The Impact of Palliative Decompressive Gastrostomy Tube Placement on Patients and Their Caregivers: A Mixed Methods Analysis.

BACKGROUND: Palliative decompressive gastrostomy tubes are intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life. The objective of this study was to assess the impact of palliative decompressive gastrostomy tube on patient and caregiver well-being. PATIENTS AND METHODS: We prospectively enrolled patients with a malignant SBO and their caregivers at the time of informed consent for decompressive gastrostomy tube placement. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and at 2-week post-procedure follow-up. The Caregiver Burden Scale survey was administered to caregivers at baseline. Survey scores were compared using paired t-tests. We also conducted semistructured interviews with patients and their caregivers at two-week follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders. RESULTS: We enrolled 15 patient-caregiver dyads. Preprocedure, the median caregiver burden scale score was 37.5 (significant burden ≥ 21). Eight patients (53%) survived to 2 weeks; among these patients, median ESAS scores (51 versus 43.5, p < 0.001) and median FACIT-Pal-14 scores (22 versus 32, p = 0.015) were significantly improved at 2-week follow-up. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for better education and resources. CONCLUSIONS: Decompressive gastrostomy tubes effectively alleviated symptoms in patients with inoperable malignant SBOs. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors.

The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization.

BACKGROUND: We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS: We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS: Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION: OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE: Retrospective cohort, Level III.

Failure to Rescue in Emergency Surgery: Is Precedence a Problem?

BACKGROUND: Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations. METHODS: National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations. RESULTS: There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy. CONCLUSIONS: Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.

The Location and Timing of Failure-to-Rescue Events Across a Statewide Trauma System.

BACKGROUND: Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur. MATERIALS AND METHODS: Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007-2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal-Wallis and chi-squared tests were used to compare variables. RESULTS: Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37-77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10-29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0-5 d] versus day 4 [IQR 2-8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths. CONCLUSIONS: Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.

Does Surgeon Sex Matter?: Practice Patterns and Outcomes of Female and Male Surgeons.

OBJECTIVE: We sought to compare postoperative outcomes of female surgeons (FS) and male surgeons (MS) within general surgery. SUMMARY OF BACKGROUND DATA: FS in the workforce are increasing in number. Female physicians provide exceptional care in other specialties. Differences in surgical outcomes of FS and MS have not been examined. METHODS: We linked the AMA Physician Masterfile to discharge claims from New York, Florida, and Pennsylvania (2012 to 2013) to examine practice patterns and to compare surgical outcomes of FS and MS. We paired FS and MS operating at the same hospital using cardinality matching with refined balance and compared inpatient mortality, any postoperative complication, and prolonged length of stay (pLOS) in FS and MS. RESULTS: Overall practice patterns differed between the 663 FS and 3219 MS. We identified 2462 surgeons (19% FS, 81% MS) at 429 hospitals who met inclusion criteria for outcomes analysis. FS were younger (mean age ±â€ŠSD FS: 48.5 ±â€Š8.4 years, MS: 54.3 ±â€Š9.4y; P < 0.001) with less clinical experience (mean years ±â€ŠSD FS: 11.6 ±â€Š8.3 y, MS: 17.6 ±â€Š10.0 years; P < 0.001) than MS before matching. FS had lower rates of inpatient mortality (FS: 1.51%, MS: 2.30%; P < 0.001), any postoperative complication (FS: 12.6%, MS: 16.1%; P < 0.001), and pLOS (FS: 18.4%, MS: 20.7%; P < 0.001) before matching. After matching, FS and MS outcomes were equivalent. CONCLUSION: Surgeon practice patterns vary by sex and experience. FS and MS with similar characteristics who treat similar patients at the same hospital have equivalent rates of inpatient morality, postoperative complications, and prolonged length of hospital stay. Patients should select the surgeon who is the best fit for them regardless of sex.

Prophylactic Cholecystectomy at Time of Surgery for Small Bowel Neuroendocrine Tumor Does Not Increase Postoperative Morbidity.

