Impact of the COVID-19 Pandemic on Inpatient and Outpatient Utilization of Bariatric Surgery

Changes in the liver transplant evaluation process during the early COVID-19 era and the role of telehealth

BACKGROUND

Coronavirus disease 2019 (COVID-19) disrupted healthcare and led to increased telehealth use. We explored the impact of COVID-19 on liver transplant evaluation (LTE).

AIM

To understand the impact of telehealth on LTE during COVID-19 and to identify disparities in outcomes disaggregated by sociodemographic factors.

METHODS

This was a retrospective study of patients who initiated LTE at our center from 3/16/20-3/16/21 (“COVID-19 era”) and the year prior (3/16/19-3/15/20, “pre-COVID-19 era”). We compared LTE duration times between eras and explored the effects of telehealth and inpatient evaluations on LTE duration, listing, and pre-transplant mortality.

RESULTS

One hundred and seventy-eight patients were included in the pre-COVID-19 era cohort and one hundred and ninety-nine in the COVID-19 era cohort. Twenty-nine percent (58/199) of COVID-19 era initial LTE were telehealth, compared to 0% (0/178) pre-COVID-19. There were more inpatient evaluations during COVID-19 era (40% vs 28%, P < 0.01). Among outpatient encounters, telehealth use for initial LTE during COVID-19 era did not impact likelihood of listing, pre-transplant mortality, or time to LTE and listing. Median times to LTE and listing during COVID-19 were shorter than pre-COVID-19, driven by increased inpatient evaluations. Sociodemographic factors were not predictive of telehealth.

CONCLUSION

COVID-19 demonstrates a shift to telehealth and inpatient LTE. Telehealth does not impact LTE or listing duration, likelihood of listing, or mortality, suggesting telehealth may facilitate LTE without negative outcomes.

Same Day Discharge after Metabolic and Bariatric Surgery in Adults 65 Years and Older: An Analysis of the 2015 to 2022 MBSAQIP

BACKGROUND

There is increasing interest in same day discharge (SDD) after metabolic and bariatric surgery (MBS). Among older adults, the safety of SDD is unclear and, as a result, this age group is often excluded from SDD protocols. We aimed to characterize the safety profile of SDD in adults ≥ 65 years.

METHODS

The 2015-2022 MBSAQIP was queried for patients ≥ 65 years undergoing primary sleeve gastrectomy or RYGB. Patients were stratified based on postoperative day (POD) of discharge: SDD, POD1, POD2, POD3, and ≥ POD4. Logistic regression was used to examine associations between SDD and 30-day Clavien-Dindo complications and readmissions.

RESULTS

We identified 63,486 patients ≥ 65 years; the median (IQR) age was 68 (4) years. Overall, 2.12% of patients underwent SDD while the majority (52.8%) were discharged on POD1. From 2015 to 2022, the proportion with SDD increased from 1.15% to 4.33%. Compared to those discharged on later days, patients undergoing SDD had proportionally fewer obesity-associated diseases, including insulin-dependent diabetes (SDD 14.2%, POD1 15.5%, POD2 20.4%, POD3 23.2%, POD4 + 26.1%) and COPD (SDD 3.2%, POD1 4.7%, POD2 5.7%, POD3 7.2%, POD4 + 9.6%) (all p < 0.001). Compared to POD1 discharge, SDD was not significantly associated with any class of Clavien-Dindo complications or 30-day readmissions (all p > 0.05).

CONCLUSIONS

Though use of SDD after MBS in adults ≥ 65 years has increased from 2015 to 2022, it remains an uncommon practice. Those undergoing SDD have fewer obesity-associated diseases and, in this select cohort of older adults, SDD is not associated with worse postoperative morbidity and mortality. Careful patient selection is critical for safe SDD in adults ≥ 65 years.

Same-Day Discharge for Elective Pediatric Laparoscopic Gastrostomy Tube Insertion is Safe and Increasing in Frequency; A NSQIP Pediatric Retrospective Review 2017 to 2021

BACKGROUND

There is limited literature reviewing same-day discharge for elective pediatric gastrostomy tube placement. Our aim was to assess the outcomes and national trends of same-day discharge following elective pediatric laparoscopic gastrostomy.

