Race and Intention to Breastfeed are the Strongest Predictors of Exclusive Breastfeeding: a Retrospective Study.

INTRODUCTION: Racial disparities exist in maternal and neonatal care including breastfeeding (BF). The purpose of this study is to assess factors associated with BF success by race with a specific focus on pre-birth BF plan and time duration from birth until initiation of skin-to-skin contact and from birth to the first feed or breastfeed. METHODS: A database query of our electronic medical records was performed for all patients who had a vaginal delivery that met our study criteria. Demographic information, pre-delivery feeding plan (exclusive BF, exclusive formula, or mixed), time to first feed and first breastfeed, and time to skin-to-skin were compared among different postpartum feeding practices (exclusive BF, exclusive formula, mixed), and compared across race/ethnic groups using ANOVA, Chi-square, and Fisher's exact statistical tests as appropriate. Logistic regression was used to investigate the independent effect of each variable on exclusive BF. RESULTS: The study analyzed 12,578 deliveries. There was a significant difference in intended feeding plans among the different racial groups. Approximately 61% of Black patients intended to exclusively BF as compared to 79% of the other groups. Overall, 3994 (32%) patients breastfed exclusively, 872 (7%) exclusively used formula, and 7712 (61%) used a mix of breast and formula. White patients were most likely to exclusively BF (35%) and Black patients were least likely (21%), p < 0.001. Our model found that self-identified race and pre-delivery feeding plan were the strongest predictors of exclusive BF. CONCLUSIONS: The main findings of this study are that self-identified race and intention to BF are the strongest predictors of exclusive BF. Black patients intend to BF at a significantly lower rate than other racial groups, for reasons not determined by this study, and this affects feeding practice. Our findings are notable because prehospital intention to BF can be modified by outreach, education, and changes to in-hospital practices.

Delayed extubation in spine surgery is associated with increased postoperative complications and hospital episode-based resource utilization.

STUDY OBJECTIVE: To elucidate the association between delayed extubation, postoperative complications, and episode-based resource utilization. DESIGN: Retrospective Propensity-Matched Cohort Study. SETTING: Single Large Academic Medical Center. PATIENTS: The computerized anesthetic records of 17,223 patients undergoing spine surgery from January 2006 through November 2016 were reviewed for this study. The records of 11,421 patients met inclusion criteria for final analysis, with 527 subjects who had delayed extubation following their procedure. INTERVENTIONS: Delayed extubation, defined as patients not extubated prior to leaving the operating room. MEASUREMENTS: Computerized anesthetic records of spine surgery patients were analyzed retrospectively. Corresponding Medicare Severity Diagnosis Related Group numbers (MS-DRGs) were then identified, as well as associated lengths of stay and costs of care. We compared hospital-acquired International Classification of Diseases-9 (ICD-9) and ICD-10 postoperative complication codes linked to each record to assess differences in outcome. MAIN RESULTS: Increasing medical and surgical complexity is associated with delayed extubation. Using propensity score matching, delayed extubation was independently associated with a higher likelihood of any postoperative complication (Odds Ratio [OR]: 1.79; 95% Confidence Interval [CI]: 1.23-2.61); major complications (OR: 2.22; 95% CI: 1.31-3.76); prolonged length of hospital stay (Hazard Ratio [HR]: 0.82 (0.72, 0.95), p = 0.006); prolonged Intensive Care Unit (ICU) stay (HR: 0.68 (0.61, 0.76), p < 0.001); and were less likely to be discharged home (OR: 1.40 (1.02, 1.92), p = 0.036). Propensity score matching demonstrated that anesthesiologist handoff was not independently associated with any of the examined adverse outcomes. CONCLUSIONS: Delayed extubation after spine surgery was associated with a statistically significant increased incidence of postoperative complications as well as increased hospital episode-based resource utilization in the form of increased hospital length of stay, ICU length of stay, post-acute care at a facility, and higher cost of hospitalization. Although anesthesiologist handoff was associated with delayed extubation, it was not independently associated with postoperative complications when propensity score matching was applied.

