (MVA) was used to determine factors associated with LOS greater than the median. Patients with postoperative complications or death were excluded. RESULTS: Among 22 647 lobectomies performed, we identified 13 099 patients (58%) with uncomplicated postoperative courses (mean age = 66 years; 56% female; 76% white, 57% Medicare; median DEYO comorbidity score = 3, 55% thoracotomy, 45% thoracoscopy/robotic). There was a wide distribution in LOS [median LOS = 5 days; interquartile range (IQR) 4-7]. By MVA, predictors of prolonged LOS included, age ≥ 75 years [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.4-2.0], male gender (OR 1.2, 95% CI 1.1-1.2), chronic obstructive pulmonary disease (OR 1.6, 95% CI 1.5-1.7) and other comorbidities, Medicaid payer (OR 1.7, 95% CI 1.4-2.1) versus private insurance, thoracotomy (OR 3.0, 95% CI 2.8-3.3) versus video-assisted thoracoscopic surgery/robotic approach and low hospital volume (OR 2.4, 95% CI 2.1-2.6). CONCLUSIONS: Variability exists in LOS following even uncomplicated pulmonary lobectomy. Variability is driven by clinical factors such as age, gender, payer and comorbidities, but also by surgical approach and volume. All of these factors should be taken into account when designing clinical care pathways or when allocating payment resources. Attempts to define an optimal LOS depend heavily upon the patient population studied.

Incidence and Factors Associated With Hospital Readmission After Pulmonary Lobectomy.

BACKGROUND: Readmission rates after major procedures are used to benchmark quality of care. We sought to identify readmission diagnoses and factors associated with readmission in patients undergoing pulmonary lobectomy. METHODS: Analyzing the State Inpatient Databases (Healthcare Cost and Utilization Project), we reviewed all lobectomies performed from 2009 to 2011 in California, Florida, and New York. The group was subdivided into open (OL) versus minimally invasive lobectomy (MIL; thoracoscopic/robotic). We used unique identifiers to determine 30- and 90-day readmission rates and diagnoses and performed regression analysis to determine factors associated with readmission. RESULTS: A total of 22,647 lobectomies were identified (58.8% OL vs 41.2% MIL; median age, 68 years; median length of stay, 6 days). Most patients (59.8%) had routine discharge home (home health care, 29.4%; transfer to other facility, 8.8%; mortality, 1.9%). The 30-day readmission rate was 11.5% (OL 12.0% vs MIL 10.8%, p = 0.01), while the 90-day readmission rate was 19.8% (OL 21.1% vs MIL 17.9%, p < 0.001). The most common readmission diagnoses were pulmonary (24.1%), cardiovascular (16.3%), and complications related to surgical/medical procedures (15.1%). Preoperative factors associated with readmission included male gender (odds ratio, 1.19), Medicaid payer (odds ratio, 1.29), and several individual comorbidities. Surgical approach and postoperative complications were not independently associated with readmission. CONCLUSIONS: Readmission is a frequent event after pulmonary lobectomy and is strongly associated with preoperative demographic factors and comorbidities. Resources and services should be directed to patients at risk for readmission and multicomponent care pathways developed that may circumvent the need for repeat hospitalization.

Incidence and implications of postoperative supraventricular tachycardia after pulmonary lobectomy.

