Clinical and Financial Outcomes of Necrotizing Soft-Tissue Infections in Safety-Net Hospitals.

Background Prior work has demonstrated inferior outcomes for a multitude of medical and surgical conditions at hospitals with high burdens of underinsured patients (safety-net). The present study aimed to evaluate trends in incidence, clinical outcomes and resource utilization in the surgical management of necrotizing soft-tissue infections (NSTI) at safety-net hospitals. Materials and methods Adults requiring surgical debridement/amputation following NSTI-related hospitalizations were identified in the 2005-2018 National Inpatient Sample. Safety-net status (SNH) was assigned to institutions in the top tertile for annual proportion of underinsured patients. Logistic multivariable regression was utilized to evaluate the association of SNH with mortality, hospitalization duration (LOS), costs and discharge disposition. Results Of an estimated 212,692 patients, 76,719 (36.1%) were managed at SNH. The annual incidence of NSTI admissions increased overall while associated mortality declined. After adjustment, SNH status was associated with greater odds of mortality (adjusted odds ratios: 1.14, 95% CI: 1.03-1.26), LOS (ß: +1.8 d, 95% CI: 1.3-2.2) and costs (ß: +$4,400, 95% CI: 2,900-5,800). SNH patients had similar rates of amputation but lower likelihood of care facility or home health discharge. Conclusion With a rising incidence and overall reduction in mortality, safety-net hospitals persistently exhibit greater mortality and resource use for surgical NSTI admissions. Variation in access, disease presentation and timeliness of operative intervention may explain the observed findings.

Association of Early Rib Plating on Clinical and Financial Outcomes: A National Analysis.

BACKGROUND: With reported improvements in patient outcomes, surgical stabilization of rib fractures (SSRF) has been increasingly adopted. While institutional series have sought to define the role of early SSRF, large scale analysis remains lacking. The present study evaluated clinical and financial outcomes of SSRF in a nationally representative cohort. METHODS: Patients (≥16 years) admitted with multiple rib fractures were identified using the 2016-2020 National Inpatient Sample. Those who underwent rib plating >14 days following admission were omitted. Using restricted cubic spline analysis, patients who underwent SSRF within 2 days of hospitalization were classified as Expedited while fixation >2 days were deemed Routine. Multivariable regressions were used to evaluate the association of operative timing on outcomes of interest. RESULTS: Of 8150 patients meeting final inclusion criteria, 4090 (50.2%) were Expedited. Compared to Routine, Expedited tended to be older but were of comparable race, primary payer, and income quartile. Traumatic mechanism was also similar but rates of concomitant sternal fracture as well as intra-abdominal and cardiac injuries were higher in Routine. After adjustment, Expedited was associated with lower odds of respiratory complications, which included need for mechanical ventilation, prolonged mechanical ventilation, and pneumonia, compared to Routine. Expedited was associated with similar hospitalization duration but had lower incremental costs (ß: -$19.1 K, 95% CI: -24.1 to -14.2). DISCUSSION: Early SSRF was associated with lower likelihood of a number of respiratory complications and in-hospital costs. While patient selection criteria may limit our findings, expeditious fixation may limit morbidity while enhancing value of care.

Prior bariatric surgery is associated with lower mortality and resource utilization following small bowel obstruction.

