Race, Insurance, and Sex-Based Disparities in Access to High-Volume Centers for Pancreatectomy.

BACKGROUND: With a large body of literature demonstrating positive volume-outcome relationships for most major operations, minimum volume requirements have been suggested for concentration of cases to high-volume centers (HVCs). However, data are limited regarding disparities in access to these hospitals for pancreatectomy patients. METHODS: The 2005-2018 National Inpatient Sample (NIS) was queried for all elective adult hospitalizations for pancreatectomy. Hospitals performing more than 20 annual cases were classified as HVCs. Mixed-multivariable regression models were developed to characterize the impact of demographic factors and case volume on outcomes of interest. RESULTS: Of an estimated 127,527 hospitalizations, 79.8% occurred at HVCs. Patients at these centers were more frequently white (79.0 vs 70.8%; p < 0.001), privately insured (39.4 vs 34.2%; p < 0.001), and within the highest income quartile (30.5 vs 25.0%; p < 0.001). Adjusted analysis showed that operations performed at HVCs were associated with reduced odds of in-hospital mortality (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.34-0.55), increased odds of discharge to home (AOR, 1.17; 95% CI, 1.04-1.30), shorter hospital stay (ß, -0.81 days; 95% CI, -1.2 to -0.40 days), but similar costs. Patients who were female (AOR, 0.88; 95% CI, 0.79-0.98), non-white (black: AOR, 0.66; 95% CI, 0.59-0.75; Hispanic: AOR, 0.56; 95% CI, 0.47-0.66; reference, white), insured by Medicaid (AOR, 0.63; 95% CI, 0.56-0.72; reference, private), and within the lowest income quartile (AOR, 0.73; 95% CI, 0.59-0.90; reference, highest) had decreased odds of treatment at an HVC. CONCLUSIONS: For those undergoing pancreatectomies, HVCs realize superior clinical outcomes but treat lower proportions of female, non-white, and Medicaid populations. These findings may have implications for improving access to high-quality centers.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies.

BACKGROUND: Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy. METHODS: Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies. RESULTS: An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches. CONCLUSIONS: Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

Impact of frailty on short term outcomes, resource use, and readmissions after transcatheter mitral valve repair: A national analysis.

BACKGROUND: Treatment options for mitral regurgitation range from diuretic therapy, to surgical and interventional strategies including TMVR in high-risk surgical candidates. Frailty has been associated with inferior outcomes following hospitalizations for heart failure and in open cardiac surgery. OBJECTIVE: The purpose of the present study was to evaluate the impact of frailty on clinical outcomes and resource use following transcatheter mitral valve repair (TMVR). METHODS: Adults undergoing TMVR were identified using the 2016-2018 Nationwide Readmissions Database, and divided into Frail and Non-Frail groups. Frailty was defined using a derivative of the Johns Hopkins Adjusted Clinical Groups frailty indicator. Generalized linear models were used to assess the association of frailty with in-hospital mortality, complications, nonhome discharge, hospitalization costs, length of stay, and non-elective readmission at 90 days. Average marginal effects were used to quantify the impact of frailty on predicted mortality. RESULTS: Of 18,791 patients undergoing TMVR, 11.6% were considered frail. The observed mortality rate for the overall cohort was 2.2%. After adjustment, frailty was associated with increased odds of in-hospital mortality (AOR 1.8, 95% CI 1.2-2.6), corresponding to an absolute increase in risk of mortality of 1.1%. Frailty was associated with a 2.7-day (95% CI 2.1-3.2) increase in postoperative LOS, and $18,300 (95% CI 14,400-22,200) increment in hospitalization costs. Frail patients had greater odds (4.4, 95% CI 3.6-5.4) of nonhome discharge but similar odds of non-elective 90-day readmission. CONCLUSIONS: Frailty is independently associated with inferior short-term clinical outcomes and greater resource use following TMVR. Inclusion of frailty into existing risk models may better inform choice of therapy and shared decision-making.

Risk factors for recurrent aphthous stomatitis: a systematic review / Factores de riesgo para la estomatitis aftosa recurrente: revisión sistemática

SUMMARY: The cause and prevention of recurrent aphthous stomatitis (also called aphthous ulcers or canker sores) are still unknown. This may be due in part to ignorance of the risk factors present in susceptible people. In this systematic review (PROSPERO record #CRD42019122214), we show that most of the risk factors for the disease are single nucleotide genetic polymorphisms in genes related to the functioning of immune system (TLR4, MMP9, E-selectin, IL-1 beta and TNF-alpha). Single nucleotide genetic polymorphisms do not constitute a modifiable risk. This indicates that, at least in part, susceptibility to recurrent aphthous stomatitis is hereditary, and that these factors cannot be modified.

