Out-of-Pocket Costs among Commercially Insured Individuals with type 2 Diabetes and Obesity: Comparison between Ozempic and Sleeve Gastrectomy.

OBJECTIVE: Determine out-of-pocket (OOP) costs two years after sleeve gastrectomy (SG) or initiating Ozempic for patients with type 2 diabetes (T2D) and obesity. SUMMARY BACKGROUND DATA: Individuals with obesity and T2D have a variety of treatment options. Risks and benefits of these treatment options are becoming more well documented; however, the real-world patient costs of these options are not known. METHODS: Adults with body mass index (BMI) 35 kg/m2 or higher, and T2D who had an SG or used Ozempic were identified in the employer-based retrospective claims database Merative™ (previously Truven IBM Marketscan) from 2017 to 2021. SG cohort was defined as having a SG (without filling a prescription for Ozempic) and Ozempic cohort was defined as continuously filling a prescription for Ozempic for at least 2 years (and not having any bariatric surgery). Individuals in each cohort were 1:1 propensity matched on demographics, obesity-related comorbidities, and baseline OOP costs. in the year before treatment. OOP costs were compared in the two years after treatment using paired t-tests. RESULTS: 302 SG were matched to 302 Ozempic patients (mean age 50, mean baseline BMI 40, 41% male). OOP healthcare costs were similar for the SG ($2,267) and Ozempic ($2,131) cohorts 1-year after index date (difference=$136, P=0.19). OOP healthcare costs were significantly lower in the SG cohort ($1,155 vs. $2,084, P<0.01) 2-years after index date. CONCLUSIONS: Within 2 years of starting treatment, OOP healthcare costs were significantly lower among individuals who had a SG versus those treated with Ozempic.

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment.

OBJECTIVE: The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients. METHODS: Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events. RESULTS: A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding. CONCLUSION: Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1169-1182, 2024.

Risk stratified venous thromboembolism prophylaxis in bariatric patients using a Caprini assessment: practice patterns and opportunities for improvement.

BACKGROUND: Venous thromboembolism (VTE) is rare after bariatric surgery but is the most common cause of mortality. The use of VTE risk-stratification tools and compliance with practice guidelines remain unclear. OBJECTIVES: Our objectives were to determine the utilization of risk-stratified VTE prophylaxis and its impact on VTE and bleeding outcomes. SETTING: Academic hospital system. METHODS: Roux-en-Y gastric bypass and sleeve gastrectomy (2016-2021) were identified from our electronic health records. Caprini score and VTE prophylaxis regimen were retrospectively determined. VTE prophylaxis consistent with Caprini guidelines was considered appropriate. Outcomes were compared between VTE prophylaxis cohorts. Variables were compared by Kruskal-Wallis test, Pearson χ2 test, and regression models. A P value of <.05 was considered significant. RESULTS: A total of 1849 bariatric cases were analyzed, including 64% Roux-en-Y gastric bypass and 36% sleeve gastrectomy cases. Of these, 70% and 3.7% received appropriate risk-stratified VTE prophylaxis during hospitalization and at discharge. The mean Caprini score was higher in those without appropriate prophylaxis (8.45 versus 8.04; P = .0004). Inpatient and 30- and 90-day VTE rates were .22%, .47%, and .64%. All discharge VTE events occurred in those not receiving appropriate Caprini risk-stratified VTE prophylaxis. Inpatient and 30- and 90-day bleeding complications were .22%, .23%, and .35%. The likelihood of receiving appropriate prophylaxis varied by hospital site, and receiving appropriate prophylaxis was not associated with increased bleeding risk. CONCLUSION: Caprini guideline-indicated VTE prophylaxis can be safely used in bariatric surgery patients and may reduce preventable VTE complications without increasing bleeding risk.

Caprini assessment utilization and impact on patient safety in gynecologic surgery.