Quantitative assessment of secondary white matter injury in the visual pathway by pituitary adenomas: a multimodal study at 7-Tesla MRI.

OBJECTIVE: The objective of this study was to investigate microstructural damage caused by pituitary macroadenomas by performing probabilistic tractography of the optic tracts and radiations using 7-T diffusion-weighted MRI (DWI). These imaging findings were correlated with neuro-ophthalmological results to assess the utility of ultra-high-field MRI for objective evaluation of damage to the anterior and posterior visual pathways. METHODS: Probabilistic tractography employing 7-T DWI was used to reconstruct the optic tracts and radiations in 18 patients with adenomas and in 16 healthy volunteers. Optic chiasm compression was found in 66.7% of the patients and visual defects in 61.1%. Diffusion indices were calculated along the projections and correlated with tumor volumes and results from neuro-ophthalmological examinations. Primary visual cortical thicknesses were also assessed. RESULTS: Fractional anisotropy was reduced by 21.9% in the optic tracts (p < 0.001) and 17.7% in the optic radiations (p < 0.001) in patients with adenomas. Patients showed an 8.5% increase in mean diffusivity of optic radiations compared with healthy controls (p < 0.001). Primary visual cortical thickness was reduced in adenoma patients. Diffusion indices of the visual pathway showed significant correlations with neuro-ophthalmological examination findings. CONCLUSIONS: Imaging-based quantification of secondary neuronal damage from adenomas strongly correlated with neuro-ophthalmological findings. Diffusion characteristics enabled by ultra-high-field DWI may allow preoperative characterization of visual pathway damage in patients with chiasmatic compression and may inform prognosis for vision recoverability.

Alive or dead: Validity of the Social Security Administration Death Master File after 2011.

OBJECTIVE: To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records. DATA SOURCES: Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse. STUDY DESIGN: Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated. DATA COLLECTION METHODS: Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking. PRINCIPAL FINDINGS: 97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS. CONCLUSIONS: The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality.

Validation of the All Patient Refined Diagnosis Related Group (APR-DRG) Risk of Mortality and Severity of Illness Modifiers as a Measure of Perioperative Risk.

The All Patient Refined Diagnosis Related Group (APR-DRG) is an inpatient visit classification system that assigns a diagnostic related group, a Risk of Mortality (ROM) subclass and a Severity of Illness (SOI) subclass. While extensively used for cost adjustment, no study has compared the APR-DRG subclass modifiers to the popular Charlson Comorbidity Index as a measure of comorbidity severity in models for perioperative in-hospital mortality. In this study we attempt to validate the use of these subclasses to predict mortality in a cohort of surgical patients. We analyzed all adult (age over 18 years) inpatient non-cardiac surgery at our institution between December 2005 and July 2013. After exclusions, we split the cohort into training and validation sets. We created prediction models of inpatient mortality using the Charlson Comorbidity Index, ROM only, SOI only, and ROM with SOI. Models were compared by receiver-operator characteristic (ROC) curve, area under the ROC curve (AUC), and Brier score. After exclusions, we analyzed 63,681 patient-visits. Overall in-hospital mortality was 1.3%. The median number of ICD-9-CM diagnosis codes was 6 (Q1-Q3 4-10). The median Charlson Comorbidity Index was 0 (Q1-Q3 0-2). When the model was applied to the validation set, the c-statistic for Charlson was 0.865, c-statistic for ROM was 0.975, and for ROM and SOI combined the c-statistic was 0.977. The scaled Brier score for Charlson was 0.044, Brier for ROM only was 0.230, and Brier for ROM and SOI was 0.257. The APR-DRG ROM or SOI subclasses are better predictors than the Charlson Comorbidity Index of in-hospital mortality among surgical patients.