RESUMEN: Aún se desconoce la causa y cómo prevenir la estomatitis aftosa recurrente (más conocida como aftas). En esta revisión sistemática (registro PROSPERO #CRD42019122214) mostramos que la mayoría de los factores de riesgo para la enfermedad son polimorfismos genéticos de un solo nucleótido en genes relacionados con el funcionamiento del sistema inmune (TLR4, MMP9, E- selectin, IL-1 beta y TNF-alfa). Los polimorfismos genéticos de un solo nucleótido no constituyen un riesgo modificable.Ello indica que, al menos en parte, la susceptibilidad para las aftas es hereditaria y que esos factores no pueden ser modificados.

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting.

BACKGROUND: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression. RESULTS: Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001). CONCLUSIONS: Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

BACKGROUND: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. METHODS: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. RESULTS: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40). CONCLUSIONS: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

Factors associated with high-cost hospitalizations in elderly ovarian cancer patients.

OBJECTIVE: To characterize factors associated with high-cost inpatient admissions for ovarian cancer. METHODS: Operative hospitalizations for ovarian cancer patients ≥65 years of age were identified using the 2010-2017 National Inpatient Sample. Admissions with high-cost were defined as those incurring ≥90th percentile of hospitalization costs each year, while the remainder were considered low-cost. Multivariable logistic regression models were developed to assess independent predictors of being in the high-cost cohort. RESULTS: During the study period, an estimated 58,454 patients met inclusion criteria. 5827 patient admissions (9.98%) were classified as high-cost. Median hospitalization cost for this high-cost group was $55,447 (interquartile range (IQR) $46,744-$74,015) compared to $16,464 (IQR $11,845-$23,286, p < 0.001) for the low-cost group. Patients with high-cost admissions were more likely to have received open (adjusted odds ratio (AOR) 2.23, 1.31-3.79) or extended (AOR 5.64, 4.79-6.66) procedures and be admitted non-electively (AOR 3.32, 2.74-4.02). Being in the top income quartile (AOR 1.77, 1.39-2.27) was also associated with high-cost. Age and hospital factors, including bed size and volume of gynecologic oncology surgery, did not affect cost group. CONCLUSION: High-cost ovarian cancer admissions were three times more expensive than low-cost admissions. Fewer open and extended procedures with subsequently shorter lengths of stay may have contributed to decreasing inpatient costs over the study period. In this cohort of patients largely covered by Medicare, clinical factors outweigh socioeconomic factors as cost drivers. Understanding the relationship of disease-specific and social factors to cost will be important in informing future value-based quality improvement efforts in gynecologic cancer care.

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting.

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US.

BACKGROUND: Gun violence remains a major burden on the US healthcare system, with annual cost exceeding $170 billion. Literature on the national trends in cost and survival of gun violence victims requiring operative interventions is lacking. STUDY DESIGN: All adults admitted with a diagnosis of gunshot wound requiring operative intervention were identified using the 2005-2016 National Inpatient Sample. The ICD Injury Severity Score, a validated prediction tool, was used to quantify the extent of traumatic injuries. Survey-weighted methodology was used to provide national estimates. Hospitalizations exceeding the 66th percentile of annual cost were considered as high-cost tertile. Multivariable logistic regressions with stepwise forward selection were used to identify factors associated with mortality and high-cost tertile. RESULTS: During the study period, 262,098 admissions met inclusion criteria with a significant increase in annual frequency and decrease in ICD Injury Severity Scores. A decline in mortality (8.6% to 7.6%; parametric test of trend = 0.03) was accompanied by increasing mean cost ($25,900 to $33,000; nonparametric test of trend < 0.001). After adjusting for patient and hospital characteristics, head and neck (adjusted odds ratio 31.2; 95% CI, 11.0 to 88.4; p < 0.001), vascular operations (adjusted odds ratio 24.5; 95% CI, 19.2 to 31.1; p < 0.001), and gastrointestinal (adjusted odds ratio 27.8; 95% CI, 17.2 to 44.8; p < 0.001) were independently associated with high-cost tertile designation compared with patients who did not undergo these operations. CONCLUSIONS: During the past decade, the increase in gun violence and severity has resulted in higher cost. Operations involving selected surgical treatments incurred higher in-hospital cost. Given the profound economic and social impact of surgically treated gunshot wounds, policy and public health efforts to reduce gun violence are imperative.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (ß: $2,398, P < .001). CONCLUSION: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

National trends and outcomes in timing of ERCP in patients with cholangitis.

