Diabetes is predictive of longer hospital stay and increased rate of complications in spinal surgery in the UK

Preoperative risk factors for extended hospital stay: A prospective study in a South African clinic

BACKGROUND

 Preoperative assessment clinics play a critical role in identifying, evaluating and mitigating perioperative risks. Despite global data highlighting the importance of preoperative risk factors on surgical outcomes, there remains limited information on their impact on post-operative length of stay (LOS) in South African contexts.

AIM

 This study aimed to describe the demographic and clinical profiles of patients referred to a preoperative clinic as well as factors associated with post-operative extended LOS.

SETTING

 The preoperative clinic is based in the city of Johannesburg in South Africa.

METHODS

 This was a prospective cohort study conducted between 2021 and 2022 at a private clinic in patients undergoing non-cardiac surgery. Data on demographics, co-morbidities, surgical procedures and clinical outcomes were collected. Statistical analysis was performed to assess relationships between preoperative risk factors, including ASA grading, Revised Cardiac Risk Index (RCRI), estimated glomerular filtration rate, diabetes mellitus, age, obesity and LOS.

RESULTS

 A total of 214 patients were assessed, of which 75.7% were female, with a median age of 62.5 years. Common co-morbidities included hypertension (59.3%) and obesity (55%). The median LOS was 3.5 days, with 47.2% of patients staying more than 3 days post-operatively. Knee (33.2%) and hip surgeries (21%) were the most common procedures. A significant association was found between longer LOS and RCRI score ≥ 1 (p = 0.007), renal dysfunction in knee surgery patients (p = 0.027) and age in patients undergoing hip surgery (p = 0.049).

CONCLUSION

 Findings note the need for targeted intereventions in preoperative care to reduce LOS, particularly for high-risk patients.Contribution: This study highlights the fact that preoperative information may play a significant role in patient's outcomes post surgery. Further research is needed to validate these results across broader healthcare settings.

Impact of insurance on outcomes of patients undergoing endoscopic transsphenoidal surgery for non-functional pituitary adenomas: a single institution study

PURPOSE

Uninsured and underinsured patients face notable healthcare disparities in neurosurgery, but limited literature exists on the impact of insurance on non-functioning pituitary adenomas (NFPAs). We investigated how insurance affects outcomes of endoscopic transsphenoidal pituitary surgery (ETPS) for NFPAs.

METHODS

We retrospectively reviewed NFPA patients who underwent ETPS at our institution from 2012 to 2023. Patients were grouped by insurance status, and insured patients were further subcategorized by insurance providers. Bivariate analyses used Fisher's exact, chi-square, and t-tests. ANOVA or Kruskal-Wallis tests were applied for ≥ 2 groups. Logistic regression identified relationships between binomial variables and insurance.

RESULTS

Our cohort (n = 651, 56.93 ± 15.53 years, 52.53% male) included 611 insured and 40 uninsured patients. Uninsured patients had lower preoperative KPS, higher rates of visual disturbances (VD), preoperative tumor volumes (TV), chiasm compression, and Knosp 4 grade, along with lower resection and longer hospital stays (LOS) (p < 0.05). Multivariate analysis showed lack of insurance was associated with increased VD (aOR 3.38), TV (aOR 2.63), Knosp 4 (aOR 3.44), subtotal resection (aOR 2.72), and prolonged LOS (aOR 7.03) (p < 0.05). When insured patients were grouped into Private (n = 361), Medicare (n = 223), and Medicaid (n = 23), Medicaid patients had larger preoperative TV, chiasm compression, Knosp 3 grade, and longer LOS (p < 0.05), with higher odds for Knosp 3 (aOR 3.00), subtotal resection (aOR 3.86), and prolonged LOS (aOR 8.38) (p < 0.05).

CONCLUSION

Our study highlights significant disparities in uninsured patients and those with Medicaid, underscoring the need for targeted interventions for these populations.

The interplay between diabetes Mellitus and soft tissue infections in general surgical patients

BACKGROUND

Diabetes mellitus (DM) is a worldwide pandemic affecting 500 million people. It is known to be associated with increased susceptibility to soft tissue infections (STI). Despite being a major public health burden, the literature relating the effects of DM and the presentation, severity and healing of STIs in general surgical patients remain limited.

METHOD

We conducted a retrospective review of all patients admitted with STI in a tertiary teaching hospital over a 12-month period. Patient demographics and surgical outcomes were collected and analysed.

