Neighborhood Socioeconomic Status and Readmission in Acute Type A Aortic Dissection Repair.

INTRODUCTION: We examined the association of socioeconomic status as defined by median household income quartile (MHIQ) with mortality and readmission patterns following open repair of acute type A aortic dissection (ATAAD) in a nationally representative registry. METHODS: Adults who underwent open repair of ATAAD were selected using the US Nationwide Readmissions Database and stratified by MHIQ. Patients were selected based on diagnostic and procedural codes. The primary endpoint was 30-d readmission. RESULTS: Between 2016 and 2019, 10,288 individuals (65% male) underwent open repair for ATAAD. Individuals in the lowest income quartile were younger (median: 60 versus 64, P < 0.05) but had greater Elixhauser comorbidity burden (5.9 versus 5.7, P < 0.05). Across all groups, in-hospital mortality was approximately 15% (P = 0.35). On multivariable analysis adjusting for baseline comorbidity burden, low socioeconomic status was associated with increased readmission at 90 d, but not at 30 d. Concomitant renal disease (odds ratio [OR], 1.68; P < 0.001), pulmonary disease (OR, 1.26; P < 0.001), liver failure (OR 1.2, P = 0.04), and heart failure (OR, 1.17; P < 0.001) were all associated with readmission at 90 d. The primary indication for readmission was most commonly cardiac (33%), infectious (16.5%), and respiratory (9%). CONCLUSIONS: In patients who undergo surgery for ATAAD, lower MHIQ was associated with higher odds of readmission following open repair. While early readmission for individuals living in the lowest income communities is likely attributable to greater baseline comorbidity burden, we observed that 90-d readmission rates are associated with lower MHIQ regardless of comorbidity burden. Further investigation is required to determine which patient-level and system-level interventions are needed to reduce readmissions in the immediate postoperative period for resource poor areas.

Timing of Noncardiac Surgery Following Transcatheter Aortic Valve Replacement: A National Analysis.

BACKGROUND: The optimal timing of noncardiac surgery (NCS) following transcatheter aortic valve replacement (TAVR) for aortic stenosis has not been elucidated by current national guidelines. OBJECTIVES: The aim of this study was to evaluate the effect of the time interval between TAVR and NCS (Δt) on the perioperative risk of major adverse events (MAEs). METHODS: All adult admissions for isolated TAVR for aortic stenosis were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients who received NCS on subsequent admission were included for analysis and grouped by Δt as follows: ≤30, 31 to 60, 61 to 90, and >90 days. Multivariable regression models were constructed to examine the association of Δt with ensuing outcomes. RESULTS: Of 3,098 patients (median age = 79 years, 41.6% female), 19.1% underwent NCS at ≤30 days, 22.9% at 31 to 60 days, 16.7% at 61 to 90 days, and 41.3% at >90 days. After adjustment, the odds of MAEs were similar for operations performed at ≤30 days (adjusted OR [AOR]: 1.05; 95% CI: 0.74-1.50), 31 to 60 days (AOR: 0.97; 95% CI: 0.71-1.31), and 61 to 90 days (AOR: 0.95; 95% CI: 0.67-1.34), with those at >90 days as reference. When examining the average marginal effect of the interval to surgery, risk-adjusted MAE rates were statistically similar across Δt groups for elective status and NCS risk category combinations. CONCLUSIONS: NCS within 30, 31 to 60, or 61 to 90 days after TAVR was not associated with increased odds of MAEs compared with operations after 90 days irrespective of NCS risk category or elective status. Our findings suggest that the interval between NCS and TAVR may not be an accurate predictor of MAE risk in this population.

Risk Analysis Index as a preoperative frailty tool for elective ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement. METHODS: The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes. RESULTS: A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70). CONCLUSIONS: In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.

Unplanned 30-Day Readmissions After Hospitalization for Irritable Bowel Syndrome.

