Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs.

BACKGROUND: Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS: Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS: All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS: A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database.

INTRODUCTION: Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury. METHODS: Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics. RESULTS: Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses. CONCLUSIONS: Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

Predictors of 30-Day Pulmonary Complications after Outpatient Surgery: Relative Importance of Body Mass Index Weight Classifications in Risk Assessment.

BACKGROUND: Current literature is controversial regarding the importance of obese BMI classifications as a risk factor for pulmonary complications after outpatient surgery. The objective of the current investigation was to evaluate predictors of pulmonary outcomes after outpatient surgery and to assess the importance of BMI weight classifications in risk assessment. STUDY DESIGN: Patients with "outpatient" recorded as their inpatient/outpatient status in the 2012 to 2013 NSQIP database were included. The primary outcome of interest was the occurrence of a new pulmonary complication (eg pneumonia, pulmonary embolism, unplanned intubation, or ventilator-assisted respiration for greater than 48 hours) within 30 days of surgery. RESULTS: There were 444,532 cases included in the final analysis. There were 996 (0.22%; 99% CI 0.21% to 0.24%) all-cause pulmonary complications. Binary logistic regression identified BMI as an independent predictor of a pulmonary complication, unadjusted odds ratio 1.091 (99.75% CI 1.026 to 1.160) per 5 kg/m2 change in BMI, p < 0.001. Adjusted odds of a pulmonary complication with a BMI of 35 to 39.99 kg/m2 was 1.44 (99.75% CI 1.01 to 2.06; p = 0.002) and with a BMI of 40 to 49.99 kg/m2 was 1.68 (99.75% CI 1.13 to 2.50; p < 0.001) compared with a BMI of 18.5 to 24.99 kg/m2. CONCLUSIONS: Obese classes II and III were associated with an independent risk of a pulmonary complication. The risk associated with obesity was low compared with the risk associated with advanced age, prolonged surgical duration, and the risk of comorbidities including congestive heart failure, COPD, and renal failure.

Impact of Type of Health Insurance on Infection Rates among Young Trauma Patients.

BACKGROUND: Many studies have described the detrimental effect of lack of health insurance on trauma-related outcomes. It is unclear, though, whether these effects are related to pre-injury health status, access to trauma centers, or differences in quality of care after presentation. The aim of this study was to determine if patient and insurance type affect outcomes after trauma surgery. METHODS: We conducted a retrospective chart review of prospectively collected data at the American College of Surgeons level 1 trauma registry in Rhode Island. All blunt trauma patients aged 18-45 observed from 2004 to 2014 were included. Patients were divided into one of four groups on the basis of their type of insurance: Private/commercial, Medicare, Medicaid, and uninsured. Co-morbidities and infections were recorded. Analysis of variance or the Mann-Whitney U test, as appropriate, was used to analyze the data. RESULTS: A total of 8,018 patients were included. Uninsured patients were more likely to be male and younger, whereas the Medicare patient group had significantly fewer male patients. Rates of co-morbidities were highest in the Medicare group (28.1%) versus the private insurance (16.7%), Medicaid (19.9%), and uninsured (12.9%) groups (p < 0.05). However, among patients with any co-morbidity, there was no difference in the average number of co-morbidities between insurance groups. The rate of infection was highest in Medicaid patients (7.7%) versus private (5.6%), Medicare (6.3%), and uninsured (4.3%) patients (p < 0.05). Only Medicaid was associated with a significantly greater risk of developing a post-injury infection (odds ratio 1.6; 95% confidence interval 1.1-2.3). CONCLUSION: The presence of insurance, namely Medicaid, does not equate to diagnosis and management of conditions that affect trauma outcomes. Medicaid is associated with worse pre-trauma health maintenance and a greater risk of infection.

Assessment of surgical residents in a vascular anastomosis laboratory.

