Risk Factors for Unscheduled 30-day Readmission after Benign Hysterectomy

Prevalence and predictors of polypharmacy and comorbidities among patients with chronic obstructive pulmonary disease: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

OBJECTIVE

This study aimed to determine the prevalence of polypharmacy, comorbidities and to investigate factors associated with polypharmacy among adult patients with Chronic Obstructive Pulmonary Disease (COPD).

METHODS

This was a retrospective single-centre cross-sectional study. Patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 February 2020 and 1 March 2023 were included in this study. Patients were excluded if a pre-emptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Population characteristics were presented as frequency for categorical variable. Logistic regression analysis was used to identify predictors of polypharmacy.

RESULTS

The study sample included a total of 705 patients with COPD. Most of the study sample were males (60%). The mean age of the study population was 65 years old. The majority of the study population had comorbid diseases (68%), hypertension and diabetes were the most common co-existent diseases. Around 55% of the study sample had polypharmacy. Females were significantly less likely to be on polypharmacy compared to males (OR = 0.68, 95% CI = [0.50-0.92], P-value = 0.012)). On the other hand, older patients aged 65.4 or more (OR = 2.31, 95% CI = [1.71-3.14], P-value ≤ 0.001), those with high BMI (≥ 29.2) (OR = 1.42, 95% CI = [1.05-1.92], P-value = 0.024), current smokers (OR = 1.9, 95% CI = [1.39-2.62], P-value ≤ 0.001), those who are receiving home care (OR = 5.29, 95% CI = [2.46-11.37], P-value ≤ 0.001), those who have comorbidities (OR = 19.74, 95% CI = [12.70-30.68], P-value ≤ 0.001) were significantly more likely to be on polypharmacy (p ≤ 0.05).

CONCLUSIONS

Polypharmacy is common among patients with COPD. Patients with high BMI, previous ICU hospitalization and older age are more likely to have polypharmacy. Future analytical studies are warranted to investigate outcomes in patients with COPD and polypharmacy.

Feasibility, Safety, and Satisfaction of Combined Hysterectomy with Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals

The demand for masculinizing breast surgery and hysterectomy with bilateral salpingo-oophorectomy (HBSO) from transmen has increased. With a multidisciplinary approach, these surgeries can be performed in a single session. The objective of this study was to retrospectively evaluate the feasibility, safety, and satisfaction of HBSO and chest surgery in transmen. A cohort of 142 subjects who underwent HBSO alone or combined with chest surgery at Sant’Orsola Hospital was analyzed. Intra and post operation events were evaluated. Subjective post-intervention satisfaction, acceptability, and impact of intervention were assessed via a semi-structured interview. Nineteen transmen underwent HBSO alone and 123 underwent combined surgery. HBSO was performed laparoscopically in 96.5% of transmen (137/142). As expected, length of hospital stay and blood loss were significantly higher in the combined surgery group. A total of 13 intra or post-operative complications occurred in the combined surgery group (10.5%) with thoracic hematoma being the most frequent complication (7.6%). Only one rare complication occurred in the HBSO group (omental herniation through a laparoscopic breach). The overall subjective satisfaction score was 9.9 out of 10 for both groups. Positive changes in all areas of life were reported, with no significant differences. We found that the combined surgery appears to be well tolerated, safe, and feasible in transmen and satisfaction with the combined procedure was high in all subjects.

Surgical Outcomes in Urogynecology-Assessment of Perioperative and Postoperative Complications Relative to Preoperative Hemoglobin A1c-A Fellow's Pelvic Research Network Study

OBJECTIVES

Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery.

METHODS

This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments.

RESULTS

Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an AM HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%.

CONCLUSIONS

Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

Hysterectomy Complications Relative to HbA1c Levels: Identifying a Threshold for Surgical Planning

STUDY OBJECTIVE

To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA_1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA_1c level past which we should consider delaying surgery owing to increased risk of complications.

DESIGN

Retrospective cohort study.

SETTING

Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017.

PATIENTS

Women with and without a diabetes diagnosis.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Data on demographics, preoperative HbA_1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA_1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA_1c value; group 2: no diabetes diagnosis, with HbA_1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA_1c value or HbA_1c levels <9%; and group 4: diabetes diagnosis with HbA_1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA_1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA_1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA_1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery.

CONCLUSION

Diabetes diagnosis and measurement of preoperative HbA_1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA_1c level ≥9%.

Risk factors of vaginal cuff infection in women undergoing laparoscopic hysterectomy for benign gynecological diseases

AIM

This study aimed to identify the risk factors for vaginal cuff infection after laparoscopic hysterectomy for benign gynecological diseases.

