National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

BACKGROUND: Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS: All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS: Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS: AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Association of insurance status with financial toxicity and outcome disparities after penetrating trauma and assault.

BACKGROUND: Financial toxicity, or the impact out-of-pocket medical expenses have on the quality of life, has not been widely enumerated in the trauma literature. We characterized the relationship between insurance status and the risk of financial toxicity after trauma and associated risk factors. METHODS: Adults admitted for gunshot wounds, other penetrating injuries, or blunt assault were identified from the 2015 to 2019 National Inpatient Sample. The outcome of interest was a risk of financial toxicity with separate regression models for uninsured and insured populations. RESULTS: Of an estimated 775,665 patients, 21.2% were at risk of financial toxicity. Patients at risk of financial toxicity were younger, more commonly male, less commonly White, and had a lower Elixhauser Index (Table 1). A higher proportion of uninsured patients were at risk of financial toxicity (40.8% vs 17.7%, P < .001) than insured patients. Whereas the proportion of uninsured patients at risk of financial toxicity significantly increased from 2015 to 2019, it was unchanged in insured patients. After adjustment, non-income demographic and clinical factors were not associated with the risk of financial toxicity amongst the insured. Conversely, the Black or Hispanic race, gunshot wounds, and any in-hospital complications were some factors associated with increased risk of financial toxicity in uninsured patients. CONCLUSION: An increasingly larger proportion of uninsured patients are at risk of financial toxicity after trauma. The risk of financial toxicity among the uninsured was more complex than in the insured and associated with race, gunshot wounds, and complications. Increasing insurance access and the adoption of trauma-informed care practices should be used to address financial toxicity in this population.

National analysis of cost disparities in robotic-assisted versus laparoscopic abdominal operations.

BACKGROUND: Although the use of robotic-assisted surgery continues to expand, the cost-effectiveness of this platform remains unclear. The present study aimed to compare hospitalization costs and clinical outcomes between robotic-assisted surgery and laparoscopic approaches for major abdominal operations. METHODS: All adults receiving minimally invasive gastrectomy, cholecystectomy, colectomy (right, left, transverse, sigmoid), ventral hernia repair, hysterectomy, and abdominoperineal resection were identified in the 2012 to 2019 National Inpatient Sample. Records with concurrent operations were excluded. Multivariable linear and logistic regressions were developed to examine the association of the operative approach with costs, length of stay, and complications. An interaction term between the year and operative approach was used to analyze cost differences over time. RESULTS: Of an estimated 1,124,450 patients, 75.8% had laparoscopic surgery, and 24.2% had robotic-assisted surgery. Compared to laparoscopic, patients with robotic-assisted operations were younger and more commonly privately insured. The average hospitalization cost for laparoscopic cases was $16,000 ± 14,800 and robotic-assisted cases was $18,300 ± 13,900 (P < .001). Regardless of procedure type, all robotic-assisted operations had higher costs compared to laparoscopic operations. Risk-adjusted trend analysis revealed that the discrepancy in costs between laparoscopic and robotic-assisted surgery persisted and widened over time from $1,600 in 2012 to $2,600 in 2019. Compared to laparoscopic procedures, robotic procedures had a 2.2% reduction in complications (9.4 vs 11.6%, P < .001) and a 0.7-day decrement in the length of stay (95% confidence interval -0.8 to -0.7). CONCLUSION: Disparities in costs between robotic and laparoscopic abdominal operations have persisted over time. Given the modest decrement in adverse outcomes, further investigation into the clinical benefits of robotic surgery is warranted to justify its greater costs.