Association of procurement technique with organ yield and cost following donation after circulatory death.

Donation after circulatory death (DCD) could account for the largest expansion of the donor allograft pool in the contemporary era. However, the organ yield and associated costs of normothermic regional perfusion (NRP) compared to super-rapid recovery (SRR) with ex-situ normothermic machine perfusion, remain unreported. The Organ Procurement and Transplantation Network (December 2019 to June 2023) was analyzed to determine the number of organs recovered per donor. A cost analysis was performed based on our institution's experience since 2022. Of 43 502 donors, 30 646 (70%) were donors after brain death (DBD), 12 536 (29%) DCD-SRR and 320 (0.7%) DCD-NRP. The mean number of organs recovered was 3.70 for DBD, 3.71 for DCD-NRP (P < .001), and 2.45 for DCD-SRR (P < .001). Following risk adjustment, DCD-NRP (adjusted odds ratio 1.34, confidence interval 1.04-1.75) and DCD-SRR (adjusted odds ratio 2.11, confidence interval 2.01-2.21; reference: DBD) remained associated with greater odds of allograft nonuse. Including incomplete and completed procurement runs, the total average cost of DCD-NRP was $9463.22 per donor. By conservative estimates, we found that approximately 31 donor allografts could be procured using DCD-NRP for the cost equivalent of 1 allograft procured via DCD-SRR with ex-situ normothermic machine perfusion. In conclusion, DCD-SRR procurements were associated with the lowest organ yield compared to other procurement methods. To facilitate broader adoption of DCD procurement, a comprehensive understanding of the trade-offs inherent in each technique is imperative.

Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation.

OBJECTIVE: The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation. BACKGROUND: Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated. METHODS: All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS: Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001). CONCLUSIONS: Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation.

INTRODUCTION: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking. METHODS: This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator. RESULTS: Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge. CONCLUSIONS: Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

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.

Association of postoperative length of stay with outcomes following orthotopic heart transplantation-A national analysis.

BACKGROUND: In the absence of standardized recovery protocols, there is little evidence to guide postoperative care to ensure optimal in-hospital and long-term outcomes following heart transplantation (HT). Using two national databases, we examined the association between postoperative length of stay (LOS) with patient/graft survival, index hospitalization costs, and non-elective readmissions. METHODS: Adult HT recipients from 2010 to 2019 were identified and analyzed within the Organ Procurement and Transplantation Network (OPTN) Database and Nationwide Readmissions Database (NRD). The risk-adjusted relationship between 1-year mortality and LOS was assessed with restricted cubic splines and subsequently used to stratify patients into Expedited (7-11 days), Routine (12-16 days), and Delayed (>16) discharge groups. Survival outcomes were analyzed using Restricted Means Survival Time analysis (RMST) and multivariable Cox models. RESULTS: Of 9995 HT recipients within the OPTN, 3777 (38%) were categorized as Expedited, and 3040 (30%) as Routine. After adjustment, expedited discharge was not associated with inferior 90-day (ΔRMST -.01, p = .91) and 1-year patient survival (ΔRMST -.02, p = .53). Additionally, expedited was not associated with increased odds of non-elective readmission at 90-days (HR 1.04, CI .77-1.43) relative to Routine discharge. Counterfactual analysis revealed an estimated cost saving of $50 million if all Routine patients received an expedited discharge. CONCLUSION: Expedited discharge after HT seems to be cost-effective and is not associated with inferior outcomes. Institutional-level outcome analyses should be performed to identify patients that would benefit from expedited discharge, and future studies should analyze the feasibility of implementing standardized discharge protocols following HT.

Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes.

BACKGROUND: Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking. METHODS: This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts. RESULTS: Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors. CONCLUSIONS: Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.

Impact of surgeon specialty on clinical outcomes following esophagectomy for cancer.

BACKGROUND: The impact of surgeon and hospital operative volume on esophagectomy outcomes is well-described; however, studies examining the influence of surgeon specialty remain limited. Therefore, we evaluated the impact of surgeon specialty on short-term outcomes following esophagectomy for cancer. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) was queried to identify all patients undergoing esophagectomy for esophageal cancer. Surgeon specialty was categorized as general (GS) or thoracic (TS). Entropy balancing was used to generate sample weights that adjust for baseline differences between GS and TS patients. Weights were subsequently applied to multivariable linear and logistic regressions, which were used to evaluate the independent association of surgeon specialty with 30-day mortality, complications, and postoperative length of stay. RESULTS: Of 2657 esophagectomies included for analysis, 54.1% were performed by TS. Both groups had similar distributions of age, sex, and body mass index. TS patients more frequently underwent transthoracic esophagectomy, while GS patients more commonly received minimally invasive surgery. After adjustment, surgeon specialty was not associated with altered odds of 30-day mortality (adjusted odds ratio [AOR] 1.10 p = 0.73) or anastomotic leak (AOR 0.87, p = 0.33). However, TS patients exhibited a 40-min reduction in operative duration and faced greater odds of perioperative transfusion, relative to GS. CONCLUSION: Among ACS NSQIP participating centers, surgeon specialty influenced operative duration and blood product utilization, but not mortality and anastomotic leak. Our results support the relative safety of esophagectomy performed by select GS and TS.

