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1.
J Law Med Ethics ; 51(4): 777-785, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38477272

RESUMO

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.


Assuntos
Atenção à Saúde , Políticas , Humanos , Estados Unidos , Oncologia
2.
PLoS One ; 17(7): e0268215, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35901087

RESUMO

INTRODUCTION: Chondrosarcoma, although relatively uncommon, represents a significant percentage of primary osseous tumors. Nonetheless, there are few large-cohort, longitudinal studies of long-term survival and treatment outcomes of chondrosarcoma patients and none using the National Cancer Database (NCDB). METHODS: Chondrosarcoma patients were identified from the 2004-2015 NCDB datasets and divided on three primary tumor sites: appendicular, axial, and other. Demographic, treatment, and long-term survival data were determined for each group. Multivariate Cox analysis and Kaplan-Meier survival curves were generated to assess long-term survival over time for each. RESULTS: In total, 5,329 chondrosarcoma patients were identified, of which 2,686 were appendicular and 1,616 were axial. Survival was higher among the appendicular cohort than axial at 1-year, 5-year, and 10-year (89.52%, 75.76%, and 65.24%, respectively). Multivariate Cox analysis identified patients in the appendicular cohort to have significantly greater likelihood of death with increasing age category, distant metastases at presentation, and male sex (p<0.001 for each). Best outcomes for seen for those undergoing surgical treatment (p<0.001). Patients in the axial cohort were with increased likelihood of death with increasing age category and distant metastases (p<0.001), while surgical treatment with or without radiation were associated with a significant decrease (p<0.001). Kaplan-Meier survival analysis showed worst survival for the axial cohort (p<0.001) and patients with distant metastases at presentation (p<0.001). Survival was not significantly different between older (2004-2007) and more recent years (2012-2016) (p = 0.742). CONCLUSIONS: For both appendicular and axial chondrosarcomas, surgical treatment remains the mainstay of treatment due to its continued superiority for the long-term survival of patients, although advancements in survival over the last decade have been insignificant. Presence of distant metastases and axial involvement are significant, poor prognostic factors perhaps because of difficulty in surgical excision or extent of disease.


Assuntos
Neoplasias Ósseas , Condrossarcoma , Neoplasias Ósseas/radioterapia , Neoplasias Ósseas/cirurgia , Condrossarcoma/radioterapia , Condrossarcoma/cirurgia , Bases de Dados Factuais , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Resultado do Tratamento
3.
Artigo em Inglês | MEDLINE | ID: mdl-35192571

RESUMO

INTRODUCTION: Previous studies about osteosarcoma patient characteristics, management, and outcomes have limited patient numbers, combine varied tumor types, and/or are older studies. METHODS: Patients with osteosarcoma from the 2004 to 2015 National Cancer Database data sets were separated into axial, appendicular, and other. Demographic and treatment data as well as 1-, 5-, and 10-year survival were determined for each group. A multivariate Cox analysis of patient variables with the likelihood of death was performed, and the Kaplan Meier survival curves were generated. RESULTS: Four thousand four hundred thirty patients with osteosarcoma (3,435 appendicular, 810 axial, and 185 other) showed survival at 1-year, 5-year, and 10-year and was highest among the appendicular cohort (91.17%, 64.43%, and 58.58%, respectively). No change in survival was seen over the periods studied. The likelihood of death was greater with increasing age category, distant metastases, and treatment with radiation alone but less with appendicular primary site, treatment with surgery alone, or surgery plus chemotherapy. DISCUSSION: Despite advances in tumor management, surgical excision remains the best predictor of survival for osteosarcomas. No difference was observed in patient survival from 2004 to 2015 and, as would be expected, distant metastases were a poor prognostic sign, as was increasing age, male sex, and axial location.


