Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection

Use of artificial intelligence to study the hospitalization of women undergoing caesarean section

OBJECTIVE

The incidence of caesarean sections (CSs) has increased significantly in recent years, especially in developed countries. This study aimed to identify the factors that most influence the length of hospital stay (LOS) after a CS, using data from 9,900 women who underwent CS at the "Federico II" University Hospital of Naples between 2014 and 2021.

METHODS

Various artificial intelligence models were employed to analyze the relationships between the LOS and a set of independent variables, including maternal and foetal characteristics. The analysis focused on identifying the model with the best predictive performance and specific comorbidities impacting LOS.

RESULTS

A multiple linear regression model determined the highest R-value (0.815), indicating a strong correlation between the identified variables and LOS. Significant predictors of LOS included abnormal foetuses, cardiovascular disease, respiratory disorders, hypertension, haemorrhage, multiple births, preeclampsia, previous delivery complications, surgical complications, and preoperative LOS. In terms of classification models, the decision tree yielded the highest accuracy (75%).

CONCLUSIONS

The study concluded that certain comorbidities, such as cardiovascular disease and preeclampsia, significantly impact LOS following a CS. These findings can assist hospital management in optimizing resource allocation and reducing costs by focusing on the most influential factors.

Cost saving in implementing ERAS protocol in emergency abdominal surgery

INTRODUCTION

ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution.

METHODS

A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed.

RESULTS

50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient.

CONCLUSIONS

ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

Having Outpatient Major Elective (HOME) Robotic Colon Resection Protocol: A Safe Approach to Ambulatory Colon Resection

BACKGROUND

Within the past decade, colorectal surgery length of stay (LOS) has decreased from an average of 5-6 days to 2-3 days. However, elective colon resections have yet to become a common procedure with the potential for same-day discharge. During the COVID pandemic, hospital capacity was exceptionally strained and colon resections were delayed due to the lack of inpatient beds available.

PURPOSE

We sought to create a protocolized ERAS (enhanced recovery after surgery) pathway that would allow for safe and feasible ambulatory colon resections as well as decreasing overall hospital inpatient burden.

RESEARCH DESIGN

Between November 2020 and March 2022, 15 patients were offered same-day discharges under the HOME protocol. Of the 15 patients, 11 patients agreed to be discharged home the day of surgery and followed prospectively for 30 days. All procedures were performed robotically.

STUDY SAMPLE

Patients were selected based on level of preoperative health (ASA class 1 and 2), low-risk for loss to follow-up, ability for close family supervision for 3 days postoperatively, and type of procedure (partial colectomy). Close follow-up was achieved with daily telephonic or televideo visits for 3 days post-operatively, as well as a 2-week outpatient clinic follow-up.

DATA COLLECTION

A total of 11 patient underwent same-day surgery utilizing the protocol, 5 females and 6 males, between the ages of 34 and 62. All patients were ASA class 2. Indications for colon resection were cecal volvulus (1), recurrent sigmmoid diverticulitis (9), and Crohn's disease (1). Primary outcome was readmission rates within the 30-days.

RESULTS

There were no readmissions or complications during the perioperative 30-day period. There was one emergency department return for pain who was not admitted. Average operative time was 132.1 minutes.

CONCLUSION

Using a novel enhanced recovery protocol, we demonstrated the feasibility and safety of ambulatory partial colectomy in a highly select small subset of patients.

Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis

Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.

[The Usefulness of ERAS Concepts for Colorectal Resections - an Economic Analysis under DRG Conditions]

BACKGROUND

ERAS (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.

GOAL OF THE WORK

The aim of this article is to examine the economic feasibility of the concept in the German DRG system.

MATERIAL AND METHODS

Since August 2019, patients have been treated in our clinic according to the later certified ERAS concept. The last 20 patients before ERAS implementation are compared below with 20 patients after ERAS implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented.

RESULTS

The cases of the patients in the pre-ERAS cohort caused median costs of € 7432.83. BWR of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10014.18. The profit generated was thus € 4993.84.

DISCUSSION

The cost reduction generated by ERAS was comparable to the "loss" caused by the BWR decrease. ERAS is therefore also possible to cover costs in the German DRG system.

Predictive Analysis of Hospital Stay after Caesarean Section: A Single-Center Study

Caesarean section (CS) rate has seen a significant increase in recent years, especially in industrialized countries. There are, in fact, several causes that justify a CS; however, evidence is emerging that non-obstetric factors may contribute to the decision. In reality, CS is not a risk-free procedure. The intra-operative, post-pregnancy risks and risks for children are just a few examples. From a cost point of view, it must be considered that CS requires longer recovery times, and women often stay hospitalized for several days. This study analyzed data from 12,360 women who underwent CS at the “San Giovanni di Dio e Ruggi D’Aragona” University Hospital between 2010 and 2020 by multiple regression algorithms, including multiple linear regression (MLR), Random Forest, Gradient Boosted Tree, XGBoost, and linear regression, classification algorithms and neural network in order to study the variation of the dependent variable (total LOS) as a function of a group of independent variables. We identify the MLR model as the most suitable because it achieves an R-value of 0.845, but the neural network had the best performance (R = 0.944 for the training set). Among the independent variables, Pre-operative LOS, Cardiovascular disease, Respiratory disorders, Hypertension, Diabetes, Haemorrhage, Multiple births, Obesity, Pre-eclampsia, Complicating previous delivery, Urinary and gynaecological disorders, and Complication during surgery were the variables that significantly influence the LOS. Among the classification algorithms, the best is Random Forest, with an accuracy as high as 77%. The simple regression model allowed us to highlight the comorbidities that most influence the total LOS and to show the parameters on which the hospital management must focus for better resource management and cost reduction.

