Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS: We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS: We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS: Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Maori and 2047/51,921 (3.9%) for non-Maori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Maori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Maori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Maori patients had worse outcomes than non-Maori.

Minimal clinically important difference in days at home up to 30 days after surgery.

Patient-centred outcomes are increasingly recognised as crucial measures of healthcare quality. Days alive and at home up to 30 days after surgery (DAH30 ) is a validated and readily obtainable patient-centred outcome measure that integrates much of the peri-operative patient journey. However, the minimal difference in DAH30 that is clinically important to patients is unknown. We designed and administered a 28-item survey to evaluate the minimal clinically important difference in DAH30 among adult patients undergoing inpatient surgery. Patients were approached pre-operatively or within 2 days postoperatively. We did not study patients undergoing day surgery or nursing home residents. Patients ranked their opinions on the importance of discharge home using a Likert scale (from 1, not important at all to 6, extremely important) and the minimum number of extra days at home that would be meaningful using this scale. We recruited 104 patients; the survey was administered pre-operatively to 45 patients and postoperatively to 59 patients. The mean (SD) age was 53.5 (16.5) years, and 51 (49%) patients were male. Patients underwent a broad range of surgery of mainly intermediate (55%) to major (33%) severity. The median minimal clinically important difference for DAH30 was 3 days; this was consistent across a broad range of scenarios, including earlier discharge home, complications delaying hospital discharge and the requirement for admission to a rehabilitation unit. Discharge home earlier than anticipated and discharge home rather than to a rehabilitation facility were both rated as important (median score = 5). Empirical data on the minimal clinically important difference for DAH30 may be useful to determine sample size and to guide the non-inferiority margin for future clinical trials.

Comparative Propensity Matched Outcomes in Severe COVID-19 Respiratory Failure-Extracorporeal Membrane Oxygenation or Maximum Ventilation Alone.

OBJECTIVE: Does extracorporeal membrane oxygenation (ECMO) improve outcomes in ECMO-eligible patients with COVID-19 respiratory failure compared to maximum ventilation alone (MVA)? SUMMARY BACKGROUND DATA: ECMO is beneficial in severe cases of respiratory failure when mechanical ventilation is inadequate. Outcomes for ECMO-eligible COVID-19 patients on MVA have not been reported. Consequently, a direct comparison between COVID-19 patients on ECMO and those on MVA has not been established. METHODS: A total of 3406 COVID-19 patients treated at two major medical centers in Chicago were studied. One hundred ninety-five required maximum ventilatory support, and met ECMO eligibility criteria. Eighty ECMO patients were propensity matched to an equal number of MVA patients using detailed demographic, physiological, and comorbidity data. Primary outcome was survival and disposition at discharge. RESULTS: Seventy-one percent of patients were decannulated from ECMO. Mechanical ventilation was discontinued in 75% ECMO and 16% MVA patients. Twenty-five percent of patients in the ECMO arm expired, 21% while on ECMO, compared with 74% in the MVA cohort. Mortality was significantly lower across all age and BMI groups in the ECMO arm. Sixty-eight percent ECMO and 26% MVA patients were discharged from the hospital. Fewer ECMO patients required long-term rehabilitation. Major complications such as septic shock, ventilator associated pneumonia, inotropic requirements, acute liver and kidney injuries are less frequent among ECMO patients. CONCLUSIONS: ECMO-eligible patients with severe COVID-19 respiratory failure demonstrate a 3-fold improvement in survival with ECMO. They are also in a better physical state at discharge and have lower overall complication rates. As such, strong consideration should be given for ECMO when mechanical ventilatory support alone becomes insufficient in treating COVID-19 respiratory failure.

The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery.

BACKGROUND: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied. OBJECTIVES: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years. METHODS: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts. RESULTS: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups. CONCLUSIONS: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.

Temporal Trends in Revision Total Hip and Knee Arthroplasty from 2008 to 2018: Gaps and Opportunities.