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database. METHODS: Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis. RESULTS: Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (ß -0.10, 95% -0.13, -0.07), reduced costs (ß -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96). CONCLUSIONS: Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Intent-to-treat survival in liver transplantation has not improved in 3 decades due to donor shortage relative to waitlist growth.

BACKGROUND: Liver Transplantation has advanced over the past 3 decades, with 1-year survival rates improving 25%. Survival rates for those transplanted has increased to remarkable levels, but survival from the time of listing may not be as revolutionary. METHODS: Kaplan-Meier with log-rank test as well as Cox regression analysis was used to retrospectively analyze 211 610 adults listed for LT and 116 299 adult transplant recipients from 1987 to 2016. Our primary endpoints were survival from time of listing to waitlist death or posttransplant death. RESULTS: One-year survival following LT improved dramatically (68% in 1987-1988 vs. 93% in 2016, P < .001). There was no improvement in 1-year intent-to-treat survival: 78.4% for those listed in 1987 and 81.8% for those listed in 2016 (P = .1). Also observed were decreases in the percentage of transplanted candidates from 74.8% in 1987-1988 to 54.7% in 2016 (P < .001) and increased 1-year wait-list mortality from 12.5% in 1987-1988 to 22.6% in 2016 (P = .002). CONCLUSION: As transplant rate has decreased while waitlist mortality has increased, no improvements have been made in intent-to-treat survival of patients listed for transplant over the past 3 decades. We speculate this observation to be resultant of a relative donor shortage outpaced by waitlist growth. SUMMARY: Liver Transplantation has experienced vast increases in survival rates over the past 3 decades; however, due to an increased donor supply outpaced by waitlist growth, the rate of transplantation has decreased significantly while the waitlist mortality has increased, leading to no improvement in 1-year intent-to-treat survival rates.

Aggressive utilization of liver allografts: Improved outcomes over time.

BACKGROUND: Aggressive acceptance of liver allografts has driven utilization of marginal allografts. Our aim was to assess the impact of the aggressive phenotype on transplant center outcomes over time. METHODS: We used a cohort of 148 361 candidates from the Organ Procurement and Transplantation Network for liver transplantation between 2002 and 2016 in 134 centers. Using the Discard Risk Index, we designated high probability discard allografts by the top 10th percentile for likelihood of discard. Aggressive phenotype was defined by usage of high probability discard (HPD) allografts (top 10th percentile). Our analysis of survival on waitlist and graft survival after transplantation included a comprehensive list of center level covariates across three equal time periods (2002-2006, 2007-2011, and 2012-2016). RESULTS: After adjusting for recipient and center-level factors, aggressive centers had improving graft survival over time. Aggressive vs non-aggressive centers: 2002-2006 HR 1.12 (1.05-1.19), 2007-2011 HR 1.13 (1.05-1.22), 2012-2016 HR 0.99 (0.89-1.10). Aggressive centers had improved waitlist survival compared with non-aggressive centers after adjusting for allograft disparity. CONCLUSIONS: Aggressive phenotype had a positive impact on waitlist survival, and graft survival in aggressive centers have improved to benchmark levels over time. These findings serve as justification for aggressive utilization of allografts.

Heart Transplantation After Donation After Circulatory Death: Early United States Experience.

BACKGROUND: Given the renewed interest in heart transplantation after donation after circulatory death (DCD), a contemporary analysis of trends and longer-term survival is warranted. METHODS: Adult heart transplant recipients (December 2019-September 2023) were identified in the Organ Procurement and Transplantation Network. Recipients were stratified as donation after brain death (DBD) or DCD. DCD procurements were further classified as direct procurement and perfusion (DCD-DPP) or normothermic regional perfusion (DCD-NRP), based on the declaration of death to cross-clamp interval (≥40 minutes DCD-NRP). The main outcome was posttransplant survival at 1 and 3 years. RESULTS: Of 11,625 transplantations, 792 (7%) involved DCD allografts (249 DCD-NRP, 543 DCD-DPP). The proportion of transplants involving DCD allografts significantly increased from 2% (December 2019) to 11% (January-September 2023, P < .001). Upon adjusted analysis, 1-year posttransplant survival was similar for DBD vs DCD-DPP (hazard ratio [HR], 1.00; 95% CI, 0.66-1.66) or DCD-NRP (HR, 0.92; 95% CI, 0.49-1.72). This remained true at 3 years for DCD-DPP (HR, 1.07; 95% CI, 0.77-1.48) and DCD-NRP (HR, 1.04; 95% CI, 0.62-1.73). Incidence of postoperative stroke, dialysis, acute graft rejection, and primary graft dysfunction were similar across groups. Across various strata of recipient risk and center volume, survival was equivalent between the DBD and DCD cohorts. CONCLUSIONS: Rates of DCD heart transplantation continue to rise. Across various recipient risk and center volume categories, DCD and DBD recipients show comparable posttransplant survival up to 3 years. These findings encourage broader use of such donors in attempts to expand the organ pool.