Assuntos
Neoplasias Ósseas , Osteossarcoma , Neoplasias Ósseas/patologia , Neoplasias Ósseas/terapia , Bases de Dados Factuais , Humanos , Estimativa de Kaplan-Meier , Masculino , Osteossarcoma/terapia , Prognóstico
4.
J Oral Maxillofac Surg ; 79(6): 1339-1343, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33610491

RESUMO

PURPOSE: Older age cleft palate (CP) repair in international settings has been associated with increased surgical morbidity. This study assesses the prevalence and risks associated with late-age CP repair (age > 5 years) in the United States. METHODS: Primary CP repair patients less than the age of 18 years were identified in the National Surgical Quality Improvement pediatric database from 2012 to 2018. Total postoperative complications, readmissions, reoperations, duration of surgery, and length of stay were recorded. T-tests and χ2 analyses were used to compare variables between age groups 0-5, 6-10, and 11-17. RESULTS: A total of 10,022 primary CP procedures were identified from 2012 to 2018, of which 868 (8.6%) received repair at age > 5 years. Hispanic patients constituted a larger proportion of CP repair from ages 11 to 17 years than repair at other ages (P < .001). In comparison with children treated from ages 0 to 5 years, children operated on between ages 6 and 10 or 11 and 17 years experienced no increases in unplanned readmissions, reoperations, or complication rates after surgery. Patients of ages 6-10 years and 11-17 years had decreased operating room time (P < .001) compared with younger patients. Patients of ages 11-17 years also had decreased hospital length of stay (P = .04). CONCLUSIONS: Many children in the United States received primary CP repair after the age of 5 years likely due to late treatment of submucosal clefts or delayed care among international immigrants/adoptees. Old age procedures were not associated with increased short-term surgical morbidity in comparison with surgery at earlier time points. The causes and implications of older age primary surgery warrant further study.


Assuntos
Fenda Labial , Fissura Palatina , Adolescente , Criança , Pré-Escolar , Fenda Labial/cirurgia , Fissura Palatina/epidemiologia , Fissura Palatina/cirurgia , Humanos , Lactente , Recém-Nascido , Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias/epidemiologia , Reoperação , Estudos Retrospectivos , Estados Unidos/epidemiologia
5.
J Oral Maxillofac Surg ; 79(2): 441-449, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33058772

RESUMO

INTRODUCTION: Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery. METHODS: Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ2 analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ2 analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts. RESULTS: There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients. CONCLUSION: There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.


Assuntos
Cirurgia Ortognática , Adolescente , Criança , Etnicidade , Disparidades em Assistência à Saúde , Hispânico ou Latino , Humanos , Tempo de Internação , Estados Unidos , População Branca , Adulto Jovem
6.
Plast Reconstr Surg ; 147(1): 131-137, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33009328

RESUMO

BACKGROUND: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS: The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Fissura Palatina/cirurgia , Procedimentos Cirúrgicos Ortognáticos/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Distúrbios da Fala/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Fatores Etários , Pré-Escolar , Fissura Palatina/complicações , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Procedimentos Cirúrgicos Ortognáticos/efeitos adversos , Procedimentos Cirúrgicos Ortognáticos/normas , Palato Duro/anormalidades , Palato Duro/cirurgia , Palato Mole/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Reoperação/estatística & dados numéricos , Distúrbios da Fala/etiologia , Tempo para o Tratamento/normas
7.
J Am Acad Orthop Surg Glob Res Rev ; 3(8): e086, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31592508

RESUMO

Previous studies evaluating the risk of perioperative adverse events after hip fracture surgery for dialysis-dependent patients are either institutional cohort studies or limited by patient numbers. The current study uses the National Surgical Quality Improvement Program database's large national patient population and 30-day follow-up window to address these weaknesses. METHODS: National Surgical Quality Improvement Program databases (2006 to 2016) were queried for patients aged 60 years or older who underwent hip fracture surgery. Differences in 30-day outcomes based on preoperative dialysis dependence were compared using risk-adjusted logistic regression and coarsened exact matching for adverse events, need for revision surgery, readmission, and mortality. The proportion of adverse events that occurred before versus after discharge was also assessed. RESULTS: A total of 288 dialysis-dependent and 16,392 non-dialysis-dependent patients met the inclusion criteria. Matched populations controlling for demographic factors (ie, age, sex, body mass index, and functional status) and overall health (American Society of Anesthesiologists class) found dialysis-dependent patients to be associated with significantly greater odds of any adverse event (odds ratio [OR] = 1.90), major adverse event (OR = 1.77), and unplanned readmission (OR = 2.48). Increased odds of minor adverse event (OR = 1.05), return to the operating room (OR = 1.66), and death (OR = 1.42) within 30 postoperative days were also found but were not statistically significant. DISCUSSION: Even after controlling for demographics and health status, geriatric dialysis patients undergoing surgery for hip fracture are at significantly greater odds of adverse outcomes. Because of increased risks for geriatric dialysis patients undergoing surgery for hip fracture, surgical caution, patient counseling, and heightened surveillance must be observed throughout the perioperative period for this fragile population. Furthermore, hospitals and physicians must take the increased risks associated with dialysis into account when considering bundled payment reimbursement strategies and resource allocation for hip fracture care.