BACKGROUND: We designed a simple, low-cost workshop to teach surgical residents the basic skills of vascular anastomosis. We studied our ability to identify objective procedural and end-product metrics that could be used to measure improvement in vascular anastomotic skill before and after training. MATERIALS AND METHODS: Ten postgraduate year 2 residents without previous vascular surgery experience and four attending surgeons (expert) performed end-to-side anastomosis using a synthetic graft. The residents were taught the basic skills of vascular anastomosis during three didactic workshops. The objective metrics included volume leakage after saline perfusion (leak) and the time needed to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures, and failure to maintain an outside-in to inside-out technique. The leak, time, and penalties before and after training were compared. RESULTS: The mean leak was 70.4 ± 13.7 mL and the mean completion time was 18.7 ± 3 min for the pretraining group versus 45.3 ± 10.6 mL (P < 0.01) and 8.5 ± 1 min (P < 0.001), respectively, for the attending group. After training, significant improvement was seen in resident leak (46.7 ± 6.8 mL; P < 0.001) and completion time (14.4 ± 3 min; P < 0.01). Leak was similar between the post-training and expert groups (46.7 ± 6.8 mL and 45.3 ± 10.6 mL, respectively; P = 0.77); however, a significant difference for the completion time remained (14.4 ± 3.0 min and 8.5 ± 1 min, respectively; P < 0.01). The mean number of technical errors improved from 2.7 in the pretraining group to zero for the post-training group after completing the workshop. CONCLUSIONS: We have reported an easy to implement workshop for teaching surgical residents the basic skills of performing vascular anastomosis.

Undiagnosed medical comorbidities in the uninsured: a significant predictor of mortality following trauma.

BACKGROUND: Lack of health care insurance has been correlated with increased mortality after trauma. Medical comorbidities significantly affect trauma outcomes. Access to health care and thereby being diagnosed with a pretrauma comorbidity is highly dependent on insurance status. The objective of this study was to determine whether rates of diagnosed or undiagnosed preexisting comorbidities significantly contribute to disparities in mortality rates observed between insured and uninsured trauma patients. METHODS: Review of trauma patients admitted to a Level I trauma center during a 5-year period. Data extracted from the registry included age, sex, Injury Severity Score (ISS), comorbidities, mortality, and insurance status. Multivariate logistic regression analysis was performed using age, sex, and insurance status to predict comorbidities and age, sex, ISS, and insurance status to predict mortality. RESULTS: Insured patients were older (54 years vs. 38, p < 0.001) and more likely female (41.3% vs. 22.5%, p < 0.001). When adjusting for age and sex, insured patients were more likely to have a pretrauma diagnosis of coronary artery disease (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.54-2.83), diabetes mellitus (OR, 2.09; 95% CI, 1.61-2.72), hypertension (OR, 1.97; 95% CI, 1.65-2.35), asthma/emphysema (OR, 1.64; 95% CI, 1.32-2.04), neurologic problems (OR, 1.79; 95% CI, 1.31-2.44), and gastroesophageal reflux disease (OR, 2.03; 95% CI, 1.33-3.11), compared with patients without insurance. In the analysis to predict mortality, having insurance was protective (OR, 0.57; 95% CI, 0.45-0.71). Among patients with no diagnosed comorbidities, insured patients had the lowest mortality risk (OR, 0.5; 95% CI, 0.38-0.67). When analyzing only patients with diagnosed comorbidities, insurance status had no impact on mortality risk (OR, 0.81; 95% CI, 0.53-1.22). CONCLUSION: Undiagnosed preexisting comorbidities play a crucial role in determining outcomes following trauma. Diagnosis of medical comorbidities may be a marker of access to health care and may be associated with treatment, which may explain the gap in mortality rates between insured and uninsured trauma patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Impact of socioethnic factors on outcomes following traumatic brain injury.