Factors Associated with Early Discharge after Non-Emergent Right Colectomy for Colon Cancer: A NSQIP Analysis

The National Surgical Quality Improvement Project (NSQIP) dataset was used to identify perioperative variables associated with the length of stay (LOS) and early discharge among cancer patients undergoing colectomy. Patients who underwent non-emergent right colectomy for colon cancer from 2012 to 2019 were identified from the NSQIP and colectomy-targeted databases. Postoperative LOS was analyzed based on postoperative day (POD) of discharge, with patients grouped into Early Discharge (POD 0-2), Standard Discharge (POD 3-5), or Late Discharge (POD ≥ 6) cohorts. Multivariable ordinal logistic regression was performed to identify risk factors associated with early discharge. The NSQIP query yielded 26,072 patients: 3684 (14%) in the Early Discharge, 13,414 (52%) in the Standard Discharge, and 8974 (34%) in the Late Discharge cohorts. The median LOS was 4.0 days (IQR: 3.0-7.0). Thirty-day readmission rates were 7% for Early Discharge, 8% for Standard Discharge, and 12% for Late Discharge. On multivariable regression analysis, risk factors significantly associated with a shorter LOS included independent functional status, minimally invasive approach, and absence of ostomy or additional bowel resection (all p < 0.001). Perioperative variables can be used to develop a model to identify patients eligible for early discharge after right colectomy for colon cancer. Efforts to decrease the overall median length of stay should focus on optimization of modifiable risk factors.

Predictive analysis of lower limb fractures in the orthopedic complex operative unit using artificial intelligence: the case study of AOU Ruggi

The length of stay (LOS) in hospital is one of the main parameters for evaluating the management of a health facility, of its departments in relation to the different specializations. Healthcare costs are in fact closely linked to this parameter as well as the profit margin. In the orthopedic field, the provision of this parameter is increasingly complex and of fundamental importance in order to be able to evaluate the planning of resources, the waiting times for any scheduled interventions and the management of the department and related surgical interventions. The purpose of this work is to predict and evaluate the LOS value using machine learning methods and applying multiple linear regression, starting from clinical data of patients hospitalized with lower limb fractures. The data were collected at the "San Giovanni di Dio e Ruggi d'Aragona" hospital in Salerno (Italy).

Implementation of Predictive Algorithms for the Study of the Endarterectomy LOS

Background: In recent years, the length of hospital stay (LOS) following endarterectomy has decreased significantly from 4 days to 1 day. LOS is influenced by several common complications and factors that can adversely affect the patient’s health and may vary from one healthcare facility to another. The aim of this work is to develop a forecasting model of the LOS value to investigate the main factors affecting LOS in order to save healthcare cost and improve management. Methods: We used different regression and machine learning models to predict the LOS value based on the clinical and organizational data of patients undergoing endarterectomy. Data were obtained from the discharge forms of the “San Giovanni di Dio e Ruggi d’Aragona” University Hospital (Salerno, Italy). R² goodness of fit and the results in terms of accuracy, precision, recall and F1-score were used to compare the performance of various algorithms. Results: Before implementing the models, the preliminary correlation study showed that LOS was more dependent on the type of endarterectomy performed. Among the regression algorithms, the best was the multiple linear regression model with an R² value of 0.854, while among the classification algorithms for LOS divided into classes, the best was decision tree, with an accuracy of 80%. The best performance was obtained in the third class, which identifies patients with prolonged LOS, with a precision of 95%. Among the independent variables, the most influential on LOS was type of endarterectomy, followed by diabetes and kidney disorders. Conclusion: The resulting forecast model demonstrates its effectiveness in predicting the value of LOS that could be used to improve the endarterectomy surgery planning.

Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis

PURPOSE

Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals.

METHODS

Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines.

RESULTS

Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87).

CONCLUSIONS

Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.

Outpatient total knee and hip arthroplasty present comparable and even better clinical outcomes than inpatient operation

Background

The purpose of this study was to compare total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days after outpatient and standard inpatient total knee and total hip arthroplasty (TKA, THA).

Methods

A literature search was conducted from the PubMed, Cochrane Library, and Embase databases for articles published before 20 August 2021. The types of studies included prospective randomized controlled trials, prospective cohort studies, retrospective comparative studies, retrospective reviews of THA and TKA registration databases, and observational case-control studies. Comparisons of interest included total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days. The statistical analysis was performed using Review Manager 5.3.

