Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum.

OBJECTIVE: To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. BACKGROUND: Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. METHODS: The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. RESULTS: A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. CONCLUSIONS: Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.

Using the Stratum-Specific Likelihood Ratio Method to Derive Outcome-Based Hospital Volume Categories for Total Knee Replacement.

BACKGROUND: Evidence of higher hospital volume being associated with improved outcomes for patients undergoing total knee replacement (TKR) is mostly based on arbitrary distribution-based thresholds. OBJECTIVE: We aimed to define outcome-based volume thresholds using data from a national database. METHODS: We used the MedPAR Limited Data Set inpatient data from 2010-2015 to identify patients who had undergone primary TKR. Surgical and TKR specific complications occurring within the index hospitalization and all-cause readmission within 90 days were considered adverse events. We derived an average annual TKR case volume for each hospital and applied the stratum-specific likelihood ratio method to determine volume categories indicative of a similar likelihood of 90-day post-operative complications. Hierarchical multivariable logistic regression with a random intercept for hospital nested within study year and adjusted for patient and hospital characteristics was performed to determine if these volume thresholds were still associated with the odds of 90-day readmission for complications after adjustment. RESULTS: SSLR analysis yielded 4 hospital volume categories based on the likelihood of 90-day postoperative complications: 1-31 (low), 32-127 (medium), 128-248 (high), and 429+ (very high) TKRs performed per year. The results of the hierarchical multivariable logistic regression showed significantly increased odds of 90-day complications at lower volume categories. Sensitivity analyses confirmed our main findings. CONCLUSIONS: This study is the first to provide national-level volume categories that are evidence-based. Publicizing these thresholds may enhance quality measures available to patients, providers, and payors.

Discordance between Subjective and Objective Assessments of Activity after Pediatric Appendectomy.

BACKGROUND: Physical activity recovery after pediatric surgery can be assessed using objective measures such as step counts, but practice currently relies on subjective assessment by proxy. It is unclear how subjective and objective assessments of activity relate. We compared caregiver assessment of return to normal physical activity after pediatric appendectomy to step count recovery measured by a Fitbit. METHODS: Pediatric patients who underwent appendectomy were recruited between 2020 and 2022 to be monitored for 21 d with a Fitbit. Patients were grouped by the postoperative day (POD) (7, 14, or 21) their caregiver first reported their activity was "back to normal." Objective return to normal step count was estimated for each group by modeling the inflection point from increasing steps to a plateau. These measures were determined discordant if the subjective report remained outside the modeled 95% confidence interval (CI) for the day the group plateaued. RESULTS: Thirty-nine simple appendicitis and 40 complicated appendicitis patients were recruited. Among simple appendicitis patients, daily steps plateaued on POD 10.8 (95% CI 7.4-14.3), POD 14.0 (95% CI 11.0-17.1), and POD 11.1 (95% CI 6.9-15.3) for the day 7, day 14, and day 21 groups, respectively. Complicated appendicitis groups plateaued on POD 12.8 (95% CI 8.7-16.9), POD 15.2 (95% CI 11.1-19.3), and POD 16.7 (95% CI 12.3-21.0), respectively. Significant discordance was observed between subjective and objective assessments for the day 7 and day 14 simple groups and for the day 7 complicated group. CONCLUSIONS: There was significant discordance between caregiver and accelerometer-assessed activity recovery after pediatric surgery. Development of objective measures of recovery could help standardize assessment of children's recovery after surgery.

Metabolic syndrome and the likelihood of knee pain and functional disability: evidence from a large middle eastern population-based study.

OBJECTIVES: Metabolic Syndrome (MetS) has been associated with knee osteoarthritis (KOA) in animal studies, but epidemiologic evidence of the association remains controversial. We investigated the association between MetS and knee pain and functional disability, the hallmarks of KOA, in a Middle Eastern population with high reported MetS rates. METHODS: A population-based study of adult individuals was conducted between 01/2016 and 03/2019. Data collected included age, sex, blood pressure, body mass index (BMI), waist circumference (WC), and comprehensive metabolic panel blood tests. Knee symptoms were assessed using The Western Ontario and McMaster Arthritis index (WOMAC) The Adult Treatment Panel III criteria was applied to determine if participants had MetS. Multivariable regression was used to determine the association of MetS, and its components, with the WOMAC total and subscale scores. RESULTS: Of 6,000 participants enrolled, 15.5% had MetS. The multivariate regression demonstrated that participants with MetS had significantly higher WOMAC total and subscale scores after adjusting for demographic variables; however, these associations were not significant after adjusting for BMI. Multivariate regression examining the association between MetS components and the WOMAC scores showed sex-based significant differences with WOMAC scores; however, the differences were not larger than the minimally clinical important differences. CONCLUSIONS: This study demonstrated that after adjustment for BMI, neither MetS nor its individual parameters were associated with worse knee symptoms. As such, the association between MetS and worse knee symptoms requires further study.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals.

