Timing of Pediatric Incarcerated Inguinal Hernia Repair: A Review of Nationwide Readmissions Data.

INTRODUCTION: In pediatric patients, incarcerated inguinal hernias are often repaired on presentation. We hypothesize that in appropriate patients, repair may be safely deferred. METHODS: The Nationwide Readmissions Database was used to identify pediatric patients (aged < 18 y) with incarcerated inguinal hernia from 2010 to 2014. Patients were stratified by management approach (Early Repair versus Deferral). Overall frequencies of these operative strategies were calculated. Propensity score matching was then performed to control for patient age, comorbidities, perinatal conditions, and congenital anomalies. Outcomes including complications, surgical procedures, and readmissions were compared. Outpatient surgeries were not assessed. RESULTS: Among 6148 total patients with incarcerated inguinal hernia, the most common strategy was to perform Early Repair (88% versus 12% Deferral). Following propensity score matching, the cohort included 1288 patients (86% male, average age 1.7 ± 4.1 years). Deferral was associated with equivalent rates of readmission within one year (13% versus 15%, P = 0.143), but higher readmissions within the first 30 days (7% versus 3%, P = 0.002) than Early Repair. Deferral patients had lower rates of orchiectomy (2% versus 5%, P = 0.001), wound infections (< 2% versus 2%, P = 0.020), and other infections (7% versus 15%, P < 0.001). The frequency of other complications including bowel resection, oophorectomy, testicular atrophy, sepsis, and pneumonia were equivalent between groups. Three percent of Deferrals had a diagnosis of incarceration on readmission. CONCLUSIONS: Deferral of incarcerated inguinal hernia repair at index admission is associated with higher rates of hospital readmissions within the first 30 days but equivalent readmission within the entire calendar year. These patients are at risk of repeat incarceration but have significantly lower rates of orchiectomy than their counterparts who undergo inguinal hernia repair at the index admission. We propose that prospective studies be performed to identify good candidates for Elective Deferral following manual reduction and overnight observation. Such studies must capture outpatient surgical outcomes.

Outcomes of Incidental Appendectomy During Ovarian Operations in a National Pediatric Cohort.

INTRODUCTION: The utility of incidental appendectomy (IA) during many ovarian operations has not been evaluated in the pediatric population. This study sought to compare outcomes after ovarian surgery with IA in the pediatric population. METHODS: Females (≤20 y old) undergoing ovarian surgeries (oophorectomy, detorsion and/or drainage) were identified from the Nationwide Readmissions Database (2016-2018). Those with appendicitis were excluded. A propensity score-matched analysis (PSMA) with 46 covariates (demographics, comorbidities, hospitalization factors, etc.) was performed between those receiving ovarian surgery with or without IA. RESULTS: There were 13,202 females (median age 17 [IQR 14-20] y old) who underwent oophorectomy (90%), detorsion (26%), and/or ovarian drainage (13%). There were more episodes of torsion in the PSMA cohort receiving ovarian surgery alone (17% versus 10% IA; P = 0.016), while other indications (ovarian mass, cyst) were similar. Open (66% versus 34% laparoscopic) IAs were more frequent. Length of stay (LOS) was longer for those undergoing IA (3 [2-4] versus 2 [2-4] days ovarian surgery alone; P < 0.001). There was a higher rate of postoperative GI complications in the IA cohort. Subgroup analysis of those undergoing laparoscopic operations demonstrated no difference in LOS or postoperative complications between patients undergoing IA or not. CONCLUSIONS: These data indicate that IA in pediatric ovarian operations is associated with longer LOS and higher GI postoperative complications. However, laparoscopic IA was not associated with higher cost, complications, LOS, or readmissions. This suggests that IA performed during ovarian surgeries in select patients may be cost-effective and worthy of future study.

Assessment of neuromonitoring use and postoperative readmission rates in pediatric Chiari I malformation with syrinx.

