Converting laparoscopic colectomies to open is associated with similar outcomes as a planned open approach among Crohn's disease patients

PURPOSE

There has been a noted reluctance to offer laparoscopic surgery to Crohn's Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn's Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open.

METHODS

Crohn's Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012-2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity.

RESULTS

Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94-1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98-1.46, P = 0.074), when compared to an open approach.

CONCLUSION

Among Crohn's Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn's Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.

The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is there associated surveillance bias in the Veterans Health Administration?

BACKGROUND

Studies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates.

METHODS

Using VA data, we examined Pearson correlations between hospital-level VTE imaging rates and risk-adjusted PSI-12 rates and post-discharge VTE rates. To determine the robustness of findings, we conducted several sensitivity analyses.

RESULTS

Hospital imaging rates were positively correlated with both PSI-12 (r = 0.24, p = 0.01) and post-discharge VTE rates (r = 0.16, p = 0.09). Sensitivity analyses yielded similar findings.

CONCLUSIONS

Like the prior VA study, we found no evidence of PSI-12-related surveillance bias. Given the use of PSI-12 in nationwide measurement, these findings warrant replication using similar methods in the non-VA setting.

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement

BACKGROUND

Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

METHODS

We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

RESULTS

There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

CONCLUSION

Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

LEVEL OF EVIDENCE

Economic analysis, level II.

Implementation of a Comprehensive Post-Discharge Venous Thromboembolism Prophylaxis Program for Abdominal and Pelvic Surgery Patients

BACKGROUND

Prophylactic anticoagulation is routinely used in the inpatient setting; however, the risk of venous thromboembolism (VTE) remains elevated after discharge. Extensive evidence and clinical guidelines suggest post-discharge VTE prophylaxis is critical in at-risk populations, but it remains severely underused in practice.

STUDY DESIGN

We performed a single-institution retrospective, nonrandomized, pre- and post-intervention analysis of a systematic post-discharge pharmacologic prophylaxis program against the primary end point, which is post-discharge symptomatic VTE. An institutional American College of Surgeons NSQIP dataset was used to identify patients and outcomes. Patients undergoing major abdominal surgery for malignancy or inflammatory bowel disease were eligible for the post-discharge VTE prevention program.

RESULTS

Among 1,043 patients who underwent abdominal surgery for malignancy or inflammatory bowel disease, 800 (77%) were in the pre-intervention cohort and 243 (23%) patients were in the post-intervention cohort. Rates of inpatient VTE did not significantly differ between cohorts (0.7%, n = 6 pre-intervention vs 1.7%, n = 4 post-intervention; p = 0.25). However, compared with the pre-intervention cohort, patients in the post-intervention cohort demonstrated a significantly lower post-discharge VTE rate (2.5%, n = 20 pre-intervention vs 0.0%, n = 0 post-intervention; p < 0.01).

CONCLUSIONS

A systematic post-discharge VTE prophylaxis program including provider education, local guideline adaptation, bedside medication delivery, and education for at-risk patients, was associated with significantly fewer post-discharge VTE events.

The truth about trauma readmissions

BACKGROUND

There is a paucity of data on the causes and associated patient factors for unplanned readmissions among trauma patients.

METHODS

We examined patients admitted for traumatic injuries between 2007 and 2011 in the California State Inpatient Database. Using chi-square tests and multivariate logistic regression models, we determined rates, reasons, locations, and patient factors associated with 30-day readmissions.

RESULTS

Among 252,752 trauma discharges, the overall readmission rate was 7.56%, with 36% of readmissions occurring at a hospital different from the hospital of initial admission. Predictors of readmissions included being discharged against medical advice (odds ratio [OR]: 2.56 [2.35 to 2.76]); Charlson scores ≥2 (OR: 2.00 [1.91 to 2.10]); and age ≥45 years (OR: 1.29 [1.25 to 1.33]). Major reasons for readmissions were musculoskeletal complaints (22.29%), psychiatric conditions (9.40%), and surgical infections (6.69%).

CONCLUSIONS

Health and social vulnerabilities influence readmission among trauma patients, with many readmitted at other hospitals. Targeted interventions among high-risk patients may reduce readmissions after traumatic injuries.