Use of prescription opioid and other drugs among a cohort of persons with Ehlers-Danlos syndrome: A retrospective study.

Against the backdrop of increased opioid prescribing in the United States and the associated high rate of side effects, dependence, and addiction, our study examined how opioids and other medications are being used among persons with Ehlers-Danlos syndrome (EDS). EDS is a set of heritable connective tissue disorders with high symptom burden, including chronic pain. Prescription medication use among persons with EDS was compared to a cohort of matched controls using 10 years of administrative claims data from a large database of privately insured patients (2005-2014). Our dataset included 4,294 persons with EDS, ages 5-62 years old. In both adults and children, we found that the percentage of persons with a prescription drug claim was higher in the EDS cohort for all prescription drug classes examined. Among children, opioid use was double in the EDS cohort compared to the control group (27.5% vs. 13.5%); in adults, it was nearly double in EDS patients (62% vs. 34.1%). Among persons who were prescribed opioids, those with EDS had higher cumulative dosages over a 2-year time period versus controls. Our study aids in understanding opioid and prescription drug use patterns in a vulnerable population with high symptom burden and chronic pain that is often severe.

Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting.

BACKGROUND: Because of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. MATERIALS AND METHODS: Data were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. RESULTS: Thirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). CONCLUSIONS: Carotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Predictors of Outcomes in Cerebellar Stroke: A Retrospective Cohort Study From the National Inpatient Sample Data.

Cerebellar strokes have high morbidity and mortality due to bleeding or edema, leading to increased pressure in the posterior fossa. This retrospective cohort study analyzed three outcomes following a cerebellar stroke: in-hospital mortality, length of hospital stay, and total hospitalization costs. It uses data from the National Inpatient Sample (NIS) and aims to identify the predictors of outcomes in cerebellar stroke patients, including 464,324 patients, 18 years of age and older, hospitalized between 2010 and 2015 in US hospitals with cerebellar strokes. In our study, for every decade age increased beyond 59 years, there was a significant increase in mortality; those aged 80+ years had 5.65 odds of mortality (95% CI: 5.32-6.00; P < 0.0001). Significant differences in patient characteristics were observed between patients who survived to discharge and those who did not, including older age (77.4 vs. 70.3 years; P < 0.0001), female sex (58% vs. 52%; P < 0.0001), and being transferred from another healthcare facility (17% vs. 10%; P < 0.0001). Patients admitted directly rather than through the emergency department were more likely to die (29% vs. 16%; P < 0.0001). The mortality rate was lower for blacks (OR: 0.75; P < 0.0001), Hispanics (OR: 0.91; P = 0.005), and Asians (OR: 0.89; P = 0.03), as compared to the white population, for females in comparison to males, and geographically, in all other areas (Midwest, South, and West) in contrast to the Northeast. Cerebellar stroke incidence and high mortality were seen in the traditional stroke belt. Mortality is also affected by the severity of the disease and increases with the Charlson Comorbidity Index (CCI), All Patient Refined Diagnosis Related Groups (APR-DRG) scores, and indirectly by place of receiving care, length of stay (LOS), cost of stay, type of insurance, and emergency department admissions. LOS increased with age, in males in the Northeast, and was less in whites compared to other races. Trend analysis showed a decrease in LOS and costs from 2010 to 2015. Increased costs were seen in non-whites, males, higher household income based on zip code, being covered under Medicaid, transfers, CCI ≥ 5, and discharges in the western US. Median household income based on the patient's zip code was well-balanced between those who lived and those who died (P = 0.091). However, payers were not evenly distributed between the two groups (P < 0.0001 for the overall comparison). A higher proportion of discharges associated with in-hospital mortality were covered under Medicare (70% vs. 65% in the died vs. lived groups, respectively). Fewer discharges were associated with death if they were covered by commercial insurance or paid for out-of-pocket (15% vs. 19% for commercial insurance and 3% vs. 5% for out-of-pocket). In-hospital mortality was associated with a longer length of hospital stay (5.6 days vs. 4.5 days; P < 0.0001) and higher costs ($16,815 vs. $11,859; P < 0.0001). Variables that were significantly associated with lower total costs were older age, having commercial insurance, paying out-of-pocket or other payers, not being admitted through the emergency department, having a lower comorbidity index (CCI = 1-2), and being discharged from a hospital that was small- or medium-sized, located in the Midwest or South, and/or was non-teaching (rural or urban).