The Impact of Hospital Size on CMS Hospital Profiling.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) profile hospitals using a set of 30-day risk-standardized mortality and readmission rates as a basis for public reporting. These measures are affected by hospital patient volume, raising concerns about uniformity of standards applied to providers with different volumes. OBJECTIVES: To quantitatively determine whether CMS uniformly profile hospitals that have equal performance levels but different volumes. RESEARCH DESIGN: Retrospective analysis of patient-level and hospital-level data using hierarchical logistic regression models with hospital random effects. Simulation of samples including a subset of hospitals with different volumes but equal poor performance (hospital effects=+3 SD in random-effect logistic model). SUBJECTS: A total of 1,085,568 Medicare fee-for-service patients undergoing 1,494,993 heart failure admissions in 4930 hospitals between July 1, 2005 and June 30, 2008. MEASURES: CMS methodology was used to determine the rank and proportion (by volume) of hospitals reported to perform "Worse than US National Rate." RESULTS: Percent of hospitals performing "Worse than US National Rate" was ∼40 times higher in the largest (fifth quintile by volume) compared with the smallest hospitals (first quintile). A similar gradient was seen in a cohort of 100 hospitals with simulated equal poor performance (0%, 0%, 5%, 20%, and 85% in quintiles 1 to 5) effectively leaving 78% of poor performers undetected. CONCLUSIONS: Our results illustrate the disparity of impact that the current CMS method of hospital profiling has on hospitals with higher volumes, translating into lower thresholds for detection and reporting of poor performance.

Economic and safety implications of introducing fast tracking in congenital heart surgery.

BACKGROUND: The feasibility of fast-tracking children undergoing congenital heart disease surgery has not been assessed adequately. Current knowledge is based on limited single-center experiences without contemporaneous control groups. METHODS AND RESULTS: We compared administrative data for atrial septal defect (ASD) and ventricular septal defect (VSD) surgeries in children 2 months to 19 years of age at the Mount Sinai Medical Center (MSMC) with data from comparable patients at 40 centers contributing to the Pediatric Health Information System. Three-year blocks, early in and after fast tracking had been implemented at the MSMC, were examined. Seventy-seven and 89 children at MSMC undergoing ASD and VSD closure, respectively, were compared with 3103 ASD and 4180 VSD patients nationally. With fast tracking fully implemented, median length of stay at the MSMC decreased by 1 day compared with the earlier era (length of stay, 1 and 3 days for ASD and VSD, respectively). Nationally, median length of stay remained unchanged (3 days for ASD and 4 days for VSD) in the observed time periods. Hospitalization costs fell by 33% and 35% at MSMC (ASD and VSD, respectively), whereas they rose by 16% to 17% nationally. When analyzed in multiple regression models, the decrease in both length of stay and cost remained significantly greater at MSMC compared with nationally (P<0.0001 for all). Hospital mortality and 2-week readmission rates were unchanged at MSMC between the 2 time periods and were not different from the national rates. CONCLUSION: Shorter length of stay and cost savings compared with national data were observed after implementation of fast tracking.

Socioeconomic position is not associated with 30-day or 1-year mortality in demographically diverse vascular surgery patients.

OBJECTIVES: Disparities in outcomes after surgical procedures have been attributed to race, sex, use of private insurance, and socioeconomic position (SEP). The purpose of this study was to determine the impact of SEP on mortality after lower-extremity bypass (LEB) surgery in a diverse patient population with extremes of SEP. DESIGN: Analysis of an electronic medical database. SETTING: A tertiary care hospital in a demographically diverse section of a large metropolitan area. PARTICIPANTS: Six hundred nine (158 white men, 156 nonwhite men, 100 white women, and 195 non-white women) patients undergoing infrarenal lower-extremity arterial bypass surgery from July 1, 2002, to December 31, 2007. MEASUREMENTS AND RESULTS: SEP was estimated using data from the 2000 US Census. The effects of race, sex, various comorbidities, the Revised Cardiac Risk Index, American Society of Anesthesiologists physical status, use of private insurance, indication for bypass surgery, and SEP on all-cause mortality was analyzed. SEP differed significantly among the 4 race-sex groups, with white men having the highest position (mean = 2.38) and non-white men having the lowest position (mean = -3.02). There was no statistically significant association in 30-day mortality among race-sex groups or with SEP. One-year mortality differed significantly between men and women for the entire cohort (13.7% and 24.1%, respectively; p < 0.01) but not among race groups or SEP. CONCLUSIONS: Disparities in SEP are not associated with short- or long-term mortality after LEB surgery. Other comorbid risk factors are more important when determining outcomes and should be the focus of interventions to improve outcomes.

Internet-based assessment of postoperative neurocognitive function in cardiac and thoracic aortic surgery patients.

OBJECTIVE: The primary purpose of this study was to determine the practicality of long-term, postoperative neurocognitive assessment via remote Internet-based testing in a cohort of patients who had undergone cardiac or thoracic aortic surgery within the previous 6 years. The secondary aim of this study was to examine the relationships among hypothermic circulatory arrest time, cardiopulmonary bypass time, and selective cerebral perfusion time with long-term postoperative neurocognitive function, as assessed by this novel testing method. METHODS: Three hundred patients who had undergone cardiac and/or proximal aortic surgery with cardiopulmonary bypass (n = 207), thoracic aortic surgery with hypothermic circulatory arrest (n = 67), or thoracic aortic surgery with hypothermic circulatory arrest and selective cerebral perfusion (n = 26) within the previous 6 years underwent Internet-based neurocognitive assessment. RESULTS: The duration of hypothermic circulatory arrest was negatively associated with processing speed scores and memory scores; arrest duration greater than 21 to 24 minutes was negatively associated with response speed scores. These associations were independent of time since surgery, age at testing, and educational level. Neither cardiopulmonary bypass duration nor selective cerebral perfusion duration was associated with test score results. CONCLUSIONS: This study demonstrated the practicality of long-term neurocognitive assessment of patients who have undergone cardiac and thoracic aortic surgery by means of Internet-based computerized testing. Furthermore, there was a negative association between the duration of intraoperative hypothermic circulatory arrest and long-term postoperative neurocognitive function that needs further examination in prospective studies.

Noninvasive cerebral oxygenation may predict outcome in patients undergoing aortic arch surgery.

OBJECTIVES: Surgical repair of the aortic arch remains technically challenging and is associated with considerable morbidity and mortality. Cerebral oximetry is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. We hypothesized that magnitude and duration of decreased intraoperative regional oxygen saturation was associated with postoperative organ dysfunction. Additionally, we sought to identify regional oxygen saturation threshold values that are predictive of organ dysfunction. METHODS: The intraoperative regional oxygen saturation values of 30 patients undergoing aortic arch surgery were recorded and analyzed. Postoperative complications were categorized as "major" and "minor." Severe adverse outcome, extubation time, intensive care unit length of stay, and hospital length of stay data were collected and compared with the integrals of regional oxygen saturation and time (area under the threshold) spent beneath predetermined absolute threshold limits. RESULTS: Twenty subjects underwent hemiarch replacement, and 10 subjects received total aortic arch replacements. There were 30 major and 29 minor complications identified. Sixteen (53.3%) patients had at least 1 major complication. Logistic regression showed statistically significant associations between area under the threshold and severe adverse outcome incidence for regional oxygen saturation thresholds of 60% (P = .038) and 65% (P = .025). Patients who spent more than 30 minutes under the absolute threshold of 60% had an extended hospital stay of 4 days leading to an additional cost of $8300.00. CONCLUSIONS: Our findings lend evidence to support the association of decreased perioperative cerebral oxygenation values with poor outcomes after aortic arch surgery.

Patient characteristics and anesthetic technique are additive but not synergistic predictors of successful motor evoked potential monitoring.