Results

Twenty studies with 582,790 cases compared relevant postoperative indicators of outpatient and inpatient total joint arthroplasty (TJA) (TKA and THA). There was a significant difference in the total complications at 30 days between outpatient and inpatient THA (p = 0.001), readmissions following TJA (p = 0.03), readmissions following THA (p = 0.001), stroke/cerebrovascular incidents following TJA (p = 0.01), cardiac arrest following TJA (p = 0.007), and blood transfusions following TJA (p = 0.003). The outcomes showed an obvious difference in 90-day total complications between outpatient and inpatient TJA (p = 0.01), readmissions following THA (p = 0.002), and surgical-related pain following TJA (p < 0.001). We did not find significant differences in the remaining parameters.

Conclusion

Outpatient procedures showed comparable and even better outcomes in total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days compared with inpatient TJA for selected patients.

The usefulness of Enhanced Recovery After Surgery concepts for colorectal resections: an economic analysis under DRG conditions

PURPOSE

ERAS® (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary, and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures. Goal of the work. The aim of this article is to examine the economic feasibility of the ERAS® concept in the German DRG (diagnosis-related groups) system.

MATERIAL AND METHODS

Since August 2019, patients have been treated in our clinic according to the later certified ERAS® concept. The last 50 patients before ERAS® implementation are compared below with 50 patients after ERAS® implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented.

RESULTS

The cases of the patients in the pre-ERAS® cohort caused median costs of € 7432.83. BWR (valuation ratio) of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11,325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS® cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10,014.18. The profit generated was thus € 4993.84.

CONCLUSION

The cost reduction generated by ERAS® was more pronounced than the "loss" due to the decrease in BWR. ERAS® is therefore also possible in the German DRG system at absolutely cost-covering levels.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates.

METHODS

The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates.

RESULTS

A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02).

CONCLUSIONS

Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Designing Dementia Care Pathways to Transform Non Dementia-Friendly Hospitals: Scoping Review

People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients' routes and processes considering the increasing demographic changes of people with cognitive impairment.

Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device

INTRODUCTION

We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD).

METHODS AND RESULTS

In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups.

CONCLUSIONS

ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

NutriCatt Protocol Improves Body Composition and Clinical Outcomes in Elderly Patients Undergoing Colorectal Surgery in ERAS Program: A Retrospective Cohort Study

BACKGROUND

A poor body composition, often found in elderly patients, negatively impacts perioperative outcomes. We evaluated the effect of a perioperative nutritional protocol (NutriCatt) on body composition and clinical outcomes in a cohort of elderly patients undergoing colorectal surgery in a high-volume center adopting the ERAS program.

METHODS

302 out of 332 elderly (>75 years) patients from 2015 to 2020 were identified. Patients were divided according to their adherence, into "NutriCatt + ERAS" (n = 166) or "standard ERAS" patients (n = 136). Anthropometric and bioelectrical impedance analysis data were evaluated for NutriCatt + ERAS patients. Complications, length of hospital stay (LOS), and other postoperative outcomes were compared between both groups. Results: In NutriCatt + ERAS patients, significant improvements of phase angle (pre-admission vs. admission 4.61 ± 0.79 vs. 4.84 ± 0.85; p = 0.001; pre-admission vs. discharge 4.61 ± 0.79 vs. 5.85 ± 0.73; p = 0.0002) and body cell mass (pre-admission vs. admission 22.4 ± 5.6 vs. 23.2 ± 5.7; p = 0.03; pre-admission vs. discharge 22.4 ± 5.6 vs. 23.1 ± 5.8; p = 0.02) were shown. NutriCatt + ERAS patients reported reduced LOS (p = 0.03) and severe complications (p = 0.03) compared to standard ERAS patients. A regression analysis confirmed the protective effect of the NutriCatt protocol on severe complications (OR 0.10, 95% CI 0.01-0.56; p = 0.009).

CONCLUSIONS

The NutriCatt protocol improves clinical outcomes in elderly patients and should be recommended in ERAS colorectal surgery.

Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review

BACKGROUND

Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings.

METHODS

A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS^®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.

RESULTS

Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.

CONCLUSIONS

The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China

BACKGROUND

Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function.

METHODS

This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators.

RESULTS

The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023).

CONCLUSION

Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.

The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic.

OBJECTIVE

This article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery.

METHODS

We performed a retrospective cohort study of surgical patients age ≥ 18 years hospitalized from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing other elective procedures. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay and 30-day readmissions.

RESULTS

We included 823 (470 and 353 in the pre- and postintervention, respectively) colon surgery patients and 3,415 (1,819 and 1,596 in the pre- and postintervention) surgical control patients in the study. Among the colon surgery cohort, there was statistically significant (p = 0.040) decrease in costs of 1.28% (95% confidence interval [CI] 0.06-2.48%) per surgical encounter per month over the 18-month postintervention period, amounting to a total savings of $2,730 per patient at the 1-year postintervention period. The surgical control group had a nonsignificant (p = 0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to - 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort.

CONCLUSION

Our study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.

Analysis of factors that influence neurosurgical length of hospital stay among newly diagnosed pediatric brain tumor patients

BACKGROUND

Postoperative length of stay (LOS) carries a high burden of healthcare costs. In resource-intense specialties such as neurosurgery, it is imperative to identify factors that influence LOS to improve care. The current study investigates the potential for variables that affect clinical presentation, tumor characteristics, treatment modalities, and postoperative complications to impact overall LOS in pediatric brain tumor patients.