Impact of subspecialty elective exposures on outcomes on the American board of internal medicine certification examination.

BACKGROUND: The American Board of Internal Medicine Certification Examination (ABIM-CE) is one of several methods used to assess medical knowledge, an Accreditation Council for Graduate Medical Education (ACGME) core competency for graduating internal medicine residents. With recent changes in graduate medical education program directors and internal medicine residents are seeking evidence to guide decisions regarding residency elective choices. Prior studies have shown that formalized elective curricula improve subspecialty ABIM-CE scores. The primary aim of this study was to evaluate whether the number of subspecialty elective exposures or the specific subspecialties which residents complete electives in impact ABIM-CE scores. METHODS: ABIM-CE scores, elective exposures and demographic characteristics were collected for MedStar Georgetown University Hospital internal medicine residents who were first-time takers of the ABIM-CE in 2006-2010 (n=152). Elective exposures were defined as a two-week period assigned to the respective subspecialty. ABIM-CE score was analyzed using the difference between the ABIM-CE score and the standardized passing score (delta-SPS). Subspecialty scores were analyzed using percentage of correct responses. Data was analyzed using GraphPad Prism version 5.00 for Windows. RESULTS: Paired elective exposure and ABIM-CE scores were available in 131 residents. There was no linear correlation between ABIM-CE mean delta-SPS and the total number of electives or the number of unique elective exposures. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures (143.4 compared to 129.7, p=0.051). Repeated electives in individual subspecialties were not associated with significant difference in mean ABIM-CE delta-SPS. CONCLUSIONS: This study did not demonstrate significant positive associations between individual subspecialty elective exposures and ABIM-CE mean delta-SPS score. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures suggesting there may be an "ideal" number of elective exposures that supports improved ABIM-CE performance. Repeated elective exposures in an individual specialty did not correlate with overall or subspecialty ABIM-CE performance.

Prevalence of immune disease in patients with wounds presenting to a tertiary wound healing centre.

Chronic leg ulcers are a significant cause of morbidity and mortality and account for considerable healthcare and socioeconomic costs. Leg ulcers are a recognised complication of immune disease, and the purpose of this study was to establish the prevalence of immune disease in a cohort of patients with chronic wounds, and to compare wound outcomes in the subjects with and without immune disease. Retrospective chart review was completed on consecutive patients scheduled with the plastic surgeon in the Georgetown University Center for Wound Healing between 1 January 2009 and 31 March 2009. Of the 520 patients scheduled for appointments, 340 were eligible for inclusion. The prevalence of immune disease was higher than expected with 78 of 340 patients (23%) having associated immune disease. At presentation, wounds in patients with immune disease had a significantly larger mean surface area [33·4 cm(2) (69·05) compared to 22·5 cm(2) (63·65), P = 0·02]. Split thickness skin graft (STSG) and bioengineered alternative tissue (BAT) graft data was available on 177 grafts from 55 subjects. There was a significantly lower response rate to STSG in subjects with immune disease (50% compared to 97%, P = 0·0002), but response rates to BAT were not different. The association between immune diseases and chronic wounds may provide unique insights into pathways of wound healing, and warrants further study.

Reproductive Factors and Risk of Thyroid Cancer in Women: An Analysis in the Nurses' Health Study II.

BACKGROUND: The incidence of thyroid cancer in women is increasing at an alarming rate, with greatest risk in the reproductive years. Establishing relationships of hormonally related reproductive factors with thyroid cancer has been difficult. We aimed to elucidate potential risk factors for thyroid cancer in a large cohort of women. METHODS: Among 116,228 women in the Nurses' Health Study II followed from 1989 to 2013, 620 cases of thyroid cancer were identified. We examined reproductive and hormone-related factors, including age at menarche, age at menopause, parity, oral contraceptive use, and postmenopausal hormone therapy use. Pregnancy, reproductive years, and months of breastfeeding were used as surrogate markers for exposure to endogenous reproductive hormones. We used multivariable Cox models to calculate relative risks and 95% confidence intervals for the associations between these factors and risk of thyroid cancer. RESULTS: Number of reproductive years of 41 years or more was associated with more than double the risk of thyroid cancer compared with 30 years or fewer (relative risk, 2.20; 95% confidence interval, 1.19-4.06). The other variables analyzed (parity number, months of breastfeeding, age at menarche, menopausal status, and postmenopausal hormone therapy) were not associated with the risk of thyroid cancer. Women who entered menopause at age 45 years or older had a higher risk of thyroid cancer compared with women who entered menopause at a younger age. This result did not reach statistical significance; however, there was a linear trend between later age at menopause and increased risk of thyroid cancer (ptrend = .009). CONCLUSIONS: This study used a unique large, longitudinal dataset to assess thyroid cancer risk factors and potential confounders over an extended time frame. Our key finding suggests increased risk of thyroid cancer may be associated with a variety of indicators of longer reproductive years. The Nurses' Health Study II has provided new insights into the hormonal risks associated with thyroid cancer.

