Ethical guidelines for antiracism work in medicine: lessons from the antiracist healing collaborative.

An explosion of antiracism in medicine efforts have transpired since 2020. However, no ethical guidelines exist to guide them. This oversight is concerning because the racism and white supremacy rife within medicine can easily thwart them. This article addresses this gap by highlighting ethical guidelines for antiracism work in medicine. We present nine core tenets derived from our experience forming the Antiracist Healing Collaborative (AHC), a medical student-led initiative committed to developing bold and disruptive antiracist medical education content. Our lessons developing and implementing these tenets can guide other antiracism in medicine collaborations striving to promote liberation and healing, rather than recapitulating the racism and white supremacy culture embedded within medicine. We close by reflecting on how these tenets have steadied our recent decision to draw AHC to a close. They have allowed us to honour what we achieved together, strengthen the relationship that formed the foundation for our activism and bolster the shared antiracism mission that will guide our individual journeys moving forwards. The first of their kind, our ethical guidelines for antiracism work in medicine can facilitate greater recognition of the risks embedded in anti-oppression work transpiring in academic settings.

Association of prior bariatric surgery with financial and clinical outcomes of acute myocardial infarction.

BACKGROUND: Superior clinical outcomes after hospitalization for cardiovascular-related disease such as acute heart failure have been linked with prior history of bariatric surgery, but similar analyses in acute myocardial infarction (MI) are currently limited. OBJECTIVE: This work examines clinical outcomes and resource utilization in patients with acute MI hospitalizations with a prior history of bariatric surgery. SETTING: Academic university-affiliated hospital in the United States. METHODS: All adult patients with hospitalizations with a primary diagnosis of acute MI were queried using the 2016-2020 Nationwide Readmissions Database. The study population was comprised of patients with an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for obesity (body mass index ≥35 kg/m2) as well as those with a prior history of bariatric surgery regardless of their body mass index status. Comparison was made between those with a prior history of bariatric surgery and those without. Univariate analysis and multivariate regression models were used to examine the association between bariatric surgery and outcomes of interest, which included in-hospital mortality, medical complications, and resource utilization. RESULTS: Of an estimated 2,736,606 hospitalizations for acute MI, 296,902 patients (10.8%) had a diagnosis of obesity and/or a prior history of bariatric surgery. The bariatric cohort was more frequently female and had a lower prevalence of congestive heart failure, chronic lung disease, diabetes, and electrolyte derangements than the nonbariatric cohort. After risk adjustment, prior history of bariatric surgery was associated with significantly lower odds of in-hospital mortality, cardiogenic shock, and acute kidney injury. Additionally, prior history of bariatric surgery was linked to a decreased duration of hospital stay and lower hospitalization costs as well as lower odds of nonhome discharge. CONCLUSION: Among acute MI patients with obesity, prior history of bariatric surgery was associated with decreased odds of in-hospital mortality, improved clinical outcomes, and lower resource utilization. Expansion of bariatric surgery programs may provide improved access to a medical intervention that is intertwined with cardiovascular health.

Association of time to resection with survival in patients with colon cancer.

PURPOSE: Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS: This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS: Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS: Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Short-term outcomes of bariatric surgery in patients with inflammatory bowel disease: a national analysis.

BACKGROUND: While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD). OBJECTIVES: The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery. SETTING: Academic, university-affiliated; United States. METHODS: All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest. RESULTS: Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 ± 1.4; CD: 3.1 ± 1.5; non-IBD: 2.7 ± 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD. CONCLUSIONS: Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.

National trends and resource associated with recurrent penetrating injury.

