The burden of readmission after discharge from necrotizing soft tissue infection.

BACKGROUND: The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization. METHODS: The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression. RESULTS: There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion. CONCLUSION: Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease. LEVEL OF EVIDENCE: Economic/Epidemiological, level IV.

Association of cardiac biomarkers and comorbidities with increased mortality, severity, and cardiac injury in COVID-19 patients: A meta-regression and decision tree analysis.

BACKGROUND: Coronavirus disease-2019 (COVID-19) has a deleterious effect on several systems, including the cardiovascular system. We aim to systematically explore the association of COVID-19 severity and mortality rate with the history of cardiovascular diseases and/or other comorbidities and cardiac injury laboratory markers. METHODS: The standardized mean difference (SMD) or odds ratio (OR) and 95% confidence intervals (CIs) were applied to estimate pooled results from the 56 studies. The prognostic performance of cardiac markers for predicting adverse outcomes and to select the best cutoff threshold was estimated by receiver operating characteristic curve analysis. Decision tree analysis by combining cardiac markers with demographic and clinical features was applied to predict mortality and severity in patients with COVID-19. RESULTS: A meta-analysis of 17 794 patients showed patients with high cardiac troponin I (OR = 5.22, 95% CI = 3.73-7.31, P < .001) and aspartate aminotransferase (AST) levels (OR = 3.64, 95% CI = 2.84-4.66, P < .001) were more likely to develop adverse outcomes. High troponin I more than 13.75 ng/L combined with either advanced age more than 60 years or elevated AST level more than 27.72 U/L was the best model to predict poor outcomes. CONCLUSIONS: COVID-19 severity and mortality are complicated by myocardial injury. Assessment of cardiac injury biomarkers may improve the identification of those patients at the highest risk and potentially lead to improved therapeutic approaches.

Gender disparities are present in academic rank and leadership positions despite overall equivalence in research productivity indices among senior members of American Head and Neck Society (AHNS) Fellowship Faculty.

BACKGROUND: This study aims to examine potential disparities in scholarly performance based on sex, academic rank, leadership positions, and regional distribution of faculty in accredited Head and Neck Surgery fellowships in the United States. METHODS: Online faculty listings for 37 accredited fellowships were organized according to academic rank, leadership position, sex, and institutional location. Academic productivity was measured with three bibliometric indices: h-index, m-index, and the weighted relative citation ratio. RESULTS: A total of 732 faculty members were included, of which 153 (21%) were female. Fifty-eight males (89.2%) held leadership positions, compared to seven females (10.8%). There was no significant difference in overall productivity between male and female senior faculty. There were regional differences in productivity by sex. CONCLUSIONS: Females are underrepresented in senior faculty and within three common leadership positions, although scholarly productivity for male and female senior faculty and for those in leadership positions is similar.

The Sunshine Act and Surgeons: A Nation-Wide Analysis of Industry Payments to Physicians.

BACKGROUND: The Physician Payments Sunshine Act mandates the submission of payment records between medical providers and industry. We used the Open Payments Program database to compare industry payments to surgeons and nonsurgeons, as well as among surgical specialties, and to identify geographic distribution of payments. MATERIALS AND METHODS: We included all reported industry payments in the Centers for Medicare and Medicaid Services' Open Payments Program in the United States, 2014-2015. Multivariable regression fixed effects panel analysis of total payments was conducted among surgeons, adjusting for surgeon specialty, payor type, payment category, and state. A geographic heat map was created. RESULTS: Of 2,097,150 subjects meeting criteria, 1,957,528 (45.66%) were physicians. The mean standard deviation (SD) payment overall was $232.64 ($6262.00), and the state with the highest mean (SD) payment was Vermont at $2691.61 ($11,508.40). Surgeons numbered 153,916 (7.86%). The specialty with the highest mean (SD) payment was orthopedic surgery at $2811.50 ($33,632.71, P < 0.001). Among 2,097,150 subjects meeting criteria, in multivariable regression fixed effects panel analysis, orthopedic compared to general surgeons were significantly likely to receive more industry payments (beta $1065.34 [95% CI $279.00-1851.00, P = 0.008), even controlling for payor, payment type, and state. Significant geographic disparities in payment were noted as 12 states received the top mean ($24.52-$500,000.00), leaving seven states with the lowest ($0.00-$12.56). CONCLUSIONS: There are significant differences in industry payments to surgeons versus nonsurgeons and among surgical specialties, as well geographic distribution of payments. These data may prompt further investigation into trends and their causality and effects on research and practice.

Post-Operative Infections: Trends in Distribution, Risk Factors, and Clinical and Economic Burdens.

