Failure to rescue following emergency general surgery: A national analysis.

Background: Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. Methods: All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. Results: Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. Conclusion: Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

Discharge against medical advice in trauma patients: Trends, risk factors, and implications for health care management strategies.

OBJECTIVE: Given the nonelective nature of most trauma admissions, patients who experience trauma are at a particular risk of discharge against medical advice. Despite the risk of unplanned readmission and financial burden on the health care system, discharge against medical advice among hospitalized patients continues to rise. The present study aimed to assess evolving trends and outcomes associated in patients with discharge against medical advice among patients hospitalized for traumatic injury. METHODS: The 2016-2020 Nationwide Readmissions Database was queried to identify all hospitalizations for traumatic injuries. The patient cohort was stratified into those who had discharge against medical advice and those who did not. Temporal trends of discharge against medical advice and associated costs over time were evaluated using nonparametric tests. Multivariable regression models were developed to assess factors associated with discharge against medical advice. Associations of discharge against medical advice with length of stay, hospitalization costs, and unplanned 30-day readmission were subsequently evaluated. RESULTS: Of an estimated 4,969,717 patients, 65,354 (1.3%) had discharge against medical advice after hospitalization for traumatic injury. Over the study period, the incidence of discharge against medical advice increased (nptrend <0.001). After risk adjustment, older age (adjusted odds ratio, 0.98/per year; 95% confidence interval, 0.97-0.98), female sex (adjusted odds ratio, 0.65; 95% confidence interval, 0.64-0.67), and management at high-volume trauma center (adjusted odds ratio, 0.71; 95% confidence interval, 0.69-0.74) were associated with lower odds of discharge against medical advice. Compared with others, discharge against medical advice was associated with decrements in length of stay by 1.3 days (95% confidence interval, 1.1-1.5 days) and index hospitalization costs by $2,200 (5% confidence interval, $1,600-2,900), while having a greater risk of unplanned 30-day readmission (adjusted odds ratio, 2.21; 95% confidence interval, 2.06-2.36). CONCLUSION: The incidence of discharge against medical advice and its associated cost burden have increased in recent years. Community-level interventions and institutional efforts to mitigate discharge against medical advice may improve the quality of care and resource allocation for patients with traumatic injuries.

Association of severe obesity with risk of conversion to open in laparoscopic cholecystectomy for acute cholecystitis.

Background: Obesity is a known risk factor for cholecystitis and is associated with technical complications during laparoscopic procedures. The present study seeks to assess the association between obesity class and conversion to open (CTO) during laparoscopic cholecystectomy (LC). Methods: Adult acute cholecystitis patients with obesity undergoing non-elective LC were identified in the 2017-2020 Nationwide Readmissions Database. Patients were stratified by obesity class; class 1 (Body Mass Index [BMI] = 30.0-34.9), class 2 (BMI = 35.0-39.9), and class 3 (BMI ≥ 40.0). Multivariable regression models were developed to assess factors associated with CTO and its association with perioperative complications and resource utilization. Results: Of 89,476 patients undergoing LC, 40.6 % had BMI ≥ 40.0. Before adjustment, class 3 obesity was associated with increased rates of CTO compared to class 1-2 (4.6 vs 3.8 %; p < 0.001). Following adjustment, class 3 remained associated with an increased likelihood of CTO (Adjusted Odds Ratio [AOR] 1.45, 95 % Confidence Interval [CI] 1.31-1.61; ref.: class 1-2). Patients undergoing CTO had increased risk of blood transfusion (AOR 3.27, 95 % CI 2.54-4.22) and respiratory complications (AOR 1.36, 95 % CI 1.01-1.85). Finally, CTO was associated with incremental increases in hospitalization costs (ß + $719, 95 % CI 538-899) and length of stay (LOS; ß +2.20 days, 95 % CI 2.05-2.34). Conclusions: Class 3 obesity is a significant risk factor for CTO. Moreover, CTO is associated with increased hospitalization costs and LOS. As the prevalence of obesity grows, improved understanding of operative risk by approach is required to optimize clinical outcomes. Our findings are relevant to shared decision-making and informed consent.

The impact of rurality on racial disparities in costs of bowel obstruction treatment.