Background Irritable bowel syndrome (IBS) continues to pose significant healthcare challenges due to its broad differential diagnosis and the often extensive yet inconclusive workup. We investigated the rates and characteristics of unplanned 30-day readmissions in adult patients hospitalized with IBS. In addition, we identified factors that predict readmission within 30 days of initial discharge. Methods We analyzed the 2020 Nationwide Readmission Database. Using the International Classification of Diseases, Tenth Revision, Clinical Modification code, we identified hospitalizations in adult patients with IBS. We excluded hospitalizations for minors and planned or elective readmissions. To compare baseline characteristics between readmissions and index hospitalizations, χ2 tests were employed. We used multivariate Cox regression analyses to identify independent predictors of readmissions. Results A total of 5,729 adult hospitalizations with IBS as the primary diagnosis were discharged alive, and 638 (11.1%) readmissions occurred within 30 days. The most common diagnoses associated with readmission were noninfective gastroenteritis and colitis, sepsis, enterocolitis due to Clostridium difficile, and irritable bowel syndrome with or without diarrhea. Patients in readmissions had a mean age of 56.3 years, similar to index hospitalizations (54.5 years, p=0.093). Readmissions had a higher burden of comorbidity (Charlson comorbidity index (CMI) scores ≥3: 26.7%, 170 cases vs. 16.6%, 953 cases; p<0.001) and were mostly Medicare beneficiaries (49.5%, 316% vs. 44.9%, 2,578) compared with index hospitalizations. Readmissions had a longer mean length of stay (LOS) (5.2 vs. 3.6 days, p<0.0001), higher inpatient mortality (0.8%, 5% vs. 0.2%, 11; p=0.032), and higher mean hospital costs ($47,852 vs. $34,592; p<0.0001) compared with index admissions. Secondary diagnoses of ulcerative colitis (adjusted hazard ratio (AHR), 2.82; p<0.0001), interstitial cystitis (AHR, 5.37; p=0.007), peripheral vascular disease (AHR, 1.59; p=0.027), and discharge to short-term hospitals (AHR, 1.03; p<0.0001) were significantly associated with a higher likelihood of readmission within 30 days. Conclusion IBS readmissions have poorer outcomes than index hospitalizations. Patients with an existing history of ulcerative colitis, interstitial cystitis, and peripheral vascular disease and those discharged to short-term hospitals following index hospitalization are more likely to be readmitted within 30 days.

Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States.

Background: Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied. Objectives: The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined. Methods: All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization. Results: Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs. Conclusions: CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.

Influence of concomitant ablation of nonparoxysmal atrial fibrillation during coronary artery bypass grafting on mortality and readmissions.

Objective: We determined the utilization rate of surgical ablation (SA) during coronary artery bypass grafting (CABG) and compared outcomes between CABG with or without SA in a national cohort. Methods: The January 2016 to December 2018 Nationwide Readmissions Database was searched for all patients undergoing isolated CABG with preoperative persistent or chronic atrial fibrillation by using the International Classification of Diseases, 10th Revision classification. Propensity score matching and multivariate logistic regressions were performed to compare outcomes, and Cox proportional hazards model was used to assess risk factors for 1-year readmission. Results: Of 18,899 patients undergoing CABG with nonparoxysmal atrial fibrillation, 78% (n = 14,776) underwent CABG alone and 22% (n = 4123) underwent CABG with SA. In the propensity score-matched cohort (n = 8116), CABG with SA (n = 4054) (vs CABG alone [n = 4112]) was not associated with increased in-hospital mortality (3.4% [139 out of 4112] vs 3.9% [159 ut of 4054]; P = .4), index-hospitalization length of stay (10 days vs 10 days; P = .3), 30-day readmission (19.1% [693 out of 3362] vs 17.2% [609 out of 3537]; P = .2), or 90-day readmission (28.9% [840 out of 2911] vs 26.2% [752 out of 2875]; P = .1). Index hospitalization costs were significantly higher for those undergoing SA ($52,556 vs $47,433; P < .001). Rates of readmission at 300 days were similar between patients receiving SA (43.8%) and no SA (42.8%; log-rank P = .3). The 3 most common causes of readmission were not different between groups and included heart failure (24.3% [594 out of 2444]; P = .6), infection (16.8% [411 out of 2444]; P = .5), and arrhythmia (11.7% [286 out of 2444]; P = .2). Conclusions: In patients with nonparoxysmal atrial fibrillation, utilization of SA during CABG remains low. SA during CABG did not adversely influence mortality or short-term readmissions. These findings support increased use of SA during CABG.