PURPOSE: Postoperative venous thromboembolism (VTE) can potentially be associated with significant morbidity, mortality, and healthcare costs. The aim of this study was to determine the utilization of Caprini guideline indicated VTE in elective gynecologic surgery patients and its impact on postoperative VTE and bleeding complications. METHODS: This was a retrospective cohort study of elective gynecologic surgical procedures performed between January 1, 2016, and May 31, 2021. Two study cohorts were generated: (1) those who received and (2) those who did not receive VTE prophylaxis based on Caprini score risk stratification. Outcome measures were then compared between the study cohorts and included the development of a VTE up to 90-days postoperatively. Secondary outcome measures included postoperative bleeding events. RESULTS: A total of 5471 patients met inclusion criteria and the incidence of VTE up to 90 days postoperatively was 1.04%. Overall, 29.6% of gynecologic surgery patients received Caprini score-based guideline VTE prophylaxis. 39.2% of patients that met high-risk VTE criteria (Caprini > 5) received appropriate Caprini score-based prophylaxis. In multivariate regression analysis, the American Society of Anesthesiologists (ASA) score (OR 2.37, CI 1.27-4.45, p < 0.0001) and Caprini score (OR 1.13, CI 1.03-1.24, p = 0.008) predicted postoperatively VTE occurrence. Increasing Charlson comorbidity score (OR 1.39, CI 1.31-1.47, P < 0.001) ASA score (OR 1.36, CI 1.19-1.55, P < 0.001) and Caprini score (OR 1.10, CI 1.08-1.13, P < 0.001) were associated with increased odds of receiving appropriate inpatient VTE prophylaxis. CONCLUSION: While the overall incidence of VTE was low in this cohort, enhanced adherence to risk-based practice guidelines may provide more patient benefit than harm to postoperative gynecologic patients.

Association of Neutralizing Antispike Monoclonal Antibody Treatment With Coronavirus Disease 2019 Hospitalization and Assessment of the Monoclonal Antibody Screening Score.

Objective: To test the hypothesis that the Monoclonal Antibody Screening Score performs consistently better in identifying the need for monoclonal antibody infusion throughout each "wave" of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant predominance during the coronavirus disease 2019 (COVID-19) pandemic and that the infusion of contemporary monoclonal antibody treatments is associated with a lower risk of hospitalization. Patients and Methods: In this retrospective cohort study, we evaluated the efficacy of monoclonal antibody treatment compared with that of no monoclonal antibody treatment in symptomatic adults who tested positive for SARS-CoV-2 regardless of their risk factors for disease progression or vaccination status during different periods of SARS-CoV-2 variant predominance. The primary outcome was hospitalization within 28 days after COVID-19 diagnosis. The study was conducted on patients with a diagnosis of COVID-19 from November 19, 2020, through May 12, 2022. Results: Of the included 118,936 eligible patients, hospitalization within 28 days of COVID-19 diagnosis occurred in 2.52% (456/18,090) of patients who received monoclonal antibody treatment and 6.98% (7,037/100,846) of patients who did not. Treatment with monoclonal antibody therapies was associated with a lower risk of hospitalization when using stratified data analytics, propensity scoring, and regression and machine learning models with and without adjustments for putative confounding variables, such as advanced age and coexisting medical conditions (eg, relative risk, 0.15; 95% CI, 0.14-0.17). Conclusion: Among patients with mild to moderate COVID-19, including those who have been vaccinated, monoclonal antibody treatment was associated with a lower risk of hospital admission during each wave of the COVID-19 pandemic.

Resident first assistance in bariatric surgery: do patients pay a price?

BACKGROUND: First assistance during metabolic and bariatric surgery (MBS) often consists of either a general surgery resident (GSR), minimally invasive surgery fellow (MISF), or advanced practice provider (APP). While APPs may be consistent members of the bariatric team, GSRs and MISFs are often rotating members. It is unclear to what extent the inclusion of APPs versus surgical trainees (GSRs or MISFs) affect surgical outcomes. OBJECTIVES: The aim of this study was to determine the effect of first assistant type on adverse outcomes following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). SETTING: Academic hospital. METHODS: From the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program databases, we identified conventional laparoscopic and robot-assisted SG or RYGB performed with an APP, GSR, or MISF as first assistant. Patient demographics, co-morbidities, and operative characteristics were used to create 1:1 case-matched first-assistant cohorts, and perioperative outcomes were compared. Variables were compared using the χ2 test, Mann-Whitney U test, and regression models. Analyses were performed with StataMP 17. A P value <.05 and a 95% confidence interval exclusive of 1 or 0 were considered statistically significant. RESULTS: Of 414,623 included cases, an APP, GSR, and MISF served as first assistant in 58%, 28%, and 14%, respectively. Mean operative length was longer in GSR (P < .001) and MISF (P < .001) versus APP cases and similar between GSR and MISF cases (P = .08). Compared with an APP as first assistant, the odds of approach conversion (P < .001), readmission (P < .001), and overall morbidity (P < .001) were significantly higher in GSR and MISF cases. Compared with an APP, GSR cases also were associated with higher odds of admission to the intensive care unit (P < .001), reintervention (P < .001), bleeding (P = .002), venous thromboembolism (P < .001), and surgical site infection (P < .001). Most outcomes were similar between GSR and MISF as first assistant cases. CONCLUSIONS: While training future surgeons is an important aspect of bariatric surgery, inexperienced trainees or shifting roles within a surgical team may confer increased surgical risks to patients. Strategies are needed to optimize patient safety while maintaining a robust resident experience.

