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Whiteside JL, Tumin D, Hildebrand JP, Harris A. Determinants of Surgical Approach for Benign Outpatient Hysterectomy. J Minim Invasive Gynecol 2024; 31:123-130.e2. [PMID: 37984517 DOI: 10.1016/j.jmig.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/11/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
STUDY OBJECTIVE Identify determinants of the surgical approach to a benign, outpatient, minimally invasive hysterectomy. DESIGN A cross-sectional sample of patients undergoing outpatient hysterectomy between the 4th quarter of 2015 and the 4th quarter of 2022, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Data Base. The primary outcome was surgical approach to hysterectomy that was analyzed using mixed-effects regression, including a surgeon-level random effects to capture unobserved surgeon-level differences influencing variation in surgical approach. SETTING The Vizient Clinical Data Base includes patient encounter data from >50 healthcare systems and >400 community hospitals and represents approximately 97% of academic medical centers in the United States. PATIENTS Women >18 years undergoing an outpatient benign hysterectomy. INTERVENTION Surgical approach to hysterectomy. MEASUREMENT AND MAIN RESULT The final sample included 411 208 cases performed by 6089 surgeons. Among observed variables, patient diagnosis, surgeon specialty, and insurance type were strongly associated with choice of approach. However, after controlling for patient, hospital, and observable surgeon characteristics, unobserved surgeon-level differences still accounted for 72% of the variance in the use of transvaginal hysterectomy (95% confidence interval, 71-73) and 85% of the variance in the use of robot-assisted total hysterectomy (95% confidence interval, 84-86). CONCLUSION The strongest determinant of surgical approach to a benign outpatient hysterectomy in the United States was not patient- or hospital-level variability, but unexplained differences across individual surgeons. This has implications in how surgeons are trained and incentivized to deliver high-value surgical care.
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Affiliation(s)
- James L Whiteside
- Department of Obstetrics and Gynecology (Drs. Whiteside and Hildebrand), East Carolina University, Brody School of Medicine, Greenville, NC.
| | - Dmitry Tumin
- Department of Pediatrics (Dr. Tumin), East Carolina University, Brody School of Medicine, Greenville, NC
| | - Jason P Hildebrand
- Department of Obstetrics and Gynecology (Drs. Whiteside and Hildebrand), East Carolina University, Brody School of Medicine, Greenville, NC
| | - Alyssa Harris
- Vizient Inc., Center for Advanced Analytics and Informatics, Chicago, IL (Ms. Harris)
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Whiteside JL, Tumin D, Hohmann SF, Harris A. Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample. Obstet Gynecol 2023; 141:765-772. [PMID: 36897129 DOI: 10.1097/aog.0000000000005109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States. METHODS A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation. RESULTS The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063. CONCLUSION The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.
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Affiliation(s)
- James L Whiteside
- Department of Obstetrics and Gynecology and the Department of Pediatrics, East Carolina University, Brody School of Medicine, Greenville, North Carolina, and Vizient Inc, Center for Advanced Analytics and Informatics, and the Department of Health Systems Management, Rush University, Chicago, Illinois
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Stachowicz AM, Lambert JW, Hohmann SF, Whiteside JL. Physician and Hospital-level Variation in Hemostatic Agent Use in Benign Gynecologic Procedures. J Minim Invasive Gynecol 2022; 29:1149-1156. [PMID: 35781055 DOI: 10.1016/j.jmig.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/17/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE To identify recent nationwide trends in hemostatic agent (HA) use and to explore factors associated with HA use in 3 benign gynecologic surgery contexts: isolated hysterectomy, pelvic organ prolapse repair, and anti-incontinence surgery. DESIGN Retrospective cohort study. SETTING Vizient Clinical Database. PATIENTS Three cohorts of female patients of ≥18 years who underwent benign isolated hysterectomy, pelvic organ prolapse repair, or anti-incontinence procedures were identified between October 2015 and December 2019. INTERVENTIONS HAs are topically applied procoagulant products used for surgical hemostasis and use during included encounters was determined by charge codes. MEASUREMENTS AND MAIN RESULTS Subject-, hospital-, and surgeon-level characteristics and costs were captured. Data were initially analyzed in the aggregate and based on procedure category using the chi-square test or independent samples t tests as appropriate. A bootstrap forest model was used to identify the factors most predictive of HA use. In the final cohort of 184 070 encounters, HAs were used most frequently in hysterectomy (20.7%) and least in anti-incontinence surgery (10.9%). The use of HAs increased from 15.6% in quarter 4 2015 to 19.2% in quarter 4 2019 (p <.001). Encounters using HAs cost more than encounters without HAs ($6271.10 vs $4572.00; p <.001). A bootstrap forest model inclusive of all variables found surgeon and hospital identity cumulatively predictive of 84.9% of HA use, 65.5% and 19.4%, respectively. There was significant variation in HA use among individual surgeons, with 59.9% never using HAs. Of those who did use HAs, 72.8% used HAs more frequently than the mean provider HA use rate (19.4%) and 9.2% used HAs in every case he/she performed. CONCLUSION The significant variation in HA use is driven primarily by physician and hospital identity, suggesting that use of HA in these benign gynecologic surgical contexts may be determined more by physician- and hospital-level factors than patient-level factors.
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Affiliation(s)
- Anne M Stachowicz
- Female Pelvic Medicine and Reconstructive Surgery, The Christ Hospital, (Dr. Stachowicz), Cincinnati, OH.
| | - Joshua W Lambert
- College of Nursing, University of Cincinnati (Dr. Lambert), Cincinnati, OH
| | - Samuel F Hohmann
- Center for Advanced Analytics and Informatics, Vizient Inc. (Dr. Hohmann), Chicago, IL; Department of Health Systems Management, Rush University (Dr. Hohmann), Chicago, IL
| | - James L Whiteside
- Department of Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, Greenville, NC (Dr. Whiteside)
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Doan LV, Padjen K, Ok D, Gover A, Rashid J, Osmani B, Avraham S, Wang J, Kendale S. Relation between preoperative benzodiazepines and opioids on outcomes after total joint arthroplasty. Sci Rep 2021; 11:10528. [PMID: 34006976 PMCID: PMC8131602 DOI: 10.1038/s41598-021-90083-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/06/2021] [Indexed: 11/09/2022] Open
Abstract
To examine the association of preoperative opioids and/or benzodiazepines on postoperative outcomes in total knee and hip arthroplasty, we retrospectively compared postoperative outcomes in those prescribed preoperative opioids and/or benzodiazepines versus those who were not who underwent elective total knee and hip arthroplasty at a single urban academic institution. Multivariable logistic regression was performed for readmission rate, respiratory failure, infection, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used for length of stay. After exclusions, there were 4307 adult patients in the study population, 2009 of whom underwent total knee arthroplasty and 2298 of whom underwent total hip arthroplasty. After adjusting for potential confounders, preoperative benzodiazepine use was associated with increased odds of readmission (p < 0.01). Preoperative benzodiazepines were not associated with increased odds of respiratory failure nor increased length of stay. Preoperative opioids were not associated with increased odds of the examined outcomes. There were insufficient numbers of infection and cardiac events for analysis. In this study population, preoperative benzodiazepines were associated with increased odds of readmission. Preoperative opioids were not associated with increased odds of the examined outcomes. Studies are needed to further examine risks associated with preoperative benzodiazepine use.