Background: Black race has been associated with increased resource utilization after operation for small bowel obstruction (SBO). While prior literature has similarly demonstrated differences between urban and rural institutions, limited work has defined the impact of rurality on resource utilization by race. Methods: The 2016-2020 National Inpatient Sample was used to identify adults undergoing adhesiolysis after non-elective admission for SBO. The primary endpoint was hospitalization costs. Additional outcomes included surgical delay (≥ hospital day 3), length of stay (LOS), and nonhome discharge. Regression models were developed to identify the impact of Black race and rurality on the outcomes of interest with an interaction term to examine the incremental association of Black race on rurality. Results: Of an estimated 132,390 patients, 11.4 % were treated at an annual average of 377 rural hospitals (18.5 % of institutions). After adjustment, rural hospitals had higher costs (ß + $4900, 95 % Confidence Interval [CI] [4200, 5700]), compared to others. However, rurality was associated with reduced odds of surgical delay (Adjusted Odds Ratio [AOR] 0. 76, CI[0.69, 0.85]), decreased LOS (ß -1.66 days, CI[-1.99, -1.36]), and nonhome discharge (AOR 0.78, CI[0.70, 0.87]). While White patients experienced significant cost reductions at urban centers ($26,100 [25,800-26,300] vs $31,000 [30,300-31,700]), this was not noted for Black patients ($30,100 [29,400-30,700] vs $30,800 [29,300-32,400]). Conclusions: We found that Black patients do not benefit from the same cost protection afforded by urban settings as White patients after operative SBO admission. Future work should focus on setting-specific interventions to address drivers of disparities within each community.

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults.

Background: Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis. Methods: The 2016-2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH). Results: Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission. Conclusions: We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Timing of Noncardiac Surgery Following Transcatheter Aortic Valve Replacement: A National Analysis.

BACKGROUND: The optimal timing of noncardiac surgery (NCS) following transcatheter aortic valve replacement (TAVR) for aortic stenosis has not been elucidated by current national guidelines. OBJECTIVES: The aim of this study was to evaluate the effect of the time interval between TAVR and NCS (Δt) on the perioperative risk of major adverse events (MAEs). METHODS: All adult admissions for isolated TAVR for aortic stenosis were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients who received NCS on subsequent admission were included for analysis and grouped by Δt as follows: ≤30, 31 to 60, 61 to 90, and >90 days. Multivariable regression models were constructed to examine the association of Δt with ensuing outcomes. RESULTS: Of 3,098 patients (median age = 79 years, 41.6% female), 19.1% underwent NCS at ≤30 days, 22.9% at 31 to 60 days, 16.7% at 61 to 90 days, and 41.3% at >90 days. After adjustment, the odds of MAEs were similar for operations performed at ≤30 days (adjusted OR [AOR]: 1.05; 95% confidence interval [CI]: 0.74-1.50), 31 to 60 days (AOR: 0.97; 95% CI: 0.71-1.31), and 61 to 90 days (AOR: 0.95; 95% CI: 0.67-1.34), with those at >90 days as reference. When examining the average marginal effect of the interval to surgery, risk-adjusted MAE rates were statistically similar across Δt groups for elective status and NCS risk category combinations. CONCLUSIONS: NCS within 30, 31 to 60, or 61 to 90 days after TAVR was not associated with increased odds of MAEs compared with operations after 90 days irrespective of NCS risk category or elective status. Our findings suggest that the interval between NCS and TAVR may not be an accurate predictor of MAE risk in this population.

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

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

Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States.

INTRODUCTION: Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS: All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS: Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION: In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.

National trends and outcomes of robotic emergency general surgery in the United States.

BACKGROUND: Robot-assisted surgery has seen exponential adoption over the last decade. Although the safety and efficacy of robotic surgery in the elective setting have been demonstrated, data regarding robotic emergency general surgery remains sparse. METHODS: All adults undergoing non-elective appendectomy, cholecystectomy, small or large bowel resection, perforated ulcer repair, or lysis of adhesions were identified in the 2008 to 2020 National Inpatient Sample. Temporal trends were analyzed using a rank-based, non-parametric test developed by Cuzick (nptrend). Using laparoscopy as a reference, multivariable regressions were used to evaluate the association between robotic techniques and in-hospital mortality, major complications, and resource use for each emergency general surgery operation. RESULTS: Of an estimated 4,040,555 patients undergoing emergency general surgery, 65,853 (1.6%) were performed using robotic techniques. The robotic proportion of minimally invasive emergency general surgery increased significantly overall, with the largest growth seen in robot-assisted large bowel resections and perforated ulcer repairs. After adjustment for various patient and hospital-level factors, robot-assisted large bowel resection (adjusted odds ratio 0.73, 95% confidence interval 0.58-0.91) and cholecystectomy (adjusted odds ratio 0.66, 95% confidence interval 0.55-0.81) were associated with significantly reduced odds of perioperative blood transfusion compared to traditional laparoscopy. Although robotic techniques were associated with modest reductions in postoperative length of stay, costs were uniformly higher by increments of up to $4,900. CONCLUSION: Robotic surgery appears to be a safe and effective adjunct to laparoscopy in minimally invasive emergency general surgery, although comparable cost-effectiveness has yet to be realized. Increasing use of robotic techniques in emergency general surgery may be attributable in part to reduced complications, including blood loss, in certain operative contexts.