Association of neighborhood socioeconomic disadvantage with use of minimally invasive resection for non-small cell lung cancer.

OBJECTIVE: Minimally invasive resection for non-small cell lung cancer has been linked to decreased postoperative morbidity. This work sought to characterize factors associated with receiving minimally invasive surgery for surgically resectable non-small cell lung cancer. METHODS: All adults undergoing lobectomy/sublobar resection for stage I non-small cell lung cancer were identified using the 2010-2020 National Cancer Database. Those undergoing thoracoscopic/robotic procedures comprised the minimally invasive resection cohort (others: open). Hospitals were stratified by minimally invasive resection procedure volume, with the top quartile considered high minimally invasive resection volume centers. Multivariable models were constructed to assess the independent association between the patients, diseases, and hospital factors and the likelihood of receiving minimally invasive resection. RESULTS: Of 217,762 patients, 112,304 (52%) underwent minimally invasive resection. The proportion of minimally invasive resection procedures increased from 27% in 2010 to 72% in 2020 (P < .001). After adjustment, several factors were independently associated with decreased odds of receiving minimally invasive resection, including lower quartiles of median neighborhood income (51st-75th percentile adjusted odds ratio, 0.92, 95% CI, 0.89-0.94; 26th-50th percentile adjusted odds ratio, 0.86, CI, 0.83-0.89; 0-25th percentile adjusted odds ratio, 0.78, CI, 0.75-0.81; reference: 76th-100th percentile income) and care at community hospitals (adjusted odds ratio, 0.70, CI, 0.68-0.71; reference: academic centers). Among patients receiving care at high minimally invasive resection volume centers, lowest income remained linked with reduced likelihood of undergoing minimally invasive resection from 2010 to 2015 (adjusted odds ratio, 0.85, CI, 0.77-0.94), but did not alter the odds of minimally invasive resection in later years (adjusted odds ratio, 1.01, CI, 0.87-1.16; reference: highest income). CONCLUSIONS: This study identified significant community income-based disparities in the likelihood of undergoing minimally invasive resection as definitive surgical treatment. Novel interventions are warranted to expand access to high-volume minimally invasive resection centers and ensure equitable access to minimally invasive surgery.

Hospital volume does not mitigate the impact of area socioeconomic deprivation on heart transplantation outcomes.

BACKGROUND: While structural socioeconomic inequity has been linked with inferior health outcomes, some have postulated reduced access to high-quality care to be the mediator. We assessed whether treatment at high-volume centers (HVC) would mitigate the adverse impact of area deprivation on heart transplantation (HT) outcomes. METHODS: All HT recipients ≥18 years were identified in the 2005-2022 Organ Procurement and Transplantation Network. Neighborhood socioeconomic deprivation was assessed using the previously validated Area Deprivation Index. Recipients with scores in the highest quintile were considered Most Deprived (others: Less Deprived). Hospitals in the highest quartile by cumulative center volume (≥21 transplants/year) were classified as HVC. The primary outcome was post-transplant survival. RESULTS: Of 38,022 HT recipients, 7,579 (20%) were considered Most Deprived. Following risk adjustment, Most Deprived demonstrated inferior survival at 3 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.06-1.21) and 5 years following transplantation (HR 1.13, CI 1.07-1.20). Similarly, Most Deprived faced greater graft failure at 3 (HR 1.14, CI 1.06-1.22) and 5 years (HR 1.13, CI 1.07-1.20). Evaluating patients transplanted at HVC, Most Deprived continued to face greater mortality at 3 (HR 1.10, CI 1.01-1.21) and 5 years (HR 1.10, CI 1.01-1.19). The interaction between Most Deprived status and care at HVC was not significant, such that transplantation at HVC did not ameliorate the survival disparity between Most and Less Deprived. CONCLUSIONS: Area socioeconomic disadvantage is independently associated with inferior survival. Transplantation at HVC did not eliminate this inequity. Future efforts are needed to increase engagement with longitudinal follow-up care and address systemic root causes to improve outcomes.