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Affiliation(s)
- Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.
| | - Kristoffer Padjen
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Deborah Ok
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Adam Gover
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jawad Rashid
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Bijan Osmani
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Shirley Avraham
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.,Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Samir Kendale
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
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Fazzalari A, Pozzi N, Alfego D, Erskine N, Shi Q, Tourony G, Mathew J, Litwin D, Cahan MA. Treatment of appendicitis: Do Medicaid and non-Medicaid–enrolled patients receive the same care? Surgery 2019; 166:793-799. [DOI: 10.1016/j.surg.2019.06.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/16/2019] [Accepted: 06/30/2019] [Indexed: 11/15/2022]
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Does Hospital Volume Affect Outcomes in Patients Undergoing Vestibular Schwannoma Surgery? Otol Neurotol 2019; 39:481-487. [PMID: 29342051 DOI: 10.1097/mao.0000000000001718] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effect of hospital surgical case volume on the outcomes of vestibular schwannoma surgery. STUDY DESIGN Retrospective case review. SETTING University HealthSystem Consortium member hospitals (includes nearly every US academic medical center). PATIENTS Three thousand six hundred ninety-seven patients who underwent vestibular schwannoma resection over a 3-year timespan (2012-2015) grouped by race, age, comorbidities, payer, and sex. INTERVENTION Surgical resection of vestibular schwannoma. MAIN OUTCOME MEASURES Morbidity and mortality following vestibular schwannoma excision are compared by hospital volume (low, medium, and high) including deciles. RESULTS There was significantly longer length of stay (p ≤ 0.005) among groups with low-volume hospitals followed by medium-volume hospitals and high-volume hospitals. Low-volume hospitals had a significantly higher rate of complications including stroke, aspiration, and respiratory failure (p ≤ 0.0175). Patient characteristics of age, sex, sex, and baseline comorbidities were similar between hospital groups. However, patients at high-volume hospitals were more likely to be Caucasian (83.1%, p = 0.0001) and have private insurance (76.7%, p < 0.0001). There was a strong negative correlation between complication rates and hospital volume (r = -0.8164, p = 0.0040). CONCLUSION The volume of vestibular schwannoma surgeries performed at a hospital impacts length of stay and rates of postoperative complications. Demographics among hospital groups were similar though high-volume hospitals had significantly more patients who were privately insured and Caucasian.
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Loehrer AP, Chang DC, Scott JW, Hutter MM, Patel VI, Lee JE, Sommers BD. Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions. JAMA Surg 2019; 153:e175568. [PMID: 29365029 DOI: 10.1001/jamasurg.2017.5568] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrew P. Loehrer
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital, Boston
| | - John W. Scott
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Virendra I. Patel
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Redmann AJ, Yuen SN, VonAllmen D, Rothstein A, Tang A, Breen J, Collar R. Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery? Otolaryngol Head Neck Surg 2019; 161:629-634. [DOI: 10.1177/0194599819861524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives (1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Study Design Retrospective case series. Setting Tertiary academic hospital. Subjects and Methods The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology–head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. Results In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. Conclusion For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.
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Affiliation(s)
- Andrew J. Redmann
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sonia N. Yuen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas VonAllmen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Rothstein
- UC Health, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alice Tang
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph Breen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ryan Collar
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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Birdas TJ, Rozycki GF, Dunnington GL, Stevens L, Liali V, Schmidt CM. “Show Me the Data”: A Recipe for Quality Improvement Success in an Academic Surgical Department. J Am Coll Surg 2019; 228:368-373. [DOI: 10.1016/j.jamcollsurg.2018.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/01/2022]
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Clapp B, Devemark CD, Jones R, Dodoo C, Mallawaarachchi I, Tyroch A. Comparison of perioperative bariatric complications using 2 large databases: does the data add up? Surg Obes Relat Dis 2019; 15:1122-1131. [PMID: 31147279 DOI: 10.1016/j.soard.2019.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database is a prospective clinical database that looks at short-term (30-day) outcomes of bariatric surgery. The Texas Inpatient Public Use Data File (PUDF) is an administrative database that uses hospital discharge information to compile data on admission and discharge diagnoses. OBJECTIVE To determine interdatabase reliability for common bariatric complications. SETTING University hospital, United States METHODS: The Texas Inpatient PUDF and MBSAQIP were queried for patients undergoing sleeve gastrectomy and gastric bypass in the year 2015. Admission diagnoses of morbid obesity with a discharge diagnosis of bariatric surgery status and also the International Classification of Diseases 9 Clinical Modification and Current Procedural Terminology procedure codes for bariatric surgeries were queried. The same postoperative complications were examined in both databases. RESULTS There were 137,291 patients in MBSAQIP and 9474 patients in the PUDF undergoing bariatric surgery. Patients in the PUDF had greater adjusted and unadjusted odds ratio for acute renal failure, cardiac arrest and postoperative myocardial infarction, pneumonia, progressive renal failure and postoperative sepsis. CONCLUSION There is a significant difference in the rates of perioperative complications of bariatric surgery when different databases are used. If surgeons are to be graded or potentially financially affected by these outcome metrics, the proper use of and interpretation of data is paramount and quality monitoring organizations should not use only administrative databases as the primary method to measure quality.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas.
| | - Carl D Devemark
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas
| | - Robert Jones
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas
| | - Christopher Dodoo
- Department of Biostatistics and Epidemiology, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas
| | - Indika Mallawaarachchi
- Department of Biostatistics and Epidemiology, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas
| | - Alan Tyroch
- Department of Surgery, Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, Texas
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Doan LV, Wang J, Padjen K, Gover A, Rashid J, Osmani B, Avraham S, Kendale S. Preoperative Long-Acting Opioid Use Is Associated with Increased Length of Stay and Readmission Rates After Elective Surgeries. PAIN MEDICINE 2019; 20:2539-2551. [DOI: 10.1093/pm/pny318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractObjectives To compare postoperative outcomes in patients prescribed long-acting opioids vs opioid-naïve patients who underwent elective noncardiac surgeries.Design Retrospective cohort study.Setting Single urban academic institution.Methods and Subjects We retrospectively compared postoperative outcomes in long-acting opioid users vs opioid-naïve patients who underwent elective noncardiac surgeries. Inpatient and ambulatory surgery cohorts were separately analyzed. Preoperative medication lists were queried for the presence of long-acting opioids or absence of opioids. Multivariable logistic regression was performed to analyze the impact of long-acting opioid use on readmission rate, respiratory failure, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used to examine length of stay.Results After exclusions, there were 93,644 adult patients in the study population, 23,605 of whom underwent inpatient surgeries and 70,039 of whom underwent ambulatory surgeries. After adjusting for potential confounders and inpatient surgeries, preoperative long-acting opioid use was associated with increased risk of prolonged length of stay (incidence rate ratio = 1.1, 99% confidence interval [CI] = 1.0–1.2, P < 0.01) but not readmission. For ambulatory surgeries, preoperative long-acting opioid use was associated with increased risk of all-cause as well as pain-related readmission (odds ratio [OR] = 2.1, 99% CI = 1.5–2.9, P < 0.001; OR = 2.0, 99% CI = 0.85–4.2, P = 0.02, respectively). There were no significant differences for respiratory failure or adverse cardiac events.Conclusions The use of preoperative long-acting opioids was associated with prolonged length of stay for inpatient surgeries and increased risk of all-cause and pain-related readmission for ambulatory surgeries. Timely interventions for patients on preoperative long-acting opioids may be needed to improve these outcomes.
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Affiliation(s)
- Lisa V Doan
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Jing Wang
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Kristoffer Padjen
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Adam Gover
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Jawad Rashid
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Bijan Osmani
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Shirley Avraham
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
| | - Samir Kendale
- Departments of *Anesthesiology, Perioperative Care and Pain Medicine and †Neuroscience and Physiology, New York University School of Medicine, New York, New York, USA
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Brown EG, Bateni SB, Burgess D, Li CS, Bold RJ. Interhospital Variability in Quality Outcomes of Pancreatic Surgery. J Surg Res 2018; 235:453-458. [PMID: 30691829 DOI: 10.1016/j.jss.2018.10.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Assessment of optimal patient outcomes from health care delivery is critical for success amidst current reform. We developed a composite index of quality for pancreaticoduodenectomy (PD) and compared high and low performers nationwide. METHODS We performed a retrospective analysis of 17,220 patients undergoing elective PD between October 2010 and June 2014 using the Vizient database. A quality index score (QIS) was developed from five variables associated with optimal outcomes: postoperative complication rate, length of stay, 30-d readmission rate, mortality rate, and hospital volume. Value was defined as hospital-based QIS divided by mean hospital charges. High-value centers (top quintile) were compared to low-value centers (bottom quintile). RESULTS The majority of high-value centers (79%) achieved top performer status in 1-2 of five quality categories though only 11% were low performer in at least one category. Conversely, 41% of low-value centers were top performers in at least one category, although rarely more than one (8%); 63% of low-value centers were low performers in two or more categories. There was no significant association between QIS and hospital charges (-570, 95% CI -1308 to 168, P = 0.13). CONCLUSIONS High-value centers infrequently provided high quality surgical care across all five metrics but instead excelled in a few quality metrics while avoiding low performance in any quality metric. Although low-value centers could achieve excellence in one quality metric, they were frequently low performers in two or more outcomes. Improvements in value of PD can be achieved by a consistent effort across all quality metrics rather than efforts at constraining financial expenditures of health care delivery.