Heart Transplantation following Donation after Circulatory Death: Early United States Experience.

BACKGROUND: Given the renewed interest in heart transplantation(HT) following donation after circulatory death(DCD), a contemporary analysis of trends, and longer-term survival is warranted. METHODS: Adult HT recipients(December 2019-September 2023) were identified in the Organ Procurement and Transplantation Network. Recipients were stratified as either donation after brain death(DBD) or DCD. DCD procurements were further classified as direct procurement and perfusion(DCD-DPP), or normothermic regional perfusion(DCD-NRP), based on the declaration of death to cross-clamp interval(≥40minutes DCD-NRP). The main outcome was post-transplant survival at 1- and 3-years. RESULTS: Of 11,625 transplantations, 792(7%) involved DCD allografts(249 DCD-NRP, 543 DCD-DPP). The proportion of transplants involving DCD allografts significantly increased from 2%(December 2019) to 11%(January-September 2023, P<0.001). Upon adjusted analysis, 1-year post-transplant survival was similar for DBD versus DCD-DPP(HR 1.00, CI 0.66-1.66) or DCD-NRP(HR 0.92, CI 0.49-1.72). This remained true at 3-years(DCD-DPP HR 1.07, CI 0.77-1.48; DCD-NRP HR 1.04, CI 0.62-1.73). Incidence of postoperative stroke, dialysis, acute graft rejection, and primary graft dysfunction were similar across groups. Across various strata of recipient risk and center volume, survival was equivalent between the DBD and DCD cohorts. CONCLUSIONS: Rates of DCD HT continue to rise. Across various recipient risk and center volume categories, DCD and DBD recipients show comparable post-transplant survival up to three years. These findings encourage broader utilization of such donors in attempts to expand the organ pool.

Utilization of minimally invasive colectomy at safety-net hospitals in the United States.

BACKGROUND: Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs. METHODS: All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes. RESULTS: Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (ß+0.26 days, confidence interval 0.17-0.35) and costs (ß+$2,510, confidence interval 2,020-3,000). CONCLUSION: Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.

Machine learning prediction of hospitalization costs for coronary artery bypass grafting operations.

BACKGROUND: With the steady rise in health care expenditures, the examination of factors that may influence the costs of care has garnered much attention. Although machine learning models have previously been applied in health economics, their application within cardiac surgery remains limited. We evaluated several machine learning algorithms to model hospitalization costs for coronary artery bypass grafting. METHODS: All adult hospitalizations for isolated coronary artery bypass grafting were identified in the 2016 to 2020 Nationwide Readmissions Database. Machine learning models were trained to predict expenditures and compared with traditional linear regression. Given the significance of postoperative length of stay, we additionally developed models excluding postoperative length of stay to uncover other drivers of costs. To facilitate comparison, machine learning classification models were also trained to predict patients in the highest decile of costs. Significant factors associated with high cost were identified using SHapley Additive exPlanations beeswarm plots. RESULTS: Among 444,740 hospitalizations included for analysis, the median cost of hospitalization in coronary artery bypass grafting patients was $43,103. eXtreme Gradient Boosting most accurately predicted hospitalization costs, with R2 = 0.519 over the validation set. The top predictive features in the eXtreme Gradient Boosting model included elective procedure status, prolonged mechanical ventilation, new-onset respiratory failure or myocardial infarction, and postoperative length of stay. After removing postoperative length of stay, eXtreme Gradient Boosting remained the most accurate model (R2 = 0.38). Prolonged ventilation, respiratory failure, and elective status remained important predictive parameters. CONCLUSION: Machine learning models appear to accurately model total hospitalization costs for coronary artery bypass grafting. Future work is warranted to uncover other drivers of costs and improve the value of care in cardiac surgery.

Nationwide Trends in Utilization of Minimally Invasive Techniques for Blunt Abdominal Trauma.