BACKGROUND: An overall assessment of how patient demographic characteristics and comorbidities are improving or worsening can allow better understanding of the value of revision total joint arthroplasty (TJA). Therefore, the purpose of this study was to identify patient demographic characteristics and comorbidities trends and episode-of-care outcome trends from 2008 to 2018 in patients undergoing revision TJA. METHODS: The National Surgical Quality Improvement Program database was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes in patients undergoing revision TJA from 2008 to 2018 (n = 45,706). Pairwise t tests and pairwise chi-square tests were performed on consecutive years with Bonferroni correction. Trends were assessed using the 2-tailed Mann-Kendall test of the temporal trend. RESULTS: Among patients undergoing revision TJA, there was no clinically important difference, from 2008 to 2018, in age, body mass index (BMI), percentages with >40 kg/m2 BMI, diabetes (18.8% to 19%), chronic obstructive pulmonary disease (4.1% to 5.4%), congestive heart failure within 30 days (0% to 1%), or acute renal failure (0% to 0.2%). However, modifiable comorbidities including smoking status (14.7% to 12.0%; p = 0.01), hypertension (66% to 26.0%; p = 0.02), anemia (34.5% to 26.3%; p < 0.001), malnutrition (10.4% to 9.3%; p = 0.004), and overall morbidity or mortality probability have improved, with a decrease in the hospital length of stay and 30-day readmission and a significant increase in home discharge (p < 0.001 for all). CONCLUSIONS: Time-difference analysis demonstrated that the overall health status of patients undergoing revision TJA improved from 2008 to 2018. However, formal time-trend analysis demonstrated improvements to a lesser degree. The multidisciplinary effort to improve value-based metrics including patient comorbidity optimization and episode-of-care outcomes for primary TJA has been shown to potentially have an impact on revision TJA. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip fracture characteristics and outcomes during COVID-19: a large retrospective national database review.

BACKGROUND: The COVID-19 pandemic has impacted healthcare in various vulnerable patient subpopulations. However, data are lacking on the impact of COVID-19 on hip fractures, seen mainly in older patients. Using national claims data, we aimed to describe the epidemiology during the first COVID-19 wave in the USA. METHODS: We compared patients admitted for hip fractures during March and April of 2020 with those admitted in 2019 in terms of patient and healthcare characteristics, COVID-19 diagnosis, and outcomes. An additional comparison was made between COVID-19-positive and -negative patients. Outcomes included length of hospital stay (LOS), admission to an ICU, ICU LOS, use of mechanical ventilation, 30-day readmission, discharge disposition, and a composite variable of postoperative complications. RESULTS: Overall, 16 068 hip fractures were observed in 2019 compared with 7498 in 2020. Patients with hip fractures in 2020 (compared with 2019) experienced earlier hospital discharge and were less likely to be admitted to ICU, but more likely to be admitted to home. Amongst 83 patients with hip fractures with concomitant COVID-19 diagnosis, we specifically observed more non-surgical treatments, almost doubled LOS, a more than 10-fold increased mortality rate, and higher complication rates compared with COVID-19-negative patients. CONCLUSIONS: The COVID-19 pandemic significantly impacted not only volume of hip fractures, but also patterns in care and outcomes. These results may inform policymakers in future outbreaks and how this may affect vulnerable patient populations, such as those experiencing a hip fracture.

Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial.

BACKGROUND: The benefit and safety of laparoscopic pancreatoduodenectomy (LPD) for the treatment of pancreatic or periampullary tumours remain controversial. Studies have shown that the learning curve plays an important role in LPD, yet there are no randomised studies on LPD after the surgeons have surmounted the learning curve. The aim of this trial was to compare the outcomes of open pancreatoduodenectomy (OPD) with those of LPD, when performed by experienced surgeons. METHODS: In this multicentre, open-label, randomised controlled trial done in 14 Chinese medical centres, we recruited patients aged 18-75 years with a benign, premalignant, or malignant indication for pancreatoduodenectomy. Eligible patients were randomly assigned (1:1) to undergo either LPD or OPD. Randomisation was centralised via a computer-generated system that used a block size of four. The patients and surgeons were unmasked to study group, whereas the data collectors, outcome assessors, and data analysts were masked. LPD and OPD were performed by experienced surgeons who had already done at least 104 LPD operations. The primary outcome was the postoperative length of stay. The criteria for discharge were based on functional recovery, and analyses were done on a modified intention-to-treat basis (ie, including patients who had a pancreatoduodenectomy regardless of whether the operation was the one they were assigned to). This trial is registered with Clinicaltrials.gov, number NCT03138213. FINDINGS: Between May 18, 2018, and Dec 19, 2019, we assessed 762 patients for eligibility, of whom 656 were randomly assigned to either the LPD group (n=328) or the OPD group (n=328). 31 patients in each group were excluded and 80 patients crossed over (33 from LPD to OPD, 47 from OPD to LPD). In the modified intention-to-treat analysis (297 patients in the LPD group and 297 patients in the OPD group), the postoperative length of stay was significantly shorter for patients in the LPD group than for patients in the OPD group (median 15·0 days [95% CI 14·0-16·0] vs 16·0 days [15·0-17·0]; p=0·02). 90-day mortality was similar in both groups (five [2%] of 297 patients in the LPD group vs six [2%] of 297 in the OPD group, risk ratio [RR] 0·83 [95% CI 0·26-2·70]; p=0·76). The incidence rate of serious postoperative morbidities (Clavien-Dindo grade of at least 3) was not significantly different in the two groups (85 [29%] of 297 patients in the LPD group vs 69 [23%] of 297 patients in OPD group, RR 1·23 [95% CI 0·94-1·62]; p=0·13). The comprehensive complication index score was not significantly different between the two groups (median score 8·7 [IQR 0·0-26·2] vs 0·0 [0·0-20·9]; p=0·06). INTERPRETATION: In highly experienced hands, LPD is a safe and feasible procedure. It was associated with a shorter length of stay and similar short-term morbidity and mortality rates to OPD. Nonetheless, the clinical benefit of LPD compared with OPD was marginal despite extensive procedural expertise. Future research should focus on identifying the populations that will benefit from LPD. FUNDING: National Natural Science Foundation of China and Tongji Hospital, Huazhong University of Science and Technology, China.