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Affiliation(s)
- Erin G Brown
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Sarah B Bateni
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Debra Burgess
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Chin-Shang Li
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California
| | - Richard J Bold
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California.
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Dy CJ, Osei DA, Maak TG, Gottschalk MB, Zhang AL, Maloney MD, Presson AP, O'Keefe RJ. Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study. J Bone Joint Surg Am 2018; 100:1902-1911. [PMID: 30480594 PMCID: PMC6636802 DOI: 10.2106/jbjs.17.01625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although overlapping surgery is used to maximize efficiency, more empirical data are needed to guide patient safety. We conducted a retrospective cohort study to evaluate the safety of overlapping inpatient orthopaedic surgery, as judged by the occurrence of perioperative complications. METHODS All inpatient orthopaedic surgical procedures performed at 5 academic institutions from January 1, 2015, to December 31, 2015, were included. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. In comparing patients who underwent overlapping surgery with those who underwent non-overlapping surgery, the primary outcome was the occurrence of a perioperative complication within 30 days of the surgical procedure, and secondary outcomes included all-cause 30-day readmission, length of stay, and mortality. To determine if there was an association between overlapping surgery and a perioperative complication, we tested for non-inferiority of overlapping surgery, assuming a null hypothesis of an increased risk of 50%. We used an inverse probability of treatment weighted regression model adjusted for institution, procedure type, demographic characteristics (age, sex, race, comorbidities), admission type, admission severity of illness, and clustering by surgeon. RESULTS Among 14,135 cases, the frequency of overlapping surgery was 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group. The overlapping surgery group was non-inferior to the non-overlapping surgery group (odds ratio [OR], 0.61 [90% confidence interval (CI), 0.45 to 0.83]; p < 0.001), with reduced odds of perioperative complications (OR, 0.61 [95% CI, 0.43 to 0.88]; p = 0.009). For secondary outcomes, there was a significantly lower chance of all-cause 30-day readmission in the overlapping surgery group (OR, 0.67 [95% CI, 0.52 to 0.87]; p = 0.003) and shorter length of stay (e, 0.94 [95% CI, 0.89 to 0.99]; p = 0.012). There was no difference in mortality. CONCLUSIONS Our results suggest that overlapping inpatient orthopaedic surgery does not introduce additional perioperative risk for the complications that we evaluated. The suitability of this practice should be determined by individual surgeons on a case-by-case basis with appropriate informed consent. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher J Dy
- Department of Orthopaedic Surgery (C.J.D. and R.J.O.) and Division of Public Health Sciences, Department of Surgery (C.J.D.), Washington University School of Medicine, St. Louis, Missouri
| | - Daniel A Osei
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Travis G Maak
- Department of Orthopaedic Surgery (T.G.M.) and Division of Biostatistics, Department of Internal Medicine (A.P.P.), University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael B Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California-San Francisco School of Medicine, San Francisco, California
| | - Michael D Maloney
- Department of Orthopaedic Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Angela P Presson
- Department of Orthopaedic Surgery (T.G.M.) and Division of Biostatistics, Department of Internal Medicine (A.P.P.), University of Utah School of Medicine, Salt Lake City, Utah
| | - Regis J O'Keefe
- Department of Orthopaedic Surgery (C.J.D. and R.J.O.) and Division of Public Health Sciences, Department of Surgery (C.J.D.), Washington University School of Medicine, St. Louis, Missouri
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Bateni SB, Olson JL, Hoch JS, Canter RJ, Bold RJ. Drivers of Cost for Pancreatic Surgery: It's Not About Hospital Volume. Ann Surg Oncol 2018; 25:3804-3811. [PMID: 30218244 DOI: 10.1245/s10434-018-6758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status. METHODS We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing ≥ 19 operations annually. RESULTS The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [- $1175, 95% confidence interval (CI) - $3254 to $904, p = 0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (- $99, 95% CI - $1612 to 1414, p = 0.90), one or more adverse outcomes (- $1586, 95% CI - $4771 to 1599, p = 0.33), or one or more complications (- $2835, 95% CI - $7588 to 1919, p = 0.24). CONCLUSIONS While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jennifer L Olson
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Robert J Canter
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Richard J Bold
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA.
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Hatch JL, Bauschard MJ, Nguyen SA, Lambert PR, Meyer TA, McRackan TR. Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database. Ann Otol Rhinol Laryngol 2018; 127:514-520. [PMID: 29962250 PMCID: PMC6728081 DOI: 10.1177/0003489418778056] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize factors that affect outcomes for patients with malignant otitis externa (MOE). METHODS Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed. RESULTS A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41). CONCLUSIONS This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.
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Affiliation(s)
- Jonathan L Hatch
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J Bauschard
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paul R Lambert
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A Meyer
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore R McRackan
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Chaudhary NS, Donnelly JP, Wang HE. Racial Differences in Sepsis Mortality at U.S. Academic Medical Center-Affiliated Hospitals. Crit Care Med 2018; 46:878-883. [PMID: 29438109 PMCID: PMC5953774 DOI: 10.1097/ccm.0000000000003020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the racial disparities in severe sepsis hospitalizations and outcomes in U.S. academic medical center-affiliated hospitals. DESIGN Retrospective analysis of sepsis hospitalizations. SETTINGS U.S. academic medical center-affiliated hospitals participating in Vizient Consortium from 2012 to 2014. PATIENTS Sepsis hospitalizations using International Classification of Diseases, Ninth revision, discharge diagnoses codes defined by the Angus method. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared rates of sepsis hospitalization, ICU admission, organ dysfunction, and hospital mortality between blacks and whites. We repeated the analyses stratified by community-acquired, healthcare-associated, and hospital-acquired sepsis subtypes. Of 10,244,780 hospitalizations in our cohort, 1,114,386 (10.9%) had sepsis. Sepsis subtypes included community-acquired sepsis (61.8%), healthcare-associated sepsis (23.8%), and hospital-acquired sepsis (14.4%). Although the proportion of discharges with sepsis was lower for blacks than whites (106.72 vs 109.43 per 1,000 hospitalizations; p < 0.001), the proportion of black sepsis hospitalizations was higher for individuals greater than 30 years old. Blacks exhibited lower adjusted sepsis hospital mortality than whites (odds ratio, 0.85; 95% CI, 0.84-0.86). The adjusted odds of hospital mortality following community-acquired, healthcare-associated, and hospital-acquired sepsis were lower for blacks than whites. CONCLUSIONS In this current series of hospital discharges at U.S. academic medical center-affiliated hospitals, blacks exhibited lower adjusted rates of sepsis hospitalizations and mortality than whites.
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Affiliation(s)
- Ninad S. Chaudhary
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John P. Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, TX
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Kim Y, Cortez AR, Wima K, Dhar VK, Athota KP, Schrager JJ, Pritts TA, Edwards MJ, Shah SA. Impact of Preoperative Opioid Use After Emergency General Surgery. J Gastrointest Surg 2018; 22:1098-1103. [PMID: 29340924 DOI: 10.1007/s11605-017-3665-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/22/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative exposure to narcotics has recently been associated with poor outcomes after elective major surgery, but little is known as to how preoperative opioid use impacts outcomes after common, emergency general surgical procedures (EGS). METHODS A high-volume, single-center analysis was performed on patients who underwent EGS from 2012 to 2013. EGS was defined as the seven emergent operations that account for 80% of the national burden. Preoperative opioid use was defined as having an active opioid prescription within 7 days prior to surgery. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days after discharge. RESULTS A total of 377 patients underwent EGS during the study period. Preoperative opioid use was present in 84 patients (22.3%). Preoperative opioid users had longer hospital LOS (10.5 vs 6 days), higher costs of care ($25,331 vs $11,454), and higher 30-day readmission rates (22.6 vs 8.2%) compared with opioid-naïve patients (p < 0.001 each). After covariate adjustment, preoperative opioid use was predictive of LOS (RR 1.19 [1.01-1.41]) and 30-day hospital readmission (OR 2.69 [1.25-5.75]) (p < 0.05 each). Total direct cost was not different after modeling. Preoperative opioid users required more narcotic refills compared with opioid-naïve patients (5 vs 0 refills, p < 0.001). After discharge, 15.4% of opioid-naïve patients met criteria for chronic opioid use, vs 77.4% in preoperative opioid users (p < 0.001). CONCLUSIONS Preoperative opioid use is associated with greater resource utilization after emergency general surgery, as well as vastly different postoperative opioid prescription patterns. These findings may help to inform the impact of preoperative opioid use on patient care, and its implications on hospital and societal cost.