Cost of Chiari I Malformation Surgery: Comparison of Treatment at Children's Hospitals Versus Non-children's Hospitals.

Chiari I malformation is a common entity in pediatric neurosurgery. Prior studies have shown that surgical treatment at children's hospitals (CH) is associated with higher costs compared to non-children's hospitals (NCH) for other diagnoses. Therefore, we hypothesized that costs would be increased for the treatment of Chiari I malformation at a CH. Data were extracted from the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). Patients who underwent surgery for Chiari I malformation were identified using International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. Univariate statistical tests, multivariable linear regression models, and propensity score matching were utilized to determine differences in hospital length of stay (LOS) and costs between patients treated at CH versus NCH. Treatment at a CH was associated with significantly higher costs compared to treatment at an NCH while hospital LOS and mortality were similar. In the multivariable linear regression model, the adjusted average cost for surgical treatment of Chiari I malformation was $13,716, and treatment at a CH was associated with an additional $6,343 (p<0.0001). Similar results were seen after propensity score matching: costs for treatment at a CH were $6,047 higher than they were for treatment at an NCH (p<0.0001). In our analysis, a significant increase in cost was seen with treatment at a CH while controlling for patient demographics and hospital characteristics, as well as imbalanced covariates between the cohorts. Further investigation is warranted to determine the drivers of increased cost outside of the patient and hospital characteristics we analyzed in our study.

Impact of a Preoperative Safety Checklist on Perioperative Quality Outcomes and Operative Efficiency.

INTRODUCTION: Additional preoperative safety checklist requirements at Penn State Health were recently implemented on the morning of surgery. We evaluate whether this added safety policy impacted reported adverse patient safety events and institutional operating room performance indicators. METHODS: Key operating room performance indicators from fiscal years 2016 through 2019 quarter 2 were reviewed. Additional attestation requirements by the attending surgeon were implemented at start of fiscal year 2018 (July 1, 2017). All reported perioperative patient safety events during this time were reviewed with events classified into one of 8 select categories. RESULTS: Total operative case volume was 49,894 cases in fiscal years 2016 and 2017, and 36,533 in fiscal years 2018 and 2019 through quarter 2 (p <0.10). Mean operating room use was 81% in both groups (p <0.46). First case on time start rates decreased from 79.5% to 58%, respectively (p <0.0001). Mean turnover time between cases also increased from 35 minutes to 40 minutes, respectively (p <0.0001). There were 252 patient events (0.51%) in fiscal years 2016 and 2017 compared to 94 (0.26%) events in fiscal years 2018 and 2019 through quarter 2 following implementation of the surgical safety checklist (p <0.0001). The number of incomplete preoperative checklists (39 vs 14, p=0.008) and missing/incomplete patient identification bands (15 vs 2, p=0.004) were also decreased between fiscal years 2016 and 2017, and fiscal years 2018 and 2019 through quarter 2, respectively. CONCLUSIONS: A day-of-surgery safety checklist decreased the number of reported patient safety events but with a negative impact on standard metrics of operating room productivity for 18 months following implementation. Further study is necessary to determine if these effects persist over time.

Adrenalectomy: should urologists not be doing more?