OBJECTIVE: To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. STUDY DESIGN: We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. RESULTS: In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. CONCLUSIONS: Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis.

STUDY OBJECTIVE: To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay. DESIGN: Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS). SETTING: SPARCS from March 1, 2016, to July 1, 2017. PARTICIPANTS: Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery. INTERVENTIONS: Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified. PRIMARY AND SECONDARY OUTCOME MEASURES: Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities. RESULTS: Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/- 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities. CONCLUSIONS: Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data.

Applicability of the AAOS appropriate-use criteria for distal radius fractures in surgical practice.

PURPOSE: The appropriate-use criteria (AUC) for distal radius fracture (DRF) was developed by the American Academy of Orthopedic Surgeons (AAOS) to aid surgeons in making evidence-based treatment decisions for DRFs. The aim of our study was to cross-reference the management of operatively treated DRFs with the web-based AAOS published AUC recommendations. METHODS: The AUC for DRF evaluates the appropriateness of ten treatment options for each of 240 mutually exclusive patient scenarios based on the combination of five factors. For every scenario, each treatment is classified as appropriate, maybe appropriate or rarely appropriate. We retrospectively reviewed the medical charts and radiographs of all adult patients ≥19 years who underwent surgery for DRFs between 1 January and 31 December 2014 and determined the rate of appropriateness of treatment in this consecutive series of patients. RESULTS: Over the study period, 108 patients (83.3% men; mean age 39.8 years) with 113 DRFs (five bilateral) were treated surgically. The most frequent scenario was represented by a type C fracture, high-energy mechanism, normal functional demand, American Society Anesthesiologists (ASA) status 1-3 and no associated injuries. The most frequently used treatment was volar locking plate (54.0%). Based on the AUC, treatment was appropriate for 96 cases (85.0%), maybe appropriate for 15 (13.2%), and rarely appropriate for two (1.8%). CONCLUSIONS: A web-based electronic AUC application can be an attractive and easy decision-making aid for orthopaedic surgeons. Application of the AUC to clinical data was relatively simple, and most operatively treated DRFs were managed appropriately. LEVEL OF EVIDENCE: IV.

A Crosswalk Between UCLA and Lower Extremity Activity Scales.

BACKGROUND: The University of California, Los Angeles (UCLA) activity scale and the Lower Extremity Activity Scale (LEAS) are the two most-widely used and rigorously developed scales for assessing activity level in patients having joint replacement. However, the two scales are not convertible, and the level of correlation between the two is not clear. Creating a crosswalk between these scales; that is, a concordance table to convert scores from one scale to the other and vice versa, will help compare results from existing studies using either scale, and pool those results for meta-analyses. It also will facilitate pooling data from multiple registries and data sources. QUESTIONS/PURPOSE: To create a crosswalk between the UCLA and the LEAS activity scales for patients having THA or TKA. METHODS: Preoperative and 2-year postoperative UCLA and LEAS scores for a cohort of patients undergoing primary TKA or THA at the Hospital for Special Surgery between May 2007 and December 2011 were matched from two registries. The scales were self-administered by patients. Three hundred sixty-four patients having TKAs (67% women; mean age, 67 years) and 403 having THA (66% women; mean age, 66 years) had both scores available. The equipercentile equating method was used to create the crosswalk. The standard response mean was used to assess responsiveness of the converted versus actual UCLA and LEAS scores from baseline to 2 years. Crosswalk validation also included comparing the area under the receiver operating characteristic curve of the actual and converted scores to evaluate their ability to discriminate different levels of function measured using the Hip dysfunction and Osteoarthritis Outcome Score activities of daily living subscale for patients having THA and the Knee injury and Osteoarthritis Outcome Score activities of daily living subscale for patients having TKA. Difference between scores was assessed using the inequality test. RESULTS: For patients having TKA, converted mean scores (UCLA to LEAS, 9.5 ± 3.0; LEAS to UCLA, 4.7 ± 2.1) were not different from the actual scores (UCLA, 4.8 ± 2.1; LEAS, 9.4 ± 2.9). Standard response means for the converted scores (UCLA to LEAS, 0.47; LEAS to UCLA, 0.52) were not different from those of the actual scores (UCLA, 0.48; LEAS, 0.56). The areas under the receiver operating characteristic curve also were not different for actual and converted scores for THA and TKA. CONCLUSION: We have developed and validated a crosswalk to easily convert UCLA to LEAS scores (and vice versa) for THA and TKA. Reproducing the crosswalk for other lower extremity conditions or surgical procedures may extend its utility to studies assessing activity in patients having these conditions or procedures.

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

BACKGROUND: Failure of THA or TKA to meet a patient's expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions. QUESTIONS/PURPOSES: To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where 'benefit' is defined as a clinically important improvement in a validated patient-reported outcomes score. METHODS: In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0-100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons' expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively. RESULTS: Surgeons' expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53-0.82; p = 0.02) and 0.74 (95% CI, 0.63-0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons' expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m2, who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons' expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42-0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40-0.61], p = 0.92). CONCLUSIONS: Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons' expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons' expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients' expectations more effectively. LEVEL OF EVIDENCE: Level II, therapeutic study.