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Affiliation(s)
- Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Krishna P Athota
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason J Schrager
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Timothy A Pritts
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Michael J Edwards
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. .,Division of Transplantation, University of Cincinnati School of Medicine, 231 Albert Sabin Way, ML 0558, MSB 2006C, Cincinnati, OH, 45267-0558, USA.
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Ghiam MK, Langerman A, Sargi Z, Rohde S. Head and Neck Cancer Patients: Rates, Reasons, and Risk Factors for 30-Day Unplanned Readmission. Otolaryngol Head Neck Surg 2018; 159:149-157. [DOI: 10.1177/0194599818776633] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective To analyze rates, risk factors, and complications for 30-day readmission among head and neck cancer (HNC) patients. Methods Retrospective review of administrative records from Vizient (Irving, Texas) Clinical Data Base/Resource Manager on HNC patients who underwent a head and neck surgical procedure from January 2013 through September 2015 at 176 academic and community medical centers. Results Of the 18,121 patients included in the study, 2502 patients were readmitted within 30 days (13.8%). Mean time to readmission was 11 ± 8.2 days. Cancer of the hypopharynx, oropharynx, pharynx, and larynx all had higher odds of readmission compared to oral cavity (odds ratio [OR], 1.8, 1.7, 1.6, and 1.5; 95% confidence interval [CI], 1.4-2.2, 1.4-1.9, 1.2-2.3, and 1.3-1.7, respectively). Consistent with this, flap procedures and laryngectomy had the highest odds of readmission (OR, 1.4 and 1.3; 95% CI, 1.3-1.6 and 1.0-1.5 vs glossectomy, respectively). The most common surgical causes for readmission were postoperative infection (17.6%) and surgical wound dehiscence (16.8%), which most commonly presented on postdischarge days 4 to 5. Acute cardiac events occurred in up to 15.4% of patients depending on complexity of surgery. Dysphagia and electrolyte disturbances were common (15.8% and 15.4%, respectively); patients with these complications typically presented earlier, between days 3 and 4. Discussion Patients with HNC are at high risk of readmission. The cancer subsite and procedure significantly influenced the risk, rate, and reason for readmission. Implications for Practice Findings from this study can help quality improvement and patient safety administrators develop interventions that uniquely target HNC populations.
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Affiliation(s)
- Michael K. Ghiam
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alexander Langerman
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zoukaa Sargi
- Department of Otolaryngology, Head and Neck Surgery, Sylvester Comprehensive Cancer Center, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sarah Rohde
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hatch JL, Bauschard MJ, Nguyen SA, Lambert PR, Meyer TA, McRackan TR. National Trends in Vestibular Schwannoma Surgery: Influence of Patient Characteristics on Outcomes. Otolaryngol Head Neck Surg 2018; 159:102-109. [PMID: 29584554 DOI: 10.1177/0194599818765717] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To characterize current vestibular schwannoma (VS) surgery outcomes with a nationwide database and identify factors associated with increased complications and prolonged hospital course. Study Design Retrospective review utilizing the University HealthSystem Consortium national inpatient database. Setting US academic health centers. Subjects and Methods Data from patients undergoing VS surgery were analyzed over a 3-year time span (October 2012 to September 2015). Surgical outcomes, such as length of stay (LOS), complications, and mortality, were analyzed on the basis of race, sex, age, and comorbidities during the 30-day postoperative period. Results A total of 3697 VS surgical cases were identified. The overall mortality rate was 0.38%, and the overall complication rate was 5.3%. Advanced age significantly affected intensive care unit LOS, mortality, and complications ( P = .04). Comorbidities, including hypertension, obesity, and depression, also significantly increased complication rates ( P = .02). Sixty-eight patients (1.8%) had a history of irradiation, and they had a significantly increased LOS ( P = .03). Conclusion Modern VS surgery has a low mortality rate and a relatively low rate of complications. Several factors contribute to high complication rates, including age and comorbidities. These data will help providers in counseling patients on which treatment course might be best suited for them.
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Affiliation(s)
- Jonathan L Hatch
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J Bauschard
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paul R Lambert
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A Meyer
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore R McRackan
- 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Malnutrition Diagnosis during Adult Inpatient Hospitalizations: Analysis of a Multi-Institutional Collaborative Database of Academic Medical Centers. J Acad Nutr Diet 2018; 118:125-131. [DOI: 10.1016/j.jand.2016.12.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/29/2016] [Indexed: 01/16/2023]
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Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score. Surg Endosc 2017; 32:2886-2893. [PMID: 29282576 DOI: 10.1007/s00464-017-5998-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 12/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties. METHODS From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien-Dindo classification. RESULTS We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2-< 3, 3-4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien-Dindo classification. CONCLUSIONS The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.
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Damle A, Damle RN, Flahive JM, Schlussel AT, Davids JS, Sturrock PR, Maykel JA, Alavi K. Diffusion of technology: Trends in robotic-assisted colorectal surgery. Am J Surg 2017; 214:820-824. [DOI: 10.1016/j.amjsurg.2017.03.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/27/2017] [Accepted: 03/12/2017] [Indexed: 12/18/2022]
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Kim Y, Wima K, Jung AD, Martin GE, Dhar VK, Shah SA. Laparoscopic subtotal cholecystectomy compared to total cholecystectomy: a matched national analysis. J Surg Res 2017; 218:316-321. [DOI: 10.1016/j.jss.2017.06.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/23/2017] [Accepted: 06/16/2017] [Indexed: 01/01/2023]
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Patanwala AE, Aljuhani O, Kopp BJ, Erstad BL. Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures. Am J Surg 2017; 214:738-742. [DOI: 10.1016/j.amjsurg.2017.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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Guterman EL, Kim AS, Josephson SA. Neurologic consultation and use of therapeutic hypothermia for cardiac arrest. Resuscitation 2017; 118:43-48. [DOI: 10.1016/j.resuscitation.2017.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/23/2017] [Accepted: 06/26/2017] [Indexed: 11/26/2022]
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Variations in survival after cardiac arrest among academic medical center-affiliated hospitals. PLoS One 2017; 12:e0178793. [PMID: 28582400 PMCID: PMC5459445 DOI: 10.1371/journal.pone.0178793] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/18/2017] [Indexed: 01/11/2023] Open
Abstract
Background Variation exists in cardiac arrest (CA) survival among institutions. We sought to determine institutional-level characteristics of academic medical centers (AMCs) associated with CA survival. Methods We examined discharge data from AMCs participating with Vizient clinical database–resource manager. We identified cases using ICD-9 diagnosis code 427.5 (CA) or procedure code 99.60 (CPR). We estimated hospital-specific risk-standardized survival rates (RSSRs) using mixed effects logistic regression, adjusting for individual mortality risk. Institutional and community characteristics of AMCs with higher than average survival were compared with those with lower survival. Results We analyzed data on 3,686,296 discharges in 2012, of which 33,700 (0.91%) included a CA diagnosis. Overall survival was 42.3% (95% CI 41.8–42.9) with median institutional RSSR of 42.6% (IQR 35.7–51.0; Min-Max 19.4–101.6). We identified 28 AMCs with above average survival (median RSSR 61.8%) and 20 AMCs with below average survival (median RSSR 26.8%). Compared to AMCs with below average survival, those with high CA survival had higher CA volume (median 262 vs.119 discharges, p = 0.002), total beds (722 vs. 452, p = 0.02), and annual surgical volume (24,939 vs. 13,109, p<0.001), more likely to offer cardiac catheterization (100% vs. 72%, p = 0.007) or cardiac surgery (93% vs. 61%, p = 0.02) and cared for catchment areas with higher household income ($61,922 vs. $49,104, p = 0.004) and lower poverty rates (14.6% vs. 17.3%, p = 0.03). Conclusion Using discharge data from Vizient, we showed AMCs with higher CA and surgical case volume, cardiac catheterization and cardiac surgery facilities, and catchment areas with higher socioeconomic status had higher risk-standardized CA survival.