INTRODUCTION: While operative intervention for Chiari malformation type I (CMI) with syringomyelia is well established, there is limited data on outcomes of intraoperative neuromonitoring (IONM). This study sought to explore differences in procedural characteristics and their effects on postoperative readmission rates. METHODS: The Nationwide Readmission Database was queried from 2010 to 2014 for patients ≤ 18 years of age with CMI and syringomyelia who underwent cranial decompression or spinal decompression. Demographics, hospital characteristics, and outcomes were analyzed. RESULTS: Over the 5-year period, 2789 patients were identified that underwent operative treatment for CMI with syringomyelia. Mean age was 10 ± 4 years with 55% female. During their index hospitalization 14% of the patients had IONM. Patients receiving IONM had no significant difference in Charleston Comorbidity Index ≥ 1 (16% vs. 15% without, p = 0.774). IONM was more often used in those with private insurance (63% vs. 58% without, p = 0.0004) and less likely in those with Medicaid (29% vs. 37% without, p = 0.004). Patients receiving IONM were more likely to have a postoperative complication (23% vs 17%, p = 0.004) and were more likely to have hospital lengths of stay > 7 days (9% vs. 5% without, p = 0.005). Readmission rates for CMI were 9% within 30 days and 15% within the year. The majority (89%) of readmissions were unplanned. 25% of readmissions were for infection and 27% of readmissions underwent a CMI reoperation. The 30-day readmission rate was higher for those with IONM (12% vs. 8% without, p = 0.010). Median cost for hospitalization was significantly higher for patients with IONM ($26,663 ($16,933-34,397)) vs. those without ($14,577 ($11,538-18,392)), p < 0.001. CONCLUSION: The use of intraoperative neuromonitoring for operative repair of CMI is associated with higher postoperative complications and readmissions. In addition, there are disparities in its use and increased cost to the healthcare system. Further studies are needed to elucidate the factors underlying this association.

Ovarian Preservation and Recurrent Torsion in Children: Both Less Common Than We Thought.

PURPOSE: Surgical management of pediatric ovarian torsion includes total oophorectomy (TO) or ovarian preservation surgery (OPS). This study sought to identify factors contributing to surgical management and readmission outcomes for ovarian torsion. METHODS: The Nationwide Readmission Database from 2010-2014 was used to identify patients < 18 years admitted with ovarian torsion. Patient factors, hospital characteristics, and readmission outcomes were compared by TO and OPS. Standard statistical analysis was performed and results were weighted for national estimates. RESULTS: There were 6028 patients (age 13 ± 4 years) identified with ovarian torsion who underwent either TO (50%) or OPS (50%). Patients had secondary pathology of ovarian cyst (41%), benign mass (19%), and malignant mass (0.4%). OPS was more common in teaching hospitals (84% vs. 74% TO, P<0.001), patients < 13 years of age (41% vs. 37% TO, P = 0.001), and those from high-income households (51% vs. 41% TO, P<0.001). The overall readmission rate was 4%, with no difference between surgical approach (4.3% OPS vs. 4.4% TO, P = 0.882). Of those readmitted (n = 265), readmission diagnoses were cyst (10%), malignant mass (9%), benign mass (7%), and torsion (5%). The overall rate of recurrent torsion was 0.2%, with no difference between OPS and TO (< 0.3% vs. < 0.2%, P = 0.282). CONCLUSION: Half of pediatric patients are undergoing TO for ovarian torsion in the U.S. and disparities exist with the utilization of OPS. There is no difference in rate of readmission or recurrent torsion between surgical approaches, and the overall rate of retorsion is lower than previously reported.

Identifying Abuse and Neglect in Hospitalized Children With Burn Injuries.

BACKGROUND: The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. RESULTS: There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001). CONCLUSIONS: This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

Hidden Readmissions after Carotid Endarterectomy and Stenting.