METHODS

A retrospective cohort study design was used with patients enrolled in the McMaster Pediatric Brain Tumor Study Group database. All patients up to 18 years of age, presenting with a newly diagnosed brain tumor admitted to and discharged from neurosurgery, were included. Patients were sorted into three cohorts: short LOS (≤3 days), extended LOS (≥20 days), and control LOS (4-19 days).

RESULTS

Of the 124 patients included, 20 (65% male; median age: 9.1 years; range, 0.8-17.4 years) were considered short LOS, 28 (61% male; median age: 4.7 years; range, 0.4-14.7 years) were considered extended LOS, and 76 (57% male; median age: 8.5 years; range, 0.3-17.9 years) were considered control LOS. Variables that prolonged LOS were emesis at presentation (P < 0.001), developmental delay (P = 0.02), multiple surgeries (P = 0.004), tumor location (P < 0.05), subtotal resection (P = 0.02), feeding tube (P < 0.001), adjuvant chemoradiotherapy (P < 0.001), and posterior fossa syndrome (P = 0.004).

CONCLUSIONS

This study identifies variables related to clinical presentation, tumor characteristics, treatment modalities, and postoperative complications associated with extended LOS. These findings uncover novel predictors of LOS that can be used to guide future research and improve health resource management.

Modern perioperative medicine - past, present, and future

Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

BACKGROUND

Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model.

METHODS

The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge.

RESULTS

A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985-0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686-3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478-0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500-0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h.

CONCLUSIONS

Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications

Objectives: To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications. Materials and Methods: We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared. Results: A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days vs 2.02 days in the non-protocol group. Between groups, there were no differences in age (p = 0.098), body mass index (p = 0.164), tumor size (p = 0.502), or R.E.N.A.L. Nephrometry score (p = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 vs 2, p = 0.033), were less likely to have a hilar tumor (15.9% vs 23.1%, p = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (-15.9% vs -7.1%, p < 0.001). There were no differences in the rates of overall (p = 0.715), major (p = 0.164), medical (p = 0.089), or surgical complications (p = 0.301) or in complications by the Clavien-Dindo category (p = 0.13). Conclusion: Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.

Relationship between patient costs and patient pathways

PURPOSE

The purpose of this paper is to identify actual (as-is) patient pathway variation among breast cancer patients and to investigate the relationship between pathways and the cost incurred by patients.

DESIGN/METHODOLOGY/APPROACH

Both quantitative and qualitative methods were employed to analyze data from four Swedish hospital groups. Quantitative methods include event-log data mining and statistical analyses on the related patient cost from the Swedish breast cancer quality registry and case-costing system. Qualitative methods included collaboration with and interviewing domain experts.

FINDINGS

Unique pathways, followed by only one patient, were generally costlier than the most and less frequent pathways. Earlier study findings are confirmed for mastectomy patients, with more frequent pathways having a lower cost, whereas contradicting and inconclusive results emerged for the partial mastectomy patient groups. Highest variation in pathways was identified for patients receiving chemotherapy.

PRACTICAL IMPLICATIONS

The common belief - if one follows a standardized patient pathway, then the cost will be lower - should be re-examined based on the actual pathways that occur in reality.

ORIGINALITY/VALUE

The relationships between patient pathways and patient cost allow more complex insights, beyond the general causal relationship between successfully implementing a "to-be" care pathway and lower cost. This highlights data-driven research's importance, where actual pathways (as-is) provide more useful information than to-be care pathways.

The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization

Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.

Referring equine veterinarians' expectations of equine veterinary specialists and referral centers

OBJECTIVE To explore referring equine veterinarians' expectations of equine veterinary referral centers and specialists. DESIGN Qualitative, focus group interview-based study. SAMPLE 6 focus groups comprised of equine practitioners with experience in referral of clients and patients to equine specialists or referral centers (48 referring veterinarians [rDVMs]). PROCEDURES Focus group sessions were conducted independently and followed a standardized discussion guide consisting of open-ended questions and follow-up probes. Discussions were recorded, and thematic analysis was performed on the content. RESULTS The overarching theme of participants' discussions was that specialists and referral centers are an extension of the care that rDVMs provide to their clients and patients. The 5 areas that participants described as important to this expectation were rDVM-client relationships, rDVM involvement during referral care, collegial rDVM-specialist relationships, communication between rDVMs and specialists, and the boundaries of referral care. Participating practitioners wanted to be involved during the referral process, which was seen as being facilitated by having a collegial relationship with the specialist and through effective communication during the course of referral care. CONCLUSIONS AND CLINICAL RELEVANCE Relationships and communications between rDVMs and specialists are important aspects of equine veterinary medicine. Both rDVMs and specialists are likely to benefit from pursuing opportunities to further their relationship by using up-front communication to establish clear role expectations and clear processes for sharing information.

ERAS protocol validation in a propensity-matched cohort of patients undergoing colorectal surgery

PURPOSE

Enhanced recovery after surgery (ERAS) provides many benefits. However, important knowledge gaps with respect to specific components of enhanced recovery after surgery remain because of limited validation data. The aim of the study was to validate a mature ERAS protocol at a different hospital and in a similar population of patients.

