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.

Features associated with travel distance for radical cystectomy in Florida: Implications for access to care.

INTRODUCTION: Characteristics associated with travel distance for radical cystectomy (RC) remain incompletely defined but are needed to inform efforts to bridge gaps in care. Therefore, we assessed features associated with travel distance for RC in a statewide dataset. METHODS: We identified RC patients in the Florida Inpatient Discharge dataset from 2013 to 2019. Travel distance was estimated using zip code centroids. The primary outcome was travel >50 miles for RC. Secondary outcomes included inpatient mortality, nonhome discharge, and inpatient complications. U.S. County Health Rankings were included as model covariates. Mixed effects logistic regression models accounting for clustering within hospitals were utilized. RESULTS: We identified 4,209 patients, of whom 2,284 (54%) traveled <25 miles, 654 (16%) traveled 25 to 50 miles, and 1271 (30%) traveled >50 miles. Patients who traveled >50 miles primarily lived in central and southwest Florida. Following multivariable adjustment, patients traveling >50 miles were less likely to be Hispanic/Latino (odds ratio [OR] 0.35, 95% CI: 0.23-0.51), and more likely to reside in a county with the lowest health behavior (OR 6.48, 95% CI: 3.81-11.2) and lowest socioeconomic (OR 7.63, 95% CI: 5.30-11.1) rankings compared to those traveling <25 miles (all P < 0.01). Travel distance >50 miles was associated with treatment at a high-volume center and significantly lower risks of inpatient mortality, nonhome discharge, and postoperative complications (all P < 0.02). CONCLUSION: These data identify characteristics of patients and communities in the state of Florida with potentially impaired access to RC care and can be used to guide outreach efforts designed to improve access to care.

Mortality assessment for pancreas transplants in the United States over the decade 2008-2018.

BACKGROUND: Pancreas transplant is the only treatment that establishes normal glucose levels for patients diagnosed with diabetes. However, since 2005, no comprehensive analysis has compared survival outcomes of: (1) Simultaneous pancreas-kidney (SPK) transplant; (2) Pancreas after kidney (PAK) transplant; and (3) Pancreas transplant alone (PTA) to waitlist survival. AIM: To explore the outcomes of pancreas transplants in the United States during the decade 2008-2018. METHODS: Our study utilized the United Network for Organ Sharing Standard Transplant Analysis and Research file. Pre- and post-transplant recipient and waitlist characteristics and the most recent recipient transplant and mortality status were used. We included all patients with type I diabetes listed for pancreas or kidney-pancreas transplant between May 31, 2008 and May 31, 2018. Patients were grouped into one of three transplant types: SPK, PAK, or PTA. RESULTS: The adjusted Cox proportional hazards models comparing survival between transplanted and non-transplanted patients in each transplant type group showed that patients who underwent an SPK transplant exhibited a significantly reduced hazard of mortality [hazard ratio (HR) = 0.21, 95% confidence intervals (CI): 0.19-0.25] compared to those not transplanted. Neither PAK transplanted patients (HR = 1.68, 95%CI: 0.99-2.87) nor PTA patients (HR = 1.01, 95%CI: 0.53-1.95) exper ienced significantly different hazards of mortality compared to patients who did not receive a transplant. CONCLUSION: When assessing each of the three transplant types, only SPK transplant offered a survival advantage compared to patients on the waiting list. PKA and PTA transplanted patients demonstrated no significant differences compared to patients who did not receive a transplant.

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.

Improving Health and Addressing Social Determinants of Health Through Hospital Partnerships.