METHODS

ACS NSQIP-P registry data from 2017 to 2021 was used to evaluate elective pediatric laparoscopic gastrostomy patients who presented from home and discharged home with a diagnosis of failure to thrive, feeding difficulty or dysphagia. Patients discharged same-day postoperatively (SDD) were compared to those discharged 1-2 days postoperatively (non-SDD) for the primary outcome of unplanned 30-day readmission. Secondary outcomes included bleeding events, wound infection, and 30-day reoperation.

RESULTS

There were 5,947 patients identified; 4.7% were discharged same-day. The annual rate of SDD over 5 years went from 2.7% to 4.6%-4.8% to 4.5%-6.3%. There were no significant differences between SDD and non-SDD patients for early readmission or reoperation (0.7% vs 0.3%, p = 0.279), 30-day unplanned readmission (8.5% vs 8.0%, p = 0.407), reoperation (0.1% vs 1.4%, p = 1.000), or any other complications (p > 0.05). Binary logistic regression found pre-operative steroid use within 30 days increased risk of serious complication (OR 2.02, 95% CI 1.29-3.15, p = 0.002) and 30-day readmission or reoperation (OR 2.10, 95% CI 1.34-3.27, p = 0.001). All 6 patients (0.1%) who required reoperation within 3 days were identified prior to discharge, and none of the 16 patients readmitted within 3 days of surgery required reoperation.

CONCLUSION

Though rates of same-day discharge following pediatric gastrostomy tube placement are low, they continue to increase annually. There were no significant differences in outcomes between same-day and non-same-day day discharge for elective cases presenting from and discharging home. In non-steroid using patients, same-day discharge following laparoscopic gastrostomy can be a safe option.

LEVEL OF EVIDENCE (I-V)

Level III.

The impact of the COVID-19 pandemic on racial disparities in postoperative outcomes after bariatric surgery

BACKGROUND

The COVID-19 pandemic has affected the outcomes and access to elective surgery across the United States. This study hypothesized that preexisting racial and ethnic disparities were exacerbated by the pandemic for bariatric surgery.

METHODS

This retrospective cohort study evaluated the outcome disparities in 1,046,578 patients who underwent bariatric surgery from 2016-2019 (before the COVID-19 pandemic) to 2020-2021 (during the COVID-19 pandemic) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. The primary outcomes of interest, Clavien-Dindo (CD) scores (0-5) and extended length of stay (eLOS; >90th percentile), were compared between non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and non-Hispanic Asian/American Indian/Pacific Islander (A/AI/PI) patients using ordinal and binomial logistic regression models, respectively. In addition, the modifying effect of COVID-19 on racial disparities in these outcomes was assessed.

RESULTS

Overall, patients during the COVID-19 pandemic had higher odds of a higher CD score (odds ratio [OR], 1.05; 95% CI, 1.04-1.06; P < .001) than patients before the COVID-19 pandemic on adjusted multivariate analysis. NHB patients were more likely to experience postoperative complications as characterized by higher CD scores (OR, 1.37; 95% CI, 1.35-1.39; P < .001) than NHW patients, and COVID-19 was a contributory factor (ratio of ORs, 1.07; 95% CI, 1.05-1.10). There was no significant difference in CD scores in Hispanic (OR, 1.00; 95% CI, 0.98-1.03; P = .800) and A/AI/PI (OR, 0.98; 95% CI, 0.92-1.06; P = .651) patients compared with NHW patients, and COVID-19 did not have a modifying effect on these patients. All non-White patients had a higher likelihood of eLOS before the COVID-19 pandemic, but COVID-19 had a modifying effect of decreased odds of eLOS for all races (ratio of ORs, 0.60-0.69; 95% CI, 0.56-0.80).

DISCUSSION

NHB patients had inferior perioperative outcomes than patients of other races after bariatric surgery during the COVID-19 pandemic. In addition, all races/ethnicities had decreased odds of eLOS during the COVID-19 pandemic.

Ambulatory discharge of patients undergoing sleeve gastrectomy results in significantly more adverse outcomes

BACKGROUND

Same-day discharge after sleeve gastrectomy (SDSG) has become more common during the COVID pandemic. Several payers have suggested that they would no longer reimburse for planned inpatient hospital stay for patients undergoing SG. The goal of our study was to determine which, if any, patient groups could safely undergo SDSG.

METHODS

A retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) from 2015-2021 was performed. Multivariable logistic regression analysis was performed using demographics, comorbid disease, and participant use data file (PUF) year to determine the risk of adverse events within 30 days of SG by postoperative discharge day.