METHODS

This is a retrospective analysis of patients undergoing elective colorectal surgery from 2009 through 2016. Patients enrolled in ERAS are compared with those undergoing the standard of care. Patient demographic characteristics, length of stay, pain scores, and perioperative morbidity are described.

RESULTS

Patients (1396) were propensity matched into two equal groups (ERAS vs non-ERAS). No significant difference was observed for age, Charlson Comorbidity Index, American Society of Anesthesiologists score, body mass index, sex, operative approach, and surgery duration. Median length of stay in ERAS and non-ERAS groups was 3 and 5 days (P < .001). Mean pain scores were lower in the ERAS group, measured at discharge from the postanesthesia unit (P < .001), on postoperative day 1 (P = .002) and postoperative day 2 (P = .02) but were identical on discharge.

CONCLUSIONS

This ERAS protocol was validated in a similar patient population but at a different hospital. ERAS implementation was associated with an improved length of stay and pain scores similar to the original study. Different than most retrospective studies, propensity score matching ensured that groups were evenly matched. To our knowledge, this study is the only ERAS validation study in a propensity-matched cohort of patients undergoing elective colorectal surgery.

Independent Predictors of Increased Operative Time and Hospital Length of Stay Are Consistent Across Different Surgical Approaches to Pancreatoduodenectomy

BACKGROUND

While minimally invasive approaches are increasingly being utilized for pancreatoduodenectomy (PD), factors associated with prolonged operative time (OpTime) and hospital length of stay (LOS) remain poorly defined, and it is unclear whether these factors are consistent across surgical approaches.

METHODS

The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was used to identify all patients who underwent open (OPD), laparoscopic (LPD), or robotic (RPD) pancreatoduodenectomy. Multivariable linear regression analyses were used to evaluate predictors of OpTime and LOS, as well as quantify the changes observed relative to each surgical approach.

RESULTS

Among 10,970 patients, PD procedure types varied: 9963 (92%) open, 418 (4%) laparoscopic, and 409 (4%) robotic. LOS was longer for the open and laparoscopic approaches (11 vs. 11 vs. 10 days, P = 0.0068), whereas OpTime was shortest for OPD (366 vs. 426 vs. 435 min, P < 0.0001). Independent predictors of a prolonged OpTime were ASA class ≥ 3 (P = 0.0002), preoperative XRT (P < 0.0001), pancreatic duct < 3 mm (P = 0.0001), T stage ≥ 3 (P = 0.0108), and vascular resection (P < 0.0001) for OPD; T stage ≥ 3 (P = 0.0510) and vascular resection (P = 0.0062) for LPD; and malignancy (P = 0.0460) and conversion to laparotomy (P = 0.0001) for RPD. Independent predictors of increased LOS were age ≥ 65 years (P = 0.0002), ASA class ≥ 3 (P = 0.0012), hypoalbuminemia (P < 0.0001), and preoperative blood transfusion (P < 0.0001) for OPD as well as an OpTime > 370 min (all p < 0.05) and specific postoperative complications (all p < 0.05) for all surgical approaches.

CONCLUSIONS

Perioperative risk factors for prolonged OpTime and hospital LOS are relatively consistent across open, laparoscopic, and robotic approaches to PD. Particular attention to these factors may help identify opportunities to improve perioperative quality, enhance patient satisfaction, and ensure an efficient allocation of hospital resources.

Perioperative Cumulative Fluid Balance and Its Association with an Increase in Costs after Major Surgery

Positive fluid balance (FB) during the perioperative period may increase the incidence of postoperative complications, which may lead to longer hospitalization and higher hospital costs. However, a definitive association between positive FB and hospital costs has not yet been established. This retrospective observational study examined the association between perioperative FB and hospital costs of patients who underwent major surgical procedures. Medical records of patients who underwent major surgery (surgery time >2 h, estimated blood loss >500 mL) from January 2010 to December 2017 were analyzed to determine the associations between calculated FB (%, total input fluid—output fluid in liter/weight (kg) at admission) and total hospital cost ($). The analysis included medical data of 7010 patients. Multivariable linear regression analyses showed that a 1% increase in FB in postoperative day (POD) 0 (24 h), 0–1 (48 h), 0–2 (72 h), and 0–3 (96 h) significantly increased the total cost by $967.8 (95% confidence interval [CI]: 803.4–1132.1), $688.8 (95% CI: 566.3–811.2), $591 (95% CI: 485.7–696.4), and $434.2 (95% CI: 349.4–519.1), respectively (all p < 0.001). Perioperative cumulative FB was positively associated with hospital costs of patients who underwent major surgery.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Nomogram to predict non-home discharge following pancreaticoduodenectomy in a national cohort of patients

BACKGROUND

Despite the development of pathways to enhance recovery and discharge to home, a significant proportion of patients are discharged to inpatient facilities after pancreaticoduodenectomy (PD). The aim of this study was to determine the rate of non-home discharge (NHD) following PD in a national cohort of patients and to develop predictive nomograms for NHD.

METHODS

The National Surgical Quality Improvement Program was used to construct and validate pre- and postoperative nomograms for NHD following PD.