BACKGROUND: Spinal cord monitoring is associated with a significantly lower rate of neurologic deficits after deformity surgery, and has been shown to have predictive value in cervical, thoracic, and lumbar surgery. Lower extremity motor evoked potentials (MEPs) are particularly sensitive to anesthetics and physiologic change, and can be difficult to obtain at baseline. The anesthesiologist is often required to modify the maintenance anesthetic to facilitate signal attainment. Although intuitive, the predictive significance of increasing age, body mass index (BMI), presence of diabetes and/or hypertension, surgical procedure, and anesthetic technique has not been well delineated. METHODS: We conducted a retrospective chart review of the anesthetic records of all patients who underwent spine surgery and MEP monitoring of the lower extremities from August 1, 2001 to December 31, 2005. Patients with preexisting paralysis of the lower extremities were excluded. Univariate analysis was performed to examine the distribution of diabetes, hypertension, anesthesia technique, age, gender, BMI, and surgical procedure. The chi(2) test and the 2-sample t test were used to test associations between MEP status and potential risk factors. Cochran-Armitage test was used to analyze trends in BMI and age by quartile. The effects of diabetes and hypertension, compared with patients with neither, were presented for each anesthetic technique. Bivariate analysis of the data was performed to analyze a potentially synergistic deleterious effect of diabetes, hypertension, and anesthetic technique using the Breslow-Day test for homogeneity of the odds ratios. Logistic regression analysis through stepwise selection was performed to form a model of the data. RESULTS: Two hundred fifty-six charts were reviewed. The univariate analysis showed that diabetes, hypertension, anesthesia technique, age, and BMI were significantly associated with failure to obtain MEP signals. None of the variables were found to have a synergistic effect on MEP signal attainment in the bivariate analysis. Hypertension, diabetes, and anesthetic technique were independent factors for MEP failure and their joint effects were additive not synergistic. CONCLUSIONS: Diabetes, hypertension, and anesthetic technique were the most important patient risk factors associated with failure to obtain lower extremity MEP signals. These results will improve anesthesiologists' ability to tailor anesthetic regimen to patient comorbidity when MEP monitoring is planned.

Pennsylvania State Hospital system's seclusion and restraint reduction program.

OBJECTIVES: This study examined the use of seclusion and mechanical restraint from 1990 to 2000 and the rate of staff injuries from patient assaults from 1998 to 2000 in a state hospital system. METHODS: Records of patients older than 18 years who were civilly committed to one of the nine state hospitals in Pennsylvania were included in the analyses. Two databases were used in each of the nine hospitals: one identified date, time, duration, and justification for each episode of seclusion or restraint and the other identified when a patient was hospitalized and the demographic characteristics and the diagnosis of the patient. Rate and duration of seclusion and restraint were calculated. Reports from compensation claims were used to determine staff injuries from patient assaults. RESULTS: The rate and duration of seclusion and mechanical restraint decreased dramatically during this period. From 1990 to 2000, the rate of seclusion decreased from 4.2 to .3 episodes per 1,000 patient-days. The average duration of seclusion decreased from 10.8 to 1.3 hours. The rate of restraint decreased from 3.5 to 1.2 episodes per 1,000 patient-days. The average duration of restraint decreased from 11.9 to 1.9 hours. Patients from racial or ethnic minority groups had a higher rate and longer duration of seclusion than whites. Seclusion tended to be less likely, but longer, during the night shift. Patients were restrained less often during the night shift, but for a longer duration. The rate of restraint was higher during the week than during weekends and holidays. Younger patients were more likely to be secluded and restrained, but older patients remained secluded and restrained longer. No significant changes were seen in rates of staff injuries from 1998 to 2000. CONCLUSIONS: Many factors contributed to the success of this effort, including advocacy efforts, state policy change, improved patient-staff ratios, response teams, and second-generation antipsychotics.