The Society of Black Academic Surgeons CV benchmarking initiative: Early career trends of academic surgical leaders.

BACKGROUND: Surgeons from under-represented backgrounds are less likely to receive academic tenure and obtain leadership positions. Our objective was to query the curriculum vitaes (CVs) of SBAS leadership to develop a benchmarking tool to promote and guide careers in academic surgery. METHODS: CVs from academic leaders were reviewed for academic productivity at early career stages-the first 5-and 10-years. Variables queried: peer-reviewed publications, grant funding, surgical societal involvement, invited lectureships and visiting professorships. RESULTS: Of 20 CVs, 41 leadership positions including 13 SBAS Presidents were identified. At 5- and 10-years, respectively, the academic productivity increased: 20.6 and 52.3 publications; 4.7 and 9.7 grants; 18 and 42.6 lectures/professorships. CONCLUSION: The CV benchmarking tool may be a useful framework for aspiring academic surgeons to track their progress relative to successful SBAS members. Creative strategies like these, paired with faculty mentorship and sponsorship are necessary to improve the ethnic diversity in academic surgery.

Prophylactic Inferior Vena Cava Filters Prior to Bariatric Surgery: Insights From the National Inpatient Sample.

OBJECTIVES: The aim of this study was to determine in-hospital mortality, post-surgical thromboembolic events, and health care costs associated with the placement of prophylactic inferior vena cava filters (IVCFs) prior to bariatric surgery. BACKGROUND: The role of prophylactic IVCFs prior to bariatric surgery is controversial, and the nationwide clinical outcomes associated with this practice are unknown. METHODS: This observational study used the National Inpatient Sample database to identify obese patients who underwent bariatric surgery from January 2005 to September 2015. Using propensity score matching, outcomes associated with patients receiving prophylactic IVCFs prior to their bariatric surgery were compared with those among patients who did not receive IVCFs. RESULTS: A total of 258,480 patients underwent bariatric surgery, of whom 1,047 (0.41%) had prophylactic IVCFs implanted. Patients with prophylactic IVCFs compared with those without IVCFs had a significantly higher rate of the combined endpoint of in-hospital mortality or pulmonary embolism (1.4% vs. 0.4%; odds ratio: 3.75; 95% confidence interval [CI]: 1.25 to 11.30; p = 0.019). Additionally, prophylactic IVCFs were associated with higher rates of lower extremity or caval deep vein thrombosis (1.8% vs. 0.3%; odds ratio: 6.33; 95% CI: 1.87 to 21.4; p < 0.01), length of stay (median 3 days vs. 2 days; p < 0.01), and hospital charges (median $63,000 vs. $37,000; p < 0.01). CONCLUSIONS: In this nationwide observational study, prophylactic IVCF implantation prior to bariatric surgery was associated with worse clinical outcomes and increased health care resource utilization.

Telemedicine in the state of Maine: a model for growth driven by rural needs.

As of mid-2002, Maine had one of the largest state-wide telemedicine systems, comprising over 150 facilities among 90 health, mental health, and social service provider organizations in two collaborative networks. The rapid growth of telemedicine in this rural, economically disadvantaged state is largely attributable to collaborative development and the service activities of the Maine Telemedicine Services division of a rural community health center, HealthWays/Regional Medical Center at Lubec (RMCL). Annual clinical uses of the system across a broad array of interactive videoconferencing applications currently exceed 1,000 instances for institutional telemedicine and 800 instances for home telehealth. The major applications include mental health/psychiatry, endocrinology/diabetes management, primary care, specialty pediatrics, genetics, and dermatology. Primary care usage derives from a relatively novel use of a mobile telemedicine boat to serve small islands off mid-coastal Maine. Strong future growth is expected in prison telemedicine, emergency medical triage, and nontraditional services such as video relay interpretive services for the deaf, domestic violence advocacy and legal services, and case management for community reintegration of juvenile offenders. The relative success of the two large networks managed by RMCL's Maine Telemedicine Services is evident from the criteria that system usage (1) addresses defined clinical needs, (2) has demonstrable organizational support, (3) is accepted by physicians and patients, (4) exhibits measurable cost and clinical benefits, and (5) is moving toward sustainable operations. Potential bases for this success are discussed in comparison with other networks.