RESULTS

A total of 702,622 SGs were performed during the study period: 31,308 (4.46%) patients were SDSGs and 409,622 (58.3%) on postoperative day (POD) 1. From 2015 to 2019, the mean percentage of cases that were SDSG was 2.9%. The proportion of SDSG increased to 6.3% in 2020 and 9.6% in 2021. Compared with those discharged on POD 1, SDSG patients were at increased risk for any complication (OR 1.22, 95% CI 1.1-1.36), minor complications (OR 1.17, 95% CI 1.03-1.32), major complications (OR 1.36, 95% CI 1.15-1.61), readmission (OR 1.09, 95% CI 1.00-1.18), and reoperation (OR 1.37, 95% CI 1.16-1.62). Other interventions within 30 days were not statistically significant.

CONCLUSION

Compared with those discharged on POD 1, SDSG patients are at significantly increased risk for all adverse events analyzed. With growing pressure to shorten or eliminate the use of hospital beds, identification of appropriate candidates for safe SDSG is crucial.

The Long Haul to Surgery: Long COVID Has Minimal Burden on Surgical Departments

Many patients infected with the SARS-CoV-2 virus (COVID-19) continue to experience symptoms for weeks to years as sequelae of the initial infection, referred to as "Long COVID". Although many studies have described the incidence and symptomatology of Long COVID, there are little data reporting the potential burden of Long COVID on surgical departments. A previously constructed database of survey respondents who tested positive for COVID-19 was queried, identifying patients reporting experiencing symptoms consistent with Long COVID. Additional chart review determined whether respondents had a surgical or non-routine invasive procedure on or following the date of survey completion. Outcomes from surgeries on patients reporting Long COVID symptoms were compared to those from asymptomatic patients. A total of 17.4% of respondents had surgery or a non-routine invasive procedure in the study period. A total of 48.8% of these patients reported experiencing symptoms consistent with Long COVID. No statistically significant differences in surgical outcomes were found between groups. The results of this analysis demonstrate that Long COVID does not appear to have created a significant burden of surgical disease processes on the healthcare system despite the wide range of chronic symptoms and increased healthcare utilization by this population. This knowledge can help guide surgical operational resource allocation as a result of the pandemic and its longer-term sequelae.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center

BACKGROUND

Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described.

METHODS

A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes.

RESULTS

Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization.

CONCLUSIONS

Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Safety of Same-Day Discharge after Bariatric Surgery: Retrospective 6-Year North American Analysis

BACKGROUND

With increasing implementation of Enhanced Recovery After Surgery protocols and rising demand for inpatient hospital beds accentuated by COVID-19, there has been interest in same-day discharge (SDD) for bariatric surgery. The aim of this study was to determine the national trends, safety profile, and risk factors for complications of SDD for minimally invasive bariatric surgery.

STUDY DESIGN

We analyzed the MBSAQIP database from 2016 to 2021 to characterize trends in SDD for minimally invasive bariatric operation. Multivariate logistic regression was performed on preoperative patient characteristics predictive of increased complications associated with SDD. A comparative analysis of postoperative outcomes within 30 days was performed for SDD and admission after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities.

RESULTS

SDD increased from 2.4% in 2016 to 7.4% in 2021. Major preoperative factors associated with increased complications for SDD included Black race, history of MI, renal insufficiency, deep vein thrombosis, and smoking. SDD for Roux-en-Y gastric bypass had 72% increased risk of postoperative complications compared with sleeve gastrectomy. The overall major complications were lower in SDD cohort vs admission cohort (odds ratio [OR] 0.62, p < 0.01). However, there was a significant increase in deaths within 30 days (OR 2.11, p = 0.01), cardiac arrest (OR 2.73; p < 0.01), and dehydration requiring treatment (OR 1.33; p < 0.01) in SDD cohort compared with admission cohort.

CONCLUSIONS

Nationally, there has been a rise in SDD for bariatric operation from 2016 to 2021. Matched analysis demonstrates that SDD is associated with a significantly higher mortality rate. Additionally, the risk of complications with SDD is higher for RYGB compared with sleeve gastrectomy. Therefore, further studies are required to appropriately select patients for whom bariatric surgery can be safely performed as an outpatient.

Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic

Background

The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US.

Methods

Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019.

Results

The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001).

Conclusions

To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.