BACKGROUND: Ethnic minorities and low income families tend to be in poorer health and have worse outcomes for a spectrum of diseases. Health care provider bias has been reported to potentially affect the distribution of care away from poorer communities, minorities, and patients with a history of substance abuse. Trauma is perceived as a disease of the poor and medically underserved. Minorities are overrepresented in low income populations and are also less likely to possess health insurance leading to a potential overlapping effect. Traumatic brain injury (TBI) is a predominant cause of mortality and long-term morbidity, which imposes a considerable social and financial burden. We therefore sought to determine the independent effect on outcome after TBI from race, insurance status, intoxication on presentation, and median income. METHODS: A 5-year retrospective chart review of admitted trauma patients aged 18 years and older to a Level I trauma center. Zip code of residency was a surrogate marker for socioeconomic status, because median income for each zip code is available from the US Census. Charts review included race, insurance status, mechanisms of trauma, and injuries sustained. Outcomes were placement of tracheostomy, hospital length of stay (HLOS), leaving Against Medical Advice (AMA), and discharge to home versus rehabilitation and mortality. RESULTS: A total of 3,101 TBI patients were included in the analyses. Multivariable logistic and proportional hazard regression analyses were undertaken adjusting for age, gender, Injury Severity Score, and mechanism. Rates of tracheostomy placement were unaffected by race, median income, or insurance status. Race and median income did not affect HLOS, but private insurance was associated with shorter HLOS and intoxication was associated with longer HLOS. Neither race nor intoxication affected rates of AMA, but higher income and private insurance was associated with lower rates of AMA. Non-Caucasian race and lack of insurance had significantly lower likelihood of placement in a rehabilitation center. Mortality was unaffected by race, increased in intoxicated patients, was variably affected by median income, and was lowest in patients with private insurance. CONCLUSIONS: An extremely complex interplay exists between socioethnic factors and outcomes after TBI. Few physicians would claim overt discrimination. Tracheostomy, the factor most directed by the surgeon, was unbiased by race, income, or insurance status. The likelihood of placement in a rehabilitation center was significantly impacted by both race and insurance status. Future prospective studies are needed to better address causation.

A time-cost analysis of teaching a laparoscopic entero-enterostomy.

OBJECTIVE: Determining the success of technical skill training for surgery residents should include not only the efficacy of the training in terms of skills learned but also the cost of the facility where the training occurs and the cost of faculty participation. Traditional training occurs in the operating room, but the cost of faculty time and operating room time has not been well established. Assessing the cost of traditional training may allow us to put the cost of building and maintaining skills laboratories in perspective. To estimate the cost of traditional training we have recorded the time and interventions necessary for our senior residents to do a laparoscopic entero-enterostomy. METHODS: Each senior resident (PGY3-5) was asked to perform a laparoscopic entero-enterostomy in its entirety as part of a laparoscopic gastric bypass. After cannulation of the abdomen and division of any adhesions, we timed the residents for the performance of the following group of tasks: finding the ligament of Treitz, dividing the bowel 50-60 cm downstream, and creating a 2-layer anastomosis at 125 or 200 cm distal to the ligament. We tracked total time and number of interventions, which are defined by the attending temporarily taking over the case. RESULTS: Twelve residents were tracked by this system. The average time to complete the task was 93.7 minutes (+/-11.9 SD). The average number of interventions per case was 1.5 (+/-1.1 SD). Nine residents completed more than 1 procedure. Seven residents reduced their operative time on the second attempt. Operative times between the first and second procedure showed a reduction of 4.4 minutes (+/-17.4 SD), although this was not statistically significant (p = 0.47). No adverse clinical sequelae developed in these small bowel anastomoses. Educational time was calculated by subtracting the resident time from the time it takes an attending or finishing laparoscopic fellow to complete this task (50 minutes). The educational time for each anastomosis was 43.7 minutes. Using the AAMC average salary for an assistant professor of surgery of $180,000 year and assuming a 60-hour work week, this is $45.52 in faculty costs per anastomosis. If the cost of an operating room is $2000 per hour, the educational cost is $1457 per anastomosis. In our program, providing our 15 senior residents an educational opportunity to perform 2 laparoscopic entero-enterostomies would cost $45,061 a year. CONCLUSION: Resident education is expensive. Knowledge of the cost of skills training in a traditional operative setting is necessary to put the costs associated with building and maintaining skills laboratories in perspective. Cost analyses and efficacy of teaching will allow us to rate the success of new educational techniques.