8.
J Craniofac Surg ; 30(4): 1201-1205, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31166266

RESUMO

BACKGROUND: High volume centers (HVC) is commonly associated with increased resources and improved patient outcomes. This study assesses efficacy and outcomes of high volume centers in cleft palate repair. METHODS: Cleft palate procedures were identified in the Kids' Inpatient Database from 2003-2009. Demographics, perioperative factors, co-morbidities, and complications in HVC (90th percentile, >48 cases/year) and non-high volume centers (NHVC) were compared across various cohorts of cleft repair. RESULTS: Four thousand five hundred sixty-three (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. The NHVC treated a higher percentage of Medicaid patients (P = 0.005) and patients from low-income quartiles (P = 0.018). HVC had larger bedsizes (P <0.001), were more often government/private owned (P <0.001), and were more often teaching hospitals (P <0.001) located predominantly in urban settings (P <0.001). The HVC treated patients at younger ages (P = 0.008) and performed more concurrent procedures (P = 0.047). The most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. Overall, length of stay and specific complication rates were lower in HVC (P = 0.048, P = 0.042). Primaries at HVCs showed lower pneumonia (P = 0.009) and specific complication rates (P = 0.023). Revisions at HVC were associated with older patients, fewer cardiac complications (P = 0.040), less wound disruption (P = 0.050), but more hemorrhage (P = 0.040).


Assuntos
Fissura Palatina/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Fenda Labial/cirurgia , Fissura Palatina/economia , Bases de Dados Factuais , Feminino , Hospitais de Ensino/estatística & dados numéricos , Humanos , Renda , Seguro Saúde/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , Serviços Urbanos de Saúde/estatística & dados numéricos
9.
Plast Reconstr Surg ; 143(6): 1738-1745, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31136493

RESUMO

BACKGROUND: Various factors can influence outcomes in cleft palate care. This study sought to determine the impact of race on admissions, hospital costs, and short-term complications in cleft palate repair. METHODS: Cleft palate operations were identified in the Kids' Inpatient Database data, from 2000 to 2009. Data were combed for demographics, perioperatives, complications, and hospital characteristics. Bivariate and multivariate analyses were performed between races in total, primary, and revision cohorts. RESULTS: There were 3464 white, 1428 Hispanic, 413 black, 398 Asian/Pacific-Islander, and 470 patients of other races captured. Black patients experienced more emergent admissions (p = 0.005) and increased length of stay (p = 0.029). Hospital charges were highest for black and Hispanic patients and lowest for white patients (p = 0.019). Black patients had more total complications than non-black patients (p = 0.039), including higher rates of postoperative fistula (p = 0.020) and nonspecific complications among revision repairs (p = 0.003). Asian/Pacific Islander in the primary cohort experienced higher rates of accidental puncture (p = 0.031) and fistula (p < 0.001). Other patients had the highest rates of wound disruption (p = 0.013). After controlling for race, diagnosis, Charlson Comorbidity Index score, region, elective/nonelective, payer, and income quartile, length of stay (p < 0.001) and age (p < 0.001) were associated with increases in both total complications and costs. CONCLUSIONS: Race may play a significant role in cleft palate repair, as white patients had fewer complications, shorter length of stay, and lower costs following repair. Delayed age at treatment may predispose patients to adverse sequelae in minority populations, in terms of influencing length of stay and costs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Fissura Palatina/etnologia , Fissura Palatina/cirurgia , Disparidades em Assistência à Saúde/etnologia , Custos Hospitalares , Procedimentos de Cirurgia Plástica/métodos , Negro ou Afro-Americano/estatística & dados numéricos , Pré-Escolar , Fissura Palatina/diagnóstico , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/economia , Masculino , Análise Multivariada , Avaliação das Necessidades , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Racismo/etnologia , Racismo/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/economia , Reoperação/métodos , Estudos Retrospectivos , Estados Unidos , População Branca/estatística & dados numéricos
10.
J Am Acad Orthop Surg ; 27(7): 256-263, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30897607