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McClelland S, Gorfinkle N, Arslan AA, Benedetto-Anzai MT, Cheon T, Anzai Y. Factors associated with cesarean delivery rates: a single-institution experience. Matern Health Neonatol Perinatol 2017; 3:8. [PMID: 28439421 PMCID: PMC5401466 DOI: 10.1186/s40748-017-0047-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to identify factors associated with variability in Cesarean delivery (CD) rates amongst providers at a single institution. METHODS A retrospective cohort analysis was carried out on all births at NYU Langone Medical Center from 2005-2013. Data was collected for subjects and linked to diagnosis codes for singleton and twin deliveries. Descriptive characteristics were generated for all deliveries, and inferential analysis was performed including multiple covariates for singleton deliveries in the 2010-2013 cohort, including both univariate and multivariate regression analyses to identify factors associated with higher CD rates. RESULTS 37,692 deliveries were identified at our institution during the study period, performed by 88 unique providers. The mean CD rate was 29.6%, with a range for individual physicians from 9.9% to 75.6%. In multivariate regression analysis, CD rate was directly correlated with average patient age, physician male gender, proportion of high-risk deliveries, and Maternal-Fetal Medicine specialty, and it was inversely correlated with total number of deliveries by physician and forceps delivery rate. There was no significant difference in CD rates between group and solo practices. Within the same group practice, each member's CD rate was strongly correlated with the average CD rate of the group. CONCLUSION Our study demonstrates the wide range of CD rates for providers practicing within the same institution and reiterates the association of CD rates with patient age, high-risk pregnancy, and provider volume. Among operative vaginal deliveries, forceps delivery rate was associated with lower CD rates whereas vacuum delivery rate was not. Despite these findings, practice patterns within individual practices appear to contribute significantly to the wide range of CD rates.
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Affiliation(s)
- Spencer McClelland
- NYU Langone Medical Center, Department of Obstetrics and Gynecology, 800 2nd Avenue, Suite 815, New York, NY 10017 USA
| | - Naomi Gorfinkle
- Johns Hopkins University School of Medicine, 4 South Broadway, Baltimore, MD 21231 USA
| | - Alan A. Arslan
- NYU Langone Medical Center, Division of Epidemiology, Departments of Obstetrics and Gynecology, Environmental Medicine, and Population Health, 650 First Ave, Rm. 532, New York, NY 10016 USA
| | - Maria Teresa Benedetto-Anzai
- NYU Langone Medical Center, Department of Obstetrics and Gynecology, 800 2nd Avenue, Suite 815, New York, NY 10017 USA
| | - Teresa Cheon
- NYU Langone Medical Center, Department of Obstetrics and Gynecology, 800 2nd Avenue, Suite 815, New York, NY 10017 USA
| | - Yuzuru Anzai
- NYU Langone Medical Center, Department of Obstetrics and Gynecology, 800 2nd Avenue, Suite 815, New York, NY 10017 USA
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Halpern AB, Culakova E, Walter RB, Lyman GH. Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit. JAMA Oncol 2017; 3:374-381. [PMID: 27832254 DOI: 10.1001/jamaoncol.2016.4858] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined. Objective To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML. Design, Setting, and Participants This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016. Main Outcomes and Measures Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost. Results Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities. Conclusions and Relevance Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.
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Affiliation(s)
- Anna B Halpern
- Hematology/Oncology Fellowship Program, Fred Hutchinson Cancer Research Center/University of Washington, Seattle
| | - Eva Culakova
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington5Division of Hematology, Department of Medicine, University of Washington, Seattle6Department of Epidemiology, University of Washington, Seattle
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington4Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington7Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
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Lentine KL, Lam NN, Schnitzler MA, Hess GP, Kasiske BL, Xiao H, Axelrod D, Garg AX, Schold JD, Randall H, Dzebisashvili N, Brennan DC, Segev DL. Predonation Prescription Opioid Use: A Novel Risk Factor for Readmission After Living Kidney Donation. Am J Transplant 2017; 17:744-753. [PMID: 27589826 DOI: 10.1111/ajt.14033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/08/2016] [Accepted: 08/21/2016] [Indexed: 01/25/2023]
Abstract
Implications of opioid use in living kidney donors for key outcomes, including readmission rates after nephrectomy, are unknown. We integrated Scientific Registry of Transplant Recipients data with records from a nationwide pharmacy claims warehouse and administrative records from an academic hospital consortium to quantify predonation prescription opioid use and postdonation readmission events. Associations of predonation opioid use (adjusted odds ratio [aOR]) in the year before donation and other baseline clinical, procedural, and center factors with readmission within 90 days postdonation were examined by using multivariate logistic regression. Among 14 959 living donors, 11.3% filled one or more opioid prescriptions in the year before donation. Donors with the highest level of predonation opioid use (>305 mg/year) were more than twice as likely as nonusers to be readmitted (6.8% vs. 2.6%; aOR 2.49, 95% confidence interval 1.74-3.58). Adjusted readmission risk was also significantly (p < 0.05) higher for women (aOR = 1.25), African Americans (aOR = 1.45), spouses (aOR = 1.42), exchange participants (aOR = 1.46), uninsured donors (aOR = 1.40), donors with predonation estimated glomerular filtration rate <60 mL/min/1.73 m2 (aOR = 2.68), donors with predonation pulmonary conditions (aOR = 1.54), and after robotic nephrectomy (aOR = 1.68). Predonation opioid use is independently associated with readmission after donor nephrectomy. Future research should examine underlying mechanisms and approaches to reducing risks of postdonation complications.
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Affiliation(s)
- K L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - N N Lam
- Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - M A Schnitzler
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - G P Hess
- Symphony Health, Pittsburgh, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
| | - B L Kasiske
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN
| | - H Xiao
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - D Axelrod
- Division of Abdominal Transplantation, Department of Surgery, Brody School of Medicine, Greenville, NC
| | - A X Garg
- Division of Nephrology, Western University, London, ON, Canada
| | - J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - H Randall
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - N Dzebisashvili
- Dickson Advanced Analytics, Carolinas HealthCare System, Charlotte, NC
| | - D C Brennan
- Transplant Nephrology, Washington University School of Medicine, St. Louis, MO
| | - D L Segev
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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Cancienne JM, Diduch DR, Werner BC. High Altitude Is an Independent Risk Factor for Postoperative Symptomatic Venous Thromboembolism After Knee Arthroscopy: A Matched Case-Control Study of Medicare Patients. Arthroscopy 2017; 33:422-427. [PMID: 27876235 DOI: 10.1016/j.arthro.2016.07.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 07/28/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To use a national database of Medicare patients to evaluate the association of uncomplicated knee arthroscopy performed at high altitude with the incidence of postoperative venous thromboembolism (VTE). METHODS The 100% Medicare Standard Analytical File database was queried for all patients undergoing isolated arthroscopic partial meniscectomy and/or chondroplasty from 2005-2012. Patients with more complex open or additional arthroscopic knee procedures, a personal history of VTE, or any hypercoagulable state were excluded. The result of this query was then stratified by the altitude of the hospital ZIP code in which the procedure was performed. The appropriate patients were placed into a high-altitude group (≥4,000 ft) and matched to patients who underwent the same procedures at an altitude less than or equal to 100 ft on the basis of age, sex, and medical comorbidities. The rate of VTE was then assessed for both the high-altitude and matched low-altitude patients within 30 days and 90 days postoperatively. RESULTS The rate of combined VTE (deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) (odds ratio [OR], 2.0; P = .0003), the rate of PE (OR, 2.5; P = .0099), and the rate of DVT (OR, 1.7; P = .0066) within 30 days were all significantly higher in patients with procedures performed at high altitude compared with matched patients with the same procedures performed at low altitude. At 90 days postoperatively, similarly elevated risks of VTE, PE, and DVT were found in patients with procedures performed at high altitude. CONCLUSIONS In this study of knee arthroscopy in Medicare patients, a procedure performed at an altitude ≥4,000 ft was a significant risk factor for the development of postoperative VTE compared with matched patients undergoing the same procedure at an altitude less than or equal to 100 ft. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:11-15. [PMID: 27471211 DOI: 10.1016/j.arth.2016.06.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/10/2016] [Accepted: 06/16/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS. RESULTS Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001). CONCLUSION Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.