RESULTS

A total of 6856 patients who underwent PD were identified, of which 927 (13.5%) had an NHD. The independent preoperative predictors of NHD were being female, older age, higher BMI, low serum albumin, >10% weight loss, ASA class III/IV, and being diagnosed with a bile duct/ampullary neoplasm or neuroendocrine tumor. A preoperative nomogram was constructed with a concordance index of 0.77. When postoperative variables were added to the model, the concordance index increased to 0.82. The postoperative predictors of NHD were return to the operating room, length of stay of ≥14 days, and any inpatient complications.

CONCLUSIONS

These nomograms could be useful risk assessment tools to predict NHD after PD and therefore facilitate patient counseling and improve resource utilization and discharge planning.

Early Ambulation Decreases Length of Hospital Stay, Perioperative Complications and Improves Functional Outcomes in Elderly Patients Undergoing Surgery for Correction of Adult Degenerative Scoliosis

STUDY DESIGN

Ambispective cohort review.

OBJECTIVE

To examine the effects of early mobilization on patient outcomes, complications profile, and 30-day readmission rates.

SUMMARY OF BACKGROUND DATA

Prolonged immobilization after surgery can result in functional decline and an increased risk of hospital-associated complications.

METHODS

We conducted an ambispective study of 125 elderly patients (>65 years) undergoing elective spinal surgery for correction of adult degenerative scoliosis. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. "Days of immobility" was defined as the number of days until a patient moved out of bed beyond a chair. Patients in the top and bottom quartiles were dichotomized into "early ambulators" and "late ambulators", respectively. Early ambulators were ambulatory within 24 hours of surgery, whereas late ambulators were ambulatory at a minimum of 48 hours after surgery. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between early ambulators and late ambulators.

RESULTS

Baseline characteristics were similar between both cohorts. Compared with patients with a longer duration of immobility (i.e., late ambulators), the prevalence of at least one perioperative complication was significantly lower in the early ambulators cohort (30% vs. 54%, P = 0.06). The length of inhospital stay was 34% shorter in the early ambulators cohort (5.33 days vs. 8.11 days, P = 0.01). Functional independence was superior in the early ambulators cohort, with the majority of patients discharged directly home after surgery compared with late ambulators (71.2% vs. 22.0%, P = 0.01).

CONCLUSION

Early ambulation after surgery significantly reduces the incidence of perioperative complications, shortens duration of inhospital stay, and contributes to improved perioperative functional status in elderly patients. Even a delay of 24 hours to ambulation is associated with higher complication rates and inferior functional outcomes.

LEVEL OF EVIDENCE

3.

Oral Multimodal Analgesia for Total Joint Arthroplasty

BACKGROUND

Oral multimodal analgesia for hip and knee arthroplasty is increasingly used as part of enhanced recovery protocols designed to minimize early postoperative pain and to facilitate early discharge, while minimizing undesirable side effects related to single-agent opioid administration.

METHODS

This article is a review of previously published data evaluating the use of various oral medications in the management of postoperative pain after lower extremity arthroplasty and was presented as part of a symposium at the November 2016 AAHKS Annual Meeting.

RESULTS

Multimodal analgesia has been shown to reduce opioid consumption and side effects, with a positive effect on both early and longer term outcomes for hip and knee arthroplasty patients. Medications directed at multiple points on the pain cascade minimize pain by different mechanisms. Suggested dosing regimens are proposed.

CONCLUSION

Oral multimodal analgesia incorporating a combination of opioid and nonopioid analgesics, selective and nonselective anti-inflammatory drugs, acetaminophen, and gabapentinoids are recommended as a part of a pre-emptive approach to pain management in patients undergoing hip or knee arthroplasty. Reduction of opioid consumption and minimization of side effects are primary outcomes, and prevention of chronic pain can positively affect long-term results.

Moving evidence based guidelines for seizures into practice in the emergency department: What's stopping us?

PURPOSE

To identify barriers to implementation of an evidence based integrated care pathway (ICP) for seizure management in the Emergency Department (ED).

METHODS

A site specific bespoke questionnaire was designed to solicit anonymous responses from all grades of ED medical and nursing staff to a series of questions regarding utility, feasibility, significance and implementation of a locally designed and championed ICP for seizure management and onward referral.

RESULTS

While 95% of respondents agreed that the pathway ensured patients were treated according to best practice, a number of human factors were identified as barriers to use. These fell into three categories 1) environmental 2) pathway design/process and 3) user related issues.

CONCLUSIONS

Most respondents understood and endorsed the evidence based utility of the pathway. Barriers to use, however, are broad with interactions involving many complex human factors. Nevertheless, solutions can be relatively easily formulated but departmental-wide effort is required to comprehensively address all issues.

Implementation of Hysterectomy Pathway: Impact on Complications

OBJECTIVE

Hysterectomy is one of the most common surgical procedures in the United States. For women who need hysterectomy, it is important to ensure that minimally invasive hysterectomy procedures are used appropriately to reduce surgical complications and improve value of care. Although we previously demonstrated a reduction in total abdominal hysterectomy rates after the implementation of hysterectomy pathway treatment algorithm in 2012, this study focuses on exploring the effect of pathways implementation on surgical outcomes.

METHODS

All retrospective medical records for hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals between the fiscal years (FY) 2012 and 2014 were identified. We analyzed the health care outcomes by route of surgery and year using Χ2 test for categorical data, and non-parametric approaches for non-normal continuous variables.