BACKGROUND: Post-operative infection (POI) is a serious complication in all surgical disciplines and can derail a patient's treatment and recovery course. In this analysis, we examine national trends, risk factors, and costs associated with POI. METHODS: Using the Nationwide Inpatient Sample (NIS) for the years available for data analysis at the time of this study (2003-2010), we performed a cross-sectional study of adult (≥18 years) inpatients with POI and designated Clinical Classification Software (CCS) procedural class codes for the operations performed. A comparison group was selected randomly from patients with the same CCS codes who underwent the same procedures but did not experience POI. As the NIS represents 20% of U.S. hospital admissions, excess cost and stay were calculated on the basis of the average difference between cost and duration of stay for POI cases and the cost and duration of stay for the comparison group, then extrapolated to estimate the national burden for the remaining 80% of stays nationwide. RESULTS: Sample admissions included 139,652 cases of POI and 941,670 comparison subjects. The POIs were most common in procedures involving the digestive tract (46.5%), cardiovascular system (16.3%), or musculoskeletal system (11.2%). Older age, male gender, high Charlson Comorbidity Index Score (CCIS), and teaching, urban, or large hospitals were independent risk factors for POI in the multivariable model (p < 0.05). A POI was associated with a higher risk of death (odds ratio 2.93; 95% confidence interval 2.82-3.04, p < 0.001). Nationally, we estimate that POI resulted in an annual average of 1.04 million days of excess hospital stay and $2.72 billion excess cost. CONCLUSIONS: Identification of independent risk factors suggests areas for quality improvement initiatives. Post-operative infection carries substantial clinical and financial burdens in the United States, and further analysis of the associated costs is needed to identify areas for intervention to reduce this burden.

Racial Disparity in Renal Transplantation: Alemtuzumab the Great Equalizer?

OBJECTIVES: Racial disparity as a barrier to successful outcomes in renal transplants for African Americans has been well described. Numerous unsuccessful attempts have been made to identify specific immunologic and socioeconomic factors. The objective of our study was to determine whether alemtuzumab (AL) induction abolishes this discrepancy and improves allograft survival in African American recipients. METHODS: A retrospective chart review of consecutive adult renal transplants was conducted between 2006 and 2014. Kaplan-Meier analysis and hazard ratios were calculated for the African Americans (AA) and white groups. Multiple linear regressions were performed to assess independent variables (race, retransplant, sex, donor type, induction agent) on allograft survival. RESULTS: A significant difference in allograft survival was identified between whites (n = 272) and AA (n = 445), with AA experiencing more graft losses (18.2% vs 12.1%, P = 0.0351). Induction with AL improved outcomes in all transplant recipients. Multiple linear regression identified that the strongest predictor of allograft failure was induction without AL (P < 0.0001). The data for a subset analysis matched for follow-up length demonstrated that whites compared with AA (n = 157, 67 whites and 90 AA) had lower rates of allograft failure in the absence of AL induction (14.9% vs 44.4%, P = 0.0156, hazard ratio = 2.077). In contrast, AL induction (n = 275, 105 whites and 170 AA) eliminated the racial disparity in allograft failure (5.7% vs 9.4%, P = 0.8248, hazard ratio = 1.504). CONCLUSIONS: This is the first study to describe the effects of AL induction therapy on AA renal transplant recipients beyond the first posttransplant year. Our early results suggest that AL induction therapy abolishes the disparity in renal allograft failure.

Generics: are all immunosuppression agents created equally?

BACKGROUND: The Affordable Care Act initiated innumerable cost-containment measures, including promoting generic conversion from brand medications and directing the Food and Drug Administration to decrease requirements for generic approvals. Despite this mandate, few data existed on generic conversion of immunosuppressant medications with narrow therapeutic troughs. METHODS: A retrospective analysis of our initial experience with generic tacrolimus (n = 39) was performed using a control cohort from our renal transplant database. A rejection and cost analysis was performed using a consecutive 2-year prior cohort (n = 159) as a control to determine the effect of generic conversion on tacrolimus a narrow therapeutic index immunosuppressant medication. RESULTS: During the first year after transplantation, the generic group had a greater drug variability (20% ± change in trough levels) that required more dosage adjustments (5.42 vs 3.59 drug dosage changes; P = .038) to obtain a stable dose, required increased number of intravenous magnesium infusions (4.95 vs 1.68 infusions; P = .001), and incurred a greater incidence of rejection (23.1% vs 10.2%; P = .024). A yearly institutional cost was evaluated against a negotiated $18,000/yearly central pharmacy cost savings compared with a $652,862 institutional cost to treat unanticipated rejections. CONCLUSION: Programmatic conversion from brand to generic tacrolimus resulted in increased drug variability, a greater incidence of magnesium wasting, and more episodes of rejection, leading to increases in institutional costs of care. This government-driven attempt at cost containment may be applicable to noncritical medications such as antibiotics and antihypertensives, but this policy should be reconsidered for narrow therapeutic index medications, such as tacrolimus and other immunosuppressant medications.

Living donor kidney transplantation: medical, legal, and ethical considerations.

The use of living donor kidneys has dramatically increased the number and success of kidney transplants across the world. But questions remain regarding the subjection of a healthy individual to surgery for the benefit of another. Donors do have medical and financial risks. The stigma of organ brokering remains today, with evidence of commercial transplantation in other countries. Here in the US, we are exposed to advertising for donors using the media. In the hope of increasing living donations, we run the risk of stretching altruism too far. In this manuscript, we highlight and discuss some of the current controversies surrounding living donor kidney transplantation across the world.