RESULTS

During the study period, 1059 patients were admitted for STIs (88% required surgery). DM was an independent risk factor for LOS. Diabetic patients presented with higher body-mass index (28 vs. 26), larger abscess size (24 vs. 14 cm2) and had a longer length of stay (4.4 days vs. 2.9 days). They also underwent a higher proportion of wide debridement and application of negative pressure wound therapy (42% vs. 35%). More diabetic patients underwent subsequent re-operation within the same sitting (8 vs. 4). Diabetic patients were two times more likely to present with carbuncles (p = 0.02).

CONCLUSION

The incidence of STIs among DM patients represent a significant disease burden, surgeons should consider intensive patient counselling and partnering with primary care providers in order to help reduce the incidence of future STI admissions based upon lifestyle modification and glucose control.

The Effect of Diabetes on Complications after Spinal Fusion: A Systematic Review and Meta-Analysis

OBJECTIVE

Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures.

METHODS

Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed.

RESULTS

Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR=2.01; 95%CI=1.31-3.08; P = 0.001), postoperative renal complications (OR=2.20; 95%CI=1.27-3.80; P = 0.005), surgical site infection (OR=2.65; 95%CI=2.19-3.20; P < 0.001), and prolonged hospital stay (OR=1.67; 95%CI=1.47-1.90; P < 0.001).

CONCLUSIONS

Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians

BACKGROUND

Hip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians.

METHODS

A retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 - 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination.

RESULTS

There was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015).

CONCLUSION

There is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds.

TRIAL REGISTRATION

Not necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

Postoperative short-term mortality between insulin-treated and non-insulin-treated patients with diabetes after non-cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus is an independent risk factor for postoperative complications. It has been reported that insulin-treated diabetes is associated with increased postoperative mortality compared to non-insulin-treated diabetes after cardiac surgery; however, it is unclear whether this finding is applicable to non-cardiac surgery.

OBJECTIVE

We aimed to assess the effects of insulin-treated and non-insulin-treated diabetes on short-term mortality after non-cardiac surgery.

METHODS

Our study was a systematic review and meta-analysis of observational studies. PubMed, CENTRAL, EMBASE, and ISI Web of Science databases were searched from inception to February 22, 2021. Cohort or case-control studies that provided information on postoperative short-term mortality in insulin-treated diabetic and non-insulin-treated diabetic patients were included. We pooled the data with a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to rate the quality of evidence.

RESULTS

Twenty-two cohort studies involving 208,214 participants were included. Our study suggested that insulin-treated diabetic patients was associated with a higher risk of 30-day mortality than non-insulin-treated diabetic patients [19 studies with 197,704 patients, risk ratio (RR) 1.305; 95% confidence interval (CI), 1.127 to 1.511; p < 0.001]. The studies were rated as very low quality. The new pooled result only slightly changed after seven simulated missing studies were added using the trim-and-fill method (RR, 1.260; 95% CI, 1.076-1.476; p = 0.004). Our results also showed no significant difference between insulin-treated diabetes and non-insulin-treated diabetes regarding in-hospital mortality (two studies with 9,032 patients, RR, 0.970; 95% CI, 0.584-1.611; p = 0.905).

CONCLUSION

Very-low-quality evidence suggests that insulin-treated diabetes was associated with increased 30-day mortality after non-cardiac surgery. However, this finding is non-definitive because of the influence of confounding factors.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021246752, identifier: CRD42021246752.

Diabetes as a Risk Factor for Perforated Appendicitis: A National Analysis

BACKGROUND

A few important risk factors play into rates of perforation following acute appendicitis. Diabetes may be an additional risk factor due to various systemic complications that may contribute to perforation and additional adverse outcomes following acute appendicitis, all of which currently remains unknown in the United States.

METHODS

Adult patients with acute appendicitis under 65 years of age were identified from the National Inpatient Sample between 2012 and 2014 and the distribution of baseline variables was examined across diabetic status using Rao-Scott chi square and student's t-test. A propensity score match was implemented for a conditional logistic regression that assessed differences in rates of perforation, outcomes, as well as postoperative complications.

RESULTS

Among all patients with acute appendicitis, approximately 7% had diabetes. Diabetics were more likely to experience perforated appendicitis (odds ratio 95% confidence interval 1.093 (1.029, 1.160); P = .0036), experience a longer length of stay (1.540 (1.434, 1.654); P < .0001), receive an open appendectomy (1.139 (1.05, 1.236); P = .0018), and experience postoperative cardiovascular complications (2.103 (1.325, 3.340)); P = .0016).

DISCUSSION

Diabetic adult patients under 65 years of age with acute appendicitis experience higher rates in perforation, a longer length of stay, more open surgical approach, and cardiovascular postoperative complications. Diabetes should be one of many risk factors considered in the evaluation and management of perforation following acute appendicitis.