BACKGROUND: Despite increasing use of minimally invasive surgical (MIS) techniques for trauma, limited large-scale studies have evaluated trends, outcomes, and resource utilization at centers that utilize MIS modalities for blunt abdominal trauma. METHODS: Operative adult admissions after blunt assault, falls, or vehicular collisions were tabulated from the 2016-2020 National Inpatient Sample. Patients who received diagnostic laparoscopy or other laparoscopic and robotic intervention were classified as MIS. Institutions with at least one MIS trauma operation in a year were defined as an MIS Performing Institution (MPI; rest: non-MPI). The primary endpoint was mortality, with secondary outcomes of reoperation, complication, postoperative length of stay (LOS), and hospitalization costs. Mixed regression models were used to determine the association of MPI status on the outcomes of interest. RESULTS: Throughout the study period, the proportion of MIS operations and MPI significantly increased from 22.6 to 29.8% and 45.9 to 58.8%, respectively. Of an estimated 77,480 patients, 66.7% underwent care at MPI. After adjustment, MPI status was not associated with increased odds of mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] [.96,1.24]), reoperation (AOR 1.02, CI [.87,1.19]), or any of the tabulated complications. There was additionally no difference in adjusted LOS (ß-.18, CI [-.85, +.49]) or costs (ß+$1600, CI [-1600, +4800]), between MPI and non-MPI. DISCUSSION: The use of MIS operations in blunt abdominal trauma has significantly increased, with performing centers experiencing no difference in mortality or resource utilization. Prospectively collected data on outcomes following MIS trauma surgery is necessary to elucidate appropriate applications.

Clinical and financial outcomes associated with the utilization of right internal mammary artery versus radial artery in multivessel coronary artery bypass grafting.

BACKGROUND: Multi-arterial coronary bypass grafting with the left internal mammary artery as a conduit has been shown to offer superior long-term survival compared to single-arterial coronary bypass grafting. Nevertheless, the selection of a secondary conduit between the right internal mammary artery and the radial artery remains controversial. Using a national cohort, we examined the relationships between the right internal mammary artery and the radial artery with acute clinical and financial outcomes. METHODS: Adults undergoing on-pump multivessel coronary bypass grafting with left internal mammary artery as the first arterial conduit were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients receiving either the right internal mammary artery or the radial artery, but not both, were included in the analysis. Multivariable regression models were fitted to examine the association between the conduits and in-hospital mortality, as well as additional secondary outcomes. RESULTS: Of an estimated 49,798 patients undergoing multi-arterial coronary bypass grafting, 29,729 (59.7%) comprised the radial artery cohort. During the study period, the proportion of multi-arterial coronary bypass grafting utilizing the radial artery increased from 51.3% to 65.2% (nptrend <0.001). Following adjustment, the radial artery was associated with reduced odds of in-hospital mortality (adjusted odds ratio 0.44), prolonged mechanical ventilation (adjusted odds ratio 0.78), infectious complications (adjusted odds ratio 0.69), and 30-day nonelective readmission (adjusted odds ratio 0.77, all P < .05). CONCLUSION: Despite no definite endorsement from surgical societies, the radial artery is increasingly utilized as a secondary conduit in multi-arterial coronary bypass grafting. Compared to the right internal mammary artery, the radial artery was associated with lower odds of in-hospital mortality, complications, and reduced healthcare expenditures. These results suggest that whenever feasible, the radial artery should be the favored conduit over the right internal mammary artery. Nevertheless, future studies examining long-term outcomes associated with these vessels remain necessary.

Mortality and resource utilization in surgical versus transcatheter repeat mitral valve replacement: A national analysis.