BACKGROUND: Prophylactic cholecystectomy at time of surgery for small bowel neuroendocrine tumor (SBNET) has been advocated, as these patients often go on to require somatostatin analogue therapy, which is known to increase risk of cholestasis and associated complications. Little is known regarding patterns of adoption of this practice or its associated morbidity. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2008-2014) was queried to identify patients who underwent SBNET resection. The risk differences of morbidity and mortality associated with performance of concurrent cholecystectomy were determined with multivariable adjustment for confounders. RESULTS: Among 1300 patients who underwent SBNET resection, 144 (11.1%) underwent concurrent cholecystectomy. Median age of patients undergoing cholecystectomy was 62 years [interquartile range (IQR) 52-69 years], and 75 were male. They more commonly had disseminated cancer (36.1 vs. 11.6%, p < 0.001) or SBNET located in duodenum (10.4 vs. 4.9%, p = 0.045) without difference in other baseline characteristics. Operative time was significantly longer in the cholecystectomy group (median 172 vs. 123 min, p < 0.001). Rate of postoperative morbidity was not significantly different between cholecystectomy and no-cholecystectomy groups (11.8 vs. 11.1%, p = 0.79). After adjustment for confounding, the risk difference of morbidity attributable to cholecystectomy was + 0.4% [95% confidence interval (CI) - 4.9 to + 5.6%]. Mortality within 30 days was not significantly different between cholecystectomy and no-cholecystectomy groups (1.4 vs. 0.6%, p = 0.29). CONCLUSIONS: Concurrent cholecystectomy at time of resection of SBNET is not associated with higher morbidity or mortality yet is performed in a minority of patients. Prospective study can identify which patients may derive benefit from this approach.

A preoperative prediction model for risk of multiple admissions after colon cancer surgery.

BACKGROUND: A subset of patients who undergo colon cancer surgery may be at a high risk of multiple subsequent admissions. We developed a simplified model to predict the preoperative risk of multiple postoperative admissions (MuAdm) among patients undergoing colon resection to aid in preoperative planning. METHODS: Patients aged ≥18 y with colon cancer who underwent elective surgical resection identified in discharge claims from California and New York (2008-2011) were included. The primary outcome, MuAdm, was defined as 2 or more admissions in the year following resection. Logistic regression models were developed to identify factors predictive of MuAdm. A weighted point system was developed using beta-coefficients (P < 0.05). A random sample of 75% of the data was used for model development, which was validated in the remaining 25% sample. RESULTS: A total of 14,780 patients underwent colon resection for cancer. Almost 30% had an admission in the year after index surgery and 9.8% had MuAdm. The significant predictors of MuAdm were higher Elixhauser comorbidity index score, metastatic disease, payer system, and the number of admissions in the year before surgery. Scores ranged from 0 to 8. Scores ≤1 had a 7% risk of MuAdm, and scores ≥6 had a >30% risk of MuAdm. CONCLUSIONS: In the year following discharge after resection of colon cancer, nearly 10% of patients are admitted 2 or more times. A simple, preoperative clinical model can prospectively predict the likelihood of multiple admissions in patients anticipating resection. This model can be used for preoperative planning and setting postoperative expectations more accurately.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery.

BACKGROUND: Hypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures. MATERIALS AND METHODS: The 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5 g/dL [normal], 3.49-3.0 g/dL [mild], 2.99-2.5 g/dL [moderate], and <2.5 g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined. RESULTS: A total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM. CONCLUSIONS: More than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.

Hospitalization in the Year Preceding Major Oncologic Surgery Increases Risk for Adverse Postoperative Events.

BACKGROUND: Hospitalization is associated with negative clinical effects that last beyond discharge. This study aimed to determine whether hospitalization in the year before major oncologic surgery is associated with adverse outcomes. METHODS: Patients 18 years of age or older with stomach, pancreas, colon, or rectal cancer who underwent resection in California and New York (2008-2010) were included in the study. Patients with hospitalization in the year prior to oncologic resection (HYPOR) were identified. Multivariable logistic regression was used to examine the association of prior hospitalization with the following adverse outcomes: inpatient mortality, complications, complex discharge needs, and 90-day readmission. Subset analysis by cancer type was performed. Outcomes based on temporal proximity of hospitalization to month of surgical admission were evaluated. RESULTS: Of 32,292 patients, 16.3% (n = 5276) were HYPOR. Patients with prior hospitalization were older (median age, 72 vs 67 years; p < 0.001) and had more comorbidities (Elixhauser Index ≥3, 86.5 vs 75.3%; p < 0.001). In the multivariable analysis, HYPOR was associated with complications (odds ratio [OR], 1.28; 95% confidence interval [CI] 1.18-1.40), complex discharge (OR, 1.44; 95% CI 1.34-1.55), and 90-day readmission (OR, 1.45; 95% CI 1.35-1.56). The interval from HYPOR to resection was not associated with adverse outcomes. CONCLUSIONS: Patients hospitalized in the year before oncologic resection are at increased risk for postoperative adverse events. Recent hospitalization is a risk factor that is easily ascertainable and should be used by clinicians to identify patients who may need additional support around the time of oncologic resection.