Chronic polytherapy after myocardial infarction: the trade-off between hospital and community-based providers in determining adherence to medication.

BACKGROUND: The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. METHODS: This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010-2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, ß-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). RESULTS: A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). CONCLUSION: Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy.

INTRODUCTION: Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups. RESULTS: A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05). CONCLUSIONS: Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.

An Early Screening Tool for Discharge Planning Shortened Length of Hospital Stay for Elderly Patients with Community-Acquired Pneumonia.

BACKGROUND: Community-acquired pneumonia is one of the most common diseases in elderly persons and usually results in a prolonged hospital stay. Discharge planning plays an important role in reducing the length of hospitalization. This study was designed to determine whether early screening for risk factors for delayed discharge could improve the quality of discharge planning. METHODS: This retrospective, observational study was conducted in two medical facilities from January 2016 to December 2018. Hospital A used a screening tool on admission (screening group): screening for risk factors for delayed discharge and initiating discharge planning immediately for those for whom it was applicable, and discharge planning in the stable phase for those for whom it was not applicable; and Hospital B initiated discharge planning without screening (usual group). Propensity score-matched pneumonia patients in the two groups were then compared. The primary outcome was length of hospital stay. RESULTS: A total of 648 patients were enrolled in this study. After adjusting for age, sex, aspiration, comorbidity, pneumonia severity index, and key person, 118 pairs underwent analysis. Length of stay was significantly different (20 days vs 13 days, p<0.001) between the groups. There were no differences in duration of antibiotic treatment, in-hospital mortality, and 30-day readmission (9 days vs 9 days, p=0.744; 10 (8.5%) vs 10 (8.5%), p=1.000; 10 (8.5%) vs 9 (7.6%), p=0.811, respectively). CONCLUSION: Early screening for delayed discharge improved the quality of discharge planning by reducing the length of stay in pneumonia patients.

Decreasing Incidence of Lumbar Discectomy Surgery in Finland in 1997-2018.

STUDY DESIGN: Retrospective register study. OBJECTIVE: The aim of this study was to assess the incidence and trends of lumbar disc surgeries in Finland from 1997 through 2018. SUMMARY OF BACKGROUND DATA: The evidence on lumbar spine discectomy has shifted from supporting surgical treatment toward nonoperative treatment. Still, the incidence of lumbar discectomy operations increased until the 1990 s. In the United States, the incidence began to decline after a downward turn in 2008, yet recent trends from countries with public and practically free health care are not widely known. METHODS: Data for this study were obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 18 years of age or older in Finland during a 22-year period from January 1, 1997, to December 31, 2018. RESULTS: A total of 65,912 lumbar discectomy operations were performed in Finland from 1997 through 2018. The annual population-based incidence of lumbar discectomy decreased 29% during the 22-year period, from 83 per 100,000 person-years in 1997 to 58 per 100,000 person-years in 2018. In addition, the incidence of microdiscectomy increased 12%, from 41 per 100,000 person-years in 1997 to 47 per 100,000 person-years in 2018, whereas the incidence of open discectomy decreased 71%, from 41 per 100,000 person-years in 1997 to 12 per 100,000 person-years in 2018. The total reoperation rate for microendoscopic, microscopic, and open discectomy surgeries was 16.3%, 15.3%, and 14.9%, respectively. CONCLUSION: The nationwide incidence of lumbar discectomy decreased in Finland from 1997 through 2018. Additionally, the incidence of open discectomy is decreasing rapidly, whereas the incidence of microsurgical techniques is increasing.Level of Evidence: 3.