Hospitals and health systems are forming partnerships to develop an integrated social network of services that better address the needs of their surrounding communities and their social determinants of health (SDOH). There is little research on the association of these partnered services with hospital outcomes. This study examined the association between hospital social need partnerships and activities to improve hospital and community outcomes. A secondary cross-sectional design to analyze 2021 census data of nonfederal short-term acute care hospitals in the United States was utilized. Data were obtained from the American Hospital Association. Four multilevel logistic regression models were used to analyze data from 1005 hospitals. The authors found that hospital partnership type differed in association to social need outcomes. They found that hospitals with a partnership with health insurance providers were more likely to have better health outcomes. Hospitals partnered with health insurance providers, local organizations addressing housing insecurity, local businesses, or chambers of commerce were more likely to have decreased health care costs. Hospitals partnered with health care providers, health insurance providers, local organizations providing legal assistance, or law enforcement/safety forces were more likely to have decreased utilization of hospital services. However, hospitals partnered with other local or state government or social service organizations were less likely to indicate decreased utilization of services. Many hospitals and health systems across the United States are screening for SDOH and are advancing health care delivery and improving the community's overall health and well-being by identifying unmet social needs and partnering with the community to address them.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in adults with inflammatory bowel disease.

BACKGROUND: Recombinant zoster vaccine (RZV) is recommended for all adults ≥19 years of age who are at increased risk for HZ, including patients with inflammatory bowel disease (IBD). METHODS: A Markov model was constructed to compare the RZV cost-effectiveness with no vaccination in patients with Crohn's Disease (CD) and ulcerative colitis (UC). A simulated cohort of 1 million patients was used for each IBD group at ages 18, 30, 40, and 50. The primary objective of this analysis was to compare RZV cost-effectiveness in patients with CD and UC, comparing vaccination to no vaccination. RESULTS: Overall, vaccination is cost-effective for both CD and UC, with the incremental cost-effectiveness ratio (ICERs) below $100,000/quality-adjusted life years (QALY) for all age cohorts. For patients with CD, 30 years of age and older, and those with UC 40 years and older, vaccination was both more effective and less expensive than the non-vaccinated strategy (CD ≥30: ICERs $6183-$24,878 and UC ≥40: ICERs $9163-$19,655). However, for CD patients under 30 (CD 18: ICER $2098) and UC patients under 40 (UC = 18: ICER $11,609, and UC = 30: $1343), costs were greater for vaccinated patients, but there was an increase in QALY. One-way sensitivity analysis of age indicates that cost break-even occurs at age 21.8 for the CD group and 31.5 for the UC group. In probabilistic sensitivity analysis, 92% of both CD and UC simulations indicated that vaccination was preferred. CONCLUSION: In our model, vaccination with RZV was cost-effective for all adult patients with IBD.

Demographic Characteristics Influence Treatment Costs of Invasive Melanoma in Florida.

BACKGROUND: Demographic characteristics are known to influence the treatment and outcomes of patients with invasive melanoma. Whether these characteristics influence treatment costs is unknown. We aimed to analyze whether patient demographics and tumor characteristics influence treatment costs for patients with invasive cutaneous melanoma in Florida. METHODS: This was a cross-sectional study in which the Florida Inpatient and Outpatient Dataset of the Agency for Health Care Administration was analyzed for patients with a diagnosis of invasive melanoma between January 1, 2013 and December 31, 2018. Categorical variables were assessed using Pearson χ2 tests, and continuous variables were evaluated using Kruskal-Wallis tests. Logistic regression analysis was conducted to identify the association between patient demographics and total costs. All analyses were done using SAS 9.4 statistical software (SAS Institute, Inc). RESULTS: Multivariate analysis showed that sex (P < 0.001), hospital setting (P < 0.001), race/ethnicity (P < 0.01), patient region (P < 0.01), Elixhauser Comorbidity Index score (P < 0.001), presence of metastasis (P < 0.01), total number of procedures (P < 0.001), and length of stay (P < 0.001) were correlated with the cost of treatment of invasive cutaneous melanoma. After stratification, the association between cost and race/ethnicity disappeared for inpatients but remained for Black patients in the outpatient setting (P < 0.001). The association between cost and patient residence regions also differed when the cohort was stratified. CONCLUSIONS: Strategies addressing disparities in treatment cost of invasive melanoma should differ, depending on the hospital setting where the patient is being treated.