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Brown EG, Anderson JE, Burgess D, Bold RJ, Farmer DL. Pediatric surgical readmissions: Are they truly preventable? J Pediatr Surg 2017; 52:161-165. [PMID: 27919406 DOI: 10.1016/j.jpedsurg.2016.10.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE Reimbursement penalties for excess hospital readmissions have begun for the pediatric population. Therefore, research determining incidence and predictors is critical. METHODS A retrospective review of University HealthSystem Consortium database (N=258 hospitals; 2,723,621 patients) for pediatric patients (age 0-17years) hospitalized from 9/2011 to 3/2015 was performed. Outcome measures were 7-, 14-, and 30-day readmission rates. Hospital and patient characteristics were evaluated to identify predictors of readmission. RESULTS Readmission rates at 7, 14, and 30days were 2.1%, 3.1%, and 4.4%. For pediatric surgery patients (N=260,042), neither index hospitalization length of stay (LOS) nor presence of a complication predicted higher readmissions. Appendectomy was the most common procedure leading to readmission. Evaluating institutional data (N=5785), patients admitted for spine surgery, neurosurgery, transplant, or surgical oncology had higher readmission rates. Readmission diagnoses were most commonly infectious (37.2%) or for nausea/vomiting/dehydration (51.1%). Patients with chronic medical conditions comprised 55.8% of patients readmitted within 7days. 92.0% of patients requiring multiple rehospitalizations had comorbidities. CONCLUSIONS Readmission rates for pediatric patients are significantly lower than adults. Risk factors for adult readmissions do not predict pediatric readmissions. Readmission may be a misnomer for the pediatric surgical population, as most are related to chronic medical conditions and other nonmodifiable risk factors. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Erin G Brown
- University of California, Davis Health System, Sacramento, CA, USA.
| | - Jamie E Anderson
- University of California, Davis Health System, Sacramento, CA, USA
| | - Debra Burgess
- University of California, Davis Health System, Sacramento, CA, USA
| | - Richard J Bold
- University of California, Davis Health System, Sacramento, CA, USA
| | - Diana L Farmer
- University of California, Davis Health System, Sacramento, CA, USA
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Hoehn RS, Hanseman DJ, Chang AL, Daly MC, Ertel AE, Abbott DE, Shah SA, Paquette IM. Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy. J Gastrointest Surg 2017; 21:23-32. [PMID: 27586190 DOI: 10.1007/s11605-016-3254-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Urgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy. METHODS The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality. RESULTS The overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84). CONCLUSIONS Mortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.
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Affiliation(s)
- Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan C Daly
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Colorectal Surgery, University of Cincinnati School of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
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Case mix-adjusted cost of colectomy at low-, middle-, and high-volume academic centers. Surgery 2016; 161:1405-1413. [PMID: 27919447 DOI: 10.1016/j.surg.2016.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. METHODS All patients undergoing colectomy (n = 90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. RESULTS Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P < .01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P < .01). CONCLUSION Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers.
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Le ST, Josephson SA, Puttgen HA, Gibson L, Guterman EL, Leicester HM, Graf CL, Probasco JC. Many Neurology Readmissions Are Nonpreventable. Neurohospitalist 2016; 7:61-69. [PMID: 28400898 DOI: 10.1177/1941874416674409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Reducing unplanned hospital readmissions has become a national focus due to the Centers for Medicare and Medicaid Services' (CMS) penalties for hospitals with high rates. A first step in reducing unplanned readmission is to understand which patients are at high risk for readmission, which readmissions are planned, and how well planned readmissions are currently captured in comparison to patient-level chart review. METHODS We examined all 5455 inpatient neurology admissions over a 2-year period to University of California San Francisco Medical Center and Johns Hopkins Hospital via chart review. We collected information such as patient age, procedure codes, diagnosis codes, all-payer diagnosis-related group, observed length of stay (oLOS), and expected length of stay. We performed multivariate logistic modeling to determine predictors of readmission. Discharge summaries were reviewed for evidence that a subsequent readmission was planned. RESULTS A total of 353 (6.5%) discharges were readmitted within 30 days. Fifty-five (15.6%) of the 353 readmissions were planned, most often for a neurosurgical procedure (41.8%) or immunotherapy (23.6%). Only 8 of these readmissions would have been classified as planned using current CMS methodology. Patient age (odds ratio [OR] = 1.01 for each 10-year increase, P < .001) and estimated length of stay (OR = 1.04, P = .002) were associated with a greater likelihood of readmission, whereas index admission oLOS was not. CONCLUSIONS Many neurologic readmissions are planned; however, these are often classified by current CMS methodology as unplanned and penalized accordingly. Modifications of the CMS lists for potentially planned neurological and neurosurgical procedures and for acute discharge neurologic diagnoses should be considered.
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Affiliation(s)
- Sidney T Le
- University of California San Francisco, San Francisco, CA, USA
| | | | - Hans A Puttgen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorrie Gibson
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elan L Guterman
- University of California San Francisco, San Francisco, CA, USA
| | | | - Carla L Graf
- University of California San Francisco, San Francisco, CA, USA
| | - John C Probasco
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ertel AE, Wima K, Hoehn RS, Chang AL, Hohmann SF, Ahmad SA, Sussman JJ, Shah SA, Abbott DE. Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible. Surgery 2016; 160:1477-1484. [PMID: 27712874 DOI: 10.1016/j.surg.2016.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/14/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. METHODS The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. RESULTS Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. CONCLUSION Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | | | - Syed A Ahmad
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Damle R, Alavi K. The University Healthsystem Consortium clinical database: An emerging resource in colorectal surgery research. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Donnelly JP, Locke JE, MacLennan PA, McGwin G, Mannon RB, Safford MM, Baddley JW, Muntner P, Wang HE. Inpatient Mortality Among Solid Organ Transplant Recipients Hospitalized for Sepsis and Severe Sepsis. Clin Infect Dis 2016; 63:186-94. [PMID: 27217215 DOI: 10.1093/cid/ciw295] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/23/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are at elevated risk of sepsis. The impact of SOT on outcomes following sepsis is unclear. METHODS We performed a retrospective cohort study using data from University HealthSystem Consortium, a consortium of academic medical center affiliates. We examined the association between SOT and mortality among patients hospitalized with severe sepsis or explicitly coded sepsis in 2012-2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify severe sepsis, explicitly coded sepsis, and SOT (kidney, liver, heart, lung, pancreas, or intestine transplants). We fit random-intercept logistic regression models to account for clustering by hospital. RESULTS There were 903 816 severe sepsis hospitalizations (39 618 [4.4%] with SOT) and 410 623 sepsis hospitalizations (14 526 [3.9%] with SOT) in 250 hospitals. SOT recipients were younger and more likely to be insured by Medicare than those without SOT. Among hospitalizations for severe sepsis and sepsis, in-hospital mortality was lower among those with vs those without SOT (5.5% vs 9.4% for severe sepsis; 8.7% vs 12.7% for sepsis). After adjustment, the odds ratio for mortality comparing SOT patients vs non-SOT was 0.83 (95% confidence interval [CI], .79-.87) for severe sepsis and 0.78 (95% CI, .73-.84) for sepsis. Compared to non-SOT patients, kidney, liver, and co-transplant (kidney-pancreas/kidney-liver) recipients demonstrated lower mortality. No association was present for heart transplant, and lung transplant was associated with higher mortality. CONCLUSIONS Among patients hospitalized for severe sepsis or sepsis, those with SOT had lower inpatient mortality than those without SOT. Identifying the specific strategies employed for populations with improved mortality could inform best practices for sepsis among SOT and non-SOT populations.