Association of socioeconomic vulnerability with clinical and financial outcomes following emergent hernia repair.

BACKGROUND: While race and insurance have been linked with greater likelihood of hernia incarceration and emergent presentation, the association of broader social determinants of health (SDOH) with outcomes following urgent repair remains to be elucidated. STUDY DESIGN: All adult hospitalizations entailing emergent repair for strangulated inguinal, femoral, and ventral hernias were identified in the 2016-2020 Nationwide Readmissions Database. Socioeconomic vulnerability was ascertained using relevant diagnosis codes. Multivariable models were developed to consider the independent associations between socioeconomic vulnerability and study outcomes. RESULTS: Of ∼236,215 patients, 20,306 (8.6 â€‹%) were Vulnerable. Following risk-adjustment, socioeconomic vulnerability remained associated with greater odds of in-hospital mortality, any perioperative complication, increased hospitalization expenditures and higher risk of non-elective readmission. CONCLUSIONS: Among patients undergoing emergent hernia repair, socioeconomic vulnerability was linked with greater morbidity, expenditures, and readmission. As part of patient-centered care, novel screening, postoperative management, and SDOH-informed discharge planning programs are needed to mitigate disparities in outcomes.

Challenges, Preoperative Assessment, and Surgical Strategies for the Left-Sided Gallbladder.

Left-sided gallbladder positioning, or sinistroposition, is a rare anatomical variation that poses challenges during surgical intervention due to associated vascular and biliary anomalies. While existing literature suggests an incidence of approximately 0.04-1.1%, it remains an underreported phenomenon that falls well outside the realm of "expected" anatomical variation and are rarely identified on preoperative imaging. Here, we present a case of acute cholecystitis in a patient with unexpected left-sided gallbladder, highlighting the associated challenges and outlining both preoperative and intraoperative strategies for managing this rare but consequential anatomical variant. In this case, a 49-year-old woman with a prior history of bilateral ovarian cysts presented with clinical, laboratory, and imaging findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy and was found to have a severely inflamed left-sided gallbladder that was obscured by omentum. Her gallbladder was found in the midline immediately beneath the falciform ligament, with most of the gallbladder body and fundus attached to liver segment III, situated to the left of the midline. An additional left-sided mid-abdominal port was required to enhance retraction, and an intraoperative cholangiogram (IOC) was performed given the elevated risk of structural injury. This case underscores the heightened intraoperative risk associated with deviations in vascular and biliary anatomy and provides recommendations for intraoperative adaptations to mitigate these risks.

Persistent income-based disparities in clinical outcomes of cardiac surgery across the United States: A contemporary appraisal.

Objective: Although national efforts have aimed to improve the safety of inpatient operations, income-based inequities in surgical outcomes persist, and the evolution of such disparities has not been examined in the contemporary setting. We sought to examine the association of community-level household income with acute outcomes of cardiac procedures over the past decade. Methods: All adult hospitalizations for elective coronary artery bypass grafting/valve operations were tabulated from the 2010-2020 Nationwide Readmissions Database. Patients were stratified into quartiles of income, with records in the 76th to 100th percentile designated as highest and those in the 0 to 25th percentile as lowest. To evaluate the change in adjusted risk of in-hospital mortality, complications, and readmission over the study period, estimates were generated for each income level and year. Results: Of approximately 1,848,755 hospitalizations, 406,216 patients (22.0%) were classified as highest income and 451,988 patients (24.4%) were classified as lowest income. After risk adjustment, lowest income remained associated with greater likelihood of in-hospital mortality (adjusted odds ratio, 1.61, 95% CI, 1.51-1.72), any postoperative complication (adjusted odds ratio, 1.19, CI, 1.15-1.22), and nonelective readmission within 30 days (adjusted odds ratio, 1.07, CI, 1.05-1.10). Overall adjusted risk of mortality, complications, and nonelective readmission decreased for both groups from 2010 to 2020 (P < .001). Further, the difference in risk of mortality between patients of lowest and highest income decreased by 0.2%, whereas the difference in risk of major complications declined by 0.5% (both P < .001). Conclusions: Although overall in-hospital mortality and complication rates have declined, low-income patients continue to face greater postoperative risk. Novel interventions are needed to address continued income-based disparities and ensure equitable surgical outcomes.

Persistent Racial Disparities in Morbidity Following Major Elective Operations.

Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.

Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis.

Background: Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations. Methods: All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes. Results: Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (ß + 0.90 days, CI +0.68-1.12) and costs (ß + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70). Conclusions: Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

BACKGROUND: Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS: All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS: Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS: AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.