The role of community-level characteristics in comparing United States hospital performance by magnet designation: A propensity score matched study.

AIMS: To assess the impact of community-level characteristics on the role of magnet designation in relation to hospital value-based purchasing quality scores, as health disparities associated with geographical location could confound hospitals' ability to meet outcome metrics. DESIGN: This cross-sectional study was carried out between October 2021 and March 2022 using data from 2016 to 2021. METHODS: Propensity score analysis was used to match hospital and community-level characteristics, implementing nearest neighbour matching to adjust for pre-treatment differences between magnet and non-magnet hospitals to account for multi-level differences. Secondary data were obtained from all operational acute-care facilities in the United States that participated in the Centers for Medicare and Medicaid Services' hospital value-based purchasing (HVBP) program. Dependent variables were the four value-based purchasing domains that comprise the Total Performance Score (TPS; Clinical Care, Person and Community Engagement, Safety, and Efficiency and Cost Reduction). RESULTS: Magnet hospitals had increased odds for better scores in the HVBP domains of Clinical Care and Person and Community Engagement, and decreased odds for having better Safety. However, no statistically significant difference was found for the Efficiency domain or the TPS. CONCLUSION: Measuring performance equitably across organizations of various sizes serving diverse communities remains a key factor in ensuring distributive justice. Analysing the TPS components can identify complex influences of community-level characteristics not evident at the composite level. More research is needed where community and nurse-level factors may indirectly affect patient safety. IMPACT: This study's findings on the role of community contexts can inform policymakers designing value-based care programs and healthcare management administrators deliberating on magnet certification investments across diverse community settings. NO PATIENT OR PUBLIC CONTRIBUTION: For this study of US hospitals' organizational performance, we did not engage members of the patient population nor the general public. However, the multi-disciplinary research team does include diverse perspectives.

Postsurgical Remote Patient Monitoring Outcomes and Perceptions: A Mixed-Methods Assessment.

Objective: To determine how postsurgical remote patient monitoring (RPM) influences readmissions and emergency visits within 30 days of discharge after operation and to understand patient and surgeon perspectives on postsurgical RPM. Patients and Methods: This study was conducted at a US tertiary academic medical center between April 1, 2021, and December 31, 2021. This mixed-methods evaluation included a randomized controlled trial evaluation of RPM after operation and a qualitative assessment of patients' and surgeons' perceptions of RPM's acceptability, feasibility, and effectiveness. Results: A total of 292 patients participated in the RPM trial, and 147 were assigned to the RPM intervention. Despite a good balance between the groups, results indicated no difference in primary or secondary outcomes between the intervention and control groups. The qualitative component included 11 patients and 9 surgeons. The overarching theme for patients was that the program brought them peace of mind. Other main themes included technological issues and perceived benefits of the RPM platform. The major themes for surgeons included identifying the best patients to receive postsurgical RPM, actionable data collection and use, and improvements in data collection needed. Conclusion: Although quantitative results indicate no difference between the groups, postsurgical RPM appears well-accepted from the patient's perspective. However, technological issues could eliminate the benefits. Hospitals seeking to implement similar programs should carefully evaluate which populations to use the program in and seek to collect actionable data.

Comparing Outcomes and Cost Between Pancreas Transplant and Standard of Care in Patients With Type 1 Diabetes.