BACKGROUND: Historically, carotid procedures incur a readmission rate of approximately 6%; however, these studies are not nationally representative and are limited to tracking only the index hospitals. We sought to evaluate a nationally representative database for readmission rates (including different hospitals) after both carotid endarterectomy (CEA) and carotid artery stenting (CAS) and determine risk factors for poor outcomes including postoperative mortality and myocardial infarction. METHODS: This study was a retrospective analysis utilizing the 2010-2014 Nationwide Readmissions Database to query patients aged >18 years undergoing CEA or CAS. Outcomes included initial admission mortality, and 30-day readmission, including mortality and myocardial infarction (MI). Univariable analysis of 39 demographic, clinical, and hospital variables was conducted with significance set at P < 0.05. Significant variables were included in a multivariable logistic regression to identify independent risk factors for readmission. Results were weighted for national estimates. RESULTS: There were 527,622 patients undergoing carotid procedures and 13% (n = 69,187) underwent CAS. The 30-day readmission rate was 7% (n = 35,782), and of those, 25% (n = 8,862) were readmitted to a different hospital. When controlling for other factors, CAS was a risk factor for mortality at both index admission (odds ratio [OR] 2.29 [2.11-2.49]) and 30-day readmission (OR 1.48 [1.3-1.69]) and 30-day readmissions at both index hospital (OR 1.11 [1.07-1.14]) and different hospital (OR 1.38 [1.29-1.48]). Readmission to a different hospital increased mortality risk (OR 1.45 [1.29-1.63]) but did not have an effect on MI. Postoperative infections comprised 15% of readmissions while 6% of all readmissions were for stroke. CONCLUSIONS: Previously unreported, one in 4 readmissions after carotid procedures occur at a different hospital and this fragmentation of care could increase mortality risk after carotid procedures particularly for CAS which was also an independent risk factor for postoperative mortality and readmissions. Further validation is required to decrease unnecessary hospital after carotid procedures.

Thirty-day readmissions following parathyroidectomy: Evidence from the National Readmissions Database, 2013-2014.

PURPOSE: Parathyroidectomy is one of the most common procedures performed in the United States, and are increasingly being performed safely in the outpatient setting. However, complications from surgery can be life-threatening, and thus an understanding of who may be at risk is essential. We analyzed and compared the risk factors for patients readmitted within 30 days following inpatient parathyroidectomy for primary or secondary hyperparathyroidism. MATERIALS AND METHODS: We reviewed the National Readmissions Database from 2013 to 2014 for patients who received inpatient parathyroidectomy for primary or secondary hyperparathyroidism. The primary outcome was non-elective readmission within 30 days. Multivariate logistic regression was used to analyze risk factor odds ratios for readmission. RESULTS: 7171 patients underwent inpatient parathyroidectomies in 2013 and 2014. 59.89% of parathyroidectomies were performed for primary hyperparathyroidism, with a 5.6% readmission rate. Most common causes of readmission were septicemia (13.69%), hypocalcemia (12.86%), heart failure (10.79%) and renal failure (9.54%). Having Medicare (OR: 1.71, CI:1.14-2.59, p = .01), Medicaid (OR: 3.24, CI: 2.03-5.17, p < .001), and self-paying (OR: 2.43, CI: 1.11-5.32, p = .02), were associated with increased odds of readmission for those with primary hyperparathyroidism. 21.99% of parathyroidectomies were performed for secondary hyperparathyroidism, with a 19.4% readmission rate. Most common causes of readmission were hypocalcemia (22.88%), hungry bone syndrome (14.38%), electrolyte disorders (13.73%), and renal failure (11.11%). CONCLUSION: Patients with secondary hyperparathyroidism are older, poorer and have more comorbidities than patients with primary hyperparathyroidism, and are more likely to be readmitted within 30 days of parathyroidectomy.

Impact of Language Congruence on Patient Outcomes Following Gastrostomy Tube Insertion.

Inadequate health literacy poses a significant public health challenge, influencing patient treatment adherence and outcomes. This study explores outcomes in the setting of language congruence at the time of discharge for pediatric patients following laparoscopic gastrostomy tube insertion. We conducted a retrospective chart review from 2019 to 2022 at a community children's hospital, including 168 patients categorized based on language congruence. Although trends did suggest increased ER visits among Spanish-speaking patients, there were no statistically significant differences in health care utilization or patient outcomes identified. Further larger studies are needed for a comprehensive analysis of the relationship of language congruence at discharge on outcomes following surgical procedures as this may enable delivery of culturally competent medical care.