BACKGROUND: Transcatheter mitral valve replacement (TMVR) has garnered interest as a viable alternative to the traditional surgical mitral valve replacement (SMVR) for high-risk patients requiring redo operations. This study aims to evaluate the association of TMVR with selected clinical and financial outcomes. METHODS: Adults undergoing isolated redo mitral valve replacement were identified in the 2016-2020 Nationwide Readmissions Database and categorized into TMVR or SMVR cohorts. Various regression models were developed to assess the association between TMVR and in-hospital mortality, as well as additional secondary outcomes. Transseptal and transapical catheter-based approaches were also compared in relation to study endpoints. RESULTS: Of an estimated 7,725 patients, 2,941 (38.1%) underwent TMVR. During the study period, the proportion of TMVR for redo operations increased from 17.8% to 46.7% (nptrend<0.001). Following adjustment, TMVR was associated with similar odds of in-hospital mortality (AOR 0.82, p = 0.48), but lower odds of stroke (AOR 0.44, p = 0.001), prolonged ventilation (AOR 0.43, p<0.001), acute kidney injury (AOR 0.61, p<0.001), and reoperation (AOR 0.29, p = 0.02). TMVR was additionally correlated with shorter postoperative length of stay (pLOS; ß -0.98, p<0.001) and reduced costs (ß -$10,100, p = 0.002). Additional analysis demonstrated that the transseptal approach had lower adjusted mortality (AOR 0.44, p = 0.02), shorter adjusted pLOS (ß -0.43, p<0.001), but higher overall costs (ß $5,200, p = 0.04), compared to transapical. CONCLUSIONS: In this retrospective cohort study, we noted TMVR to yield similar odds of in-hospital mortality as SMVR, but fewer complications and reduced healthcare expenditures. Moreover, transseptal approaches were associated with lower adjusted mortality, shorter pLOS, but higher cost, relative to the transapical. Our findings suggest that TMVR represent a cost-effective and safe treatment modality for patients requiring redo mitral valve procedures. Nevertheless, future studies examining long-term outcomes associated with SMVR and TMVR in redo mitral valve operations, are needed.

Persistent Racial Disparities in Morbidity Following Major Elective Operations.

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

Association of socioeconomic vulnerability with outcomes after emergency general surgery.

PURPOSE: Social determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied. METHODS: All adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes. RESULTS: Of ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55-77] vs 58 years [41-70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3-5] vs 2 [1-3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58-1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98-2.06). Vulnerable also experienced a greater duration of stay (ß+4.64 days, confidence interval +4.54-4.74) and hospitalization costs (ß+$1,360, confidence interval +980-1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38-2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26-1.32). CONCLUSION: Socioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.

Cost variation of nonelective surgery for ulcerative colitis across the United States.

BACKGROUND: Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS: All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS: An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION: The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis.

BACKGROUND: Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort. METHODS: All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest. RESULTS: Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (ß + 1.04 days, CI + .91-1.17) and greater costs (ß+$3,490, CI + 2840-4140). DISCUSSION: While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Trends in the adoption of diverting loop ileostomy for acute complicated diverticulitis in the United States.

BACKGROUND: Acute complicated diverticulitis poses a substantial burden to individual patients and the health care system. A significant proportion of the cases necessitate emergency operations. The choice between Hartmann's procedure and primary anastomosis with diverting loop ileostomy remains controversial. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program patient user file data from 2012 to 2020, patients undergoing Hartmann's procedure and primary anastomosis with diverting loop ileostomy for nonelective sigmoidectomy for complicated diverticulitis were identified. Major adverse events, 30-day mortality, perioperative complications, operative duration, reoperation, and 30-day readmissions were assessed. RESULTS: Of 16,921 cases, 6.3% underwent primary anastomosis with diverting loop ileostomy, showing a rising trend from 5.3% in 2012 to 8.4% in 2020. Primary anastomosis with diverting loop ileostomy patients, compared to Hartmann's procedure, had similar demographics and fewer severe comorbidities. Primary anastomosis with diverting loop ileostomy exhibited lower rates of major adverse events (24.6% vs 29.3%, P = .001). After risk adjustment, primary anastomosis with diverting loop ileostomy had similar risks of major adverse events and 30-day mortality compared to Hartmann's procedure. While having lower odds of respiratory (adjusted odds ratio 0.61, 95% confidence interval 0.45-0.83) and infectious (adjusted odds ratio 0.78, 95% confidence interval 0.66-0.93) complications, primary anastomosis with diverting loop ileostomy was associated with a 36-minute increment in operative duration and increased odds of 30-day readmission (adjusted odds ratio 1.30, 95% confidence interval 1.07-1.57) compared to Hartmann's procedure. CONCLUSION: Primary anastomosis with diverting loop ileostomy displayed comparable odds of major adverse events compared to Hartmann's procedure in acute complicated diverticulitis while mitigating infectious and respiratory complication risks. However, primary anastomosis with diverting loop ileostomy was associated with longer operative times and greater odds of 30-day readmission. Evolving guidelines and increasing primary anastomosis with diverting loop ileostomy use suggest a shift favoring primary anastomosis, especially in complicated diverticulitis. Future investigation of disparities in surgical approaches and patient outcomes is warranted to optimize acute diverticulitis care pathways.