OBJECTIVES: Pancreas transplant is the only treatment that establishes normal glucose levels for patients diagnosed with diabetes. We analyzed the outcome of pancreas transplant alone (PTA) versus standard of care in the United States from 2008 to 2018. We also developed an economic model to analyze the cost-effectiveness of pancreas transplant versus continuing standard of care. METHODS: We used the Scientific Registry of Transplant Recipients database and analyzed PTA recipient survival. Using those results, we developed a Markov model that followed a cohort of 40-year-old patients with type 1 diabetes over a 10-year time horizon. The primary outcomes were (i) the survival benefit of a pancreas transplant, (ii) quality-adjusted life-years (QALYs), and (iii) total costs. RESULTS: We found no difference in survival advantage of PTA compared with standard of care (hazard ratio, 1.09; 95% confidence interval, 0.56-2.14). However, pancreas transplant ($172,823, 6.87 QALY) was cost-saving compared with standard of care ($232,897, 6.04 QALY) for type 1 diabetes. Pancreas transplantation was cost-effective in 95% of 10,000 simulations in probabilistic sensitivity analysis, using a $100,000/QALY willingness-to-pay threshold. CONCLUSIONS: Although there is no difference in survival for PTA compared with standard of care, PTA is a cost-saving therapy for type 1 diabetes.

Assessment of length of stay and cost of minimally invasive versus open thymectomies in patients with myasthenia gravis in Florida.

Background: Thymectomy has become a standard component in treatment for myasthenia gravis. The best surgical approach is still subject to debate. Minimally invasive surgery may have a lower mortality and morbidity rate, improved cosmetic results, and equivalent efficacy at improving neurologic symptoms to open approaches. We compared the perioperative outcomes and cost between the two techniques. Methods: We queried Florida Inpatient Discharge Dataset for patients who underwent thymectomy and had a primary diagnosis of non-thymomatous myasthenia gravis using International Classification of Diseases (ICD)-9 and ICD-10 codes to carry out this retrospective cohort study. The dates ranged between January 1st, 2013, to December 31st, 2018. We compared outcomes of patients who underwent minimally invasive thymectomy versus those who had open thymectomy. Results: An open approach was used in 108 patients, whereas a minimally invasive approach was used in 40 patients. Minimally invasive surgery group had a shorter length of stay (3.0 vs. 6.0 days, P<0.001) and had a non-significant lower total cost ($18.4K vs. $22.1K, P=0.186). After adjusting for age and Elixhauser score, length of stay for minimally invasive group was 32% (P=0.01) lower compared to the open surgery group. Conclusions: Patients who underwent minimally invasive thymectomy for Myasthenia gravis had a significantly shorter length of stay and a lower, although not significant, overall cost.

The Hospital Value-Based Purchasing Program: Do hospitalists improve health care value.

INTRODUCTION: As healthcare organizations examine the associated benefits of employing a larger hospitalist workforce, there is a need to better understand the association with patients' quality, experience, and efficiency. However, there is a lack of information regarding how hospital use of hospitalists over time influences hospital scoring on quality programs, such as the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Value-Based Purchasing (HVBP) Program. This study examines the association between hospitalist staffing between 2014 and 2019 and HVBP scores. METHODS: We used a cross-sectional panel study design. Total Performance Score (TPS) and its domains were obtained from CMS from 2014 to 2019 and merged with the American Hospital Association Annual Survey Database. We utilized random-effects multivariable panel regression models and zero-inflated negative binomial regression to examine the association between the hospitalist-staffing ratio and the HVBP Program. All models were adjusted for hospital characteristics. RESULTS: A total of 2126 hospitals were included in the study. The average ratio of hospitalists per staffed bed was 0.06, with a standard deviation of 0.15. This study suggests that hospitals that employ a higher percentage of hospitalists see improvement in their overall TPS (ß = 5.40; p < .001), Patient Experience (ß = 2.49; p <.05), and Efficiency (incidence-rate ratio= 1.41; p < .001) domain. However, the Clinical Care domain was no different in organizations employing more hospitalists. CONCLUSION: There are benefits associated with TPS, Patient Experience, and Efficiency from employing hospitalists. Managers should seek opportunities to leverage hospitalists' expertise in providing care, particularly in improving care processes.

Association of hospital and community factors on the attainment of Baby-Friendly designation: A breastfeeding health promotion.