RESUMO

INTRODUCTION: Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program. METHODS: Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication. RESULTS: A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001). DISCUSSION: Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period. LEVEL OF EVIDENCE: Level III.


Assuntos
Parada Cardíaca/epidemiologia , Complicações Intraoperatórias/epidemiologia , Infarto do Miocárdio/epidemiologia , Procedimentos Ortopédicos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/prevenção & controle , Humanos , Incidência , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/prevenção & controle , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Procedimentos Ortopédicos/mortalidade , Procedimentos Ortopédicos/estatística & dados numéricos , Readmissão do Paciente , Período Perioperatório , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Fatores de Tempo , Adulto Jovem
11.
J Craniofac Surg ; 29(7): 1755-1759, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30095569

RESUMO

PURPOSE: Limited cross-institutional studies compare strip craniectomy versus cranial vault remodeling (CVR) for craniosynostosis management. Given competing surgical preferences, the authors conducted a large-scale analysis of socioeconomic differences, costs, and complications between treatment options. METHODS: Nonsyndromic craniosynostosis patients receiving strip craniectomies or CVR were identified in the Kids' Inpatient Database for years 2000 to 2009. Demographics, socioeconomic background, hospital characteristics, charge, and outcomes were tabulated. Univariate and multivariate analyses were performed for comparison. RESULTS: Two hundred fifty-one strip craniectomies and 1811 CVR patients were captured. Significantly more strip craniectomy patients were White while more CVR patients were Hispanic or Black (P < 0.0001). Strip craniectomy patients more often had private insurance and CVR patients had Medicaid (P < 0.0001). Over time, CVR trended toward treating a higher proportion of Hispanic and Medicaid patients (P = 0.036). Peri-operative charges associated with CVR were $27,962 more than strip craniectomies, and $11,001 after controlling for patient payer, income, bedsize, and length of stay (P < 0.0001). Strip craniectomies were performed more frequently in the West and Midwest, while CVR were more common in the South (P = 0.001). Length of stay was not significant. Postsurgical complications were largely equivocal; CVR was associated with increased accidental puncture (P = 0.025) and serum transfusion (P = 0.002). CONCLUSION: Our national longitudinal comparison demonstrates widening socioeconomic disparities between strip craniectomy and CVR patients. Cranial vault remodeling is more commonly performed in underrepresented minorities and patients with Medicaid, while strip craniectomy is common in the White population and patients with private insurance. While hospital charges and complications were higher among CVR, differences were smaller than expected.


Assuntos
Craniossinostoses/cirurgia , Craniotomia/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Crânio/cirurgia , Negro ou Afro-Americano/estatística & dados numéricos , Craniotomia/efeitos adversos , Craniotomia/economia , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Humanos , Lactente , Seguro Saúde/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/economia , Estudos Retrospectivos , Fatores Socioeconômicos , Resultado do Tratamento , Estados Unidos , População Branca/estatística & dados numéricos
12.
Spine J ; 18(11): 2033-2042, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30077772

