The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients.

BACKGROUND: The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown. METHODS: We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention. RESULTS: Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates. CONCLUSION: We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.

Malpractice Litigation for Compartment Syndrome.

BACKGROUND: The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. METHODS: Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. RESULTS: A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7 years, suffering injuries for an average of 5 years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. CONCLUSIONS: Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Association of Surgical Treatment With Adverse Events and Mortality Among Medicare Beneficiaries With Proximal Humerus Fracture.

Importance: Meta-analyses of randomized clinical trials suggest that the advantages and risks of surgery compared with conservative management as the initial treatment for proximal humerus fracture (PHF) vary, or are heterogeneous across patients. Substantial geographic variation in surgery rates for PHF suggests that the optimal rate of surgery across the population of patients with PHF is unknown. Objective: To use geographic variation in treatment rates to assess the outcomes associated with higher rates of surgery for patients with PHF. Design, Setting, and Participants: This comparative effectiveness research study analyzed all fee-for-service Medicare beneficiaries with proximal humerus fracture in 2011 who were continuously enrolled in Medicare Parts A and B for the 365-day period before and immediately after their index fracture. Data analysis was performed January through June 2019. Exposure: Undergoing 1 of the commonly used surgical procedures in the 60 days after an index fracture diagnosis. Main Outcomes and Measures: Risk-adjusted area surgery ratios were created for each hospital referral region as a measure of local area practice styles. Instrumental variable approaches were used to assess the association between higher surgery rates and adverse events, mortality risk, and cost at 1 year from Medicare's perspective for patients with PHF in 2011. Instrumental variable models were stratified by age, comorbidities, and frailty. Instrumental variable estimates were compared with estimates from risk-adjusted regression models. Results: The final cohort included 72 823 patients (mean [SD] age, 80.0 [7.9] years; 13 958 [19.2%] men). The proportion of patients treated surgically ranged from 1.8% to 33.3% across hospital referral regions in the United States. Compared with conservatively managed patients, surgical patients were younger (mean [SD] age, 80.4 [8.1] years vs 78.0 [7.2] years; P < .001) and healthier (Charlson Comorbidity Index score of 0, 14 863 [24.4%] patients vs 3468 [29.1%] patients; Function-Related Indicator score of 0, 20 720 [34.0%] patients vs 4980 [41.8%] patients; P < .001 for both), and a larger proportion were women (49 030 [80.5%] patients vs 9835 [82.5%] patients; P < .001). Instrumental variable analysis showed that higher rates of surgery were associated with increased total costs ($8913) during the treatment period, increased adverse event rates (a 1-percentage point increase in the surgery rate was associated with a 0.19-percentage point increase in the 1-year adverse event rate; ß = 0.19; 95% CI, 0.09-0.27; P < .001), and increased mortality risk (a 1-percentage point increase in the surgery rate was associated with a 0.09-percentage point increase in the 1-year mortality rate; ß = 0.09; 95% CI, 0.04-0.15; P < .01). Instrumental variable mortality results were even more striking for older patients and those with higher comorbidity burdens and greater frailty. Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1-percentage point increase in the surgery rate was associated with a 0.12-percentage point increase in the 1-year adverse event rate; ß = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1-percentage point increase in the surgery rate was associated with a 0.01-percentage point decrease in the 1-year mortality rate; ß = -0.01; 95% CI, -0.015 to -0.005; P < .001). Conclusions and Relevance: This study found that higher rates of surgery for treatment of patients with PHF were associated with increased costs, adverse event rates, and risk of mortality. Orthopedic surgeons should be aware of the harms of extending the use of surgery to more clinically vulnerable patient subgroups.

Comparative assessment of early versus delayed surgery to treat proximal femoral fractures in elderly patients: A systematic review and meta-analysis.