RESULTS

A total of 6,569 hysterectomies for benign indications were performed between FY 2012 and 2014. In FY 2012, 1,154 patients (59.15%) had a length of stay of 1 day or less, whereas in FY 2014 this number increased to 1,791 (74.53%; p < .0001). Within 3 years of implementing the pathway, surgical site infections had a reduction of 47%, with a considerable trend toward significance (p = .067).

CONCLUSIONS

Implementation of hysterectomy pathway has been associated with reduction of surgical complications in benign hysterectomy settings. Implementation of clinical pathways offers an opportunity for improving patient outcomes that should be investigated in various health care settings and across procedures.

Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

OBJECTIVE

To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery.

BACKGROUND

Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices.

METHODS

Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS).

RESULTS

There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings.

CONCLUSIONS

Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.

Hospital Analgesia Practices and Patient-reported Pain After Colorectal Resection

OBJECTIVE

The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative.

BACKGROUND

Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals.

METHODS

We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics.

RESULTS

Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01).

CONCLUSIONS

Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective.

Utilizing Electronic Medical Records to Discover Changing Trends of Medical Behaviors Over Time

Objectives

Medical behaviors are playing significant roles in the delivery of high quality and cost-effective health services. Timely discovery of changing frequencies of medical behaviors is beneficial for the improvement of health services. The main objective of this work is to discover the changing trends of medical behaviors over time.

Methods

This study proposes a two-steps approach to detect essential changing patterns of medical behaviors from Electronic Medical Records (EMRs). In detail, a probabilistic topic model, i.e., Latent Dirichlet allocation (LDA), is firstly applied to disclose yearly treatment patterns in regard to the risk stratification of patients from a large volume of EMRs. After that, the changing trends by comparing essential/critical medical behaviors in a specific time period are detected and analyzed, including changes of significant patient features with their values, and changes of critical treatment interventions with their occurring time stamps.

Results

We verify the effectiveness of the proposed approach on a clinical dataset containing 12,152 patient cases with a time range of 10 years. Totally, 135 patients features and 234 treatment interventions in three treatment patterns were selected to detect their changing trends. In particular, evolving trends of yearly occurring probabilities of the selected medical behaviors were categorized into six content changing patterns (i.e, 112 growing, 123 declining, 43 up-down, 16 down-up, 35 steady, and 40 jumping), using the proposed approach. Besides, changing trends of execution time of treatment interventions were classified into three occurring time changing patterns (i.e., 175 early-implemented, 50 steady-implemented and 9 delay-implemented).

Conclusions

Experimental results show that our approach has an ability to utilize EMRs to discover essential evolving trends of medical behaviors, and thus provide significant potential to be further explored for health services redesign and improvement.

The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: A retrospective study of Taiwanese patients

Objectives To assess the impact of minor, major and individual complications on prolonged length of hospital stay in patients with colorectal cancer (CRC) after surgery using multivariate models. Methods This was a retrospective review of data from patients who underwent surgery for stage I-III CRC at two medical centres in southern Taiwan between 2005-2010. Information was derived from four databases. Multivariate logistic regression methods were used to assess the impact of complications on prolonged length of stay (PLOS) and prolonged postoperative length of stay (PPOLOS). Results Of 1658 study patients, 251 (15.1%) experienced minor or major postsurgical complications during hospitalizations. Minor and major complications were significantly associated with PLOS (minor, odds ratio [OR] 3.59; major, OR 8.82) and with PPOLOS (minor, OR 5.55; major, OR 10.00). Intestinal obstruction, anastomosis leakage, abdominal abscess and bleeding produced the greatest impact. Conclusions Minor and major complications were stronger predictors of prolonged hospital stay than preoperative demographic and disease parameters. Compared with the PLOS model, the PPOLOS model better predicted risk of prolonged hospital stay. Optimal surgical and medical care have major roles in surgical CRC patients.

Enhanced recovery after surgery in gastric resections

INTRODUCTION

Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery.

METHODS

According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery.

RESULTS

The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge.

CONCLUSIONS

The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.

Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty

BACKGROUND

Length of stay after total hip arthroplasty (THA) has decreased over the last two decades. However, published studies that have examined same-day and early discharge protocols after THA have been done in highly selected patient groups operated on by senior surgeons in a nonrandomized fashion without control subjects.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate and compare patients undergoing THA who are discharged on the same day as the surgery ("outpatient," less than 12-hour stay) with those who are discharged after an overnight hospital stay ("inpatient") with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission, emergency department or physician office); and (3) relative work effort for the surgeon's office staff.

METHODS

A prospective, randomized study was conducted at two high-volume adult reconstruction centers between July 2014 and September 2015. Patients who were younger than 75 years of age at surgery, who could ambulate without a walker, who were not on chronic opioids, and whose body mass index was less than 40 kg/m² were invited to participate. All patients had a primary THA performed by the direct anterior approach with spinal anesthesia at a hospital facility. Study data were evaluated using an intention-to-treat analysis. A total of 220 patients participated, of whom 112 were randomized to the outpatient group and 108 were randomized to the inpatient group. Of the 112 patients randomized to outpatient surgery, 85 (76%) were discharged as planned. Of the remaining 27 patients, 26 were discharged after one night in the hospital and one was discharged after two nights. Of the 108 patients randomized to inpatient surgery with an overnight hospital stay, 81 (75%) were discharged as planned. Of the remaining 27 patients, 18 met the discharge criteria on the day of their surgery and elected to leave the same day, whereas nine patients stayed two or more nights.