Urinary Tract Infection after Elective Spine Surgery: Timing, Predictive Factors, and Outcomes.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The aim of this study was to investigate risk factors associated with the timing of urinary tract infection (UTI) after elective spine surgery, and to determine whether postoperative UTI timing affects short-term outcomes. SUMMARY OF BACKGROUND DATA: Urinary tract infection (UTI) is a common post-surgical complication; however, the predominant timing, location, and potential differential effects have not been carefully studied. METHODS: We analyzed elective spine surgery patients from 2012 to 2018 in the ACS National Surgical Quality Improvement Program (NSQIP). We grouped patients with postoperative UTI by day of onset relative to discharge, to create cohorts of patients who developed inpatient UTI and post-discharge UTI. We compared both UTI cohorts with a control (no UTI) population and with each other to identify differences in baseline characteristics including demographic, comorbidity and operative factors. We performed multivariate logistic regression to identify predictors of UTI in each cohort and to assess adjusted risks of poor outcomes associated with UTI timing. RESULTS: A total of 289,121 patients met inclusion criteria and 0.88% developed UTI (n = 2553). Only 31.6% of UTIs occurred before discharge (n = 806), with 68.4% occurring after discharge (n = 1747). The inpatient UTI cohort had significantly longer operative time, more fusion procedures, more posterior procedures, and more procedures involving the lumbar levels than the post-discharge cohort. Predictors of inpatient UTI included procedure type, spine region, and approach. Predictors of post-discharge UTI included length-of-stay and discharge destination. Both UTI cohorts were significantly associated with sepsis; however, post-discharge UTI carried a higher odds (adjusted odds ratio [aOR] = 24.90, 95% confidence interval [CI] = 21.05-29.45, P < 0.001 vs. aOR = 14.31, 95% CI = 11.09-18.45, P < 0.001). Inpatient UTI was not associated with 30-day readmission, although post-discharge UTI was (aOR = 8.23, 95% CI = 7.36-9.20, P < 0.001). Conversely, inpatient UTI was associated with increased odds of 30-day mortality (aOR = 3.23, 95% CI = 1.62-6.41, P = 0.001), but post-discharge UTI was not. CONCLUSION: Predictive factors and outcomes differ based on timing of UTI after elective spine surgery. Before discharge, procedure -specific details predict UTI, but after discharge they do not. These findings suggest that traditional thinking about UTI prevention may need modification.Level of Evidence: 3.

Predicting Discharge Disposition Following Meningioma Resection Using a Multi-Institutional Natural Language Processing Model.

BACKGROUND: Machine learning (ML)-based predictive models are increasingly common in neurosurgery, but typically require large databases of discrete variables for training. Natural language processing (NLP) can extract meaningful data from unstructured text. OBJECTIVE: To present an NLP model that predicts nonhome discharge and a point-of-care implementation. METHODS: We retrospectively collected age, preoperative notes, and radiology reports from 595 adults who underwent meningioma resection in an academic center from 1995 to 2015. A total of 32 algorithms were trained with the data; the 3 best performing algorithms were combined to form an ensemble. Predictive ability, assessed by area under the receiver operating characteristic curve (AUC) and calibration, was compared to a previously published model utilizing 52 neurosurgeon-selected variables. We then built a multi-institutional model by incorporating notes from 693 patients at another center into algorithm training. Permutation importance was used to analyze the relative importance of each input to model performance. Word clouds and non-negative matrix factorization were used to analyze predictive features of text. RESULTS: The single-institution NLP model predicted nonhome discharge with AUC of 0.80 (95% CI = 0.74-0.86) on internal and 0.76 on holdout validation compared to AUC of 0.77 (95% CI = 0.73-0.81) and 0.74 for the 52-variable ensemble. The multi-institutional model performed similarly well with AUC = 0.78 (95% CI = 0.74-0.81) on internal and 0.76 on holdout validation. Preoperative notes most influenced predictions. The model is available at http://nlp-home.insds.org. CONCLUSION: ML and NLP are underutilized in neurosurgery. Here, we construct a multi-institutional NLP model that predicts nonhome discharge.

An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care.

OBJECTIVE: We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system. SUMMARY BACKGROUND DATA: Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood. METHODS: Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group. RESULTS: Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers. CONCLUSIONS: Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.

