Evaluation of Firearm-Related Reinjury in Connecticut: An Opportunity for Gun Violence Prevention.

BACKGROUND: The regional extent of the risk of repeat firearm-related injury (FRI) and homicide mortality for victims of firearm injury in Connecticut is unknown. In this study, we evaluate the risk of repeat firearm injury in survivors of firearm violence in Connecticut. METHODS: Using medical record data from the Yale New Haven Health (YNHH) system and data from the Connecticut Office of the Chief Medical Examiner, we conducted a cohort study of patients with an FRI in 2014 to determine their risk of a repeat firearm injury or mortality from homicide in the ensuing 5 years compared with nonviolence-related trauma patient controls. RESULTS: We identified 94 patients with an FRI in the YNHH system from 2014 who survived to discharge. Of these patients, 8.5% (8 of 94) had a repeat FRI and 2% (2 of 94) died from homicide within the next 5 years. Compared with nonviolence-related trauma patients from 2014 (n = 2001), those with an FRI had 12 times the odds of a repeat firearm injury (odds ratio: 12.0, P = 0.047) in the next 5 years after adjustment for relevant covariates. CONCLUSIONS: Of the patients presenting with an initial FRI in the YNHH system, one in twelve will experience another firearm injury within the next 5 years. These data indicate that firearm-related reinjury is common in Connecticut and suggest the need for further violence prevention efforts.

Assessing the Race, Ethnicity, and Gender Inequities in Blood Alcohol Testing After Trauma.

INTRODUCTION: Alcohol use remains a significant contributing factor in traumatic injuries in the United States, resulting in substantial patient morbidity and societal cost. Because of this, the American College of Surgeons Verification, Review, and Consultation Program requires the screening of 80% of trauma admissions. Multiple studies suggest that patients who use alcohol are subject to stigma by health care providers and may ultimately face legal and financial ramifications of a positive alcohol screening test. There is also evidence that sociodemographic factors may dictate drug and alcohol screening patterns among patients. Because this screening target is often not uniformly achieved among all patients presenting with injury, we sought to investigate whether there are any discrepancies in screening across sociodemographic groups. METHODS: We investigated the Trauma Quality Program Participant User File for all trauma cases admitted during 2017 and compared the rates of the serum alcohol screening test across different demographic factors, including race and ethnicity. We then performed an adjusted multivariable logistic regression to determine the odds ratio (OR) for receiving a test based on these demographic factors adjusted for hospital and clinical factors. RESULTS: There were 729,174 traumas included in the study. Of this group, 345,315 (47.4%) were screened with a serum alcohol test. Screening rates varied by injury mechanism and were highest among motorcycle crashes (66.0% of patients screened) and lowest among falls (32.8% of patients screened). Overall, Asian and Pacific Islander (52.5% screened), Black (57.7% screened), and other race (58.4% screened) had higher rates of alcohol screening than White patients (43.7% screened, P < 0.001). Similarly, Hispanic patients were screened at higher rates than non-Hispanic patients (56.4% screening versus 46.2% screening, P < 0.001). These differences persisted across nearly all injury categories. In multivariable logistic regression, Asian and Pacific Islanders were associated with the highest odds of being screened (OR 1.34, P < 0.001) followed by other race (OR 1.25, P < 0.001) in comparison to White patients. CONCLUSIONS: There are consistent and significant differences in alcohol screening rates across race and ethnicity, despite accounting for injury mechanism and comorbidities.

Temporal relationship of computed and structured diagnoses in electronic health record data.

BACKGROUND: The electronic health record (EHR) holds the prospect of providing more complete and timely access to clinical information for biomedical research, quality assessments, and quality improvement compared to other data sources, such as administrative claims. In this study, we sought to assess the completeness and timeliness of structured diagnoses in the EHR compared to computed diagnoses for hypertension (HTN), hyperlipidemia (HLD), and diabetes mellitus (DM). METHODS: We determined the amount of time for a structured diagnosis to be recorded in the EHR from when an equivalent diagnosis could be computed from other structured data elements, such as vital signs and laboratory results. We used EHR data for encounters from January 1, 2012 through February 10, 2019 from an academic health system. Diagnoses for HTN, HLD, and DM were computed for patients with at least two observations above threshold separated by at least 30 days, where the thresholds were outpatient blood pressure of ≥ 140/90 mmHg, any low-density lipoprotein ≥ 130 mg/dl, or any hemoglobin A1c ≥ 6.5%, respectively. The primary measure was the length of time between the computed diagnosis and the time at which a structured diagnosis could be identified within the EHR history or problem list. RESULTS: We found that 39.8% of those with HTN, 21.6% with HLD, and 5.2% with DM did not receive a corresponding structured diagnosis recorded in the EHR. For those who received a structured diagnosis, a mean of 389, 198, and 166 days elapsed before the patient had the corresponding diagnosis of HTN, HLD, or DM, respectively, recorded in the EHR. CONCLUSIONS: We found a marked temporal delay between when a diagnosis can be computed or inferred and when an equivalent structured diagnosis is recorded within the EHR. These findings demonstrate the continued need for additional study of the EHR to avoid bias when using observational data and reinforce the need for computational approaches to identify clinical phenotypes.