RESULTS

On the day of surgery, there was no difference in visual analog scale (VAS) pain among patients who were randomized to discharge on the same day and those who were randomized to remain in the hospital overnight (outpatient 2.8 ± 2.5, inpatient 3.3 ± 2.3, mean difference -0.5, 95% confidence interval [CI], -1.1 to 0.1, p = 0.12). On the first day after surgery, outpatients had higher VAS pain (at home) than inpatients (3.7 ± 2.3 versus 2.8 ± 2.1, mean difference 0.9, 95% CI, 0.3-1.5, p = 0.005). With the numbers available, there was no difference in the number of reoperations, hospital readmissions without reoperation, emergency department visits without hospital readmission, or acute office visits. At 4-week followup, there was no difference in the number of phone calls and emails with the surgeon's office (outpatient: 2.4 ± 1.9, inpatient: 2.4 ± 2.2, mean difference 0, 95% CI, -0.5 to 0.6, p = 0.94).

CONCLUSIONS

Outpatient THA can be implemented in a defined patient population without requiring additional work for the surgeon's office. Because 24% (27 of 112) of patients planning to have outpatient surgery were not able to be discharged the same day, facilities to accommodate an overnight stay should be available.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Accelerated Discharge Protocol for Posterior Spinal Fusion Patients With Adolescent Idiopathic Scoliosis Decreases Hospital Postoperative Charges 22

STUDY DESIGN

A retrospective study of consecutive patients.

OBJECTIVE

The purpose of this study was to determine implementing an accelerated protocol could decrease our average hospital stay and what impact this had on postoperative pain management.

SUMMARY OF BACKGROUND DATA

To our knowledge, no prior studies have reviewed the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion.

METHODS

This is a retrospective review of all consecutive patients undergoing posterior spinal fusion (PSF) for AIS before (June 1, 2008-May 31, 2013 = traditional protocol) and after (June 1, 2013-October 22, 2014 = accelerated protocol) protocol implementation. Subjective response to the FACES Pain Intensity scale was collected for each postoperative day while in the hospital by the nursing staff.

RESULTS

There were 194 patients in the traditional pathway and 90 patients in the accelerated pathway. No significant differences in age at surgery, sex, or number of levels fused were present between the groups. Patients managed under the accelerated discharge had an average hospital stay of 3.7 days compared with 5.0 days for the traditional discharge (P < 0.001). There was no increased incidence of wound complications between the two groups [3.6% (7/194) vs. 3.3% (3/90), P = 0.91] or readmission [1.5% (3/194) vs. 4.4% (4/90), P = 0.213]. Hospital charges for postoperative care were significantly less in the accelerated discharge group than in the traditional group ($18,360 vs. $23,640, P < 0.0001). This corresponded to a 22% ($5280/$23,640) decrease in postoperative hospital charges. Patients had a small (<1 point change on FACES pain scale) but statistically significant increase in pain on postoperative days 2, 3, and 4 (P = 0.0001, P = 0.0079, P = 0.0076).

CONCLUSION

Accelerated discharge following PSF for AIS was associated with a 22% decrease in hospital charges in the postoperative period.

LEVEL OF EVIDENCE

4.

Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma

OBJECTIVES

The purpose of this study was to explore the relationship between preoperative Charlson Comorbidity Index (CCI) and postoperative length of stay (LOS) for lower extremity and hip/pelvis orthopaedic trauma patients.

DESIGN

Retrospective.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 1561 patients treated for isolated lower extremity and pelvis fractures between 2000 and 2012.

INTERVENTIONS

Surgical intervention for fractures MAIN OUTCOME MEASUREMENTS:: The main outcome metric was LOS. Negative binomial regression analysis was used to examine the association between CCI and LOS while controlling for significant confounders.

RESULTS

One thousand five hundred sixty-one patients met the inclusion criteria, 1302 (83.4%) of which had lower extremity injuries and 259 (16.6%) experienced hip/pelvis trauma. A total of 1001 (64.1%) patients presented with a CCI score of 1 and stayed an average of 7.9 days. Patients with a CCI of 3 experienced a mean LOS of 1.2 days longer than patients presenting with a CCI of 1, whereas patients presenting with a CCI score of 5 stayed an average of 4.6 days longer. After controlling for age, race, American Society of Anesthesiologists score, sex, anesthesia type, and anesthesia time, a higher preoperative CCI was found to be associated with longer LOS for patients with lower extremity fractures (Incidence Rate Ratio: 1.04, P = 0.01). No significant association was found between CCI and LOS for patients with hip/pelvic fractures.

CONCLUSIONS

This study demonstrated the potential utility of the CCI as a predictor of hospital LOS for lower extremity patients; however, the association may be small given the smaller Incidence Rate Ratio value. Further studies are needed to clarify the predictive value of the CCI for different types of orthopaedic injuries.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete.