Obesity Increases Risk-Adjusted Morbidity, Mortality, and Cost Following Cardiac Surgery.

BACKGROUND: Despite the epidemic rise in obesity, few studies have evaluated the effect of obesity on cost following cardiac surgery. We hypothesized that increasing body mass index (BMI) is associated with worse risk-adjusted outcomes and higher cost. METHODS AND RESULTS: Medical records for 13 637 consecutive patients who underwent coronary artery bypass grafting (9702), aortic (1535) or mitral (837) valve surgery, and combined valve-coronary artery bypass grafting (1663) procedures were extracted from a regional Society of Thoracic Surgeons certified database. Patients were stratified by BMI: normal to overweight (BMI 18.5-30), obese (BMI 30-40), and morbidly obese (BMI >40). Differences in outcomes and cost were compared between BMI strata and also modeled as a continuous function of BMI with adjustment for preoperative risk using Society of Thoracic Surgeons predictive risk indices. Morbidly obese patients incurred nearly 60% greater observed mortality than normal weight patients. Moreover, morbidly obese patients had greater than 2-fold increase in renal failure and 6.5-fold increase in deep sternal wound infection. After risk adjustment, a significant association was found between BMI and mortality (P<0.001) and major morbidity (P<0.001). The risk-adjusted odds ratio for mortality for morbidly obese patients was 1.57 (P=0.02) compared to normal patients. Importantly, risk-adjusted total hospital cost increased with BMI, with 17.2% higher costs in morbidly obese patients. CONCLUSIONS: Higher BMI is associated with increased mortality, major morbidity, and cost for hospital care. As such, BMI should be more strongly considered in risk assessment and resource allocation.

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS: Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS: Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.

Delayed Sternal Closure After Continuous Flow Left Ventricle Assist Device Implantation: Analysis of Risk Factors and Impact on Outcomes and Costs.

Patient and institutional factors predictive of delayed sternal closure (DSC) practice and its impact on clinical and cost outcomes when compared with primary sternal closure (PSC) following continuous-flow left ventricular assist device (CF-LVAD) implantation were examined. Statewide Society of Thoracic Surgeons and hospital cost data on CF-LVADs implanted were analyzed. Between January 2007 and December 2013, 558 CF-LVADs were implanted (PSC = 464, 83.2%; DSC = 94, 16.8%). Among the six institutions implanting CF-LVADs, DSC practice ranged from 3.1% to 37.8%. Compared with PSC, the DSC group had higher body mass index (BMI), renal failure, anemia, IIb/IIIa inhibitor use, emergency surgery, and extracorporeal membrane oxygenation (ECMO) support. Delayed sternal closure patients had significantly longer bypass time (139 ± 63 min vs. 107.6 ± 42 min) and higher use of intraoperative blood products (82% vs. 69%) and right ventricular assist device (RVAD) support (4.3% vs. 0.2%). Postoperative morbidities and mortality (23.4% vs. 6.5%; p ≤ 0.0001) were higher in the DSC group compared with PSC. Mean hospital costs for DSC were higher than PSC ($249,144 ± 123,273 vs. $155,915 ± 95,032; p ≤ 0.0001). Multivariate predictors of DSC include institution with higher DSC practice, preoperative ECMO support, use of IIb/IIIa inhibitors, tricuspid valve surgery, and intraoperative red blood cell transfusion. Delayed sternal closure was an independent risk factor for postoperative mortality, odds ratio 3.0 (1.2-7.2).

Minimally Invasive Mitral Valve Surgery Provides Excellent Outcomes Without Increased Cost: A Multi-Institutional Analysis.

BACKGROUND: Minimally invasive mitral valve surgery (mini-MVR) has grown in popularity. Although single centers have reported excellent outcomes, data on real-world outcomes and costs of mini-MVR are limited. Moreover, mini-MVR has been criticized as adding additional cost without clear benefit. We hypothesized that mini-MVR provides superior outcomes with incremental increased costs in a multi-institutional cohort. METHODS: Records for patients undergoing mitral valve surgical procedures with or without atrial ablation from 2011 to 2014 were extracted from a multi-institutional, regional Society of Thoracic Surgeons database and stratified according to right chest approach/minimally invasive or conventional sternotomy. Patients undergoing coronary artery bypass grafting or other concomitant procedures were excluded. Patients undergoing isolated mitral surgical procedure were propensity matched according to factors, including age, comorbidities, and preoperative laboratory values; clinical outcomes and cost differences were assessed by approach. RESULTS: A total of 1,304 patients underwent mitral operations, including 425 (32.6%) by minimally invasive approach. In the propensity-matched analysis (n = 355 per group), patients undergoing mini-MVR had similar rates of mortality, stroke, and other complications compared with conventional MVR. Meanwhile, patients with mini-MVR experienced shorter intensive care unit and hospital lengths of stay and fewer transfusions. Importantly, total hospital costs were no different between the two matched groups. CONCLUSIONS: Compared with conventional sternotomy, mini-MVR in the "real world" demonstrated no differences in rates of major morbidity, but it was associated with shorter length of stay and fewer transfusions. Contrary to our hypothesis, mini-MVR can be performed with similar total hospital costs as conventional sternotomy. In summary, minimally invasive mitral surgical procedure in select patients can provide superior outcomes without increased cost.

Contemporary Costs Associated With Transcatheter Aortic Valve Replacement: A Propensity-Matched Cost Analysis.

BACKGROUND: The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the "real world" by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients. METHODS: A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts. RESULTS: Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR. CONCLUSIONS: TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients.

Preoperative Renal Function Predicts Hospital Costs and Length of Stay in Coronary Artery Bypass Grafting.

BACKGROUND: Renal failure remains a major source of morbidity after cardiac surgery. Whereas the relationship between poor renal function and worse cardiac surgical outcomes is well established, the ability to predict the impact of preoperative renal insufficiency on hospital costs and health care resource utilization remains unknown. METHODS: Patient records from a statewide The Society for Thoracic Surgeons (STS) database linked with estimated cost data were evaluated for isolated coronary artery bypass graft (CABG) operations (2000 to 2012). Patients with documented preoperative renal failure/dialysis were excluded. Preoperative renal function was determined using calculated creatinine clearance (CrCl). Multivariable regression analyses utilizing restricted cubic splines evaluated the continuous relationship between CrCl and risk-adjusted outcomes. RESULTS: A total of 46,577 isolated CABG operations were evaluated with a median STS predicted risk of mortality score of 1.2% (interquartile range, 0.7% to 2.4%), including 9% off-pump CABG. Median CrCl was 85 mL/min (range, 2 to 120 mL/min), and median total cost was $25,011. After adjustment for preoperative risk factors, worsening CrCl (declining renal function) was highly associated with greater total costs of hospitalization (coefficient = -122, p < 0.001) and postoperative length of stay (coefficient = -0.03, p < 0.001). Furthermore, predicted total costs were incrementally increased by 10%, 20%, and 30% with worsening of CrCl from 80 mL/min to 60, 40, and 20 mL/min. As expected, decreasing CrCl was also associated with an increased risk-adjusted likelihood for hemodialysis and mortality (both p < 0.001). CONCLUSIONS: Preoperative renal function is highly associated with the cost of CABG. Assessment of renal function may be used to preoperatively predict cost and resource utilization. Optimizing renal function preoperatively has the potential to improve patient quality and costs by approximately 6% ($1,250) for every 10 mL/min improvement in creatinine clearance.

Targets to prevent prolonged length of stay after endovascular aortic repair.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days. RESULTS: Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03). CONCLUSIONS: This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.

A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014.

BACKGROUND: During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents' career paths, training, and perceptions changed during this period. METHODS: The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors' Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. RESULTS: During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p = 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p = 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). CONCLUSIONS: With the evolution in CTS over the last decade, residents' training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.

Minimally invasive aortic valve replacement provides equivalent outcomes at reduced cost compared with conventional aortic valve replacement: A real-world multi-institutional analysis.

BACKGROUND: Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost. METHODS: Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed. RESULTS: A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02). CONCLUSIONS: Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective.

Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks.

BACKGROUND: Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center. STUDY DESIGN: We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact. RESULTS: Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs. 28.4%; p < 0.0001), length of stay (13 vs. 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs. 2.5%; p < 0.0001), long-term mortality (36.4% vs. 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6-381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0-20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6-8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1-5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2-0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06-0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6-75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6-46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3-46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8-26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5-17.7; p = 0.009). CONCLUSIONS: Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.

Risk factors for 30-day hospital readmission after thyroidectomy and parathyroidectomy in the United States: An analysis of National Surgical Quality Improvement Program outcomes.

BACKGROUND: The 30-day readmission rate is a quality metric under the Affordable Care Act. Readmission rates after thyroidectomy and parathyroidectomy and associated factors remain ill-defined. We evaluated patient and perioperative factors for association with readmission after thyroidectomy and parathyroidectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) data for thyroid (n = 3,711) and parathyroid (n = 3,358) resections were analyzed. Patient- and operation-related factors were assessed by univariate and multivariate analyses. RESULTS: Among 7,069 patients, 30-day readmission rate was 4.0%: 4.1% after thyroidectomy and 3.8% after parathyroidectomy. Significant associations for 30-day readmission included declining functional status (odds ratio [OR], 6.4-10.1), preoperative hemodialysis (OR, 2.6; 95% CI, 1.5-4.7), malnutrition (OR, 3.4; 95% CI, 1.2-10.1), increasing American Society of Anesthesiologists class (OR 1.3-4.7), unplanned reoperation (OR, 61.6), and length of stay (LOS) <24 hours (OR, 0.61; 95% CI, 0.45-0.85; all P < .05). Readmission was associated with greater total and postoperative LOS and major postoperative complications, including renal insufficiency (all P < .01). CONCLUSION: Thirty-day readmission after cervical endocrine resection occurs in 4% of patients. Discharge within 24 hours of operation does not affect the likelihood of readmission. Risk factors for readmission are multifactorial and driven by preoperative conditions. Decreasing the index hospital stay and preventing major postoperative complications may decrease readmissions and improve quality metrics.

Postoperative atrial fibrillation significantly increases mortality, hospital readmission, and hospital costs.

BACKGROUND: New-onset postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. However, the magnitude of POAF on length of stay, resource utilization, and readmission rates remains an area of clinical interest. The purpose of this study was to examine the risk-adjusted impact of POAF on measures of mortality, hospital resources, and costs among multiple centers. METHODS: A total of 49,264 patient records from a multi-institutional Society of Thoracic Surgeons (STS) certified database for cardiac operations (2001 to 2012) were extracted and stratified by the presence of POAF (19%) versus non-POAF (81%). The influence of POAF on outcomes was assessed by hierarchic regression modeling, adjusted for calculated STS predictive risk indices. RESULTS: Mean age was 64±11 years, and median STS predicted risk of mortality for patients who developed POAF were incrementally higher (2% vs 1%, p<0.001) compared with non-POAF patients. The rate of POAF was highest among those undergoing aortic valve replacement+coronary artery bypass grafting, aortic valve, and mitral valve replacement operations. The POAF patients had a higher unadjusted incidence of mortality, morbidity, hospital readmission, longer intensive care unit (ICU) and postoperative length of stay, and higher hospital costs. After risk adjustment, POAF was associated with a twofold increase in the odds of mortality (adjusted odds ratio=2.04, p<0.001), greater hospital resource utilization, and increased costs; POAF was associated with 48 additional ICU hours (p<0.001), 3 additional hospital days (p<0.001), and $3,000 (p<0.001) and $9,000 (p<0.001) of increased ICU and total hospital-related costs, respectively. CONCLUSIONS: New onset POAF is associated with increased risk-adjusted mortality, hospital costs, and readmission rates. Protocols to reduce the incidence of POAF have the potential to significantly impact patient outcomes and the delivery of high-quality, cost-effective patient care.

The effect of race and gender on pediatric surgical outcomes within the United States.

PURPOSE: The purpose of this study was to examine risk-adjusted associations between race and gender on postoperative morbidity, mortality, and resource utilization in pediatric surgical patients within the United States. METHODS: 101,083 pediatric surgical patients were evaluated using the U.S. national KID Inpatient Database (2003 and 2006): appendectomy (81.2%), pyloromyotomy (9.8%), intussusception (6.2%), decortication (1.9%), congenital diaphragmatic hernia repair (0.7%), and colonic resection for Hirschsprung's disease (0.2%). Patients were stratified according to gender (male: 63.1%, n=63,783) and race: white (n=58,711), Hispanic (n=26,118), black (n=9,103), Asian (n=1,582), Native American (n=474), and other (n=5,096). Multivariable logistic regression modeling was utilized to evaluate risk-adjusted associations between race, gender, and outcomes. RESULTS: After risk adjustment, race was independently associated with in-hospital death (p=0.02), with an increased risk for black children. Gender was not associated with mortality (p=0.77). Postoperative morbidity was significantly associated with gender (p<0.001) and race (p=0.01). Gender (p=0.003) and race (p<0.001) were further associated with increased hospital length of stay. Importantly, these results were dependent on operation type. CONCLUSION: Race and gender significantly affect postoperative outcomes following pediatric surgery. Black patients are at disproportionate risk for postoperative mortality, while black and Hispanic patients have increased morbidity and hospital resource utilization. While gender does not affect mortality, gender is a determinant of both postoperative morbidity and increased resource utilization.

Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases.

OBJECTIVE: Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. METHODS: Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES. RESULTS: A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. CONCLUSIONS: Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.

A contemporary cost analysis of postoperative morbidity after coronary artery bypass grafting with and without concomitant aortic valve replacement to improve patient quality and cost-effective care.

BACKGROUND: The financial burden of postoperative morbidity after cardiac operations remains ill defined. This study evaluated the costs associated with the performance of coronary artery bypass grafting (CABG) with and without aortic valve replacement (AVR) and determined the incremental costs associated with major postoperative complications. METHODS: A total of 65,534 regional patients undergoing CABG (n = 55,167) ± AVR (n = 10,367) were evaluated from 2001 to 2011. Patient-related, hospital-related, and procedure-related cost data were analyzed by use of Medicare-based cost reports. Hierarchical multivariable regression modeling was used to estimate risk-adjusted incremental cost differences in postoperative complications. RESULTS: The mean age was 64 years, and women accounted for 31% of patients. CABG + AVR patients had higher rates of overall complication (40% vs 35%, p < 0.001) and operative mortality (5% vs 3%, p < 0.001) than did CABG patients. CABG + AVR patients also accrued increased median postoperative lengths of stay (7 vs 5 days, p < 0.001) and total costs ($26,527 vs $24,475, p < 0.001). After mortality risk adjustment, significant positive relationships existed between total costs and major postoperative complications. Interestingly, the highest incremental costs among CABG patients included newly instituted hemodialysis ($71,833), deep sternal wound infection ($56,003), and pneumonia ($50,025). Among CABG + AVR patients, these complications along with perioperative myocardial infarction ($68,917) dominated costs. CONCLUSIONS: Postoperative complications after CABG ± AVR are associated with significantly increased incremental costs. The most costly complications include newly instituted hemodialysis, infectious complications, and perioperative myocardial infarction. Identification of the most common and the most costly complications provides opportunities to target improvement in patient quality and the delivery of cost-effective care.

Minimally invasive surgery fellowship does not adversely affect general surgery resident case volume: a decade of experience.

BACKGROUND: With the advent of clinical fellowships in general surgery, there has been a continual debate over the effect on general surgical resident training. Will a fellowship interfere with a chief resident's experience or case volume? The aim of this study was to test the hypothesis that the presence of an advanced laparoscopic fellow in a tertiary care hospital and residency has had no deleterious effect on chief resident laparoscopic case volume. METHODS: The operative case logs of graduating residents and fellows from 2001 to 2011 were reviewed, focusing on laparoscopic basic and complex cases and comparing between those 2 groups and comparing residents' case numbers with the national average published by the Accreditation Council for Graduate Medical Education. RESULTS: Residents graduating from 2001 to 2011 (4-6 chief residents per year) performed an average of 989 ± 76.2 laparoscopic cases per graduating chief class, with each chief averaging 207.7 ± 10.7. The average number of laparoscopic basic cases per graduating chief year was 555.3 ± 42.1, with each chief averaging 116.2 ± 4.9. The average number of laparoscopic complex cases per graduating chief year was 434.4 ± 39.2, with each chief averaging 91.5 ± 7.2. Over the same period of time (1 or 2 fellows per year), fellows performed an average of 336 ± 23.3 cases per year. When comparing residents' total average cases with the national data, the residents performed a similar number of cases (209.9 ± 11.9 vs 195.0 ± 19.5, P = .53). When comparing years when there were 2 clinical fellows vs years with 1 fellow, there was no change in the total number of laparoscopic cases per chief (224.2 vs 195.6, P = .26) and no change in the number of complex laparoscopic cases (97.1 vs 88.7, P = .63). There was a significant difference for basic laparoscopic cases, with a slight decrease when there were 2 fellows (127.8 vs 106.9, P = .04). CONCLUSIONS: A laparoscopic fellowship has not had an adverse impact on the complex or basic laparoscopic case experience of surgical residents. In a busy academic practice, laparoscopic fellowships and general surgical residency can coexist.

Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery.

BACKGROUND: Efforts to reduce blood product use have the potential to avoid transfusion-related complications and reduce health care costs. The purpose of this investigation was to determine whether a multi-institutional effort to reduce blood product use affects postoperative events after cardiac surgical operations and to determine the influence of perioperative transfusion on risk-adjusted outcomes. METHODS: A total of 14,259 patients (2006-2010) undergoing nonemergency, primary, isolated coronary artery bypass grafting operations at 17 different statewide cardiac centers were stratified according to transfusion guideline era: pre-guideline (n = 7059, age = 63.7 ± 10.6 years) versus post-guideline (n = 7200, age = 63.7 ± 10.5 years). Primary outcomes of interest were observed differences in postoperative events and mortality risk-adjusted associations as estimated by multiple regression analysis. RESULTS: Overall intraoperative (24% vs 18%, P < .001) and postoperative (39% vs 33%, P < .001) blood product transfusion were significantly reduced in the post-guideline era. Patients in the post-guideline era demonstrated reduced morbidity with decreased pneumonia (P = .01), prolonged ventilation (P = .05), renal failure (P = .03), new-onset hemodialysis (P = .004), and composite incidence of major complications (P = .001). Operative mortality (1.0% vs 1.8%, P < .001) and postoperative ventilation time (22 vs 26 hours, P < .001) were similarly reduced in the post-guideline era. Of note, after mortality risk adjustment, operations performed in the post-guideline era were associated with a 47% reduction in the odds of death (adjusted odds ratio, 0.57; P < .001), whereas the risk of major complications and mortality were significantly increased after intraoperative (adjusted odds ratio, 1.86 and 1.25; both P < .001) and postoperative (adjusted odds ratio, 4.61 and 4.50, both P < .001) transfusion. Intraoperative and postoperative transfusions were associated with increased adjusted incremental total hospitalization costs ($4408 and $10,479, respectively). CONCLUSIONS: Implementation of a blood use initiative significantly improves postoperative morbidity, mortality, and resource utilization. Limiting intraoperative and postoperative blood product transfusion decreases adverse postoperative events and reduces health care costs. Blood conservation efforts are bolstered by collaboration and guideline development.

Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States.

PURPOSE: Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. METHODS: A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. RESULTS: Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. CONCLUSIONS: Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting.

BACKGROUND: Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status. METHODS AND RESULTS: From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001). CONCLUSIONS: Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery.

OBJECTIVE: With the escalating demands to increase the efficiency and decrease the cost, innovations in postoperative cardiac surgical patient care are needed. The universal bed model is an innovative care delivery system that allows patient care to be managed in one setting from postoperation to discharge. We hypothesized that the universal bed model in the context of cardiac surgery would improve outcomes and efficacy. METHODS: A total of 610 consecutive patients were admitted to the universal bed unit and prospectively entered into the Society of Thoracic Surgeons National Cardiac Database. Intensive care unit level of care was determined by acuity and staffing needs. Telemetry was employed from admission to discharge, and multidisciplinary rounds were conducted twice daily. Postoperative outcomes were recorded during hospital stay, and comparisons were made with the Society of Thoracic Surgeons National Cardiac Database using identical variables over the same period of time. RESULTS: Decreased ventilation time, intensive care unit and hospital stay, and reduction in the incidence of atrial fibrillation and infectious complications yielded a financial benefit in the universal bed group compared with the traditional model of admission. Stroke rate and in-hospital mortality were the same compared with regional and national centers. Compared with regional centers, there was an average cost savings between $6200 and $9500 per patient depending on the operation. Patient care satisfaction by independent survey was in the 99th percentile. CONCLUSIONS: The universal bed patient care model allows for expedient and efficacious care as measured by decreased length of intensive care unit and hospital stay, improved postoperative outcomes, patient satisfaction, and cost savings.