METHODS

We conducted a retrospective cohort study among 1559 Japanese women who underwent total laparoscopic hysterectomy (TLH) for benign indications between 2014 and 2018 at Teine Keijinkai Hospital in Sapporo, Japan. All patients received preoperative antibiotics based on appropriate timing, choice, and weight-based dosing. We assessed the risk factors of vaginal cuff infection after TLH, including demographic and clinical variables, and patient- and surgery-related factors, using univariable and multivariable logistic regression analyses.

RESULTS

Among all the patients who underwent TLH, 71 cases of vaginal cuff infections (4.6%) were recorded. Univariate analyses showed that current smoking, pathological result of adenomyosis, use of Seprafilm as an antiadhesive material, white blood cell counts on postoperative day (POD) 2, C-reactive protein (CRP) level on POD2 and postoperative vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. In multivariate analysis, current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection.

CONCLUSION

Current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were identified as significant risk factors of vaginal cuff infection in the 30 days after surgery in Japanese women who underwent TLH for benign indications.

Risk factors for potentially avoidable readmissions following gynecologic oncology surgery

OBJECTIVE

Determine the incidence and identify factors associated with potentially avoidable hospital readmissions due to uncontrolled symptoms or minor complications after surgery for gynecologic cancers.

METHODS

Women who underwent major abdominal or pelvic surgery for a gynecologic malignancy between 2015 and 2017 were identified from the National Surgical Quality Improvement Program targeted hysterectomy dataset. Hospital readmissions within 30 days of surgery were categorized as indicated readmissions or potentially avoidable readmissions by three independent reviewers. Demographic, clinical, and operative covariates were evaluated to determine their association with type of readmission using bivariable tests and adjusted multinomial logistic regression models.

RESULTS

A total of 20,986 women were identified. 19,814 (94.4%) were not readmitted, 894 (4.3%) were indicated readmissions, and 278 (1.3%) were potentially avoidable readmissions. Among those readmitted, 24% were potentially avoidable readmissions. Presence of ascites, increasing length of stay, and discharge to facility were associated with an increased risk of indicated and potentially avoidable readmissions. Age < 60 years old (RR 1.4, 95%CI 1.1-1.8), BMI ≥ 30 (RR 1.7, 95%CI 1.3-2.3), history of abdominal/pelvic surgery (RR 1.6, 95%CI 1.2-2.1), cervical cancer (RR 2.1, 95%CI 1.4-3.1), and open surgery (RR 2.1, 95%CI 1.4-3.2) were associated with an increased risk of a potentially avoidable readmission but not with increased risk of an indicated readmission. Median time to readmission did not differ between the two readmission groups (indicated = 8 days; avoidable = 7 days; p = .72).

CONCLUSIONS

Among women with gynecologic cancer, 24% of all unplanned readmissions were attributed to uncontrolled symptoms or minor complications that were potentially avoidable. Age <60 years old, history of previous abdominal/pelvic surgery, obesity, cervical cancer, and open surgery were associated with an increase in risk of a potentially avoidable readmission.

Readmission After Gynecologic Surgery: A Comparison of Procedures for Benign and Malignant Indications

OBJECTIVE

To compare 30-day postsurgical readmission rates and associated risk factors for readmission among women undergoing gynecologic surgery for benign and malignant conditions.

METHODS

In a retrospective cohort study, we identified patients after surgery for benign and malignant gynecologic conditions in the National Surgical Quality Improvement Program database between January 1, 2011, and December 31, 2012. Data collected included surgical factors, perioperative characteristics, surgical complications, and 30-day readmissions. The primary study outcome was readmission rates after gynecologic surgery for benign and oncologic conditions. Secondary study outcomes were risk factors associated with readmission among gynecologic surgeries performed for benign and oncologic conditions.

RESULTS

Approximately 3% (1,444/46,718) compared with 8.2% (623/7,641) of patients who underwent gynecologic surgery for benign and malignant indications, respectively, were readmitted (P<.01). Compared with patients with benign surgical indications, those with uterine cancer (readmission rate 6.6%; odds ratio [OR] 2.21, 95% CI 1.95-2.51), ovarian cancer (readmission rate 10.9%; OR 3.82, 95% CI 3.29-4.45), and cervical cancer (readmission rate 10.1%; OR 3.51, 95% CI 2.71-4.53) were more likely to be readmitted. In multivariable models, independent risk factors for readmission for gynecologic cancer surgery included worse preoperative conditions (OR 1.49, 95% CI 1.17-1.90) and major complications (OR 17.84, 95% CI 14.19-22.43). In comparison, independent risk factors for readmission after surgery for benign indications included comorbid conditions (OR 1.36, 95% CI 1.18-1.57), operative time (15-59 minutes: referent; 60 minutes or greater: 1.37, 95% CI 1.14-1.63) and major complications (OR 53.91, 95% CI 46.98-61.85).

CONCLUSION

Among gynecologic surgeries, those performed for oncologic indications were associated with readmission rates 2.8 times that of surgeries performed for benign indications. In adjusted models, worse preoperative conditions and surgical complications remained independent risk factors associated with the higher rate of readmission among patients with gynecologic cancer.

Risk factors of adverse health outcomes after hospital discharge modifiable by clinical pharmacist interventions: a review with a systematic approach

The present review assessed the evidence on risk factors for the occurrence of adverse health outcomes after discharge (i.e. unplanned readmission or adverse drug event after discharge) that are potentially modifiable by clinical pharmacist interventions. The findings were compared with patient characteristics reported in guidelines that supposedly indicate a high risk of drug-related problems. First, guidelines and risk assessment tools were searched for patient characteristics indicating a high risk of drug-related problems. Second, a systematic PubMed search was conducted to identify risk factors significantly associated with adverse health outcomes after discharge that are potentially modifiable by a clinical pharmacist intervention. After the PubMed search, 37 studies were included, reporting 16 risk factors. Only seven of 34 patient characteristics mentioned in pertinent guidelines corresponded to one of these risk factors. Diabetes mellitus (n = 11), chronic obstructive lung disease (n = 9), obesity (n = 7), smoking (n = 5) and polypharmacy (n = 5) were the risk factors reported most frequently in the studies. Additionally, single studies also found associations of adverse health outcomes with different drug classes {e.g. warfarin [hazard ratio 1.50; odds ratio (OR) 3.52], furosemide [OR 2.25] or high beta-blocker starting doses [OR 3.10]}. Although several modifiable risk factors were found, many patient characteristics supposedly indicating a high risk of drug-related problems were not part of the assessed risk factors in the context of an increased risk of adverse health outcomes after discharge. Therefore, an obligatory set of modifiable patient characteristics should be created and implemented in future studies investigating the risk for adverse health outcomes after discharge.

Timing of and Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease

OBJECTIVE

To characterize timing and reasons associated with unplanned 30-day readmissions after hysterectomy for benign indications.

METHODS

We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project database files from 2012 to 2013. We identified patterns of 30-day readmission after benign hysterectomy for all surgical approaches (abdominal, laparoscopic, vaginal). Readmission timing was determined from discharge date and readmission diagnoses were tabulated. Statistical analyses included χ tests and multivariable logistic regression.

RESULTS

The 30-day readmission rate was 2.8% (1,118/40,580 hysterectomies). Readmissions complicated 3.7% (361/9,869) of abdominal, 2.6% (576/22,266) of laparoscopic, and 2.1% (181/8,445) of vaginal hysterectomies. Readmissions were more likely when hysterectomy was performed abdominally (adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.2-1.76) but not laparoscopically (adjusted OR 1.1, 95% CI 0.9-1.4) compared with a vaginal approach. Eighty-two percent of readmissions occurred within 15 days of discharge. The shortest median time to readmission was associated with pain (3 days), and the longest was associated with noninfectious wound complications (10 days). Surgical site infection was the most common diagnosis (abdominal 36.6%, laparoscopic 28.3%, vaginal 32.6%). Surgical site infections, surgical injuries, and wound complications combined accounted for 51.5% of abdominal, 51.9% of laparoscopic, and 50.8% of vaginal hysterectomy readmissions. Medical complications such as cardiovascular events and venous thromboembolism were responsible for 5.8% of abdominal, 6.9% of laparoscopic, and 8.8% of vaginal hysterectomy readmissions. Surgical injuries were responsible for more readmissions after laparoscopic (unadjusted OR 2.3, 95% CI 1.48-3.65) and vaginal hysterectomies (unadjusted OR 2.3, 95% CI 1.29-3.97) than abdominal cases.

CONCLUSION

Readmissions after hysterectomy tend to occur shortly after discharge. Most readmissions are related to surgical issues, most commonly surgical site infection. Medical complications, including venous thromboembolism, account for less than 10% of readmissions. Readmission reduction efforts should focus on early postdischarge follow-up, preventing infectious complications, and determining preventability of surgical-related reasons for readmission.