BACKGROUND: Recently, many studies have suggested that timely surgery to treat proximal femoral fractures can benefit patients in many respects. However, both the short- and long-term outcomes, and the perioperative complications, of early surgery remain controversial. In addition, the optimal cut-off time for early surgery remains unclear. Thus, we performed a meta-analysis to compare and evaluate the benefits of early versus delayed surgery in terms of the clinical outcomes of patients with proximal femoral fractures. METHODS: We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases to February 1, 2018 and retrieved original studies comparing the efficacy of early versus delayed surgery for proximal femoral fractures. We calculated risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (CIs) and compared the outcomes of early and delayed surgery. We performed subgroup analyses to explore mortality and perioperative complications associated with different cut-off times for surgery, for various periods. Two reviewers assessed the quality of the included studies and independently extracted the data. We followed the suggestions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. All statistical analyses were performed using the standard statistical procedures of Review Manager 5.2. RESULTS: A total of 27 studies (N = 33,727 participants) were included in the present analysis. Compared to delayed surgery, early surgery significantly reduced mortality and complications. The mortality rates of patients who underwent surgery within 48 and 24 h of fracture were 28 and 23% less than those of patients operated upon after 48 h (RR = 0.72; 95% CI: 0.71-0.73) and 24 h (RR = 0.77; 95% CI: 0.65-0.93). In addition, early surgery was associated with fewer perioperative complications than delayed surgery (OR = 0.52; 95% CI: 0.35-0.76), especially in terms of postoperative pressure ulcers (OR = 0.55; 95% CI: 0.45-0.68), urinary tract infections (OR = 0.57; 95% CI: 0.49-0.67), and thromboembolic events (OR = 0.61; 95% CI: 0.39-0.96). CONCLUSIONS: Early surgery reduces mortality associated with proximal femoral fractures and the frequency of serious perioperative complications when comparing with delayed surgery.

Surgical intervention in pediatric trauma at a level 1 trauma hospital: a retrospective cohort study and report of cost data.

BACKGROUND: Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario. METHODS: All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group. RESULTS: Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group. CONCLUSION: One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.

CONTEXTE: La prise en charge des enfants grièvement blessés nécessite la coordination des soins fournis dans le contexte de plusieurs surspécialités chirurgicales pédiatriques. Dans ce contexte, nous avons cherché à décrire la fréquence et les coûts des interventions chirurgicales chez les patients pédiatriques victimes de trauma admis dans un centre de traumatologie de niveau 1 dans le sud-ouest de l'Ontario. MÉTHODES: Tous les patients pédiatriques (moins de 18 ans) ayant subi un trauma traités à l'Hôpital pour enfants du Centre des sciences de la santé de London entre 2002 et 2013 ont été retenus pour l'étude. Nous avons comparé les caractéristiques démographiques et les résultats cliniques des patients ayant subi une intervention chirurgicale et de ceux n'en ayant pas subi. Les coûts d'hospitalisation n'ont été calculés que pour le premier groupe. RÉSULTATS: Parmi les 784 enfants à l'étude, 258 (33 %) avaient eu besoin d'une intervention chirurgicale; 40 % de ceux-ci avaient subi des interventions orthopédiques. Ces patients étaient plus âgés et plus grièvement blessés que les enfants n'ayant pas subi d'intervention chirurgicale, et leur séjour à l'hôpital était généralement plus long. Nous n'avons relevé aucune différence entre les 2 groupes quant à la mortalité. En outre, 74 des patients ayant subi une intervention chirurgicale ont dû être opérés dans les 4 heures suivant l'admission; 45 % d'entre eux ont eu besoin d'une intervention neurochirurgicale. Le coût médian d'une hospitalisation était de 27 571 $. CONCLUSION: Le tiers des patients pédiatriques victimes de trauma ont eu besoin d'une intervention chirurgicale, et le tiers de ceux-ci ont dû être opérés dans les 4 heures suivant leur arrivée. Malgré les coûts, le traitement chirurgical des enfants était associé à un taux de mortalité comparable à celui du traitement non chirurgical des patients blessés moins grièvement. Cette étude est la source d'information la plus récente sur le coût par patient associé au traitement chirurgical des enfants victimes de trauma en Ontario, et elle met en évidence le besoin de soins de multiples spécialités.

Effect of patient safety incident review and reflection in an extended morbidity and mortality meeting.

BACKGROUND: We modified the departmental mortality and morbidity (M&M) meetings to evaluate whether patient safety incident review as a part of this meeting was associated with reduced patient safety incidents. METHOD: A pilot programme of peer review of patient safety incidents (PSI) supported by education relevant to that event and follow-on action plan was introduced as a part of an extended morbidity and mortality meeting in a university hospital orthopaedic department. The pilot programme was conducted over six months (January 2012-June 2012). This programme involved junior and senior doctors including consultants although multidisciplinary groups were invited to attend. We investigated PSI rate/1000 hospital admissions for trauma and elective surgery, which were collected prospectively and independently between Jan 2011 to June 2013. We noted if the incident was caused by a medical or a nursing error and compared PSI rates. RESULTS: Rates of PSI (33/1000) were 7.8 times higher in trauma cases (80.2/1000) than in elective admissions (11.2/1000). There was 18% reduction in trauma and 27% reduction in planned elective admissions. The rate increased after the pilot programme finished but there was still a 7% reduction compared to the pre-pilot period. This study found a significant reduction in the PSI rate for medical error but no change in the rate of nursing error. CONCLUSION: This continuous reflection, education and action process, where safety events are reviewed as a part of the extended morbidity and mortality meeting, is associated with reduction of patient safety incidents. We recommend that PSI reflection should be introduced in Mortality and Morbidity meetings with mandated attendance of the entire multidisciplinary health care team.