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Affiliation(s)
- John P Donnelly
- Department of Emergency Medicine, School of Medicine Department of Medicine, Division of Preventive Medicine Department of Epidemiology, School of Public Health
| | - Jayme E Locke
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation
| | - Paul A MacLennan
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation
| | | | - Roslyn B Mannon
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation Department of Medicine, Division of Nephrology
| | - Monika M Safford
- Department of Medicine Department of Medicine, Weill Cornell Medical College, New York, New York
| | - John W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Paul Muntner
- Department of Epidemiology, School of Public Health
| | - Henry E Wang
- Department of Emergency Medicine, School of Medicine
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Ertel AE, Wima K, Chang AL, Hoehn RS, Hohmann SF, Edwards MJ, Abbott DE, Shah SA. Risk of Reoperation Within 90 Days of Liver Transplantation: A Necessary Evil? J Am Coll Surg 2016; 222:419-28. [PMID: 26905185 DOI: 10.1016/j.jamcollsurg.2016.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The rate and consequences of reoperation after liver transplantation (LT) are unknown in the United States. STUDY DESIGN Adult patients (n = 10,295; 45% of all LT) undergoing LT from 2009 through 2012 were examined using a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases providing recipient, donor, center, hospitalization, and survival details. Median follow-up was 2 years. Reoperations were identified within 90 days after LT. RESULTS Overall 90-day reoperation rate after LT was 29.3%. Risk factors for 90-day reoperation included recipients with a history of hemodialysis, severely ill functional status, government insurance, increasing Model for End-Stage Liver Disease score, and increasing donor risk index. Reoperation within 90 days was found to be an independent predictor of adjusted 1-year mortality (odds ratio = 1.8; 95% CI, 1.5-2.1), as was government-provided insurance and increasing donor risk index. Additionally, patients undergoing delayed reoperative intervention (after 30 days) were found to have increased risk of 1-year mortality compared with those undergoing early reoperative intervention (odds ratio = 1.96; 95% CI, 1.4-2.7; p < 0.01). CONCLUSIONS This is the first national study reporting that nearly one-third of transplant recipients undergo reoperation within 90 days of LT. Although necessary at times, reoperation is associated with increased risk of death at 1 year; however, it appears that the timing of these interventions can be critical, due to the type of intervention required. Early reoperative intervention does not appear to influence long-term outcomes, and delayed intervention (after 30 days) is strongly associated with decreased survival.
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Affiliation(s)
- Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Samual F Hohmann
- University Health Consortium, Chicago, IL; Department of Health Systems Management, Rush University, Chicago, IL
| | - Michael J Edwards
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH; Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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Guterman EL, Douglas VC, Shah MP, Parsons T, Barba J, Josephson SA. National characteristics and predictors of neurologic 30-day readmissions. Neurology 2016; 86:669-75. [DOI: 10.1212/wnl.0000000000002379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/22/2015] [Indexed: 11/15/2022] Open
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Ertel AE, Wima K, Hoehn RS, Abbott DE, Shah SA. Hospital Utilization of Nationally Shared Liver Allografts from 2007 to 2012. World J Surg 2015; 40:958-66. [DOI: 10.1007/s00268-015-3357-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Sutton JM, Wilson GC, Wima K, Hoehn RS, Cutler Quillin R, Hanseman DJ, Paquette IM, Sussman JJ, Ahmad SA, Shah SA, Abbott DE. Readmission After Pancreaticoduodenectomy: The Influence of the Volume Effect Beyond Mortality. Ann Surg Oncol 2015; 22:3785-3792. [DOI: 10.1245/s10434-015-4451-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Indexed: 08/30/2023]
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Donnelly JP, Hohmann SF, Wang HE. Unplanned Readmissions After Hospitalization for Severe Sepsis at Academic Medical Center-Affiliated Hospitals. Crit Care Med 2015; 43:1916-27. [PMID: 26082977 PMCID: PMC4537666 DOI: 10.1097/ccm.0000000000001147] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In the United States, national efforts to reduce hospital readmissions have been enacted, including the application of substantial insurance reimbursement penalties for hospitals with elevated rates. Readmissions after severe sepsis remain understudied and could possibly signify lapses in care and missed opportunities for intervention. We sought to characterize 7- and 30-day readmission rates following hospital admission for severe sepsis as well as institutional variations in readmission. DESIGN Retrospective analysis of 345,657 severe sepsis discharges from University HealthSystem Consortium hospitals in 2012. SETTING United States. PATIENTS We applied the commonly cited method described by Angus et al for identification of severe sepsis, including only discharges with sepsis present at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified unplanned, all-cause readmissions within 7 and 30 days of discharge using claims-based algorithms. Using mixed-effects logistic regression, we determined factors associated with 30-day readmission. We used risk-standardized readmission rates to assess institutional variations. Among 216,328 eligible severe sepsis discharges, there were 14,932 readmissions within 7 days (6.9%; 95% CI, 6.8-7.0) and 43,092 within 30 days (19.9%; 95% CI, 19.8-20.1). Among those readmitted within 30 days, 66.9% had an infection and 40.3% had severe sepsis at readmission. Patient severity, length of stay, and specific diagnoses were associated with increased odds of 30-day readmission. Observed institutional 7-day readmission rates ranged from 0% to 12.3%, 30-day rates from 3.6% to 29.1%, and 30-day risk-standardized readmission rates from 14.1% to 31.1%. Greater institutional volume, teaching status, trauma services, location in the Northeast, and lower ICU rates were associated with poor risk-standardized readmission rate performance. CONCLUSIONS Severe sepsis readmission places a substantial burden on the healthcare system, with one in 15 and one in five severe sepsis discharges readmitted within 7 and 30 days, respectively. Hospitals and clinicians should be aware of this important sequela of severe sepsis.
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Affiliation(s)
- John P. Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham AL
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham AL
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham AL
| | - Samuel F. Hohmann
- University HealthSystem Consortium and Department of Health Systems Management, Rush University, Chicago IL
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham AL
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Page DB, Donnelly JP, Wang HE. Community-, Healthcare-, and Hospital-Acquired Severe Sepsis Hospitalizations in the University HealthSystem Consortium. Crit Care Med 2015; 43:1945-51. [PMID: 26110490 PMCID: PMC4537676 DOI: 10.1097/ccm.0000000000001164] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Severe sepsis poses a major burden on the U.S. healthcare system. Previous epidemiologic studies have not differentiated community-acquired severe sepsis from healthcare-associated severe sepsis or hospital-acquired severe sepsis hospitalizations. We sought to compare and contrast community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis hospitalizations in a national hospital sample. DESIGN Retrospective analysis of severe sepsis discharges from University HealthSystem Consortium hospitals in 2012. SETTING United States. PATIENTS We used the criteria from Angus et al (discharge diagnoses for both a serious infection and organ dysfunction) to identify severe sepsis hospitalizations. We defined healthcare-associated severe sepsis as severe sepsis hospitalizations with an infection present at admission, where the patient was a nursing home resident, was on hemodialysis, or was readmitted within 30 days of a prior hospitalization. We defined community-acquired severe sepsis as all other severe sepsis patients with an infection present at admission. We defined hospital-acquired severe sepsis as severe sepsis patients where the documented infection was not present at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Prevalence of community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis, adjusted hospital mortality, length of hospitalization, length of stay in an ICU, and hospital costs. Among 3,355,753 hospital discharges, there were 307,491 with severe sepsis, including 193,081 (62.8%) community-acquired severe sepsis, 79,581 (25.9%) healthcare-associated severe sepsis, and 34,829 (11.3%) hospital-acquired severe sepsis. Hospital-acquired severe sepsis and healthcare-associated severe sepsis exhibited higher in-hospital mortality than community-acquired severe sepsis (hospital acquired [19.2%] vs healthcare associated [12.8%] vs community acquired [8.6%]). Hospital-acquired severe sepsis had greater resource utilization than both healthcare-associated severe sepsis and community-acquired severe sepsis, with higher median length of hospital stay (hospital acquired [17 d] vs healthcare associated [7 d] vs community acquired [6 d]), median length of ICU stay (hospital acquired [8 d] vs healthcare associated [3 d] vs community acquired [3 d]), and median hospital costs (hospital acquired [$38,369] vs healthcare associated [$8,796] vs community acquired [$7,024]). CONCLUSIONS In this series, severe sepsis hospitalizations included community-acquired severe sepsis (62.8%), healthcare-associated severe sepsis (25.9%), and hospital-acquired severe sepsis (11.3%) cases. Hospital-acquired severe sepsis was associated with both higher mortality and resource utilization than community-acquired severe sepsis and healthcare-associated severe sepsis.