The impact of diabetes on postoperative outcomes following spine surgery: A meta-analysis of 40 cohort studies with 2.9 million participants

OBJECTIVE

Although diabetes mellitus (DM) is considered to be an important prognostic factor in spinal surgery, the relationship between these two factors remains unclear. The purpose of this study was to investigate whether diabetes is associated with an increased risk of postoperative complications in patients undergoing spinal surgery.

METHODS

We systematically searched the PubMed, Embase, and Cochrane Library for relevant articles published on or before December 25, 2021. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random effects meta-analysis. The primary outcome was the risk of postoperative complications following spinal surgery, including postoperative infection and reoperation. Furthermore, we conducted subgroup analyses and leave-one-out sensitivity analyses to explore the main sources of heterogeneity and the stability of the results.

RESULTS

A total of 40 cohort studies including 2,998,891 participants met the inclusion criteria. Meta-analysis showed that diabetes was significantly associated with postoperative infection (OR 2.21, 95% CI 1.70-2.88, p < 0.001) and reoperation (OR 1.35, 95% CI 1.12-1.64, p = 0.002). Furthermore, the results also found that diabetes was significantly associated with surgery-related death (OR 1.61, 95% CI 1.13-2.30, p = 0.008) and transfusions (OR 1.39, 95% CI 1.11-1.75, p = 0.005), whereas diabetes failed to account for nervous system complications (OR 1.12, 95% CI 0.82-1.52, p = 0.470) and embolism (OR 1.15, 95% CI 0.83-1.60, p = 0.386) for patients following spine surgery. These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses.

CONCLUSIONS

Diabetes appears to be a risk factor for postoperative infection and reoperation for patients following spinal surgery. Special attention should be devoted to reducing the occurrence of postoperative complications in diabetic patients undergoing spinal surgery.

Feasibility and Assessment of a Machine Learning-Based Predictive Model of Outcome After Lumbar Decompression Surgery

STUDY DESIGN

Retrospective study at a unique center.

OBJECTIVE

The aim of this study is twofold, to develop a virtual patients model for lumbar decompression surgery and to evaluate the precision of an artificial neural network (ANN) model designed to accurately predict the clinical outcomes of lumbar decompression surgery.

METHODS

We performed a retrospective study of complete Electronic Health Records (EHR) to identify potential unfavorable criteria for spine surgery (predictors). A cohort of synthetics EHR was created to classify patients by surgical success (green zone) or partial failure (orange zone) using an Artificial Neural Network which screens all the available predictors.

RESULTS

In the actual cohort, we included 60 patients, with complete EHR allowing efficient analysis, 26 patients were in the orange zone (43.4%) and 34 were in the green zone (56.6%). The average positive criteria amount for actual patients was 8.62 for the green zone (SD+/- 3.09) and 10.92 for the orange zone (SD 3.38). The classifier (a neural network) was trained using 10,000 virtual patients and 2000 virtual patients were used for test purposes. The 12,000 virtual patients were generated from the 60 EHR, of which half were in the green zone and half in the orange zone. The model showed an accuracy of 72% and a ROC score of 0.78. The sensitivity was 0.885 and the specificity 0.59.

CONCLUSION

Our method can be used to predict a favorable patient to have lumbar decompression surgery. However, there is still a need to further develop its ability to analyze patients in the "failure of treatment" zone to offer precise management of patient health before spinal surgery.

Intensive glucose control during the perioperative period for diabetic patients undergoing surgery: An updated systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate the impact of intensive glucose control on diabetic patients undergoing surgery.

DESIGN

A systematic review and meta-analysis of randomized controlled trials. PubMed, CENTRAL, EMBASE, ISI Web of Science, and CINAHL databases were searched from inception to 13 December 2020.

SETTING

Operating room, postoperative recovery area and ward, up to 30 days after surgery.

PATIENTS

Diabetic patients undergoing surgery.

INTERVENTIONS

We used Review Manager 5.4 to pool the data with a random-effects model. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.

MEASUREMENTS

The primary outcomes were infectious complications, postoperative mortality, and hypoglycaemia. The secondary outcomes included atrial fibrillation, myocardial infarction, stroke, delirium, renal failure, postoperative mechanical ventilation time, length of intensive care unit (ICU) stay, and hospital stay.

MAIN RESULTS

Thirteen studies involving 1582 participants were included. Compared with conventional glucose control, intensive glucose control was associated with a lower risk of infectious complications (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.19-0.63; low-quality evidence), atrial fibrillation (RR, 0.55; 95% CI, 0.42-0.71; high-quality evidence), and renal failure (RR, 0.38; 95% CI, 0.15-0.95; moderate-quality evidence), as well as a shorter length of stay in the ICU (mean difference (MD), -0.55 day; 95% CI, -1.05 to -0.05 days; very-low-quality evidence) and hospital (MD, -1.61 days; 95% CI, -2.78 to -0.44 days; very-low-quality evidence). However, intensive glucose control was associated with a higher risk of hypoglycaemia (RR, 3.00; 95% CI, 1.97-4.55; high-quality evidence). There were no significant differences in postoperative mortality, myocardial infarction, stroke, delirium, or postoperative mechanical ventilation time.