RESUMO

BACKGROUND CONTEXT: The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data. PURPOSE: The present study uses a large, national sample with 30-day follow-up to investigate dialysis as risk factor for perioperative complications independent of patient demographics or comorbidities. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: Patients undergoing elective spine surgery with or without dialysis from the 2005-2015 National Surgical Quality Improvement Program (NSQIP) database were included in the study. OUTCOME MEASURES: Postoperative complications within 30 days and binomial reoperation, readmission, and mortality within 30 days were determined. METHODS: The 2005-2015 NSQIP databases were queried for adult dialysis-dependent and dialysis-independent patients undergoing elective spinal surgery. Differences in 30-day outcomes were compared using risk-adjusted multivariate regression and coarsened exact matching analysis for adverse events, unplanned readmission, reoperation, and mortality. The percentage of complications occurring before versus after hospital discharge was also assessed. The authors have no financial disclosures related to the present study. RESULTS: A total of 467 dialysis and 173,311 non-dialysis patients met the inclusion criteria. Controlling for age, gender, body mass index, functional status, and American Society of Anesthesiologists (ASA) class, dialysis patients were found to be at significantly greater odds of any adverse event (odds ratio [OR]=2.52 before, 2.17 after matching, p=<.001), major adverse event (OR=2.90 before, 2.52 after matching, p=<.001), and minor adverse event (OR=1.50 before matching, p=<.025, but not significantly different after matching). Further, dialysis patients were significantly more likely to return to the operating room (OR=2.77 before, 2.50 after matching, p=<.001), have unplanned readmissions (OR=2.73 before, 2.37 after matching, p=<.001), and die within 30 days (OR=3.77 before, 2.71 after matching, p=<.001). Adverse events occurred after discharge for 51.78% of non-dialysis patients and for 43.80% of dialysis patients. CONCLUSIONS: Dialysis patients undergoing elective spine surgery are at significantly higher risk of aggregated adverse outcomes, return to the operating room, readmission, and death than non-dialysis patients, even after controlling for patient demographics and overall health (as indicated by ASA class). These differences need to be considered when determining treatment options. Additionally, with bundled payments expected in spine surgery, physicians and hospitals need to account for increased costs and liabilities when working with dialysis patients.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Diálise Renal/efeitos adversos , Coluna Vertebral/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Reoperação/estatística & dados numéricos
13.
Spine J ; 18(11): 1982-1988, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29649610

RESUMO

BACKGROUND CONTEXT: The use of national databases in spinal surgery outcomes research is increasing. A number of variables collected by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) changed between 2010 and 2011, coinciding with a rapid increase in the number of patients included per year. However, there has been limited study evaluating the effect that these changes may have on the results of outcomes studies. PURPOSE: The present study aimed to investigate the influence of changing data elements and growth of the NSQIP database on results of lumbar fusion outcomes studies. STUDY DESIGN/SETTING: This is a retrospective cohort study of prospectively collected data. PATIENT SAMPLE: The NSQIP database was retrospectively queried to identify 19,755 patients who underwent elective posterior lumbar fusion surgery with or without interbody fusion between 2005 and 2014. Patients were split into two groups based on year of surgery: 2,802 from 2005 to 2010 and 16,953 from 2011 to 2014. OUTCOME MEASURES: The occurrence of adverse events after discharge from the hospital, within postoperative day 30, was determined. METHODS: Preoperative characteristics and 30-day perioperative outcomes were compared between the era groups using bivariate analysis. To illustrate the effect of such changing data elements, the association between age and postoperative outcomes in the era groups was analyzed using multivariate Poisson regression. The present study had no funding sources, and there were no study-related conflicts of interest for any authors. RESULTS: There were significant differences between the era groups for a variety of preoperative characteristics. Postoperative events such blood transfusion and deep vein thrombosis were also significantly different between the era groups. For the 2005-2010 cohort, age was significantly associated with septic shock by multivariate analysis. For the 2011-2014 cohort, age was significantly associated with septic shock, urinary tract infection, blood transfusion, myocardial infarction, and extended length of stay. CONCLUSIONS: The NSQIP database has undergone substantial changes between 2005 and 2014. These changes may contribute to different results in analyses, such as the association between age and postoperative outcomes, when using older versus newer data. Conclusions from early studies using this database may warrant reconsideration.