BACKGROUND: While recurrent penetrating trauma has been associated with long-term mortality and disability, national data on factors associated with reinjury remain limited. We examined temporal trends, patient characteristics, and resource utilization associated with repeat firearm-related or stab injuries across the US. METHODS: This was a retrospective study using 2010-2019 Nationwide Readmissions Database (NRD). NRD was queried to identify all hospitalizations for penetrating trauma. Recurrent penetrating injury (RPI) was defined as those returned for a subsequent penetrating injury within 60 days. We quantified injury severity using the International Classification of Diseases Trauma Mortality Prediction model. Trends in RPI, length of stay (LOS), hospitalization costs, and rate of non-home discharge were then analyzed. Multivariable regression models were developed to assess the association of RPI with outcomes of interest. RESULTS: Of an estimated 968,717 patients (28.4% Gunshot, 71.6% Stab), 2.1% experienced RPI within 60 days of the initial injury. From 2010 to 2019, recurrent gunshot wounds increased in annual incidence while that of stab cohort remained stable. Patients experiencing recurrent gunshot wounds were more often male (88.9 vs 87.0%, P<0.001), younger (30 [23-40] vs 32 [24-44] years, P<0.001), and less commonly insured by Medicare (6.5 vs 11.2%, P<0.001) compared to others. Those with recurrent stab wounds were younger (36 [27-49] vs 44 [30-57] years, P<0.001), less commonly insured by Medicare (21.3 vs 29.3%, P<0.001), and had lower Elixhauser Index Comorbidities score (2 [1-3] vs 3 [1-4], P<0.001) compared to others. After risk adjustment, RPI of both gunshot and stab was associated with significantly higher hospitalization costs, a shorter time before readmission, and increased odds of non-home discharge. CONCLUSION: The trend in RPI has been on the rise for the past decade. National efforts to improve post-discharge prevention and social support services for patients with penetrating trauma are warranted and may reduce the burden of RPI.

Reimagining Medical Education Toward Antiracist Praxis.

Medicine has a longstanding history of racism that promulgates existing health inequities. Current medical education, largely based on the biomedical framework, omits critical discourse on racism and White supremacy, which continue to harm individuals and communities of color. Such ahistorical and apolitical orientation inadequately trains learners to identify and address racism in clinical practice. Although curricula on racial health disparities, social determinants of health, cultural competency, and implicit bias have been operationalized by several medical schools, they do not identify the racism embedded in systems of care, nor do they provide transformative steps toward true health equity and justice. As such, this article proposes bold radical frameworks as the foundation for reimagining medical education in the United States. Founded on critical race theory, abolition, and decolonization, the authors provide a view of an antiracist medical education, one that highlights the history and legacy of racism in medicine and positions medical trainees and practicing physicians as active agents in medicine's antiracist transformation.

Impact of delayed intervention following admission for small bowel obstruction: A contemporary analysis.

Background: The optimal timing of surgical intervention for small bowel obstruction (SBO) remains debated. Methods: All adults admitted for SBO were identified in the 2018-2019 National Inpatient Sample. Patients undergoing small bowel resection or lysis of adhesion after three days were considered part of the Delayed cohort. All others were classified as Early. Multivariable regressions were used to assess independent predictors of delayed surgical intervention as well as associations between delayed management and in-hospital mortality, major adverse events (MAE), perioperative complications, postoperative length of stay (LOS), hospitalization costs and non-home discharge. Results: Among 28,440 patients who met study criteria, 52.0 % underwent delayed intervention. Black race (AOR 1.19, 95 % CI 1.03-1.36, ref.: White) and Medicare coverage (AOR 1.16, 95 % CI 1.01-1.33, ref.: private payer) were associated with increased odds of delayed surgical management. While delayed intervention was not significantly associated with death (AOR 1.27, 95 % CI 0.97-1.68), it was linked to greater odds of MAE (AOR 1.30, 95 % CI 1.16-1.45) and several perioperative complications. The Delayed cohort also faced an incremental increase in postoperative LOS (+1.29 days, 95 % CI 0.89-1.70) and hospitalization costs (+$11,000, 95 % CI 10,000-12,000). Moreover, delayed intervention was linked to increased odds of non-home discharge (AOR 1.64, 95 % CI 1.47-1.84). Conclusions: Delay in surgical management following SBO is linked to inferior clinical outcomes and increased resource use. Our findings highlight the need to ensure proper timing of surgery for SBO as well as efforts to standardize these practices across all demographics of patients.

Teaching the Legacy of Slavery in American Medicine and Psychiatry to Medical Students: Feasibility, Acceptability, Opportunities for Growth.