Background: Small bowel obstruction (SBO) is a complication of bariatric surgery. However, outcomes of surgical intervention for SBO among patients with prior bariatric surgery remain ill-defined. We used a nationally representative cohort to characterize the outcomes of the SBO management approach in patients with a prior bariatric operation. Methods: All adult hospitalizations for SBO were tabulated from the 2018-2020 National Readmissions Database. Patients with a prior history of bariatric surgery comprised the Bariatric cohort (others: Non-Bariatric). Multivariable models were subsequently developed to evaluate the association of prior bariatric surgery with outcomes of interest. Results: Of an estimated 299,983 hospitalizations for SBO, 15,788 (5.3 %) had a history of prior bariatric surgery. Compared to Non-Bariatric, Bariatric patients were younger (54 [46-62] vs 57 [47-64] years, P < 0.001) and were more frequently privately insured (45.1 vs 39.4 %, P < 0.001). On average, the Bariatric more frequently underwent operative management, relative to Non-Bariatric (44.8 vs 29.7 %, P < 0.001). Following risk adjustment, among those surgically managed, Bariatric demonstrated lower odds of mortality (Adjusted Odds Ratio [AOR] 0.69, 95 % Confidence Interval [CI] 0.55-0.87) compared to Non-Bariatric. Bariatric also demonstrated lower odds of infectious and renal complications. Furthermore, the Bariatric cohort had lower costs, length of stay, and non-home discharge. Conclusions: Patients with prior bariatric surgery demonstrated a lower likelihood of mortality, decreased complications, and reduced resource utilization, relative to others. As the incidence of bariatric surgery continues to rise, future work is needed to minimize the incidence of SBO among these patients, especially in the current era of value-based healthcare.

Percutaneous cholecystostomy tube placement as a bridge to cholecystectomy for grade III acute cholecystitis: A national analysis.

Introduction: Percutaneous cholecystostomy (PCT) is an alternative to cholecystectomy (CCY) in high-risk surgical candidates with severe acute cholecystitis. A subset of these patients ultimately undergo delayed CCY. We therefore compared outcomes of delayed CCY in patients with grade III acute cholecystitis who received a PCT on index admission, to those who did not. Methods: Non-elective adult hospitalizations for grade III acute cholecystitis that underwent delayed CCY were identified in the 2016-2020 Nationwide Readmission Database. Patients who received a PCT during their index admission comprised the PCT group (others: Non-PCT). Outcomes were assessed for the CCY hospitalization. Entropy balancing was used to generate sample weights to adjust for differences in baseline characteristics. Regression models were created to evaluate the association between PCT and the outcomes of interest. Results: Of an estimated 13,782 patients, 13.3 % comprised PCT. Compared to Non-PCT, PCT were older (71.1 ± 13.1 vs 67.4 ± 15.3 years) and more commonly in the highest income quartile (22.5 vs 16.1 %, both p < 0.001). After risk adjustment, PCT was associated with reduced odds of respiratory (AOR 0.67, CI 0.54-0.83) and infectious (AOR 0.77, CI 0.62-0.96) complications after eventual CCY. Finally, PCT had comparable pLOS (ß +0.31, CI [-0.14, 0.77]) and operative hospitalization costs (ß $800, CI [-2300, +600]). Conclusion: In the present study, PCT was associated with decreased odds of perioperative complications and comparable resource utilization upon readmission CCY. Our findings suggest that PCT may be helpful in bridging patients with grade III acute cholecystitis to eventual CCY.

High-Quality Hospital Status on Health Care Costs for Pediatric Congenital Heart Disease Care for U.S. Military Beneficiaries.

INTRODUCTION: Congenital heart disease (CHD) is the most common and resource demanding birth defect managed in the United States, with approximately 40,000 children undergoing CHD surgery year. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and health care costs after CHD surgery. MATERIALS AND METHODS: Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries diagnosed with CHD were tabulated based on ICD-10 codes (International Classification of Diseases, 10th revision). We examined the relationships between total costs and total hospitalizations costs post 1-year CHD diagnosis and presence or absence of High-Quality Hospital (HQH) designation. We applied both the naive generalized linear model (GLM) to control for the observed patient and hospital characteristics and the 2-stage least squares (2SLS) model to account for the unobserved confounding factors. This study was approved by University of Maryland, College Park Institutional Review Board (IRB) (Approval Number: 1576246-2). RESULTS: A relationship between HQH designation and total CHD related costs was not seen across 2SLS model specifications (marginal effect; -$41,579; 95% CI, -$83,429 to $271). For patients diagnosed with a moderate-complex or single ventricle CHD, the association of HQH status was a statistically significant reduction in total costs (marginal effect; -$84,395; 95% CI, -$140,560 to -$28,229) and hospitalization costs (marginal effect; -$73,958; 95% CI, -$121,878 to -$26,039). CONCLUSIONS: It is very imperative for clinicians and patient support advocates to urge policymakers to deliberate the establishment of a quality designation authority for CHD management. These efforts will not only help to identify and standardize quality care metrics but to improve long-term health, effectiveness, and equity in the management of CHD. Furthermore, these efforts can be used to navigate patients to proven HQH, thereby improving care and reducing associated treatment costs for CHD patients.