Readmission destination and risk of mortality after major surgery: an observational cohort study.

BACKGROUND: Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations. METHODS: By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission. FINDINGS: 9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital. INTERPRETATION: In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care. FUNDING: None.

Elevated costs and high one-year mortality in patients with diabetic foot ulcers after surgery.

INTRODUCTION: In Denmark, approximately 300,000 patients have a diabetes mellitus diagnosis. Recently published guidelines emphasise that health-care professionals who are in direct contact with citizens should be aware of the importance of prevention and early detection of diabetic foot ulcers. The objective of this study was to evaluate the mortality, length of hospital stay and economic impact on health care in patients with acute diabetic foot ulcers who were hospitalised in the Department of Orthopaedic Surgery, Aalborg University Hospital, Denmark. METHODS: This was a prospective cohort study including all patients admitted with a diagnosis of acute foot ulcer to the Department of Orthopaedic Surgery, Aalborg, Denmark, from September 2011 to February 2012. RESULTS: A total of 48 patients were referred for surgical treatment of a diabetic foot ulcer. The average age on admission was 64 years (35-87 years). The median length of hospital stay was 17 days (3-150 days), and 14 patients were readmitted within the first year. Within the first year of enrolment, 13 patients died, corresponding to a 36% mortality rate. Based on the Danish Diagnosis-Related Groups rates, the median cost associated with a case in the study population was 133,867 DKK. CONCLUSION: Patients referred for surgical revision of diabetic foot ulcers are often severely ill, and the condition is associated with a high one-year mortality rate. Furthermore, the cost of these cases is considerable. Preventive interventions, early diagnosis and treatment and multidisciplinary interventions ­ before and during hospitalisation ­ should be implemented. FUNDING: not relevant. TRIAL REGISTRATION: The Danish Data Protection Agency (J. No. 2008-58-0028) approved the study.

Does Patient Sex Affect the Rate of Mortality and Complications After Spine Surgery? A Systematic Review.

BACKGROUND: Available studies disagree regarding the influence of patient sex on mortality and complications after spine surgery. We sought to conduct a systematic review and pool the results of existing research to better understand this issue. QUESTIONS/PURPOSES: We performed a systematic review to address two questions: (1) Does sex (male versus female) influence mortality after spine surgery? (2) Does sex impact the development of postoperative complications after spine surgery? METHODS: This systematic review was performed through a query of PubMed using a structured search algorithm. Additional queries of Embase, SCOPUS, Web of Science, and the tables of contents of orthopaedic and neurosurgical journals were also conducted using search terms such as "sex factors", "male or female", "risk factors", and "spine surgery". Selected papers were independently abstracted by three of the authors (AJS, ENR, EIW) and pooling was performed. Our literature search returned 720 studies, of which 99 underwent full review. Of these, 50 were selected for final abstraction. The Cochrane Q test was used to assess study heterogeneity; significant study heterogeneity was present and so a random-effects model was used. A Harbord test was used to evaluate for the presence of publication bias; this analysis found no statistically significant evidence of publication bias. RESULTS: Males were at increased odds of mortality after spine surgery (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.35-1.97; p<0.001). No differences between the sexes were identified for the odds of complications (OR, 1.04; 95% CI, 0.95-1.13; p=0.42). CONCLUSIONS: Our results determined that males were at elevated odds of mortality but not of complications after spine surgery. These results should be used to inform preoperative discussion and decision-making at the time of surgical consent. Future work should be directed at determining the underlying factors responsible for increased mortality among males and prospective studies specifically designed to evaluate sex-based differences in outcomes after spine surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Characterization of comorbid factors in hip fracture related in-hospital mortality.