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Affiliation(s)
- David B Page
- 1Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL. 2Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 3Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Gaitonde SG, Hanseman DJ, Wima K, Sutton JM, Wilson GC, Sussman JJ, Ahmad SA, Shah SA, Abbott DE. Resource utilization in esophagectomy: When higher costs are associated with worse outcomes. J Surg Oncol 2015; 112:51-5. [DOI: 10.1002/jso.23958] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 06/05/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Shrawan G. Gaitonde
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Dennis J. Hanseman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Jeffrey M. Sutton
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Gregory C. Wilson
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Jeffrey J. Sussman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Syed A. Ahmad
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Shimul A. Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Daniel E. Abbott
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
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Wilson GC, Hoehn RS, Ertel AE, Wima K, Quillin RC, Hohmann S, Paterno F, Abbott DE, Shah SA. Variation by center and economic burden of readmissions after liver transplantation. Liver Transpl 2015; 21:953-60. [PMID: 25772696 DOI: 10.1002/lt.24112] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/14/2015] [Accepted: 03/08/2015] [Indexed: 12/13/2022]
Abstract
The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n = 11,937; 43.1% of all LT cases) undergoing LT from 2007 to 2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine the incidence and risk factors for 30-day readmissions and utilization metrics 90 days after LT. The overall 30-day hospital readmission rate after LT was 37.9%, with half of patients admitted within 7 days after discharge. Readmitted patients had worse overall graft and patient survival with a 2-year follow-up. Multivariate analysis identified risk factors associated with 30-day hospital readmission, including a higher Model for End-Stage Liver Disease score, diabetes at LT, dialysis dependence, a high donor risk index allograft, and discharge to a rehabilitation facility. After adjustments for donor, recipient, and geographic factors in a hierarchical model, we found significant variation in readmission rates among hospitals ranging from 26.3% to 50.8% (odds ratio, 0.53-1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 of added costs in comparison with patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions are associated with center variation and increased resource utilization.
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Affiliation(s)
- Gregory C Wilson
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sam Hohmann
- Department of Health Systems Management, University Health Consortium, Rush University, Chicago, IL
| | - Flavio Paterno
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Padula WV, Makic MBF, Wald HL, Campbell JD, Nair KV, Mishra MK, Valuck RJ. Hospital-Acquired Pressure Ulcers at Academic Medical Centers in the United States, 2008–2012: Tracking Changes Since the CMS Nonpayment Policy. Jt Comm J Qual Patient Saf 2015; 41:257-63. [DOI: 10.1016/s1553-7250(15)41035-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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The relationship between duration of stay and readmissions in patients undergoing bariatric surgery. Surgery 2015; 158:501-7. [PMID: 26032831 DOI: 10.1016/j.surg.2015.03.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/05/2015] [Accepted: 03/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital readmissions are a quality indicator in bariatric surgery. In recent years, duration of stay after bariatric surgery has trended down greatly. We hypothesized that a shorter postoperative hospitalization does not increase the likelihood of readmission. METHODS The University HealthSystem Consortium (UHC) is an alliance of academic medical centers and affiliated hospitals. The UHC's clinical database contains information on inpatient stay and returns (readmissions) up to 30 days after discharge. A multicenter analysis of outcomes was performed by the use of data from the January 2009 to December 2013 for patients 18 years and older. Patients were identified by bariatric procedure International Classification of Diseases, Ninth Revision, codes and restricted by diagnosis codes for morbid obesity. RESULTS A total of 95,294 patients met inclusion criteria. The mean patient age was 45.4 (±0.11) years, and 73,941 (77.6%) subjects were female. There were 5,423 (5.7%) readmissions within the study period. Patients with hospitalizations of 3 days and more than 3 days were twice and four times as likely to be readmitted than those with hospitalizations of one day, respectively (P < .001). CONCLUSION Patients with longer postoperative hospitalizations were more likely to be readmitted after bariatric surgery. Early discharge does not appear to be associated with increased readmission rates.
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Ceppa EP, Pitt HA, Nakeeb A, Schmidt CM, Zyromski NJ, House MG, Kilbane EM, George-Minkner AN, Brand B, Lillemoe KD. Reducing Readmissions after Pancreatectomy: Limiting Complications and Coordinating the Care Continuum. J Am Coll Surg 2015; 221:708-16. [PMID: 26228016 DOI: 10.1016/j.jamcollsurg.2015.05.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/08/2015] [Accepted: 05/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recent analyses of gastrointestinal operations document that complications are a key driver of readmissions. Pancreatectomy is a high outlier with respect to readmission. This analysis sought to determine if a multifactorial approach could reduce readmissions after pancreatectomy. STUDY DESIGN From 2007 to 2012, the number of patients readmitted by 30 days after pancreaticoduodenectomy, and distal and total pancreatectomy was measured. Steps to decrease readmissions were implemented independently at 1-year intervals; these efforts included strategies to reduce complications, creation of a Readmissions Team with a "discharge coach," increased use of home health, preferred relationships with post-acute care facilities, and the adoption of "Project RED" (Re-Engineered Discharge). The ACS NSQIP was used to track 30-day outcomes for all pancreatic resections. The University HealthSystem Consortium was used to determine length of stay index. RESULTS Over 5 years, 1,163 patients underwent proximal (66%), distal (32%), or total pancreatectomy (2%). The observed 30-day mortality was 2.9% for the study period, and the length of stay index (observed/expected days) was 1.10. Neither varied significantly over time. However, 30-day morbidity decreased from 57% to 46%, and proportion of patients with 30-day all-cause readmissions decreased from 23.0% to 11.5% (p = 0.001). CONCLUSIONS All-cause 30-day readmissions after pancreatectomy decreased without increasing length of stay. Efforts by surgeons to decrease complications and an increased emphasis on coordination of care may be useful for reducing readmissions.
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Affiliation(s)
- Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Henry A Pitt
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA.
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - E Molly Kilbane
- Department of Nursing, Indiana University Health, Indianapolis, IN
| | | | - Beth Brand
- Clinical Decision Support, Indiana University Health, Indianapolis, IN
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Factors related to readmission after major elective surgery. Dig Dis Sci 2015; 60:47-53. [PMID: 25064214 DOI: 10.1007/s10620-014-3306-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/16/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hospital readmissions have received increased scrutiny as a marker for excessive resource utilization and also quality care. AIM To identify the rate of and risk factors for hospital readmission after major surgery at academic medical centers. METHODS Using the University Health Consortium Clinical Database, 30-day readmission rates in all adult patients undergoing colectomy (n = 103,129), lung resection (n = 73,558), gastric bypass (n = 62,010) or abdominal aortic surgery (n = 17,997) from 2009 to 2012 were identified. Logistic regression was performed to examine risks for readmission. RESULTS Overall readmission rates ranged from 8.9 % after gastric bypass to 15.8 % after colectomy. Black race was associated with increased likelihood for readmission after three of the four procedures with odds ratios ranging from 1.13 after colectomy to 1.44 after gastric bypass. For all procedures, moderate, severe, or extreme severity of illness (SOI) and need for transitional care were associated with increased odds for hospital readmission. Lower center volume was an independent predictor of readmission after gastric bypass surgery and aortic surgery. CONCLUSION Readmission rates after major elective surgery are high across national academic centers. Center volume, SOI, and need for transitional care after discharge are factors associated with readmission and may be used to identify patients at high risk of readmission and hospital utilization after major surgery.
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