Association of prior bariatric surgery with outcomes following emergency general surgery.

BACKGROUND: Despite the favorable outcomes and safety profile associated with metabolic and bariatric surgery (MBS), complications may occur postoperatively, necessitating emergency general surgery (EGS) intervention. OBJECTIVES: To evaluate the association of outcomes in patients with prior MBS following EGS interventions. SETTING: Academic, University-affiliated; USA. METHODS: All adults undergoing nonelective EGS operations were identified using the 2016 to 2020 Nationwide Readmission Database. Patients with a history of MBS were subsequently categorized as Bariatric, with the remainder of patients as NonBariatric. The primary outcome of interest was in-hospital mortality, while perioperative complications, length of stay (LOS), hospitalization costs, non-home discharge, and 30-day readmission were secondarily assessed. Multivariable regression models were developed to evaluate the association of history of MBS with outcomes of interest. RESULTS: Of an estimated 632,375 hospitalizations for EGS operations, 29,112 (4.6%) had a history of MBS. Compared to Nonbariatric, Bariatric were younger, more frequently female and more commonly had severe obesity. Following risk adjustment, Bariatric had significantly lower odds of in-hospital mortality (AOR .83, 95%CI .71-.98). Compared to others, Bariatric had reduced LOS by .5 days (95%CI .4-.7) and hospitalization costs by $1600 (95%CI $900-2100). Patients with prior MBS had reduced odds of nonhome discharge (AOR .89, 95%CI .85-.93) and increased likelihood of 30-day readmissions (AOR 2.32, 95%CI 1.93--2.79) following EGS. CONCLUSIONS: Prior MBS is associated with decreased mortality and perioperative complications as well as reduced resource utilization in select EGS procedures. Our findings suggest that patients with a history of MBS can be managed effectively by acute surgical interventions.

Association of rurality with short-term outcomes of peripheral vascular trauma.

BACKGROUND: Peripheral vascular trauma is a major contributing factor to long-term disability and mortality among patients with traumatic injuries. However, an analysis focusing on individuals at a high risk of experiencing limb loss due to rural and urban peripheral vascular trauma is lacking. METHOD: This was a retrospective analysis of the 2016 to 2020 Nationwide Readmissions Database. Patients (≥18 years) undergoing open or endovascular procedures after admission for peripheral vascular trauma were identified using the 2016 to 2020 Nationwide Readmissions Database. Patients from rural regions were considered Rural, whereas the remainder comprised Urban. The primary outcome of the study was primary amputation. Multivariable regression models were developed to evaluate rurality with outcomes of interest. RESULTS: Of 29,083 patients, 4,486 (15.6%) were Rural. Rural were older (41 [28-59] vs 37 [27-54] years, P < .001), with a similar distribution of female sex (23.0 vs 21.3%, P = .09) and transfers from other facilities (2.8 vs 2.5%, P = .34). After adjustment, Rural status was not associated with the odds of mortality (P = .82), with urban as reference. Rural status was, however, associated with greater odds of limb amputation (adjusted odds ratio 1.85, 95% confidence interval 1.47-2.32) and reduced index hospitalization cost by $7,100 (95% confidence interval $3,500-10,800). Additionally, compared to patients from urban locations, rurality was associated with similar odds of non-home discharge and 30-day readmission. Over the study period, the marginal effect of rurality on the risk-adjusted rates of amputation significantly increased (P < .001). CONCLUSION: Patients who undergo peripheral vascular trauma management in rural areas appear to increasingly exhibit a higher likelihood of amputation, with lower incremental costs and a lower risk of 30-day readmission. These findings underscore disparities in access to optimal trauma vascular care as well as limited resources in rural regions.