It is important to delineate factors which influence in-hospital mortality rates following a hip fracture. The current study aimed to identify the nature and frequency of comorbidities prevalent in this patient cohort. A retrospective chart review of cases of in-patient mortality following admission for a hip fracture was performed. These cases (n=127) were characterized for comorbidities, complications, medical status indicators, and other contributory factors. Cardiovascular 104 (81.9%), respiratory 66 (52.0%), genitourinary 41 (32.3%), psychiatric 41 (32.3%), vascular 40 (31.5%), and gastrointestinal 40 (31.5%), are the physiological systems, most commonly associated with comorbidity amongst hip fracture patients who succumb to in-hospital mortality. Renal failure, pneumonia, sepsis, myocardial infarction, congestive cardiac failure (CCF), respiratory failure, and Clostridium difficile infection are conditions which are associated with postoperative complications leading to in-patient mortality. Analysis of medical status indicators illustrated an inverse correlation between ASA scores and postoperative survival time, in this cohort-of hip fracture patients (R2 = 0.9485).

Impact of age and comorbidity burden on mortality and major complications in older adults undergoing orthopaedic surgery: an analysis using the Japanese diagnosis procedure combination database.

BACKGROUND: The purpose of this study was to examine how complications in older adults undergoing orthopaedic surgery vary as a function of age, comorbidity, and type of surgical procedure. METHODS: We abstracted data from the Japanese Diagnosis Procedure Combination database for all patients aged ≥ 50 who had undergone cervical laminoplasty, lumbar decompression, lumbar arthrodesis, or primary total knee arthroplasty (TKA) between July 1 and December 31 in the years 2007 to 2010. Outcome measures included all-cause in-hospital mortality and incidence of major complications. We analyzed the effects of age, sex, comorbidities, and type of surgical procedure on outcomes. Charlson comorbidity index was used to identify and summarize patients' comorbid burden. RESULTS: A total of 107,104 patients were identified who underwent cervical laminoplasty (16,020 patients), lumbar decompression (31,605), lumbar arthrodesis (18,419), or TKA (41,060). Of these, 17,339 (16.2%) were aged 80 years or older. Overall, in-hospital death occurred in 121 patients (0.11%) and 4,448 patients (4.2%) had at least one major complication. In-hospital mortality and complication rates increased with increasing age and comorbidity. A multivariate analysis showed mortality and major complications following surgery were associated with advanced age (aged ≥ 80 years; odds ratios 5.88 and 1.51), male gender, and a higher comorbidity burden (Charlson comorbidity index ≥ 3; odds ratio, 16.5 and 5.06). After adjustment for confounding factors, patients undergoing lumbar arthrodesis or cervical laminoplasty were at twice the risk of in-hospital mortality compared with patients undergoing TKA. CONCLUSIONS: Our data demonstrated that an increased comorbid burden as measured by Charlson comorbidity index has a greater impact on postoperative mortality and major complications than age in older adults undergoing orthopaedic surgery. After adjustment, mortality following lumbar arthrodesis or cervical laminoplasty was twice as high as that in TKA. Our findings suggest that an assessment of perioperative risks in elderly patients undergoing orthopaedic surgery should be stratified according to comorbidity burden and type of procedures, as well as by patient's age.

Utility of the Surgical Apgar Score in a district general hospital.

BACKGROUND: The Surgical Apgar Score (SAS) is a simple tool for intraoperative risk stratification. The aim of this prospective observational study was to assess its performance in predicting outcome after general/vascular and orthopedic surgery and its utility in a U.K. district general hospital. METHOD: A prospective cohort of 223 consecutive general, vascular, and orthopedic surgical cases was studied. The SAS was calculated for all patients, and its relationship to 30 day mortality and major complication assessed with reference to the mode of surgery (elective or emergent). Statistical analysis of categorical data was performed with Fisher's exact test and the AUC (area under the curve) on receiver operating characteristic (ROC) analysis. Selected cases were reviewed to assess the potential of the SAS to modify postoperative management. RESULTS: The proportion of patients who died or experienced major complications increased monotonically with Surgical Apgar Score category in general and vascular but not orthopedic cases. The relative risks of mortality or major complication between SAS categories were less marked than in previous publications. The SAS performed variably on ROC curve analysis, with an AUC of 0.62-0.73. Discrimination achieved significance in general and vascular cases (p = 0.0002) but not in orthopedic cases (p = 0.15). Subgroup analysis of high (SAS < 7) and low risk (SAS ≥ 7) groups demonstrated utility of the score in general surgery and vascular cases overall (p < 0.0001), and in the emergency (p = 0.004) but not elective (p = 0.12) subgroups. Case note review of those patients who died indicated that despite their identification by the SAS, there would have been limited scope to modify outcome. CONCLUSION: This study provides further evidence that the SAS is a simple and effective predictive tool in the emergency general and vascular surgical setting. It appears to have a limited role in the management of individual patients after orthopedic surgery and elective general/vascular surgery. The SAS has been proven to reliably stratify risk in larger populations and might be applied most usefully as a marker of quality. Further studies are required to determine whether its application can influence outcome.

Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults.

STUDY DESIGN: A retrospective data analysis. OBJECTIVE: To report a comprehensive assessment of preoperative prophylactic inferior vena cava (IVC) filter placement in spine surgery. SUMMARY OF BACKGROUND DATA: Venous thromboembolism (VTE) is a serious complication after major spinal reconstructive surgery in adults. Specifically, pulmonary embolism (PE) can result in significant morbidity and mortality, and it has been reported in up to 13% of patients. Prophylactic IVC filter placement was initiated for all "high-risk" spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality. METHODS: After institutional review board approval, the medical records of all patients receiving an IVC filter at a single institution from 2000 to 2007 were reviewed. Age, sex, surgical approach, postoperative deep vein thrombosis (DVT), postoperative superficial thrombus, presence of pulmonary or paradoxical embolus, mortality, and IVC filter complications were all evaluated. Indications for IVC filter placement included history of DVT or PE, malignancy, hypercoagulability, prolonged immobilization, staged procedures of longer than 5 segment levels, combined anterior-posterior approaches, iliocaval manipulation during exposure, and anesthetic time of more than 8 hours. Descriptive statistics were used for the analysis of patient characteristics. Nonparametric frequency statistics (odds ratios [OR], χ) were used for analysis of main outcomes. RESULTS: A total of 219 patients (150 women, 69 men) with a mean age of 58.8 (range, 17-86) years, were analyzed. There were 2 complications from IVC filter placement (66 Greenfield filters; 157 retrievable filters). The incidence of lower extremity DVT was 18.7% (41/219) in 36 patients. PE incidence was 3.7% (8/219 patients), and the paradoxical embolus rate was 0.5% (1 patient). Prophylactic IVC filter use reduced the odds of developing a pulmonary embolus (OR = 3.7, P < 0.05) compared with population controls. Patients receiving Greenfield filters had significantly higher VTE incidence than those receiving retrievable filters (OR = 2.8, P = 0.008). Anesthesia duration of more than 8 hours significantly increases VTE incidence (P = 0.029). No statistical significance (P < 0.05) was noted with combined anterior-posterior approach (118 patients) versus posterior-only approach (101 patients) and the incidence of DVT (24/118, 20.3% for former; 17/101, 16.8% for latter). There were a total of 14 deaths; none related to PE or paradoxical embolism during an 8-year period. Mean and median follow-up was 2.8 and 2.4 years, respectively, with 126 achieving 2 or more years of follow-up. CONCLUSION: VTE-related morbidity and mortality have heightened the awareness within the spine community to the perioperative management of patients undergoing major spinal reconstruction. Prophylactic IVC filter placement significantly lowers VTE-related events, including PE development, than population controls.

The risk of risk-adjustment measures for perioperative spine infection after spinal surgery.

STUDY DESIGN: Cross-sectional data analysis of the Nationwide Inpatient Sample (NIS). OBJECTIVE: To develop a risk-adjustment index specific for perioperative spine infection and compare this specific index to the Deyo Comorbidity Index. Assess specific mortality and morbidity adjustments between teaching and nonteaching facilities. SUMMARY OF BACKGROUND DATA: Risk-adjustment measures have been developed specifically for mortality and may not be sensitive enough to adjust for morbidity across all diagnosis. METHODS: This condition-specific index was developed by using the NIS in a two-step process to determine confounders and weighting. Crude and adjusted point estimates for the Deyo and condition-specific index were compared for routine discharge, death, length of stay, and total hospital charges and then stratified by teaching hospital status. RESULTS: A total of 23,846 perioperative spinal infection events occurred in the NIS database between 1988 and 2007 of 1,212,241 procedures. Twenty-three diagnoses made up this condition-specific index. Significant differences between the Deyo and the condition-specific index were seen among total charges and length of stay at nonteaching hospitals (P < 0.001) and death, length of stay, and total charges (P < 0.001) for teaching hospitals. CONCLUSION: This study demonstrates several key points. One, condition-specific measures may be useful when morbidity is of question. Two, a condition-specific perioperative spine infection adjustment index appears to be more sensitive at adjusting for comorbidities. Finally, there are inherent differences in hospital disposition characteristics for perioperative spine infection across teaching and nonteaching hospitals even after adjustment.