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study.

BACKGROUND: Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade. METHODS: We used Pennsylvania Trauma Outcomes Study registry data from 2006-15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS. RESULTS: Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40-2.55), African American race (OR 1.71 95%CI 1.34-2.18), and Asian race (OR 2.25, 95%CI 1.22-4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures. CONCLUSIONS: PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.

A Contemporary Analysis of Delayed Diagnoses After Traumatic Injury : The Role of Operative Therapy.

BACKGROUND: Factors associated with delayed injury diagnosis (DID) have been examined, but incompletely researched. METHODS: We evaluated demographics, mechanism, and measures of mental status and injury severity among 10 years' worth of adult trauma patients at our center for association with DID in a multivariable regression model. Descriptions of DID injuries were reviewed to highlight characteristics of these injuries. RESULTS: We included 13 509 patients, 89 (0.7%) of whom had a recognized DID. In regression analysis, ISS (OR 1.04 per point, 95% CI 1.02-1.06) and number of injuries (OR 1.08 per injury, 95% CI 1.04-1.11) were associated with DID. Operative patients had twice the odds of DID (OR 2.02, 95% CI 1.18-3.44). The most common category of DID was orthopedic extremity injury (22/89). CONCLUSION: DID is associated with injury severity and operative intervention. This suggests that the presence of an injury requiring operation may distract the trauma team from additional injuries.

Enterocutaneous fistula after emergency general surgery: Mortality, readmission, and financial burden.

BACKGROUND: The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions. METHODS: Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively. RESULTS: A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery. CONCLUSIONS: Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study, Level III.

A 'weekend effect' in operative emergency general surgery.

BACKGROUND: Evidence of a "weekend effect" is limited in emergency general surgery (EGS). We hypothesized that there are increased rates of complications, death, and failure-to-rescue (FTR) in patients undergoing weekend EGS operations. METHODS: National Inpatient Sample (NIS) data, January 2014-September 2015 were used. Operative EGS patients were identified by ICD-9 procedure code and timing to operation. Complications were defined by ICD-9 code. We performed survey-weighted multivariable regression analyses. RESULTS: Of 438,110 EGS patients, 103,450 underwent weekend operation. There was no association between weekend operation and FTR (OR 1.17; 95%CI 0.95-1.45) or complications (OR 1.04; 95%CI 0.97-1.13). There was a weekend effect on mortality (OR 1.22; 95%CI 1.02-1.46) and an interactive effect between weekend operation and teaching status on complications (teaching OR 1.22; 95%CI 1.15-1.29; interaction OR 1.13; 95%CI 1.03-1.25). CONCLUSIONS: There is evidence for a "weekend effect" on mortality, but not complications or FTR, in this cohort.

Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience.

BACKGROUND: Emergent procedures are infrequent in pediatric trauma. We sought to determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center. METHODS: The National Trauma Data Bank (2010-2014) was queried for patients 19 years or younger who underwent LSIs within 1 hour of arrival to the emergency department. Life-saving interventions included emergency department thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality. RESULTS: Of 725,284 recorded traumatic encounters, only 1,488 (0.2%) pediatric patients underwent at least one of the defined LSI during the 5-year study period (EDT, 1,323; EAP, 187). Most patients (85.6%) were 15 years or older. Mortality was high but varied by procedure type (EDT, 64.3%; EAP, 28.3%). Mortality for patients younger than 1 year undergoing EDT was 100%, decreasing to 62.6% in patients aged 15 years to 19 years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15-year-old to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately one LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center. CONCLUSION: Life-saving interventions in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Failure to rescue as a center-level metric in pediatric trauma.

BACKGROUND: Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database. METHODS: We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test. RESULTS: Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%). CONCLUSION: Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.

Disparities in operative outcomes in patients with comorbid mental illness.