PURPOSE: Adrenalectomy is an operation performed by both urologists and general surgeons; however, the majority are performed by general surgeons. We investigated whether there was a difference in outcomes based on surgical specialty performing the procedure. If no differences exist, an argument can be made that urologists should be doing more adrenalectomies. METHODS: The National Surgical Quality Improvement Project (NSQIP) Participant Use File (PUF) was queried to extract all cases of adrenalectomies performed from 2011 to 2015. Current Procedural Technology (CPT) codes 60540 and 60650 were used. The data were stratified by surgical specialty performing the adrenalectomy (urology or general surgery). Our outcomes of interest included post-surgical complications, reoperations, 30-day readmission, mortality, and hospital length of stay. RESULTS: A total of 3358 patients who underwent adrenalectomy between 2011 and 2015 were included. General surgeons performed 90% of these (n = 3012) and urologists performed 10% (n = 334). Differences in number of post-surgical complications, length of stay, rate of reoperation, 30-day readmission, and mortality were not statistically significant between general surgeons and urologists (p = 0.76, p = 0.29, p = 0.37, p = 0.98, and p = 0.59, respectively). Small complication rates disallowed multivariable analyses, but unadjusted rates for reoperation, presence of any post-operative complication, readmission within 30 days, and mortality were similar between specialties. CONCLUSIONS: Surgical specialty did not make a difference in outcomes for patients undergoing adrenalectomy, despite a large disparity in the number of procedures performed by general surgeons versus urologists. Urologists should continue performing adrenalectomies and, given their familiarity with the retroperitoneum, perhaps perform more than is the current trend.

Economic implications of localization strategies for cerebrospinal fluid rhinorrhea.

BACKGROUND: The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described. METHODS: A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters. RESULTS: Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values. CONCLUSION: This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

Reimbursement Penalties and 30-Day Readmissions Following Total Joint Arthroplasty.

BACKGROUND: The U.S. Patient Protection and Affordable Care Act created the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition Reduction Program (HACRP). Under these programs, hospitals face reimbursement reductions for having high rates of readmission and hospital-acquired conditions. This study investigated whether readmission following total joint arthroplasty (TJA) under the HRRP was associated with reimbursement penalties under the HACRP. METHODS: Hospital-level data on hospital-acquired conditions, readmissions, and financial penalties were obtained from Definitive Healthcare. Outcomes included receipt of an HACRP penalty and the associated losses in revenue in 2018. Logistic regression and linear regression models were used to determine whether the all-cause, 30-day readmission rate following TJA was associated with the receipt or magnitude of an HACRP penalty. RESULTS: Among 2,135 private, acute care hospitals, 477 (22.3%) received an HACRP penalty. After controlling for other patient and hospital characteristics, hospitals with a 30-day readmission rate of >3% after TJA had over twice the odds of receiving an HACRP penalty (odds ratio, 2.20; p = 0.043). In addition, hospitals with a readmission rate of >3% after TJA incurred $77,519 more in revenue losses due to HACRP penalties (p = 0.011). These effects were magnified in higher-volume hospitals. CONCLUSIONS: Acute care hospitals in the United States with higher 30-day readmission rates following TJA are more likely to be penalized and to have greater revenue losses under the HACRP than hospitals with lower readmission rates after TJA. This strengthens the incentive to invest in the prevention of readmissions after TJA, for example, through greater efforts to reduce surgical site infections and other modifiable risk factors.

Readmissions attributable to skilled nursing facility use after a colectomy: Evidence using propensity scores matching.

BACKGROUND: Postacute care (PAC) is a major driver of the rising health care costs in the United States (US). There is limited evidence on the causal effect of skilled nursing facility (SNF) use on readmission after an inpatient colectomy. STUDY DESIGN: We performed a retrospective analysis of data from the Pennsylvania Health Care Cost Containment Council (PHC4) on 38,635 patients who underwent an inpatient colectomy between 2011 and 2014 in a Pennsylvania hospital. Using propensity scores, we matched patients who were discharged to a SNF to those who were discharged elsewhere. We compared the probability of readmissions within 30 days for the two groups of matched patients in a regression framework. For the subset of patients who were readmitted within 30 days, we assessed whether patients discharged to SNF were readmitted earlier than those discharged to other entities. RESULTS: The use of a SNF after a colectomy significantly raises the patients' chance of readmissions within 30 days, even after controlling for their demographic characteristics and illness severity. Based on our estimates, being discharged to a SNF raises the chance of a readmission by 7.7 percentage points. For patients who were admitted within 30 days, we find no association between discharge to a SNF and the timing of readmission. CONCLUSION: Sending less severe patients to facilities other than a SNF following inpatient colectomy may help hospitals reduce 30-day readmission rates.