Assuntos
Coleta de Dados/normas , Bases de Dados Factuais/normas , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Região Lombossacral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade/normas , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Humanos , Melhoria de Qualidade/estatística & dados numéricos
14.
Arthroscopy ; 34(1): 213-219, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28866341

RESUMO

PURPOSE: The purpose of the current study was to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to determine whether there were differences in 30-day perioperative complications between open arthrotomy and arthroscopy for the treatment of septic knees in a large national sample. METHODS: Patients who were diagnosed with a septic knee and underwent open arthrotomy or arthroscopy were identified in the 2005-2014 NSQIP data sets. Patient demographics and perioperative complications were characterized and compared between the 2 procedures. RESULTS: In total, 168 patients undergoing knee arthrotomy and 216 patients undergoing knee arthroscopy for septic knee were identified. There were no statistically significant differences in demographic variables between the 2 groups. On univariate analysis, the rate of minor adverse events (MAEs; 15.48% vs 8.80%, P = .043) was higher in the open arthrotomy treatment group, while the rate of serious adverse events (SAEs; 37.50% vs 26.19%, P = .019) was higher in the arthroscopic surgery treatment group. On multivariate analysis, which controlled for patient characteristics/comorbidities and used the Bonferroni correction for multiple comparisons, there were no statistically significant differences in risk of any adverse events (relative risk [RR] = 0.851; 99% confidence interval [CI], 0.598-1.211; P = .240), MAE (RR = 1.653; 99% CI, 0.818-3.341; P = .066), SAE (RR = 0.706; 99% CI, 0.471-1.058; P = .027), return to the operating room (RR = 0.810; 99% CI, 0.433-1.516; P = .387), or readmission (RR = 1.022; 99% CI, 0.456-2.294; P = .944) between open compared with arthroscopic surgery. CONCLUSIONS: Univariate analysis revealed a lower rate of MAE but a higher rate of SAE in the arthroscopic surgery treatment group. However, on multivariate analysis, similar perioperative complications, rate of return to the operating room, and rate of readmission were found after open and arthroscopic debridement for septic knees. Based on the lack of demonstrated superiority of either of these 2 treatment modalities for this given diagnosis, and the expectation that most differences in perioperative complications for this diagnosis would have declared themselves within the first 30 days, deciding between the studied treatment modalities may be based more on other factors not included in this study. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.


Assuntos
Artrite Infecciosa/cirurgia , Artroscopia/efeitos adversos , Desbridamento/efeitos adversos , Articulação do Joelho/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Artroscopia/métodos , Bases de Dados Factuais , Desbridamento/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
15.
Spine (Phila Pa 1976) ; 43(7): 526-532, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28767639

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine if International Classification of Diseases (ICD) coding for obesity is biased toward certain subgroups and how potential bias may influence the outcomes of database research in spine. SUMMARY OF BACKGROUND DATA: There has been increased use of national databases using administrative data in the spine surgery literature. Past research demonstrates that sensitivity of ICD codes for obesity is poor, but it is unknown if such inaccuracies are systematically biased and if they may bias studies utilizing such data. METHODS: Patients who underwent elective posterior lumbar fusion, 2013 to 2016, at a large academic hospital were identified. All ICD codes assigned to the encounter were obtained. Body mass index (BMI) was calculated based on height and weight. The sensitivity of ICD coding for obesity was calculated. Sensitivity was compared for subgroups defined by demographic, comorbidity, intraoperative, and postoperative factors. The association of obesity (as defined by BMI≥30 and ICD coding) with 30-day postoperative adverse events was tested with multivariate regression. RESULTS: The study included 796 patients. The overall sensitivity of ICD coding for obesity was 42.5%. The sensitivity of ICD coding for obesity was significantly higher in patients with greater BMI, diabetes, American Society of Anesthesiologists class≥III, increased length of stay, venous thromboembolism, any adverse event, and major adverse event. Multivariate analysis for determining outcomes of increased risk with obesity as defined by ICD coding included venous thromboembolism, major adverse events, and any adverse events. However, multivariate analysis for determining outcomes of increased risk with obesity defined by BMI did not yield any positive associations. CONCLUSION: ICD codes for obesity are more commonly assigned to patients with other comorbidities or postoperative complications. Further, use of such nonrandomly assigned ICD codes for obesity has the potential to skew studies to suggest greater associated adverse events than calculated BMI would demonstrate. LEVEL OF EVIDENCE: 3.