BACKGROUND: Patients with mental health disorders have worse medical outcomes and experience excess mortality compared with those without a mental health comorbidity. This study aimed to evaluate the relationship between mental health comorbidities and surgical outcomes. METHODS: This retrospective cohort study used the National Inpatient Sample (2009-2011) to select patients who underwent one of the 4 most common general surgery procedures (cholecystectomy and common duct exploration, colorectal resection, excision and lysis of peritoneal adhesions, and appendectomy). Patients with a concurrent mental health diagnosis were identified. Multivariable logistic regression examined outcomes, including prolonged length of stay, in-hospital mortality, and postoperative complications. RESULTS: Of the 579,851 patients included, 38,702 patients (6.7%) had a mental health diagnosis. Mood disorders were most prevalent (58.7%), followed by substance abuse (23.8%). After adjustment for confounders, including sex, race, number of comorbidities, admission status, open operations, insurance, and income quartile, we found that having a mental health diagnosis conferred a 40% greater odds of including prolonged length of stay (OR 1.41, P < .001) and increased odds of any complication (OR 1.18, P < .001). Odds of death were slightly less in the mental health diagnosis cohort. CONCLUSIONS: General surgery patients with comorbid mental disease experience a greater incidence of postoperative complications and longer hospitalizations. Recognizing these disparate outcomes is the first step in understanding how to optimize care for this frequently marginalized population.

Association of Surgical Practice Patterns and Clinical Outcomes With Surgeon Training in University- or Nonuniversity-Based Residency Program.

Importance: Important metrics of residency program success include the clinical outcomes achieved by trainees after transitioning to practice. Previous studies have shown significant differences in reported training experiences of general surgery residents at nonuniversity-based residency (NUBR) and university-based residency (UBR) programs. Objective: To examine the differences in practice patterns and clinical outcomes between surgeons trained in NUBR and those trained in UBR programs. Design, Setting, and Participants: This observational cohort study linked the claims data of patients who underwent general surgery procedures in New York, Florida, and Pennsylvania between January 1, 2012, and December 31, 2013, to demographic and training information of surgeons in the American Medical Association Physician Masterfile. Patients who underwent a qualifying procedure were grouped by surgeon. Practice pattern analysis was performed on 3638 surgeons and 1 237 621 patients, representing 214 residency programs. Clinical outcomes analysis was performed on 2301 surgeons and 312 584 patients. Data analysis was conducted from February 1, 2017, to July 31, 2017. Exposures: NUBR or UBR training status. Main Outcomes and Measures: Inpatient mortality, complications, and prolonged length of stay. Results: No significant differences were observed between the NUBR-trained surgeons and UBR-trained surgeons in age (mean, 53.3 years vs 53.7 years), sex (female, 18.2% vs 16.9%), or years of clinical experience (mean, 16.5 years vs 16.5 years). Overall, NUBR-trained surgeons compared with UBR-trained surgeons performed more procedures (median interquartile range [IQR], 328 [93-661] vs 164 [49-444]; P < .001) and performed a greater proportion of procedures in the outpatient setting (risk difference, 6.5; 95% CI, 6.4 to 6.7; P < .001). Before matching, the mean proportion of patients with documented inpatient mortality was lower for NUBR-trained surgeons than for UBR-trained surgeons (risk difference, -1.01; 95% CI, -1.41 to -0.61; P < .001). The mean proportion of patients with complications (risk difference, -3.17%; 95% CI, -4.21 to -2.13; P < .001) and prolonged length of stay (risk difference, -1.89%; 95% CI, -2.79 to -0.98; P < .001) was also lower for NUBR-trained surgeons. After matching, no significant differences in patient mortality, complications, and prolonged length of stay were found between NUBR- and UBR-trained surgeons. Conclusions and Relevance: Surgeons trained in NUBR and UBR programs have distinct practice patterns. After controlling for patient, procedure, and hospital factors, no differences were observed in the inpatient outcomes between the 2 groups.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission.

BACKGROUND: Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30 days, and complications. METHODS: Patients >18 years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18 days; n = 581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes. RESULTS: Of 10,093 patients with emergency operations, most were elderly (median 66 years old [interquartile ratio: 53-77 years]), white, and female. Postoperative 30-day mortality was 12.6% (n = 1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30 days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30 days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]). CONCLUSION: Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.