The Baby-Friendly Hospital Initiative is a global health promotion intervention that outlines the Ten Steps hospitals should implement to support newborns' breastfeeding. This US-based study aimed to determine which hospital characteristics and community factors are associated with hospitals' attainment of Baby-Friendly designation. We used a cross-sectional design and used 2018 data from the Baby-Friendly, USA Inc. designation program merged with the American Hospital Association annual survey data set. Multilevel logistic regression analysis was used to assess hospital characteristics of interest among the sample consisting of 312 Baby-Friendly hospitals and 1449 non-Baby-Friendly. Our results show that Baby-Friendly hospitals are more likely to be government nonfederal hospitals, in the Midwest or South regions, serve communities with higher birth totals, and reside in competitive markets. Based on the results of this study, hospitals should seek further and examine their community's characteristics and structures to identify opportunities and encourage the attainment of improved breastfeeding initiatives such as Baby-Friendly designation.

Observational Trends in Publicly Reported Quality Measures of Hospital Outpatient Quality Reporting Program, 2013-2019.

In 2011, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Outpatient Quality Reporting Program to assess the quality of outpatient imaging efficiency (OIE). In this study, trends in hospital performance on these national hospital OIE measures a year after inception and public reporting were described. An observational trend analysis was conducted using 2013-2019 data from CMS 6 OIE measures. The trend analysis of metric scores indicates year-to-year variability in all 6 OIE variables. The reporting of these measures appears to have effectively improved the efficiency of most of the measures since the inception of the program.

Hospital-Acquired Conditions Reduction Program, Racial and Ethnic Diversity, and Magnet Designation in the United States.

OBJECTIVE: A key quality indicator in any health system is its ability to reduce morbidity and mortality. In recent years, healthcare organizations in the United States have been held to stricter measures of accountability to provide safe, quality care. This study aimed to explore the contextual factors driving racial disparities in hospital-acquired conditions incident rates among Medicare recipients in Magnet and non-Magnet hospitals. METHODS: A cross-sectional observational study was performed using data from Hospital-Acquired Condition Reduction Program. Performance from 1823 hospitals were used to examine the association between Magnet recognition and community's racial and ethnic differences in hospital performance on the Hospital-Acquired Condition Reduction Program. The unit of analysis was the hospital level. A propensity score matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. The outcome measures were risk-standardized hospital performance on the Hospital-Acquired Condition Reduction Program domains and overall performance. RESULTS: Study findings show that Magnet hospitals had decreased methicillin-resistant Staphylococcus aureus (MRSA) rate (ß = -0.22; 95% confidence interval, -0.36 to -0.08) compared with non-Magnet hospitals. No other statistical difference was identified. CONCLUSIONS: Results from this study show community's racial and ethnic differences in hospital-acquired conditions occurrence differ between Magnet and non-Magnet hospitals for MRSA, indicating its association with nursing practice. However, because this improvement is limited to only MRSA, there are likely opportunities for Magnet hospitals to continue process improvements focused on additional Hospital-Acquired Condition Reduction Program measures.

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.

Temporary vs. permanent stoma: factors associated with the development of complications and costs for rectal cancer patients.

OBJECTIVE: To compare in-hospital complication rates and treatment costs between rectal cancer patients receiving permanent and temporary stomas. Surgical complications and costs associated with permanent stoma formation are still poorly understood. While choosing between the two stoma options is usually based on clinical and technical factors, disparities exist. METHODS: Patients with rectal cancer, stoma formation, complications, and cost of care were identified from the Florida Agency for Health Care Administration Discharge Database. Rectal cancer patients who underwent elective surgery and received a permanent or temporary stoma were identified using ICD-10 codes. Patients who underwent colostomy with resection were included in the "Permanent stoma" group, and those who underwent "resection with ileostomy" were included in the "temporary stoma" group. Multivariable models compared patients receiving temporary vs. permanent stomas. RESULTS: Regression models revealed no difference in the odds of having a complication between patients who obtained permanent versus temporary stoma (OR 0.96, 95% CI: 0.70-1.32). Further, after adjusting for the number of surgeries, demographic variables, socioeconomic and regional factors, comorbidities, and type of surgery, there was a significant difference between permanent and temporary stomas for rectal cancer (ß - 0.05, p = 0.03) in the log cost of creating a permanent stoma. CONCLUSION: Our findings suggest there are no differences associated with complications, and reduced cost for permanent compared to temporary stomas. Increased costs are also associated with receiving minimally invasive surgery. As a result, disparities associated with receipt of MIS could ultimately influence the type of stoma received.