CONCLUSIONS

Intensive glucose control in diabetic patients is associated with a reduction in some adverse postoperative outcomes including infectious complications, but also appears to increase the risk of hypoglycaemia. Further well-designed studies may be needed to determine appropriate regimens to reduce hypoglycaemia incidence.

PROSPERO REGISTRATION NUMBER

CRD42021226138.

The effect of diabetes on perioperative complications following spinal surgery: a meta-analysis

Background

Degenerative spinal diseases and diabetes mellitus (DM) have increasingly become a social and economic burden. The effect of DM on spinal surgery complications reported by previous studies remains controversial.

Methods

We searched MEDLINE, Cochrane CENTRAL, ScienceDirect, EMBASE, and Google Scholar to identify studies reporting the relationship between DM and spinal surgery complications. Two independent reviewers performed independent data abstraction. The I2 statistic was used to assess heterogeneity. A fixed-effects or random-effects model was used for the meta-analysis.

Results

Twenty-four studies met the inclusion criteria. Surgical site infection and the incidence of deep venous thrombosis after spinal surgery were significantly higher in patients with than in patients without diabetes, and the length of hospital stay was significantly longer in patients with diabetes (P<0.05). No significant differences were observed in the risk of reoperation, blood loss, and operation time between patients with and those without diabetes (P.0.05).

Conclusion

Patients with diabetes have a higher risk when undergoing spinal surgery than patients without diabetes. Diabetes increases the risks of postoperative mortality, surgical site infection, deep venous thrombosis, and a prolonged hospitalization time after spinal surgery.

Minimally invasive spinal decompression surgery in diabetic patients: perioperative risks, complications and clinical outcomes compared with non-diabetic patients' cohort

BACKGROUND

Prior studies have documented an increased complication rate in diabetic patients undergoing spinal surgery. However, the impact of diabetes on the risk of postoperative complications and clinical outcome following minimally invasive spinal (MIS) decompression is not well understood.

OBJECTIVES

To compare complication rates and outcomes of MIS decompression in diabetic patients with a cohort of non-diabetic patients undergoing similar procedures.

METHODS

Medical records of 48 patients with diabetes and 151 control patients that underwent minimally invasive lumbar decompression between April 2009 and July 2014 at our institute were reviewed and compared. Past medical history, the American Society of Anesthesiologists score, perioperative mortality, complication and revision surgeries rates were analyzed. Patient outcomes included: the visual analog scale and the EQ-5D scores.

RESULTS

The mean age was 68.58 ± 11 years in the diabetic group and 51.7 ± 17.7 years in the control group. No major postoperative complications were recorded in either group. Both groups were statistically equivalent in their postoperative length of stay, minor complications and revision rates. Both groups showed significant improvement in their outcome scores following surgery.

CONCLUSIONS

Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for diabetic patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the diabetic population. These slides can be retrieved under Electronic Supplementary Material.

Predicting length of stay from an electronic patient record system: a primary total knee replacement example

Background

To investigate whether factors can be identified that significantly affect hospital length of stay from those available in an electronic patient record system, using primary total knee replacements as an example. To investigate whether a model can be produced to predict the length of stay based on these factors to help resource planning and patient expectations on their length of stay.

Methods

Data were extracted from the electronic patient record system for discharges from primary total knee operations from January 2007 to December 2011 (n = 2,130) at one UK hospital and analysed for their effect on length of stay using Mann-Whitney and Kruskal-Wallis tests for discrete data and Spearman’s correlation coefficient for continuous data. Models for predicting length of stay for primary total knee replacements were tested using the Poisson regression and the negative binomial modelling techniques.

Results

Factors found to have a significant effect on length of stay were age, gender, consultant, discharge destination, deprivation and ethnicity. Applying a negative binomial model to these variables was successful. The model predicted the length of stay of those patients who stayed 4–6 days (~50% of admissions) with 75% accuracy within 2 days (model data). Overall, the model predicted the total days stayed over 5 years to be only 88 days more than actual, a 6.9% uplift (test data).

Conclusions

Valuable information can be found about length of stay from the analysis of variables easily extracted from an electronic patient record system. Models can be successfully created to help improve resource planning and from which a simple decision support system can be produced to help patient expectation on their length of stay.