OBJECTIVE: We sought to determine the rate of postoperative supraventricular tachycardia (POSVT) in patients undergoing pulmonary lobectomy, and its association with adverse outcomes. METHODS: Using the State Inpatient Database, from the Healthcare Cost and Utilization Project, we reviewed lobectomies performed (2009-2011) in California, Florida, and New York, to determine POSVT incidence. Patients were grouped by presence or absence of POSVT, with or without other complications. Stroke rates were analyzed independently from other complications. Multivariable regression analysis was used to determine factors associated with POSVT. RESULTS: Among 20,695 lobectomies performed, 2449 (11.8%) patients had POSVT, including 1116 (5.4%) with isolated POSVT and 1333 (6.4%) with POSVT with other complications. Clinical predictors of POSVT included age ≥75 years, male gender, white race, chronic obstructive pulmonary disease, congestive heart failure, thoracotomy surgical approach, and pulmonary complications. POSVT was associated with an increase of: stroke (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.03-2.94); in-hospital death (OR 1.85; 95% CI 1.45-2.35); LOS (OR 1.33; 95% CI 1.29-1.37); and readmission (OR 1.29; 95% CI 1.04-1.60). The stroke rate was <1% in patients who had isolated POSVT, and 1.5% in patients with POSVT with other complications. Patients with isolated POSVT had increased readmission and LOS, and a marginal increase in stroke rate, compared with patients with an uncomplicated course. CONCLUSIONS: POSVT is common in patients undergoing pulmonary lobectomy and is associated with adverse outcomes. Comparative studies are needed to determine whether strict adherence to recently published guidelines will decrease the rate of stroke, readmission, and death after POSVT in thoracic surgical patients.

Provider Board Certification Status and Practice Patterns in Total Knee Arthroplasty.

PURPOSE: The presumption that board certification directly affects the quality of clinical care is a topic of ongoing discussion in medical literature. Recent studies have demonstrated disparities in patient outcomes associated with type of anesthesia provided for total knee arthroplasty (TKA); improved outcomes are associated with neuraxial (or regional) versus general anesthesia. Whether board-certified (BC) and non-board-certified (nBC) anesthesiologists make different choices in the anesthetic they administer is unknown. The authors sought to study potential associations of board certification status with anesthesia practice patterns for TKA. METHOD: The authors accessed records of anesthetics provided from 2010 to 2013 from the National Anesthesia Clinical Outcomes Registry database. They identified TKA cases using Clinical Classifications Software and Current Procedural Terminology codes. The authors divided practitioners into two groups: those who were BC and those who were nBC. For each of these groups, the authors compared the following: their patient populations, the hospitals in which they worked, the nature of their practices, and the anesthetics they administered to their patients. RESULTS: BC anesthesiologists provided care for 81.7% of 97,508 patients having TKA; 18.3% were treated by nBC anesthesiologists. BC anesthesiologists administered neuraxial/regional anesthesia more frequently than nBC anesthesiologists (41.4% versus 21.2%; P < .001). CONCLUSIONS: The rates at which regional/neuraxial anesthesia were administered for TKA were relatively low, and there were significant differences in practice patterns of BC and nBC anesthesiologists providing care for patients undergoing TKA. More research is necessary to understand the causes of these disparities.

Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute.

Anesthetic practice utilization and related characteristics of total knee arthroplasties (TKAs) are understudied. The research team sought to characterize anesthesia practice patterns by utilizing National Anesthesia Clinical Outcomes Registry data of the Anesthesia Quality Institute. The proportions of primary TKAs performed between January 2010 and June 2013 using general anesthesia (GA), neuraxial anesthesia (NA), and regional anesthesia (RA) were determined. Utilization of anesthesia types was analyzed using anesthesiologist and patient characteristics and facility type. In all, 108 625 eligible TKAs were identified; 10.9%, 31.3%, and 57.9% were performed under RA, NA, and GA, respectively. Patients receiving RA had higher median age and higher frequency of American Society of Anesthesiology score ≥3 compared with those receiving other anesthesia types under study. Relative to GA (45.0%), when NA or RA were used, the anesthesiologist was more frequently board certified (75.5% and 62.1%, respectively; P < .0001). Anesthetic technique differences for TKAs exist, with variability associated with patient and provider characteristics.

Perioperative morbidity and mortality after anterior, posterior, and anterior/posterior spine fusion surgery.

