Anal Sphincteroplasty in the Minimally Invasive Era: Assessment of National Trends and Complications.

Fecal incontinence is a debilitating and underreported condition. Despite introduction of novel therapies in recent years, anal sphincteroplasty (AS) remains the surgical choice for certain patients. Previous reports have primarily focused on single-surgeon or single-center experience with AS. The purpose of this study was to assess patient characteristics and perioperative outcomes of AS using a national cohort. Patients (n = 586) who underwent AS as a primary procedure between 2009 and 2015 were identified by the CPT code as recorded in the study and were evaluated and examined for association with 30-day complications. The number of sphincteroplasties performed decreased seven-fold between 2009 and 2015. Wound infection, wound dehiscence, and urinary tract infection were the most common complications, occurring in 30 (5.1%), 12 (2.1%), and 6 (1%) patients, respectively. Preoperative steroid use and surgeon specialty were associated with wound complications on multivariate analysis. We present the first national study of patients undergoing AS and identify factors that predispose to wound complications. In addition, we demonstrate that the number of anal sphincteroplasties performed in the United States is decreasing dramatically, likely because of novel therapy for fecal incontinence. We hope that this study will assist in patient counseling and call attention to preserving surgical training as utilization of AS rapidly declines.

Racial Disparities in the Incidence of Pulmonary Embolism after Colectomy.

Disparities in the incidence of pulmonary embolism (PE) based on racial and socioeconomic factors remain ill-defined. The present study evaluated the impact of race and hospital characteristics on rates of PE for all adult colectomy patients in the 2005 to 2014 Nationwide Inpatient Sample. Hospitals were designated as high-burden hospitals (HBHs) or low-burden hospitals of underinsured payers. Chi-squared tests of trend and multivariable regression adjusting for patient and hospital characteristics were performed. Of the 2,737,977 adult patients who underwent colectomy in the study period, 79 per cent were White, 10 per cent Black, and 7 per cent Hispanic. The annual rate of PE increased from 0.6 per cent in 2005 to 0.95 per cent in 2014 (P < 0.0001). Black patients had significantly higher incidence of PE than Whites (1.5% vs 0.9%, P < 0.001) and Hispanics (1.5% vs 0.8%, P < 0.001). Colectomy at HBHs was also associated with significantly higher rates of PE (1% vs 0.86%, P < 0.001). After adjusting for baseline differences, colectomy at HBHs (odds ratio 1.14, 95% confidence interval 1.02-1.27, P = 0.02) and Black race (odds ratio 1.4, 95% confidence interval 1.26-1.66, P < 0.001) were independent predictors of PE. In this national study of colectomy patients, Black patients experienced a disproportionate burden of postoperative PE. Further investigation into the causes and prevention of PE in vulnerable populations may identify targets for surgical quality improvement.

Point/Counterpoint: Are Outstanding Leaders Born or Made?

The question of whether outstanding leaders are born or made has been debated for years. There are numerous examples of historical figures that came naturally to leadership, while others developed their leadership skills through tenacity and experience. To understand leadership, both nature (the genetic component) and nurture (the environmental influences) must be considered. This article represents the work of two Academic Leadership Fellows Program groups who debated each position at the 2016 American Association of Colleges of Pharmacy (AACP) Interim Meeting in Tampa, Fla., in February 2016.

Evaluation of hospital readmissions in surgical patients: do administrative data tell the real story?

IMPORTANCE: The Centers for Medicare & Medicaid Services has developed an all-cause readmission measure that uses administrative data to measure readmission rates and financially penalize hospitals with higher-than-expected readmission rates. OBJECTIVES: To examine the accuracy of administrative codes in determining the cause of readmission as determined by medical record review, to evaluate the readmission measure's ability to accurately identify a readmission as planned, and to document the frequency of readmissions for reasons clinically unrelated to the original hospital stay. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all consecutive patients discharged from general surgery services at a tertiary care, university-affiliated teaching hospital during 8 consecutive quarters (quarter 4 [October through December] of 2009 through quarter 3 [July through September] of 2011). Clinical readmission diagnosis determined from direct medical record review was compared with the administrative diagnosis recorded in a claims database. The number of planned hospital readmissions defined by the readmission measure was compared with the number identified using clinical data. Readmissions unrelated to the original hospital stay were identified using clinical data. MAIN OUTCOMES AND MEASURES: Discordance rate between administrative and clinical diagnoses for all hospital readmissions, discrepancy between planned readmissions defined by the readmission measure and identified by clinical medical record review, and fraction of hospital readmissions unrelated to the original hospital stay. RESULTS: Of the 315 hospital readmissions, the readmission diagnosis listed in the administrative claims data differed from the clinical diagnosis in 97 readmissions (30.8%). The readmission measure identified 15 readmissions (4.8%) as planned, whereas clinical data identified 43 readmissions (13.7%) as planned. Unrelated readmissions comprised 70 of the 258 unplanned readmissions (27.1%). CONCLUSIONS AND RELEVANCE: Administrative billing data, as used by the readmission measure, do not reliably describe the reason for readmission. The readmission measure accounts for less than half of the planned readmissions and does not account for the nearly one-third of readmissions unrelated to the original hospital stay. Implementation of this readmission measure may result in unwarranted financial penalties for hospitals.