Assuntos
Procedimentos Cirúrgicos Eletivos , Obesidade , Complicações Pós-Operatórias , Doenças da Coluna Vertebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Viés , Feminino , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Estudos Retrospectivos , Doenças da Coluna Vertebral/complicações , Coluna Vertebral/cirurgia
16.
Int J Spine Surg ; 12(6): 713-717, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30619675

RESUMO

BACKGROUND: Although publication rates from multiple orthopedic research conferences have been published in the literature, the publication rates of abstracts presented at the Lumbar Spine Research Society (LSRS) meetings have never been reported. The purpose of this study is to evaluate the publication rates from the LSRS annual meeting years 2008-2012 and then to compare those rates with that of other spine research society meetings. METHODS: Podium presentations from 2008 to 2012 and poster presentations from 2010 to 2012 were reviewed. For each presentation, a PubMed search was performed to determine if a full-text publication existed. χ2 tests were used to compare LSRS publication rates to those of other spine meetings. In addition, impact of published articles was evaluated by average citation count and average journal impact factor. RESULTS: From 2008 to 2012, a total of 332 podium and poster presentations were identified. The overall publication rate was 55.1% (183/332). For podium presentations, this was greatest in 2012 (66.0%) and lowest in 2008 (51.5%). For poster presentations, this was greatest in 2012 (53.6%) and lowest in 2010 (25.0%). The publication rate of presentations is statistically greater than the publication rates of Eurospine (37.8%, P < .001), North American Spine Society (40.0%, P < .001), The International Society for the Study of the Lumbar Spine (45.0%, P = .012), and the Scoliosis Research Society (47.0%, P = .042) but not statistically different than that of Cervical Spine Research Society (65.7%, P = .059). In addition, the average citation count per published article categorized by year ranged from 13 to 31. The average journal impact factor of published articles categorized by year ranged from 2.31 to 2.55. CONCLUSIONS: While LSRS is a relatively young society, these findings point to the high quality of presentations at this scientific meeting. These findings speak to the scientific rigor of presentations at LSRS. CLINICAL RELEVANCE: This study helps clinicians and scientists gauge the quality of a research meeting and make informed choices on which gatherings to attend.

17.
Spine J ; 18(6): 970-978, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29056565

RESUMO

BACKGROUND CONTEXT: Venous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery. PURPOSE: The objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery. STUDY DESIGN/SETTING: This is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center. PATIENT SAMPLE: This study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery. OUTCOME MEASURES: The incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort. MATERIALS AND METHODS: Associations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression. RESULTS: Among 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048). CONCLUSIONS: Pharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Tromboembolia Venosa/epidemiologia , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/uso terapêutico , Heparina/administração & dosagem , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle
18.
Spine (Phila Pa 1976) ; 43(1): E52-E59, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-28723873

RESUMO

STUDY DESIGN: Retrospective matched cohort study of prospectively collected data. OBJECTIVE: To compare rates of adverse events and readmission between lumbar total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF) using the American College of Surgeons National Surgical Quality Improvement Program database. SUMMARY OF BACKGROUND DATA: TDA and ALIF may be considered for similar degenerative indications. However, there have been a few large-cohort comparison studies of short-term clinical outcomes for these procedures. METHODS: The 2011-2015 NSQIP databases were retrospectively queried to identify patients who underwent elective stand-alone ALIF and TDA. After propensity matching, the association of procedure type with adverse events and readmission was determined using McNemar's test. Operative time and postoperative length of stay (LOS) were compared using multivariate linear regression. Risk factors for adverse events were determined using multivariate Poisson regression. RESULTS: In total, 1801 ALIF and 255 TDA patients were identified. After matching with propensity scores, there were no significant differences in the rates of any adverse event, serious adverse events, individual adverse events, or readmission other than blood transfusion, which occurred more frequently in the ALIF cohort (3.92% vs. 0.39%, P = 0.007). Operative time was not significantly different between the two cohorts, but postoperative LOS was significantly longer for ALIF cases (+0.28 days, P < 0.001). When evaluating 10 preoperative variables as potential risk factors for adverse events and readmission after TDA and ALIF, the majority of results were similar. CONCLUSION: The only identified differences in perioperative outcomes between TDA and ALIF were a 3.53% higher incidence of blood transfusion and 0.28-day longer LOS for the ALIF group. These results suggest overall similar short-term general-health outcomes between the two groups, and that the choice between the two procedures, for the appropriately selected patient, should be based on longer-term functional outcomes. LEVEL OF EVIDENCE: 3.