Introduction: Understanding the legacy of slavery in the United States is crucial for engaging in anti-racism that challenges racial health inequities' root causes. However, few medical educational curricula exist to guide this process. We created a workshop illustrating key historical themes pertaining to this legacy and grounded in critical race theory. Methods: During a preclinical psychiatry block, a second-year medical school class, divided into three groups of 50-60, attended the workshop, which comprised a 90-minute lecture, 30-minute break, and 60-minute small-group debriefing. Afterwards, participants completed an evaluation assessing self-reported knowledge, attitudes and beliefs, and satisfaction with the workshop. Results: One hundred eighty students watched the lecture, 15 attended small-group debriefings, and 132 completed the survey. Seventy-six percent (100) reported receiving no, very little, or some prior exposure to the legacy of slavery in American medicine and psychiatry. Over 80% agreed or strongly agreed that the workshop made them more aware of this legacy and that the artwork, photographs, storytelling, and media (videos) facilitated learning. Qualitative feedback highlighted how the workshop improved students' knowledge about the legacy of slavery's presence in medicine and psychiatry. However, students criticized the lecture's scripted approach and requested more discussion, dialogue, interaction, and connection of this history to anti-racist action they could engage in now. Discussion: Though this workshop improved awareness of the legacy of slavery, students criticized its structure and approach. When teaching this legacy, medical schools should consider expanding content, ensuring opportunities for discussion in safe spaces, and connecting it to immediate anti-racist action.

Association of body mass index with morbidity following elective ventral hernia repair.

Background: Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes. Methods: Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest. Results: Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay. Conclusion: BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care. Key message: Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Acute clinical and financial outcomes of esophagectomy at safety-net hospitals in the United States.

BACKGROUND: While safety-net hospitals (SNH) play a critical role in the care of underserved communities, they have been associated with inferior postoperative outcomes. This study evaluated the association of hospital safety-net status with clinical and financial outcomes following esophagectomy. METHODS: All adults (≥18 years) undergoing elective esophagectomy for benign and malignant gastroesophageal disease were identified in the 2010-2019 Nationwide Readmissions Database. Centers in the highest quartile for the proportion of uninsured/Medicaid patients were classified as SNH (others: non-SNH). Regression models were developed to evaluate adjusted associations between SNH status and outcomes, including in-hospital mortality, perioperative complications, and resource use. Royston-Parmar flexible parametric models were used to assess time-varying hazard of non-elective readmission over 90 days. RESULTS: Of an estimated 51,649 esophagectomy hospitalizations, 9,024 (17.4%) were performed at SNH. While SNH patients less frequently suffered from gastroesophageal malignancies (73.2 vs 79.6%, p<0.001) compared to non-SNH, the distribution of age and comorbidities were similar. SNH was independently associated with mortality (AOR 1.24, 95% CI 1.03-1.50), intraoperative complications (AOR 1.45, 95% CI 1.20-1.74) and need for blood transfusions (AOR 1.61, 95% CI 1.35-1.93). Management at SNH was also associated with incremental increases in LOS (+1.37, 95% CI 0.64-2.10), costs (+10,400, 95% CI 6,900-14,000), and odds of 90-day non-elective readmission (AOR 1.11, 95% CI 1.00-1.23). CONCLUSIONS: Care at safety-net hospitals was associated with higher odds of in-hospital mortality, perioperative complications, and non-elective rehospitalization following elective esophagectomy. Efforts to provide sufficient resources at SNH may serve to reduce complications and overall costs for this procedure.

Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States.

BACKGROUND: Hypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair. METHODS: Adults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission. RESULTS: Of 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission. CONCLUSION: We used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.

Interventions Associated With Racial and Ethnic Diversity in US Graduate Medical Education: A Scoping Review.

Importance: Racially and ethnically minoritized individuals remain underrepresented in graduate medical education relative to their proportion in the population. While many programs and initiatives have been developed to address this problem, there is little consensus regarding strategies that work to improve representation across specialties. Objective: To examine and synthesize evidence-based practices that have been used to increase the proportions of underrepresented in medicine (URiM) trainees at US residency and fellowship programs. Evidence Review: The authors searched PubMed, Google Scholar, Embase, PsycInfo, ERIC, Cochrane Reviews, Cochrane Trials, CINAHL, Scopus, and PROSPERO electronic databases to identify relevant studies published through January 2022. They screened all titles and abstracts for relevance and read full-text articles to identify articles reporting reliable data describing the outcomes of interventions to improve racial and ethnic diversity among trainees. Findings: Twenty-seven articles were included in this review. Two studies reported on fellowship programs. The most common interventions included holistic review (48%), decreased emphasis on United States Medical Licensing Examination Step 1 scores (48%), and explicit institutional messaging regarding the importance of diversity (37%). A combination of interventions was associated with an increased number of URiM applicants, interviewees, and matriculants across various medical and surgical specialties. Conclusions and Relevance: In this scoping review, approaches and interventions associated with increased diversity in residency and fellowship programs were identified. Continued efforts are necessary to sustain such efforts and assess long-term outcomes.