The Impact of Redosing Antibiotics for Pediatric Patients Undergoing Appendectomy for Complicated Appendicitis.

Currently, there is no universally accepted, standardized protocol for pre-operative antibiotic administration in the setting of appendectomy for complicated appendicitis among pediatric patients. Strategies to mitigate surgical site infections (SSIs) must be balanced with optimal antibiotic use and exposure. We conducted a retrospective chart review to compare outcomes between patients treated pre-operatively with a single pre-operative dose of antibiotics with those who received additional antibiotics prior to laparoscopic appendectomy for complicated appendicitis between 2020 and 2022. Of 124 pediatric patients, 18% received an additional dose of pre-operative antibiotics after initial treatment dose. Surgical site infection rates between the two groups were not statistically significant (P-value = .352), thereby suggesting that redosing antibiotics closer to the time of incision may not impact SSI rates. Additional studies are necessary to make clinical recommendations.

Resilience and Value: Pediatric Trauma Care in Safety Net Hospitals.

Background: In the setting of limited funding and high expectations for quality care, safety net hospitals play a crucial role in treating pediatric trauma patients. This study aimed to compare outcomes and hospitalization costs of pediatric trauma patients in safety net hospitals across the United States. Methods: The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years hospitalized for traumatic injury. Patients admitted to safety net hospitals were propensity matched 1:1 to all other patients. The primary outcome was mortality. The secondary outcomes were readmission within 1-year, mean length of stay (LOS), total charges, and total hospitalization costs including readmissions. Results: There were 176,325 patients meeting inclusion criteria, and 30,869 were admitted to safety net hospitals. All safety net patients were successfully matched across predictors, and 61,738 patients were included. The overall mortality rate was 1.4% (n = 834), and the mortality risk was similar in safety net hospitals (OR 1.11 [.96-1.27] P = .15). The overall readmission rate, mean LOS, and mean total cost were similar for safety net hospitals when compared to all hospitals. However, the overall mean total charge was $78,724 (±$224,884) and was lower in safety net hospitals ($76,575 [±$198,342], P = .02). Discussion: Safety net hospitals deliver comparable outcomes as other health care facilities when caring for pediatric trauma patients. Notably, these hospitals appear to undercharge for their services, despite incurring similar costs in the process. These results shed light on the resilience of safety net hospitals in delivering quality and cost-effective care.

Uncovering Risk Factors and Outcomes of Pulmonary Embolism in a Nationwide Cohort of Hospitalized Children.

PURPOSE: The incidence of pulmonary embolism (PE) in hospitalized children has increased in recent years. This study sought to characterize factors and outcomes associated with PE using a national pediatric cohort. METHODS: The Nationwide Readmissions Database was queried (2016-2018) for patients (<18 years) with a diagnosis of PE. Index and prior hospitalizations (PHs) within 1 year were analyzed. A binary logistic regression utilizing 37 covariates (demographics, procedures, comorbidities, etc.) was constructed to examine a primary outcome of in-hospital mortality. RESULTS: 3440 patients were identified (57% female) with the majority >12 years old (77%). One-third had a known deep vein thrombosis (69% lower and 31% upper extremity). Nineteen percent underwent central venous catheter (CVC) placement. Twenty-one percent had a PH within 1 year. Nine percent underwent an operation with the majority being cardiothoracic (5%). Overall mortality was 5%. Neurocranial surgery, cardiothoracic surgery, and CVC placement were associated with the highest odds of inpatient mortality after logistic regression. CONCLUSION: Pediatric patients with PE have a high rate of PHs, CVC placement, and inpatient operations, which may be associated with higher mortality. This information can be utilized to improve screening measures and clinical suspicion for PE in hospitalized children.