Clinical Outcomes and Resource Utilization in Patients With Peripheral Arterial Disease Hospitalized for Acute Coronary Syndrome.

Previous studies have shown an association between acute limb ischemia and higher mortality in patients with acute myocardial infarction. Although peripheral artery disease (PAD) is a well-known risk factor for development of macrovascular pathology, the effect of its severity is not well investigated in patients hospitalized for acute coronary syndrome (ACS). Using a national cohort of patients with various degrees of PAD, we investigated in-hospital outcomes in patients who were admitted for ACS. Using the 2016 to 2020 Nationwide Readmissions Database, we queried all patients who were hospitalized for ACS (unstable angina, non-ST-elevation myocardial infarction, and ST-elevation myocardial infarction). Patients were further divided into 3 groups, either no PAD (non-PAD), PAD, or critical limb ischemia (CLI). Multivariable models were designed to adjust for patient and hospital factors and examine the association between ACS and PAD severity. Of approximately 3,834,181 hospitalizations for ACS, 6.4% had PAD, 0.2% had CLI, and all others were non-PAD. After risk adjustment, in-hospital mortality was higher by 24% in PAD (adjusted odds ratio 1.24, 95% confidence interval [CI] 1.21 to 1.28) and 86% in CLI (adjusted odds ratio 1.86, 95% CI 1.62 to 2.09) compared with non-PAD. Furthermore, PAD and CLI were linked to 1.23-fold (95% CI 1.20 to 1.26) and 1.67-fold (95% CI 1.45 to 1.86) greater odds of cardiogenic shock compared with non-PAD. Additionally, PAD and CLI were linked with higher odds of mechanical circulatory support usage, cardiac arrest and acute kidney injury compared with non-PAD. Lastly, duration of hospital stay, hospitalization costs and odds of non-home discharge and 30-day readmissions were greater in patients with PAD and CLI compared with non-PAD. PAD severity was associated with worse clinical outcomes in patients with ACS, including in-hospital mortality and resource utilization.

Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

BACKGROUND: The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS: The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS: Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS: After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Trends and associated outcomes of fat embolism after trauma surgery.

BACKGROUND: Fat embolism is a life-threatening complication often occurring in patients with traumatic injuries. However, temporal trends and perioperative outcomes of fat embolism remain understudied. Using a nationally representative cohort, we aimed to characterize temporal trends of fat embolism and its associated resource utilization in operatively managed trauma patients. METHODS: All patients (≥18 years) undergoing any major operations after traumatic injuries were tabulated using the 2005 to 2020 National Inpatient Sample. Patients were stratified into those with fat embolism and those without. Multivariable logistic and linear regressions were developed to assess the association between fat embolism and outcomes of interest. RESULTS: Of an estimated 10,600,000 hospitalizations, 7,479 (0.07%) patients had fat embolism. Compared to the non-fat embolism cohort, the fat embolism cohort was younger (55 [26-79] vs 69 [49-82] years, standard mean difference = 0.46) and more likely to receive treatment at a high-volume trauma center (42.9 vs 33.7%, standard mean difference = 0.19). Over the study period, there was an increase in annual mortality and hospitalization costs among the fat embolism group (nptrend <0.001). After risk adjustment, fat embolism was associated with greater odds of mortality (adjusted odds ratio: 2.65, 95% confidence interval: 2.24-3.14) compared to others. Additionally, fat embolism was associated with increased odds of cerebrovascular, infectious, and renal complications. CONCLUSION: Among all operatively managed trauma patients, those who developed fat embolism had increased mortality, rates of complications, length of stay, and costs. Optimization of early and accurate identification of fat embolism is warranted to mitigate complications and improve resource allocation among trauma patients.

Outcomes of Hospitalized Injured Suspects Sustaining Gunshot Wounds From Law Enforcement Action.