Bariatric surgery improves outcomes of hospitalizations for acute heart failure: a contemporary, nationwide analysis.

BACKGROUND: The link between obesity and poor outcomes in heart failure (HF) has been well-established. OBJECTIVES: This retrospective study sought to examine national rates and outcomes of acute HF hospitalizations in obese individuals with a prior history of bariatric surgery. SETTING: Academic, university-affiliated; the United States. METHODS: Adult admissions (≥18 years) including a diagnosis of severe obesity were identified in the 2016-2019 Nationwide Readmissions Database. Patients who previously underwent bariatric operations were categorized into the Bariatric cohort. Multivariable linear and logistic models were used to assess the association of prior bariatric surgery with outcomes of interest. RESULTS: Of an estimated 10,343,828 admissions for a diagnosis of severe obesity, 925,716 (8.9%) comprised the bariatric cohort. After risk adjustment, bariatric surgery was associated with significantly decreased odds of acute HF hospitalization (adjusted odds ratio [AOR]: .40, 95% confidence interval [CI]: .38-.41). Among acute HF hospitalizations, prior bariatric surgery was linked to lower odds of mortality (AOR: .68, 95% CI: .52-.89), prolonged mechanical ventilation (AOR .44, 95% CI: .32-.61), acute renal failure (AOR: .76, 95% CI: .70-.82), and prolonged hospitalization (AOR: .77, 95% CI: .68-.87). Bariatric surgery was linked to a decrement of 1 day (95% CI: .7-1.1) and $1200 in hospitalization costs (95% CI: 400-1900), but no significant difference in odds of 30-day readmission. CONCLUSIONS: Bariatric surgery is associated with reduced admissions for acute HF. Among acute HF hospitalizations, bariatric surgery is linked to significantly improved clinical and financial outcomes. Given its potential benefits in obesity and related diseases, bariatric surgery holds promise for promoting value-based healthcare for HF.

Preoperative stents for the treatment of obstructing left-sided colon cancer: a national analysis.

BACKGROUND: Given the risks associated with urgent colectomy for large bowel obstruction, preoperative colonic stenting has been utilized for decompression and optimization prior to surgery. This study examined national trends in the use of colonic stenting as a bridge to resection for malignant large bowel obstruction and evaluated outcomes relative to immediate colectomy. METHODS: Adults undergoing colonic stenting or colectomy for malignant, left/sigmoid large bowel obstruction were identified in the 2010-2016 Nationwide Readmissions Database. Patients were classified as immediate resection (IR) or delayed resection (DR) if undergoing colonic stenting prior to colectomy. Generalized linear models were used to evaluate the impact of resection strategy on ostomy creation, in-hospital mortality, and complications. RESULTS: Among 9,706 patients, 9.7% underwent colonic stenting, which increased from 7.7 to 16.4% from 2010 to 2016 (p < 0.001). Compared to IR, the DR group was younger (63.9 vs 65.9 years, p = 0.04), had fewer comorbidities (Elixhauser Index 3.5 vs 3.9, p = 0.001), and was more commonly managed at high-volume centers (89.4% vs 68.1%, p < 0.001). Laparoscopic resections were more frequent among the DR group (33.1% vs 13.0%, p < 0.001), while ostomy rates were significantly lower (21.5% vs 53.0%, p < 0.001). After risk adjustment, colonic stenting was associated with reduced odds of ostomy creation (0.34, 95% confidence interval 0.24-0.46), but similar odds of mortality and complications. CONCLUSION: Colonic stenting is increasingly utilized for malignant, left-sided bowel obstructions, and associated with lower ostomy rates but comparable clinical outcomes. These findings suggest the relative safety of colonic stenting for malignant large bowel obstruction when clinically appropriate.

Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals.

OBJECTIVE: Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use. METHODS: All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest. RESULTS: Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs. CONCLUSIONS: Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.

Impact of malnutrition on outcomes following groin hernia repair: Insights from the ACS NSQIP.