Surgical Urgency, Patient Comorbidities, and Socioeconomic Factors in Surgical Site Infections in Pediatric Surgery.

BACKGROUND: The rise of value-based purchasing has led to decreased compensation for hospital-acquired conditions, including surgical site infections (SSI). This study aims to assess the risk factors for SSI in children and teenagers undergoing gastrointestinal surgery across US hospitals. METHODS: The 2018-2020 Nationwide Readmissions Database was queried for patients undergoing gastrointestinal surgery under the age of 18. The primary outcome was SSI during index admission or readmission within a year. Comparison groups were elective, trauma, and emergent surgery based on anatomic location and urgency. Univariable comparison used chi-squared tests for relevant variables. Confounders were addressed through multivariable logistic regression with significant variables from univariable analysis. RESULTS: 113 108 total patients met the study criteria. The SSI rate during admission or readmission was 2.9% (n = 3254). Infections during admission and readmission were 1.4% (n = 1560) and 1.5% (n = 1694), respectively. The most common site was organ space (48.6%, n = 1657). Increased infection risk was associated with trauma (OR 1.80 [1.51-2.16] P < .001), emergency surgery (OR 1.31 [1.17-1.47] P < .001), large bowel surgery (OR 2.78 [2.26-3.43] P < .001), and those with three or more comorbidities (OR 2.03 [1.69-2.45] P < .001). Investor-owned hospitals (OR .65 [.56-.76] P < .001) and highest quartile income (OR .80 [.73-.88] P < .001) were associated with decreased infection risk. CONCLUSIONS: Pediatric patients undergoing gastrointestinal surgery face an elevated risk of SSI, especially in trauma and emergency surgeries, particularly with multiple comorbidities. Meanwhile, a reduced risk is observed in high-income and investor-owned hospital settings. Hospitals and surgeons caring for high risk patients should advocate for risk adjustment in value-based payment systems.

Venous Thromboembolism in Children and Teenagers Admitted for Trauma: A 5-Year Nationwide Perspective.

Venous thromboembolism (VTE) in pediatric trauma patients is under-investigated. The purpose of this study was to perform an evaluation of the risk factors for VTE after pediatric trauma, including readmissions across the United States. The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years admitted for trauma. 276 670 patients were identified; 2063 (.8%) were diagnosed with VTE. Among those with VTE, 300 (15%) were identified during a readmission. Higher rates of VTE were seen in ages 15-17 years (n = 1,294, 1.3%, P < .001), penetrating injuries (n = 478, .9%, P < .001), and assault (n = 271, 2.7%, P < .001). The strongest risk factor for VTE was prolonged mechanical ventilation (OR 5.5 [4.9-6.3] P < .001). Our study found that a significant portion of post-traumatic VTE in children and teenagers occur during readmissions. A deeper understanding of the risk factors outlined here can guide enhanced clinical protocols, ensuring early detection and prevention of this complication.

Optimizing Triage Practice in Pediatric Trauma: Lessons From Under-triage and Over-triage Rates and Risk Factors.

BACKGROUND: Triage accuracy is essential for delivering effective trauma care, especially in the pediatric population where unique challenges exist. The purpose of this study was to investigate risk factors contributing to under-triage and over-triage in an urban pediatric trauma center. METHODS: This retrospective cohort study included all trauma activations at an urban level 1 trauma center between January 1, 2021, and July 31, 2023 (patients <18 years old.) Patients who were under- or over-triaged were identified based on the level of trauma activation and injury severity score. RESULTS: There were 1094 trauma activations included in this study. The rate of under-triage was 3.8% (n = 42) and over-triage was 13.6% (n = 149). Infants aged 0-1 years had the highest rate of under-triage (10.9%, n = 19, P < .001), while those aged 11-17 had the highest rate of over-triage (17.0%, n = 82, P = .003). Non-accidental trauma was the strongest risk factor for under-triage (OR 30.2 [6.4-142.8] P < .001). Penetrating mechanism was the strongest risk factor for over-triage (OR 12.2 [5.6-26.2] P < .001). DISCUSSION: This study reveals the complexity of trauma triage in the pediatric population. We identified key predictive factors, such as age, comorbidities, and mechanism of injury, that can be used to refine triage practices and improve the care of pediatric trauma patients.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia.