Medicare and telehealth: The impact of COVID-19 pandemic.

STUDY RATIONALE: The swift progression of the COVID-19 pandemic appeared to facilitate the increase in telehealth utilization. However, it is clear neither how telehealth was offered by providers nor how it was used by patients during this time of unusual and rapid change within the health industry. AIM: To investigates the telehealth utilization patterns of Medicare beneficiaries during the height of the COVID-19 pandemic. METHODS AND MATERIALS: A cross-sectional study design was used to examine the responses of 9686 Medicare beneficiaries to the Centers for Medicare and Medicaid Services (CMS) Medicare Current Beneficiary Survey, Fall 2020 COVID-19 Supplement. Multiple logistic regression analyses were conducted to examine the relationship between telehealth offering and beneficiaries' sociodemographic variables. RESULTS: Over half (58%) of primary care providers provided telehealth services, while only 26%-28% of specialists did. Less than 8% of Medicare beneficiaries reported that they were unable to obtain care because of COVID-19. CONCLUSIONS: This research found that changes in Medicare policy, associated with CMS' declaration of telehealth waivers during the Public Health Emergency (PHE), likely increased the proliferation and utilization of telehealth services during the COVID-19 pandemic, providing important access to care for certain populations. With the impending conclusion of the PHE, policymakers must 1) ascertain which elements of the new telehealth landscape will be retained, 2) modernize the regulatory, accreditation and reimbursement framework to maintain pace with care model innovation and 3) address disparities in access to broadband connectivity with a particular focus on rural and underserved communities.

Smoke-Free Policies and 30-Day Mortality Rates for Chronic Obstructive Pulmonary Disease.

BACKGROUND: Smoke-free policies have been shown to impact 30-day readmission rates due to chronic obstructive pulmonary disease (COPD) among adults aged ≥65 years. However, little is known about the association between smokefree policies and 30-day mortality rates for COPD. Therefore, we investigated the association between comprehensive smoke-free policies and 30-day mortality rates for COPD. METHODS: We used a cross-sectional study design and retrospectively examined risk-adjusted 30-day mortality rates for COPD across US hospitals in 1171 counties. Data were sourced from Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) Program, American Hospital Association (AHA) Annual Surveys, US Census Bureau Current Population Survey, and US Tobacco Control Laws Database from the American Nonsmokers' Rights Foundation (ANRF). Data were averaged at the county level for years 2015-2018. Hierarchical Poisson models adjusted for differences in hospital characteristics and accounted for the clustering of hospitals within a county were used. RESULTS: Our findings show a consistent association between stronger smoke-free policies and a reduction in COPD mortality. When evaluating smoke-free policy, county characteristics, and hospital characteristics individually, we found that counties with full coverage or partial coverage had a reduced incidence rate of COPD mortality compared to no coverage counties. After adjusting for the county and hospital characteristics, counties with full coverage of smoke-free policies had a reduced rate of 30-day COPD mortality (adjusted incidence rate ratio [IRR]: 0.87, 95% CI: 0.79, 0.96) compared to counties with no policy coverage. CONCLUSION: Comprehensive smoke-free policies are associated with a reduction in 30-day mortality following hospital admission for COPD. Partial smoke-free legislation is an insufficient preventative measure. These findings have strong implications for hospital policy-makers, suggesting that policy interventions to reduce COPD-related 30-day mortality should include implementing smoke-free policies and public health policy-makers to incentivize comprehensive smokefree policies.