Comparison of tools for nutrition assessment and screening for predicting the development of complications in orthopedic surgery.

BACKGROUND: Malnutrition in hospitalized patients is a significant problem. The purpose of this study was to compare 2 assessment tools-the Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA)-in predicting development of complications in patients undergoing orthopedic surgery. METHODS: Nutrition status was assessed by the SGA, and nutrition screening was performed using the NRS 2002 in 256 consecutively admitted patients scheduled for orthopedic surgery. Additional information recorded for all patients included age, gender, body mass index, and American Society of Anesthesiologists (ASA) physical status. Patient outcomes (postoperative complications), mortality rate, and length of hospital stay (LOS) were investigated. RESULTS: Malnourished or nutritionally at-risk patients were significantly older than nonmalnourished or not at-risk patients according to the SGA and NRS 2002. Also, ASA physical status was correlated with malnutrition or malnutrition risk. Malnourished and at-risk patients in both the SGA and NRS 2002 groups showed longer LOS and higher morbidity and mortality rates. Sensitivity was 50% with the SGA and 69% with the NRS 2002; specificity was 77% with the SGA and 80% with the NRS 2002. Agreement between 2 methods was 0.672. The odds ratio for the association between malnutrition or risk of malnutrition and the occurrence of complications was 3.5 (1.7-7.1) for the SGA and 4.1 (2.0-8.5) for NRS 2002. CONCLUSIONS: Age and ASA physical status are risk factors for malnutrition. In patients undergoing orthopedic surgery, NRS 2002 predicted development of complications better than the SGA. Malnutrition also increased length of hospital stay.

Outcomes in heart failure patients after major noncardiac surgery.

OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control 6.2% (HF vs. CAD, p < 0.001; CAD vs. Control, p = 0.518). The risk-adjusted 30-day readmission rate was HF 20.0%, CAD 14.2%, and Control 11.0% (p < 0.001). CONCLUSIONS: In patients 65 years of age and older, HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care, whereas patients with CAD without HF have similar mortality compared with a more general population.

Pharmacoeconomic considerations.

Pharmacoeconomic analyses can be readily applied to the study of venous thromboembolism (VTE) in the orthopedic postsurgical setting. The cost of VTE to the health care system and a cost-effectiveness trial that utilized a factor Xa inhibitor for VTE prophylaxis are discussed. The rationale for preventing VTE can be justified by its high frequency, asymptomatic nature, and high morbidity and mortality that result from unprevented thromboemboli. However, the economic burden that results from VTE is indeed significant. More effective antithrombotic prophylaxis would reduce the occurrence of VTE, the incidence of complications, and subsequent costs. Previous pharmacoeconomic analyses underscore the financial burden VTE places on the health care system in terms of increased length of hospital stay, time spent in the intensive care unit, and mean total cost. Trial-based and effectiveness-based analyses were utilized to compare the cost-effectiveness of a 7-day regimen of fondaparinux (2.5 mg once daily) and enoxaparin (30 mg twice daily). In the trial-based analysis, fondaparinux was estimated to prevent 15.1 thromboembolic events per 1000 patients at three months compared with enoxaparin; fondaparinux produced cost savings per patient at 30 days, 3 months, and 5 years postdischarge. In the effectiveness analysis, fondaparinux was estimated to prevent 17.7 thromboembolic events per 1000 patients at 3 months compared with enoxaparin; fondaparinux produced cost savings per patient at discharge, 1 month, 3 months, and 5 years postdischarge. These analyses demonstrate fondaparinux to be cost-effective for the prophylaxis of VTE in the orthopedic postsurgical setting.

An assessment of the POSSUM system in orthopaedic surgery.

We describe the development and validation of a scoring system for auditing orthopaedic surgery. It is a minor modification of the POSSUM scoring system widely used in general surgery. The orthopaedic POSSUM system which we have developed gives predictions for mortality and morbidity which correlate well with the observed rates in a sample of 2326 orthopaedic operations over a period of 12 months.

Use these data to compare mortality rates by patient volume.

Data Library: In this era of provider accountability, tracking mortality rates is as important as ever. This month's study offers some good benchmarks on mortality rates by orthopedic DRG and patient volume.