INTRODUCTION: Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT. METHODS: The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates. RESULTS: We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration. CONCLUSION: In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery. LEVEL OF EVIDENCE: Level III TYPE OF STUDY: Retrospective Comparative Study.

Outcomes After Pectus Excavatum Repair: Center Volume Matters.

PURPOSE: Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume. METHODS: The Nationwide Readmission Database was queried (2016-2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests. RESULTS: A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs. CONCLUSION: Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship. TYPE OF STUDY: Retrospective Comparative. LEVEL OF EVIDENCE: III.

Comparing Payments to Surgeons From Drug and Medical Device Corporations Reveals Inequalities Between Genders and Specialties.

INTRODUCTION: Maintaining trust in the patient-doctor relationship requires transparency in the details of the financial relationships between physicians and drug and medical device corporations. These details are publicly available through the Open Payments database, and patients are encouraged to ask surgeons to interpret their implications. The purpose of this study was to better equip surgeons in responding to these inquiries and to compare the distribution of these payments by gender and specialty. METHODS: The 2021 Open Payments dataset was searched for all payments to surgeons from the 14 different specialties recognized by the American College of Surgeons. The total payments per surgeon were compared by calculating the mean and median payments. The Gini index, a measure of income inequality, was also calculated for each specialty. RESULTS: There were 96 724 surgeons who received over $755 million in payments from drug and medical device companies. There were 72 245 (74.7%) men and 24 479 (25.3%) women. The total amount of payments to men was $712 million (94.2%) and for women it was $44 million (5.8%). The overall Gini index was .9508. The specialty with the highest Gini index was pediatric surgery (.9844) and the lowest was cardiothoracic surgery (.8656). DISCUSSION: Male surgeons received disproportionately higher payments from drug and device corporations than female surgeons. Surgeons should be aware of their own standing within the Open Payments database in order to respond appropriately to patient inquiries.

Comparing Severely Injured Trauma Patients Admitted to Investor-Owned versus Public and Not-For-Profit Hospitals Reveals Opportunities for Improvement in the US.

BACKGROUND: Non-elderly trauma patients represent the largest portion of preventable years of life loss in the US. The purpose of this study was to compare outcomes in patients admitted to investor-owned vs public and not-for-profit hospitals across the US. MATERIAL AND METHODS: The Nationwide Readmissions Database 2018 was queried for trauma patients with an Injury Severity Score greater than 15 and age 18-65 years. The primary outcome was mortality; secondary outcomes were prolonged length of stay (LOS) greater than 30 days, readmission within 30 days, and readmission to a different hospital. Patients admitted to investor-owned hospitals were compared to public and not-for-profit hospitals. Univariable analysis was performed using chi-squared tests. Multivariable logistic regression was performed for each outcome. RESULTS: 157 945 patients were included with 11.0% (n = 17 346) admitted to investor-owned hospitals. The overall mortality rate and prolonged LOS were similar for both groups. The overall readmission rate was 9.2% (n = 13 895), with the rate in investor-owned hospitals at 10.5% (n = 1,739, P < .001). Multivariable logistic regression revealed investor-owned hospitals had an increased risk of readmission (OR 1.2 [1.1-1.3] P < .001) and readmission to a different hospital (OR 1.3 [1.2-1.5] P < .001). DISCUSSION: Severely injured trauma patients have similar rates of mortality and prolonged length of stay in investor-owned vs public and not-for-profit hospitals. However, patients admitted to investor-owned hospitals have an increased risk of readmission and readmission to different hospitals. Efforts to improve outcomes after trauma must consider hospital ownership and readmission to different hospitals.

Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison.

BACKGROUND: Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. STUDY DESIGN: The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. RESULTS: There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). CONCLUSIONS: Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.