BACKGROUND: The present study examined the association of nutrition status, as defined by preoperative serum albumin, with postoperative outcomes and resource use after groin hernia repair. METHODS: The 2006 to 2019 American College of Surgeons National Surgical Quality Improvement Program database was queried for adults (≥18 years) undergoing open or laparoscopic repair of inguinal or femoral hernia. Patients were stratified based on the following preoperative serum albumin levels: <2.5 g/dL (severe hypoalbuminemia), 2.5 to <3.0 (moderate hypoalbuminemia), 3.0 to <3.5 (mild), and ≥3.5 (normal albumin). Multivariable regression models were developed to assess the association of hypoalbuminemia with outcomes of interest, including 30-day mortality, postoperative complications, length of stay, and 30-day readmission. RESULTS: Of the 261,052 patients meeting inclusion criteria, 0.3% had severe, 1.1% had moderate, and 7.4% had mild hypoalbuminemia, with 91.2% classified as normal albumin. After risk adjustment, mortality risk was greater for severe (5.8%, 95% confidence interval: 4.1-7.6), moderate (4.4%, 95% confidence interval: 3.4-5.3), and mild hypoalbuminemia (1.5%, 95% confidence interval: 1.2-1.8) relative to normal albumin (0.3%, 95% confidence interval: 0.2-0.3). Decreasing serum albumin levels were associated with a stepwise increase in risk of complications, length of stay, and 30-day readmission. CONCLUSION: Decreased preoperative serum albumin is associated with increased mortality and morbidity after open and laparoscopic groin hernia repair. Serum albumin remains a relevant predictor of postsurgical outcomes and can thus be used in shared decision-making and optimization of malnourished patients in need of groin hernia repair.

Characterizing the Association of Race and Insurance Status with Resource Utilization in Brachial Plexopathy Surgery.

BACKGROUND: Understanding the link between socioeconomic status and immediate postoperative brachial plexus injury (BPI) management outcomes is critical to mitigating disparities and optimizing postoperative recovery plans. The present study aimed to elucidate the association between socioeconomic status and resource utilization following surgery for BPI. METHODS: We conducted a cross-sectional study of adult patients (18 years) with a BPI diagnosis from the 2002-2017 National Inpatient Sample. Primary outcomes included home discharge rates, length of stay (LOS), and cost. We used multivariable regressions to analyze outcome measures. RESULTS: A total of 23,755 BPI admissions were identified, 14.67% of whom received surgical intervention. Patients receiving Medicare had lower odds of home discharge compared with privately insured patients (adjusted odds ratio 0.65, 95% confidence interval 0.58-0.74; P < 0.001). Medicaid, Medicare, and uninsured patients had 6%-32% longer LOS than privately insured patients (P < 0.001, P = 0.004, and P = 0.006, respectively). Patients in the top income quartile had a 12% increase in costs compared with those in the bottom quartile (P < 0.001). Latinx and Other race groups had 11%-14% increased costs compared with White patients (Latinx P < 0.001, Other P = 0.003). CONCLUSIONS: Differences in BPI resource utilization and allocation exist, from increased LOS among non-privately insured and non-White patients to increased BPI treatment costs among patients in higher-income quartiles. Further research is necessary to elucidate how these disparities exist and impact functional outcomes.

Association of chronic kidney disease with perioperative outcomes following acute lower limb revascularization.

Background: There is a paucity of data examining the impact of advancing chronic kidney disease stages on outcomes following revascularization for acute limb ischemia. The present study examined the association of chronic kidney disease with in-hospital mortality, amputation, and resource utilization following revascularization for acute limb ischemia using a nationally representative cohort. Methods: The 2016-2018 National Inpatient Sample was queried to identify all adult hospitalizations with lower extremity acute limb ischemia requiring surgical and/or endovascular interventions. Patients were grouped according to the presence of chronic kidney disease and its severity: no chronic kidney disease, chronic kidney disease 1-3 (chronic kidney disease stages 1 through 3), chronic kidney disease 4-5 (chronic kidney disease stages 4 through 5), and end-stage renal disease. Multivariable logistic and linear models were used to evaluate association of chronic kidney disease stage with outcomes of interest. Results: Of an estimated 82,610 patients meeting study criteria, 14.8% had chronic kidney disease (chronic kidney disease 1-3: 63.4%, chronic kidney disease 4-5: 12.1%, end-stage renal disease: 24.5%). Compared to those with chronic kidney disease, chronic kidney disease patients were on average older, were more frequently female, and had a higher median Elixhauser Comorbidity Index. Increasing severity of chronic kidney disease was associated with a stepwise increase in unadjusted mortality rates (4.7% in no chronic kidney disease to 12.6% in end-stage renal disease, P < .001). Following risk adjustment, only end-stage renal disease was associated with increased odds of mortality (adjusted odds ratio 3.10, 95% confidence interval 2.28-4.22) and limb amputation (adjusted odds ratio 1.99, 95% confidence interval 1.59-2.48) compared to patients with no chronic kidney disease. Similarly, advancing chronic kidney disease stage conferred increased odds of prolonged length of stay and greater hospitalization costs. Conclusion: Advanced renal dysfunction demonstrated inferior perioperative outcomes and greater health care expenditures in the study population. These findings imply that quality improvement efforts in acute limb ischemia revascularization should target patients with chronic kidney disease 4-5 and end-stage renal disease.