Selective clinical management of anterior abdominal stab wounds.

BACKGROUND: The optimal management of clinically stable patients with anterior abdominal stab wounds (AASWs) is debated. We implemented a protocol of serial clinical assessments to determine the need for laparotomy. The purpose of this study was to determine whether the approach is safe and effective. METHODS: Records of patients sustaining AASWs from 1999 to 2003 were reviewed. RESULTS: Seventy-seven patients sustained AASWs. Twenty-five were taken directly to the operating room because of hypotension (5), evisceration (7), or peritonitis (15). Seventeen patients had diagnostic peritoneal lavage (DPL) for associated thoracoabdominal wounds and 5 had local wound exploration (LWE) off protocol. The remaining 30 patients were managed with serial clinical assessments and were discharged uneventfully. CONCLUSION: Patients sustaining AASWs who present without hypotension, evisceration, or peritonitis may be managed safely under a protocol of serial clinical evaluations. This approach should be compared with LWE/DPL in a prospective, randomized multicenter trial.

Differential effects of macrophage inflammatory chemokine-2 and keratinocyte-derived chemokine on hemorrhage-induced neutrophil priming for lung inflammation: assessment by adoptive cells transfer in mice.

Prior studies have shown that hemorrhage (Hem) can serve as a priming stimulus for acute lung injury (ALI) triggered by subsequent septic challenge (cecal ligation and puncture, CLP). Furthermore, we have reported that in vivo antibody neutralization of the chemokines, macrophage inflammatory chemokine-2 (MIP-2) and keratinocyte-derived chemokine (KC), immediately after Hem appears to differentially effect the onset of ALI. However, although we hypothesize that this is due to divergent effects of MIP-2 and KC on Hem-induced neutrophil (PMN) priming, this has not been tested. To examine this hypothesis, PMN donor mice were Sham-Hem or Hem for 90 min at 35 +/- 5 mmHg and were then administered anti-MIP- 2 (Hem/anti-MIP2), anti-KC (Hem/anti-KC), or nonspecific immunoglobulin (Ig) G (Hem/IgG) during resuscitation (Ringer's lactate = four times the amount of drawn blood volume). Twenty-four hours post-Hem, the peripheral blood PMN were purified from these donor animals and were introduced into PMN-depleted recipient mice [depleted by prior anti-Gr1 (mouse PMN-specific marker) antibody treatment]. One hour after PMN transfer, recipient mice were subjected to CLP, euthanized 24 h later, and plasma as well as lung tissue samples were collected. PMN influx was assessed by myeloperoxidase assay (MPO; microU/mg protein) and histologically (IL-6, MIP-2, KC, and IL-10 levels) by enzyme-linked immunoabsorbant assay (ELISA; ng/mg). The results show that donor PMN from Hem/IgG but not Sham-Hem mice produce increased PMN influx (increased MPO, increased % esterase+ cells in tissue) into the lung and local tissue inflammation (increased IL-6/MIP-2, decreased IL-10) in PMN-depleted CLP recipient mice, which was attenuated in mice receiving cells from Hem/anti-MIP-2 but not Hem/anti-KC treated donors. Interestingly, although Hem/anti-MIP-2 donor PMN produced comparable effects on blood IL-6/MIP-2 levels, they were ineffective in altering the change in plasma IL-10/KC levels induce by Hem. Taken together, these data demonstrate that Hem-induced priming of PMN not only mediates ALI in the mouse, but also that this process is differentially effected by MIP2 and KC, despite the fact that both signal through CXCR2.