Assuntos
Tempo de Internação , Vértebras Lombares/cirurgia , Readmissão do Paciente , Complicações Pós-Operatórias/etiologia , Fusão Vertebral/efeitos adversos , Substituição Total de Disco/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Incidência , Dor Lombar/cirurgia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fusão Vertebral/métodos , Substituição Total de Disco/métodos , Adulto Jovem
19.
Spine J ; 18(7): 1149-1156, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29155251

RESUMO

BACKGROUND CONTEXT: The Rothman Index (RI) is a comprehensive rating of overall patient condition in the hospital setting. It is used at many medical centers and calculated based on vital signs, laboratory values, and nursing assessments in the electronic medical record. Previous research has demonstrated an association with adverse events, readmission, and mortality in other fields, but it has not been investigated in spine surgery. PURPOSE: The present study aims to determine the potential utility of the RI as a predictor of adverse events after discharge following elective spine surgery. STUDY DESIGN/SETTING: This retrospective cohort study was carried out at a large academic medical center. PATIENT SAMPLE: A total of 2,687 patients who underwent elective spine surgery between 2013 and 2016 were included in the present study. OUTCOME MEASURES: The occurrence of adverse events and readmission after discharge from the hospital, within postoperative day 30, was determined in the present study. METHODS: Patient characteristics and 30-day perioperative outcomes were characterized, with events being classified as "major adverse events" or "minor adverse events" using standardized criteria. Rothman Index scores from the hospitalization were analyzed and compared for those who did or did not experience adverse events after discharge. The association of lowest and latest scores on adverse events was determined with multivariate regression, controlling for demographics, comorbidities, surgical procedure, and length of stay. RESULTS: Postdischarge adverse events were experienced by 7.1% of patients. The latest and lowest RI values were significantly inversely correlated with any adverse events, major adverse events, minor adverse events and readmissions after controlling for age, gender, body mass index, American Society of Anesthesiologists (ASA) class, surgical site, and hospital length of stay. Rates of readmission and any adverse event consistently had an inverse correlation with lowest and latest RI scores, with patients at increased risk with lowest score below 65 or latest score below 85. CONCLUSIONS: The RI is a tool that can be used to predict postdischarge adverse events after elective spine surgery that adds value to commonly used indices such as patient demographics and ASA. It is found that this can help physicians identify high-risk patients before discharge and should be able to better inform clinical decisions.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente
20.
J Cardiothorac Surg ; 12(1): 45, 2017 May 31.
Artigo em Inglês | MEDLINE | ID: mdl-28569201

RESUMO

BACKGROUND: To compare the perioperative and long term survival after aortic valve replacement using stentless versus stented valves in a large cohort of patients grouped using propensity score matching. METHODS: From 1991 to 2012, 4,563 patients underwent aortic valve replacement with stentless and stented valves at our institution. Propensity score matching identified 444 pairs using 13 independent variables: incidence of operation, smoking status, renal failure, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, chronic lung disease, ejection fraction, gender, age, valve status, and use of coronary artery bypass graft. Data were collected from our Society of Thoracic Surgeons database and the Social Security Death Index. Groups were compared using univariate and Kaplan-Meier analysis. RESULTS: The two groups demonstrated no significant differences for the 13 matching variables and the majority of 30-day outcomes (p > 0.05). The stented valve group showed a higher incidence of postoperative bleeding (3.6% vs 1.1%, p = 0.015), but a lower incidence of stroke (0.9% vs. 2.9%, p = 0.028). One, five, and 10-year survival was 95.0, 80.7, and 52.8% for stented and 93.2, 80.5, and 51.3% for stentless valves. Overall survival did not differ significantly between the two groups (p = 0.641). CONCLUSIONS: Stentless and stented valves had identical 30-day outcomes except for a higher postoperative incidence of bleeding and a lower incidence of stroke in the stented group. There was no significant difference in long term survival between valve types. Both valves may be used for aortic valve replacement with low morbidity and excellent long term survival.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Stents , Idoso , Estenose da Valva Aórtica/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Fatores de Tempo , Estados Unidos/epidemiologia
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