BACKGROUND: Although firearms are implicated in the majority of law enforcement intervention (LEI)-related deaths, scientific research is lacking. The present study sought to characterize clinical and financial outcomes between injured suspects and other gunshot wound (GSW) patients. STUDY DESIGN: The 2016-2020 National Inpatient Sample was queried for patients ≥16 years old admitted following GSW. Patients were categorized as injured suspects (ISs) if they were injured in LEI and non-IS otherwise. The primary outcome was in-hospital mortality with complications, hospitalization duration (LOS), and costs secondarily considered. Multivariable regression models were used to adjust for patient characteristics, injury burden using the Trauma Mortality Prediction Model (TMPM), and hospital factors. RESULTS: Of 143,125 hospitalizations, 1575 (1.10%) were IS. Compared to non-IS, ISs were less frequently Black (24.4% vs 54.3%) but had a higher proportion of psychiatric conditions (19.4% vs 6.4%) (P < .05). Although having a similar requirement for major operations and TMPM score, ISs more frequently underwent thoracic (11.4% vs 4.1%) and gastrointestinal operations (33.0% vs 25.7%) (P < .05). After adjustment, IS was associated with similar odds of mortality but was associated with greater odds of cardiac complications, respiratory failure, and need for intensive care. While LOS was similar, IS was associated with greater costs (ß: +$14,300, 95% CI: 6,200-22,400). CONCLUSIONS: Suspects injured during law enforcement intervention have similar in-hospital mortality but greater complication rates and costs. Through the quantification of the clinical and financial burden of IS, our findings may help inform further policy discussions regarding use of potentially lethal force in law enforcement intervention.

Failure to rescue following emergency general surgery: A national analysis.

Background: Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. Methods: All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. Results: Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. Conclusion: Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

National analysis of racial disparities in emergent surgery for colorectal cancer.

Background: Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery. Methods: All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends. Results: Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type. Conclusion: Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis.

BACKGROUND: Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort. METHODS: All non-elective pediatric (<18 years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE). RESULTS: Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]). CONCLUSION: Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Care fragmentation is associated with increased mortality after ileostomy creation.

BACKGROUND: Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures. METHODS: All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures. RESULTS: Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5). CONCLUSION: Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.

National Trends and Clinical Outcomes after Scooter Injury in the US: 2016 to 2020.

BACKGROUND: In recent years, the adoption of electric scooters has been accompanied by a surge of scooter-related injuries in the US, raising concerns for their severity and associated healthcare costs. This study aimed to assess temporal trends and outcomes of scooter-related hospital admissions compared with bicycle-related hospitalizations. STUDY DESIGN: This was a retrospective cohort study using the 2016 to 2020 National Inpatient Sample for patients younger than 65 years who were hospitalized after bicycle- and scooter-related injuries. The Trauma Mortality Prediction Model was used to quantify injury severity. The primary outcomes of interest were temporal trends of micromobility injuries. In-hospital mortality, rates of long bone fracture, traumatic brain injury, paralysis, length of stay, hospitalization costs, and nonhome discharge were secondarily assessed. RESULTS: Among 92,815 patients included in the study, 6,125 (6.6%) had scooter-related injuries. Compared with patients with bicycle-related injuries, patients with scooter-related injuries were more commonly younger than 18 years (26.7% vs 16.4%, p < 0.001) and frequently underwent major operations (55.8% vs 48.1%, p < 0.001). After risk adjustment, scooter-related injuries were associated with greater risks of long bone fracture (adjusted odds ratio 1.40, 95% CI 1.15 to 1.70) and paralysis (adjusted odds ratio 2.06, 95% CI 1.16 to 3.69) compared with bicycle-related injuries. Additionally, patients with bicycle- or scooter-related injuries had comparable index hospitalization durations of stay and costs. CONCLUSIONS: The prevalence and severity of scooter-related injuries have significantly increased in the US, thereby attributing to a substantial cost burden on the healthcare system. Multidisciplinary efforts to inform safety policies and enact targeted interventions are warranted to reduce scooter-related injuries.

Hospital-level variation in hospitalization costs for spinal fusion in the United States.