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017.

BACKGROUND: Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS: We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS: Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS: Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

Impact of center volume on outcomes of surgical repair for type A acute aortic dissections.

BACKGROUND: Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS: Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS: An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION: The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.

Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States.

BACKGROUND: Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS: We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS: During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS: High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States.

INTRODUCTION: Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy. MATERIAL AND METHODS: We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality. RESULTS: Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01). CONCLUSIONS: Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.

Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support.

BACKGROUND: The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS: The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS: Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION: Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.

National Analysis of Coronary Artery Bypass Grafting in Autoimmune Connective Tissue Disease.

BACKGROUND: Autoimmune connective tissue diseases (CTDs) are associated with accelerated atherosclerosis and inflammation, while often requiring immunosuppression. Large-scale outcomes of coronary artery bypass graft (CABG) surgery in this population have not been reported thus far. This study characterized trends in use of CABG in patients with CTDs and the impact of the disease on mortality, in-hospital complications, length of stay, and costs. METHODS: The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing isolated CABG. The CTDs cohort included rheumatoid arthritis, lupus erythematosus, and antiphospholipid syndrome (APLS), among others. Hierarchical multivariable logistic models were used to calculate the independent impact of CTDs on clinical outcomes and costs. RESULTS: Of an estimated 2,101,591 patients, 41,567 (1.8%) were diagnosed with CTDs (rheumatoid arthritis, 58%; systemic lupus erythematosus, 12%; APLS, 11%) Although the overall annual use of CABG decreased, the proportion of patients with CTDs receiving the operation significantly increased. After adjusting for patient and hospital characteristics, CTDs were not associated with increased mortality (adjusted odds ratio [AOR], 0.91; P = .34) but were protective against cardiovascular (AOR, 0.92; P < .003), neurologic (AOR, 0.81; P = .01), and infectious (AOR, 0.80; P = .01) complications. The diagnosis of CTDs was also predictive of reduced length of hospital stay (ß-coefficient = -0.40; P < .001) and costs (ß-coefficient, -$1200; P = .01). On subgroup analysis patients with APLS had significantly increased odds of mortality (AOR, 1.5) and increased renal (AOR, 1.3), infectious (AOR, 1.7), and thromboembolic (AOR, 4.3) complications (all P < .05). CONCLUSIONS: CABG in patients with CTDs provides acceptable outcomes and paradoxically improved resource use. However CABG in patients with APLS warrants careful consideration given inferior outcomes.

Outcomes and Resource Utilization in Robotic Mitral Valve Repair: Beyond the Learning Curve.

BACKGROUND: After the initial learning curve associated with mastering a robotic procedure, there is a plateau where operative time and complication rates stabilize. Our objective was to evaluate one surgeon's experience with robotic mitral valve repairs (MVRep) beyond the learning curve and to compare its effectiveness against the traditional open approach. METHODS: Data from Ronald Reagan University of California, Los Angeles Medical Center was prospectively collected from January 2008 to March 2016 to identify adult patients undergoing robotic MVRep. Operative times, complication rates, and cost for robotic versus open MVRep were compared using multivariate regressions, adjusting for comorbidities and previous cardiac surgeries. RESULTS: During the study period, 175 robotic (41%) and 259 open (59%) MVRep cases were performed at our institution. As the surgeon performed more robotic operations, there was a decrease in room time (554-410 min, P < 0.001), surgery time (405-271 min, P < 0.001), and cross-clamp times (179-93 min, P < 0.001). After application of a multivariate regression model, robotic MVRep was associated with lower odds of complications (odds ratio = 0.42, P = 0.001), shorter length of stay (ß = -2.51, P < 0.001), and a reduction of 11% in direct (P = 0.003) and 24% in room costs (P < 0.001), but a 51% increase in surgery cost (P < 0.001). CONCLUSIONS: As the surgeon gained experience with robotic MVRep, operative times decreased in a steady manner. Robotic MVRep had comparable outcomes to open MVRep and lower overall cost. The observed difference in costs is likely related to shorter length of stay and lower room cost with the robotic approach.