A Prospective Approach to Inform and Treat 1340 Patients at Risk for BIA-ALCL.

BACKGROUND: The increasing incidence and associated mortality of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has become alarming. However, many patients remain unaware of their risk for BIA-ALCL and may overlook early warning signs of the cancer. The authors aim to contact all breast implant patients at a single institution to educate them on the disease and provide screening and treatment as indicated. METHODS: All patients who had breast implants placed at Penn State Hershey Medical Center from 1979 to November of 2017 were mailed a letter to describe BIA-ALCL and to encourage a follow-up visit. Patient information regarding demographics, implant type, the number of calls and follow-up visits, physical examination findings, and patient decisions after being informed of the disease were recorded prospectively. RESULTS: One thousand two hundred eighty-four letters were mailed to 1020 patients (79.4 percent) with smooth implants and 264 patients (20.6 percent) with textured implants. Seventy-six calls were received and 100 patients (84 smooth and 16 textured) were evaluated within the first 2 months. Of the 16 patients with textured implants, nine are undergoing secondary surgery to remove or replace their textured device. CONCLUSIONS: Informing patients at risk for BIA-ALCL is an important endeavor. Patients educated on the disease will likely be diagnosed and treated earlier, which can prevent the need for adjuvant chemotherapy and/or radiation therapy and decrease mortality. The authors provide a method, supporting documents, and preliminary data to help other institutions contact their breast implant patients at risk for BIA-ALCL.

Resistance to local anesthesia in people with the Ehlers-Danlos Syndromes presenting for dental surgery.

BACKGROUND: People with the Ehlers-Danlos Syndromes (EDS), a group of heritable disorders of connective tissue, often report experiencing dental procedure pain despite local anesthetic (LA) use. Clinicians have been uncertain how to interpret this apparent LA resistance, as comparison of EDS and non-EDS patient experience is limited to anecdotal evidence and small case series. The primary goal of this hypothesis-generating study was to investigate the recalled adequacy of pain prevention with LA administered during dental procedures in a large cohort of people with and without EDS. A secondary exploratory aim asked people with EDS to recall comparative LA experiences. METHODS: We administered an online survey through various social media platforms to people with EDS and their friends without EDS, asking about past dental procedures, LA exposures, and the adequacy of procedure pain prevention. Among EDS respondents who both received LA and recalled the specific LA used, we compared agent-specific pain prevention for lidocaine, procaine, bupivacaine, mepivacaine, and articaine. RESULTS: Among the 980 EDS respondents who had undergone a dental procedure LA, 88% (n = 860) recalled inadequate pain prevention. Among 249 non EDS respondents only 33% (n = 83) recalled inadequate pain prevention (P < 0.001 compared to EDS respondents). The agent with the highest EDS-respondent reported success rate was articaine (30%), followed by bupivacaine (25%), and mepivacaine (22%). CONCLUSIONS: EDS survey respondents reported nearly three times the rate of LA non-response compared to non-EDS respondents, suggesting that LAs were less effective in preventing their pain associated with routine office dental procedures.

The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review.

BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are the most common healthcare-acquired condition. The attributable cost of CAUTIs is frequently cited to be approximately $1,000. However, there is a paucity of recent literature that confirms this estimate. The purpose of this study was to perform a systematic review of the literature that estimates the attributable cost of CAUTIs in the United States. METHODS: A systematic review was conducted using Pubmed. Studies conducted between the years 2000 and 2017, conducted at a facility within the United States, and that used novel patient-level cost data were included. Attributable cost estimates were adjusted for inflation to 2016 U.S. dollars using the medical care component of the Consumer Price Index. RESULTS: Only 4 articles met our inclusion criteria. Adjusted to 2016 U.S. dollars, the attributable costs of a CAUTI as reported in these studies were: $876 (inpatient cost to the hospital for additional diagnostic tests and medications); $1,764 (inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for ICU patients). CONCLUSIONS: The cost of a CAUTI ranges widely depending on population, patient acuity, and cost perspective. Attributable costs likely exceed $1,000. Additional research is needed to assess the full economic effect of CAUTIs.

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias.

BACKGROUND: After open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care. METHODS: Records of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR. RESULTS: In this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh. CONCLUSIONS: Even in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.