Hip Preservation Surgery Expectations Survey: A New Method to Measure Patients' Preoperative Expectations.

PURPOSE: To develop a patient-derived expectations survey for hip preservation surgery. METHODS: Patients were eligible if they were undergoing primary hip surgery and were recruited in person or by telephone. The survey was developed in 3 phases. During phase 1, 64 patients were interviewed preoperatively and asked open-ended questions about their expectations of surgery; a draft survey was assembled by categorizing responses. During phase 2, the survey was administered twice to another group of 50 patients preoperatively to assess test-retest reliability and concordance was measured with weighted kappa values and intraclass correlations. All patients also completed valid standard hip surveys electronically. During phase 3, final items were selected, factor analysis was performed, and a scoring system was developed. RESULTS: In phase 1, 509 expectations were volunteered from which 21 distinct categories were discerned and became the items for the draft survey. In phase 2, the draft survey was completed twice, 4 days apart. In phase 3, all 21 items were retained for the final survey addressing pain, mobility, sports, resumption of active lifestyles, future function, and psychological well-being. An overall score is calculated from the number of items expected and the amount of improvement expected, and ranges from 0 to 100; higher is more expectations. For phase 2 patients, mean scores for both administrations were 82, Cronbach alpha coefficients were 0.88 and 0.91, and the intraclass correlation was 0.92. A higher score (i.e., greater expectations) was associated with worse hip condition measured by standard hip surveys (P ≤ .05). CONCLUSIONS: We developed a patient-derived survey that is valid, reliable, and addresses a spectrum of expectations. The survey generates an overall score that is easy to calculate and interpret and offers a practical and comprehensive way to record patients' preoperative expectations. LEVEL OF EVIDENCE: Level II, prognostic study, prospective sample.

Utility of the AAOS Appropriate Use Criteria (AUC) for Pediatric Supracondylar Humerus Fractures in Clinical Practice.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) recently developed an Appropriate Use Criteria (AUC) for pediatric supracondylar humerus fractures (PSHF). The AUC is intended to improve quality of care by informing surgeon decision making. The aim of our study was to cross-reference the management of operatively treated PSHF with the AAOS-published AUC. METHODS: The AUC for PSHF include 220 patient scenarios, based on different combinations of 6 factors. For each patient scenario, 8 treatment options are evaluated as "appropriate," "maybe appropriate," and "rarely appropriate." We retrospectively reviewed the medical charts and radiographs of all operatively treated PSHF at our hospital from January 2013 to December 2014 and determined the appropriateness of the treatment. RESULTS: Over the study period, 94 children (mean age: 5.2 y; 51 male, 43 female) were admitted with PSHF and underwent a surgical procedure (type IIA: 7, type IIB: 14, type III: 70, flexion type: 3). Only 8 of the 220 scenarios were observed in our patient cohort. The most frequent scenario was represented by a type III fracture, palpable distal pulse, no nerve injury, closed soft-tissue envelope, no radius/ulna fracture, and typical swelling. Of the 94 fractures, the AUC was "appropriate" for 84 cases and "maybe appropriate" for 9 cases. There was only 1 case of "rarely appropriate" management. Closed reduction with lateral pinning and immobilization was the most prevalent treatment option (58.5%). The rate of appropriateness was not affected by the operating surgeon. However, the definition of a case as emergent had a significant impact on the rate of appropriateness. CONCLUSIONS: Application of the AUC to actual clinical data was relatively simple. The majority of operatively treated PSHF (89.4%) were managed appropriately. With the introduction of electronic medical charts, an AUC application becomes attractive and easy for orthopaedic surgeons to utilize in clinical practice. However, validity studies of the AUC in different clinical settings are still required. LEVEL OF EVIDENCE: Level IV.

Cost-Effectiveness of Staphylococcus aureus Decolonization Strategies in High-Risk Total Joint Arthroplasty Patients.

BACKGROUND: The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients. METHODS: An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective. RESULTS: Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective). CONCLUSION: S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system.

The potential influence of regionalization strategies on delivery of care for elective total joint arthroplasty.

Regionalization of total joint arthroplasty (TJA) to high volume hospitals (HVHs) may affect access to care and complication risk. Using administrative data, 2,560,314 patients who underwent primary total hip or knee arthroplasty from 1991 to 2006 were categorized by whether an HVH (>200 annual TJAs) was available locally. Associations among patient characteristics, hospital utilization, and in-hospital complications were estimated using regression modeling. The complication risk was higher (Odds Ratio 1.18 [95% CI: 1.16, 1.20]) if patients went to a local low volume hospital. Black and Medicaid patients were more likely to utilize the local low volume hospital than a local HVH. Utilizing a local HVH is associated with lower complication risks. However, patients from vulnerable groups were less likely to utilize these patterns.