STUDY DESIGN: Analysis of population-based national hospital discharge data collected for the National Inpatient Sample. OBJECTIVE: To examine demographics of patients undergoing primary anterior spine fusion (ASF), posterior spine fusion (PSF), and anterior/posterior spine fusion (APSF) of the noncervical spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death. SUMMARY OF BACKGROUND DATA: The utilization of surgical fusion has been increasing dramatically. Despite this trend, a paucity of literature addressing perioperative outcomes exists. METHODS: Data collected for each year between 1998 and 2006 for the National Inpatient Sample were analyzed. Discharges with a procedure code for primary noncervical spine fusion were included in the sample. The prevalence of patient as well as health care system-related demographics were evaluated by procedure type (ASF, PSF, and APSF). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined. RESULTS: We identified 261,256 entries representing an estimated 1,273,228 hospitalizations for primary spine fusion. Patients undergoing ASF and APSF were significantly younger (44.8 ± 0.08 and 44.22 ± 0.11 years) and had lower average comorbidity indeces (0.30 ± 0.002 and 0.31 ± 0.004) than those undergoing PSF (52.12 ± 0.04 years and 0.41 ± 0.002) (P < 0.0001). The incidence of procedure-related complications was 18.68% among ASF, 15.72% in PSF, and 23.81% in APSF patients (P < 0.0001). In-hospital mortality rates after APSF were approximately twice those of PSF (0.51 ± 0.038 vs. 0.26 ± 0.012) (P < 0.0001). Adjusted risk factors for in-hospital mortality included the following: APSF and ASF compared to PSF, male gender, increasing age, and increasing comorbidity burden. Several comorbidities and complications independently increased the risk for perioperative death, as did underlying spinal pathology. CONCLUSION: Despite being performed in generally younger and healthier patients, APSF and ASF are associated with increased morbidity and mortality. Our findings can be used for the purposes of risk stratification, accurate patient consultation, and hypothesis formation for future research.

Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery.

BACKGROUND: Although patients with sleep apnea (SA) are considered to be at increased risk for postoperative complications, evidence supporting increased risk of perioperative pulmonary morbidity is limited. The objective of this study, therefore, was to analyze perioperative demographics and pulmonary outcomes of patients with SA after orthopedic and general surgical procedures using a population-based sample. We hypothesized that SA is an independent risk factor for perioperative pulmonary complications, thus providing a basis for an increase in the utilization of resources, including intensive monitoring and development of strategies to prevent and treat these events. METHODS: National Inpatient Sample data for each year between 1998 and 2007 were accessed. Orthopedic and general surgical procedures were included and discharges with a diagnosis code for SA were identified. Patients with the diagnosis of SA were matched to those without the disease based on demographic variables using the propensity scoring method. Aspiration pneumonia, adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and the need for intubation and mechanical ventilation were the primary outcomes. Odds ratio (OR) and absolute risk reduction along with 95% confidence interval were reported. RESULTS: We identified 2,610,441 entries for orthopedic and 3,441,262 for general surgical procedures performed between 1998 and 2007. Of those, 2.52% and 1.40%, respectively, carried a diagnosis of SA. Patients with SA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures, respectively (i.e., aspiration pneumonia: 1.18% vs 0.84% and 2.79% vs 2.05%; ARDS: 1.06% vs 0.45% and 3.79% vs 2.44%; intubation/mechanical ventilation: 3.99% vs 0.79% and 10.8% vs 5.94%, all P values <0.0001). Comparatively, PE was more frequent in SA patients after orthopedic procedures (0.51% vs 0.42%, P = 0.0038) but not after general surgical procedures (0.45% vs 0.49%, P = 0.22). SA was associated with a significantly higher adjusted OR of developing pulmonary complications after both orthopedic and general surgical procedures, respectively, with the exception of PE (OR for aspiration pneumonia: 1.41 [1.35, 1.47] and 1.37 [1.33, 1.41]; for ARDS: 2.39 [2.28, 2.51] and 1.58 [1.54, 1.62]; for PE: OR 1.22 [1.15, 1.29] and 0.90 [0.84, 0.97]; for intubation/mechanical ventilation: 5.20 [5.05, 5.37] and 1.95 [1.91, 1.98]). CONCLUSION: SA is an independent risk factor for perioperative pulmonary complications. Our results may be used for hypothesis generation for clinical studies targeted to improve perioperative outcomes in this patient population.