BACKGROUND: With a growing emphasis on value of care, understanding factors associated with rising healthcare costs is increasingly important. In this national study, we evaluated the degree of center-level variation in the cost of spinal fusion. METHODS: All adults undergoing elective spinal fusion were identified in the 2016 to 2020 National Inpatient Sample. Multilevel mixed-effect models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient (ICC) was utilized to tabulate the amount of variation attributable to hospital-level characteristics. The association of high cost-hospital (HCH) status with in-hospital mortality, perioperative complications, and overall resource utilization was analyzed. Predictors of increased costs were secondarily explored. RESULTS: An estimated 1,541,740 patients underwent spinal fusion, and HCH performed an average of 9.5% of annual cases. HCH were more likely to be small (36.8 vs 30.5%, p<0.001), rural (10.1 vs 8.8%, p<0.001), and located in the Western geographic region (49.9 vs 16.7%, p<0.001). The ICC demonstrated 32% of variation in cost was attributable to the hospital, independent of patient-level characteristics. Patients who received a spinal fusion at a HCH faced similar odds of mortality (0.74 [0.48-1.15], p = 0.18) and perioperative complications (1.04 [0.93-1.16], p = 0.52), but increased odds of non-home discharge (1.30 [1.17-1.45], p<0.001) and prolonged length of stay (ß 0.34 [0.26-0.42] days, p = 0.18). Patient factors such as gender, race, and income quartile significantly impacted costs. CONCLUSION: The present analysis identified 32% of the observed variation to be attributable to hospital-level characteristics. HCH status was not associated with increased mortality or perioperative complications.

The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System.

INTRODUCTION: Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. MATERIALS AND METHODS: Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). RESULTS: The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). CONCLUSIONS: After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma.

Background: Alcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development. Methods: The 2016-2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge. Results: Of an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23-1.73), along with infectious (AOR 1.73, 95 % CI 1.58-1.88), cardiac (AOR 1.24, 95 % CI 1.06-1.46), and respiratory (AOR 1.96, 95 % CI 1.81-2.11) complications. AWS was associated with prolonged LOS, (ß: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (ß: +$8900, 95 % CI $7900-9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34-1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS. Conclusion: In the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.

Discharge against medical advice in trauma patients: Trends, risk factors, and implications for health care management strategies.

OBJECTIVE: Given the nonelective nature of most trauma admissions, patients who experience trauma are at a particular risk of discharge against medical advice. Despite the risk of unplanned readmission and financial burden on the health care system, discharge against medical advice among hospitalized patients continues to rise. The present study aimed to assess evolving trends and outcomes associated in patients with discharge against medical advice among patients hospitalized for traumatic injury. METHODS: The 2016-2020 Nationwide Readmissions Database was queried to identify all hospitalizations for traumatic injuries. The patient cohort was stratified into those who had discharge against medical advice and those who did not. Temporal trends of discharge against medical advice and associated costs over time were evaluated using nonparametric tests. Multivariable regression models were developed to assess factors associated with discharge against medical advice. Associations of discharge against medical advice with length of stay, hospitalization costs, and unplanned 30-day readmission were subsequently evaluated. RESULTS: Of an estimated 4,969,717 patients, 65,354 (1.3%) had discharge against medical advice after hospitalization for traumatic injury. Over the study period, the incidence of discharge against medical advice increased (nptrend <0.001). After risk adjustment, older age (adjusted odds ratio, 0.98/per year; 95% confidence interval, 0.97-0.98), female sex (adjusted odds ratio, 0.65; 95% confidence interval, 0.64-0.67), and management at high-volume trauma center (adjusted odds ratio, 0.71; 95% confidence interval, 0.69-0.74) were associated with lower odds of discharge against medical advice. Compared with others, discharge against medical advice was associated with decrements in length of stay by 1.3 days (95% confidence interval, 1.1-1.5 days) and index hospitalization costs by $2,200 (5% confidence interval, $1,600-2,900), while having a greater risk of unplanned 30-day readmission (adjusted odds ratio, 2.21; 95% confidence interval, 2.06-2.36). CONCLUSION: The incidence of discharge against medical advice and its associated cost burden have increased in recent years. Community-level interventions and institutional efforts to mitigate discharge against medical advice may improve the quality of care and resource allocation for patients with traumatic injuries.