Incidence and predictors of early and late hospital readmission after transurethral resection of the prostate: a population-based cohort study.

OBJECTIVES: To evaluate the incidence and predictors of hospital readmission and emergency department (ED) visits in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate (TURP). PATIENTS AND METHODS: We conducted a retrospective cohort study using a linked administrative dataset from Calgary, Canada. Participants were men who underwent their first TURP procedure between 2015 and 2017. We examined patient demographics, and type of surgery (elective or urgent). Comorbidities were scored using the Charlson comorbidity index (CCI). The primary outcomes were unplanned hospital readmissions and ED visits at 30, 60 and 90 days after TURP. The secondary aim was to identify potential predictors across these groups. RESULTS: We identified 3059 men, most of whom underwent elective TURP (83%). The mean (sd) patient age was 71.0 (10.0) years. A total of 224 patients (7.4%) were readmitted to the hospital within 30 days, 290 (9.5%) within 60 days, and 339 (11.1%) within 90 days of discharge. The frequency of return visits within 30, 60 and 90 days of TURP were 21.4%, 26% and 28.6%, respectively. The most responsible diagnoses for ED visit within 90 days were haematuria (15.4%) and retention of urine (12.8%). Multivariable analysis showed that age (odds ratio [OR] 1.61, P < 0.001), surgery type (OR 2.20, P < 0.001), and CCI score (OR 2.03, P < 0.001) were independently associated with odds of readmission and ED visits at all time points. CONCLUSION: Older age, poorer health and urgent surgery predicted return to ED or readmission after TURP; efforts should be made to improve selection, counselling and preoperative optimization based on these risks.

Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery.

INTRODUCTION: In 2018, our institution implemented opioid prescribing guidelines for endocrine surgery. METHODS: We evaluated prescribing trends before and after the guidelines (60 MME following adrenal procedures and 37.5 MME for thyroid/parathyroid procedures) using chi-squared and Wilcoxon Rank-Sum tests. RESULTS: We identified 357 patients in the pre-guideline and 397 in the post-guideline period. The proportion discharged with any opioid prescription decreased from 96.1% to 77.3%, p < 0.01, and the median (IQR) prescribed amount decreased from 150.0 (100.0, 200.0) to 50.0 (25.0, 75.0), p < 0.01 overall and within each category. The proportion receiving prescription above the upper guidelines limit also decreased, while opioid refills within 30-day of discharge remained stable (2.8% before and 4.5% after the guidelines, p = 0.21). CONCLUSION: Opioid prescribing guidelines for endocrine surgical procedures decreased both the proportion of patients receiving opioids and the amount when prescribed, therefore further supporting the utility of opioid prescribing guidelines in decreasing over-prescription.

Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease.

OBJECTIVES: Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. METHODS: Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. RESULTS: We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). CONCLUSIONS: Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.

Very Early Discharge After Coronary Artery Bypass Grafting Does Not Affect Readmission or Survival.

BACKGROUND: This study evaluated the impact of very early hospital discharge after coronary artery bypass grafting (CABG) on subsequent readmission and survival. METHODS: Adults undergoing isolated CABG from 2011 to 2018 at a single institution were included. Patients were stratified on the basis of their postoperative length of hospital stay: short stay (≤4 days) and nonshort stay (>4 days). The primary outcomes were longitudinal survival and freedom from hospital readmission. Secondary outcomes included rates of postoperative complications. Propensity score matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics. RESULTS: A total of 6327 patients underwent CABG during the study period, and a matched cohort of 2286 patients was identified. In matched analysis, the average Society of Thoracic Surgeons predicted risk of operative mortality was low in both groups (average, 0.7%). Rates of postoperative complications were low and several complication rates were even lower in the short-stay cohort: stroke (1.14% vs 0.26%; P = .01), renal failure (0.87% vs 0.09%; P = .007), reoperations (1.84% vs 0.26%; P < .001), and new-onset atrial fibrillation (34.21% vs 13.04%; P < .001). Survival was similar between the matched groups at 30 days (99.56% vs 99.21%), 1 year (97.73% vs 97.46%), and 5 years (91.15% vs 92.48%) (all P > .05). Readmission rates were also comparable at all time intervals, and there were no differences in cardiac-related or heart failure-specific readmissions (all P > .05). Risk-adjusted analyses confirmed these findings. CONCLUSIONS: This study demonstrates that very early discharge within 4 days of isolated CABG is safe and has no substantial impact on subsequent mortality or readmission risk.