Association of frailty with clinical and financial outcomes of esophagectomy hospitalizations in the United States.

Background: Frailty, defined as impaired physiologic reserve and function, has been associated with inferior results after surgery. Using a coding-based tool, we examined the clinical and financial impact of frailty on outcomes following esophagectomy. Methods: Adults undergoing elective esophagectomy were identified using the 2010-2018 Nationwide Readmissions Database. Using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator, patients were classified as frail or nonfrail. Multivariable regression models were used to evaluate the association of frailty with in-hospital mortality, complications, hospitalization duration, costs, nonhome discharge, and unplanned 30-day readmission. Results: Of 45,361 patients who underwent esophagectomy, 18.7% were considered frail. Most frail patients were found to have diagnoses of malnutrition (70%) or weight loss (15%) at the time of surgery. After adjustment, frailty was associated with increased risk of in-hospital mortality (adjusted odds ratio 1.67, 95% confidence interval 1.29-2.16) and overall complications (adjusted odds ratio 1.57, 95% confidence interval 1.44-1.71). Frailty conferred a 5.6-day increment in length of stay (95% confidence interval 4.94-6.45) and an additional $19,900 hospitalization cost (95% confidence interval $16,700-$23,100). Frail patients had increased odds of nonhome discharge (adjusted odds ratio 1.53, 95% confidence interval 1.35-1.75) as well as unplanned 30-day readmissions (adjusted odds ratio 1.17, 95% confidence interval 1.02-1.34). Conclusion: Frailty, as detected by an administrative tool, is associated with worse clinical and financial outcomes following esophagectomy. The inclusion of standardized assessment of frailty in risk models may better inform patient selection and shared decision-making prior to operative intervention.

Factors and Outcomes Associated With Venous Thromboembolism Following Bariatric Surgery.

BACKGROUND: The present national study characterized the incidence and factors associated with VTE following bariatric operations and its association with postoperative outcomes and resource use. METHODS: Adults (≥18 years) undergoing elective sleeve gastrectomy or gastric bypass (laparoscopic and open) were identified in the 2016-2018 Nationwide Readmissions Database. International Classification of Diseases 10th Revision codes for deep venous thrombosis and/or pulmonary embolism were used to ascertain the presence of VTE. Multivariable linear and logistic models were developed to evaluate the independent association of VTE with outcomes of interest. RESULTS: Of an estimated 537,522 patients meeting inclusion criteria, .55% developed VTE during index hospitalization (.14%) or within 90 days of index discharge (.41%). Compared to others, VTE patients were older (51.8 vs 44.9 years, P<.001), more commonly male (20.0% vs 31.5%, P<.001), and had gastric bypass (56.3% vs 31.9%, P<.001) or an open procedure (21.9% vs 2.6%, P<.001). After risk adjustment, several factors including increasing age, male gender, gastric bypass and open approach remained associated with increased odds of VTE. Patients with VTE during index hospitalization had greater odds of mortality (AOR 11.6, 95% CI: 6.12-22.19) and increased index LOS (ß:+14.1 days, 95% CI: 11.7-16.5) and hospitalization costs (ß: +$53,100, 95% CI: 43,100-63,500). Additionally, VTE patients had greater odds of readmission within 90 days (AOR 1.86, 95% CI: 1.40-2.47). CONCLUSIONS: Although VTE is uncommon following bariatric operations, it is significantly associated with increased mortality, readmission, and resource use. Further research is necessary to ascertain optimal management of VTE for bariatric surgery patients.