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses.

BACKGROUND: Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses. METHODS: Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses. RESULTS: Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization. CONCLUSIONS: Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.

When to Admit to Observation: Predicting Length of Stay for Anticoagulated Elderly Fall Victims.

BACKGROUND: Geriatric patients who fall while taking an anticoagulant have a small but significant risk of delayed intracranial hemorrhage requiring observation for 24 h. However, the medical complexity associated with geriatric care may necessitate a longer stay in the hospital. Little is known about the factors associated with a successful observational status stay (<2 d) for this population. MATERIALS AND METHODS: Elderly patients who fell while taking an anticoagulant admitted from 2012 to 2017 at an ACS level II trauma center were included in a retrospective cohort study to determine what factors were associated with a stay consistent with observational status. INCLUSION CRITERIA: age> 65 y old, negative initial head CT, and one of the following: INR>3.5 if on warfarin, GCS<14, external signs of trauma, or focal neurological deficits. RESULTS: The cohort included 369 patients. Factors associated with decreased likelihood of successful observational status included the need for services after discharge such as an extended care facility (OR 0.06, 95% CI 0.02-0.19, P < 0.001) or visiting nurse agency services (OR 0.27, 95% CI 0.10-0.75, P < 0.001), a dementia diagnosis (OR 0.17, 95% CI 0.04-0.70, P = 0.014), increasing number of medications (OR 0.91, 95% CI 0.84-0.99, P = 0.031), and the use of coumadin (OR 0.28, 95% CI 0.12-0.70, P = 0.006). CONCLUSIONS: For trauma providers, knowing your patient's medication use and particularly type of anticoagulant, comorbidities including dementia, and likely need for services after discharge will help guide the decision to admit the patient for what may be a reasonably lengthy stay versus a brief observation in the hospital for elderly fall victims on anticoagulation.

The Unintended Consequences of Nonoperative Management of Acute Appendicitis.

BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.

Quality Versus Quantity: The Potential Impact of Public Reporting of Hospital Safety for Complex Cancer Surgery.

OBJECTIVE: To estimate the potential mortality reduction if patients chose the safest hospitals for complex cancer surgery. BACKGROUND: Mortality after complex oncologic surgery is highly variable across hospitals, and directing patients away from unsafe hospitals could potentially improve survivorship. Hospital quality measures are becoming increasingly accessible at a time when patients are more engaged in choosing providers. It is currently unclear what information to share with patients to maximally capitalize on patient-centered realignment. METHODS: The National Cancer Database was queried for adults undergoing 5 complex cancer surgeries (pulmonary lobectomy, pneumonectomy, esophagectomy, gastrectomy, and colectomy) for a primary cancer between 2008 and 2012. Risk-standardized mortality rate (RSMR) methodology, currently used by Medicare-based hospital rating systems, was used to classify hospitals as "safest" and "least safe" by procedure. Patients were modeled moving from "least safe" to "safest" hospitals and the potential number of lives saved through patient realignment determined. As surgical volume has historically been used to distinguish safe hospitals, comparisons were made to models moving patients from low-volume to high-volume hospitals. RESULTS: A total of 292,040 patients were analyzed. In an optimally modeled scenario, realignment using RSMR would result in a greater number of lives saved (3592 vs 2161, P < 0.01) and require only 15 patients to change hospitals to save a life, compared to 78 patients using volume models (P < 0.01). CONCLUSIONS: Public reporting of hospital safety, specifically based on RSMR instead of volume, has the potential to lead to meaningful reductions in surgical mortality after complex cancer surgery, even in the setting of a modest patient realignment.

Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) continues to be one of the most devastating diagnoses requiring emergent vascular intervention. There is a national trend toward increased use of endovascular procedures, with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed the treatment of AMI and the subsequent impact on length of hospitalization and hospitalization costs. METHODS: We identified all patients admitted for AMI from the National Inpatient Sample from 2004 to 2014 who received open surgical revascularization (OPEN) or an endovascular intervention (ENDO). Primary end points included length of hospital stay and cost of hospitalization. Our secondary end points included acute kidney injury (AKI), in-hospital mortality, and routine discharge. RESULTS: Among 10,381 discharges identified in the data set, 3833 (37%; 97.5% confidence interval [CI], 35%-39%) were male patients with a mean age of 69 years (range, 18-98 years); 4543 (44%; 97.5% CI, 41%-47%) patients were treated ENDO, and 5839 (56%; 97.5% CI, 53%-59%) patients were treated OPEN. Although a higher proportion of patients in the ENDO group (28%; 97.5% CI, 24%-31%) vs the OPEN group (14%; 97.5% CI, 11%-16%) had a moderate to severe Charlson Comorbidity Index (P < .0001), ENDO was associated with a lower mortality rate (12.3% [97.5% CI, 9.8%-14.8%] vs 33.1% [97.5% CI, 29.9%-36.2%]; P < .0001) and a lower mean hospitalization cost ($41,615 [97.5% CI, $38,663-$44,567] vs $60,286 [97.5% CI, $56,736-$63,836]; P < .0001). After propensity-adjusted logistic regression analysis, OPEN retained a significant association with higher mortality than ENDO (odds ratio, 3.0; 97.5% CI, 2.2-4.1) and with higher costs (mean, $9196; 97.5% CI, $3797-$14,595). Patients in the OPEN group had higher risk for AKI (P < .0001) and discharge to a skilled nursing facility (P < .0001) rather than home. CONCLUSIONS: Although the rate of ENDO continues to rise nationally, it still has not surpassed OPEN revascularization in the face of AMI. Patients treated endovascularly demonstrated one-third the rate of in-hospital mortality (odds ratio, 3.0; 97.5% CI, 2.2-4.1), an increased hazard ratio for discharge alive (hazard ratio, 2.27; 97.5% CI, 2.00-2.58), and a cost saving of $9196 (97.5% CI, $3797-$14,595) per hospitalization. Furthermore, they were less likely to develop AKI and to be discharged home after hospitalization.

Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia.

OBJECTIVE: Chronic mesenteric ischemia (CMI) continues to be a devastating diagnosis. There is a national trend toward increased use of endovascular procedures with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed CMI patients' length of hospitalization and health care cost. METHODS: We identified all patients admitted for CMI from the National Inpatient Sample (NIS) from 2000 to 2014. Our primary end points included length of hospital stay (LOS) and cost of hospitalization (COH). Our secondary end points included mortality assessment of the CMI hospitalization. RESULTS: There were 15,475 patients admitted for CMI. The mean age of patients was 71 years, and 4022 (26.0%) were male. There were 10,920 (70.6%) patients treated endovascularly (ENDO) and 4555 (29.4%) patients treated in an open fashion (OPEN). Although a higher proportion of patients in the ENDO (43.3%) group vs OPEN (33.1%) had a Charlson Comorbidity Index score of ≥2 (P < .0001), they had a lower mortality rate (2.4% vs 8.7%; P < .0001), lower mean LOS (6.3 vs 14.0 days; P < .0001), and lower COH ($21,686 vs $42,974; P < .0001). After adjusting for clinical and hospital factors, OPEN continued to demonstrate higher mortality than ENDO (odds ratio, 7.2; 95% confidence interval, 4.9-10.6; P < .0001), longer LOS (mean, +9.7 days; P < .0001), and higher COH (mean, +$25,834; P < .0001). CONCLUSIONS: The rate of ENDO continues to rise nationally in the treatment of CMI patients. After adjusting for clinical and hospital factors, patients in the ENDO group tend to have lower in-hospital mortality of 2.4% and lower LOS by 10 days, and they incur a cost saving of >$25,000 compared with patients in the OPEN group. ENDO should be considered first line of therapy for patients with CMI.

Increased mortality in octogenarians treated for lifestyle limiting claudication.

OBJECTIVE: Treatment for lifestyle limiting claudication (LLC) that is due to infra-inguinal peripheral artery disease relies on either bypass, angioplasty, and/or stenting. Given the enthusiasm and shift toward more endovascular therapy for treatment of LLC, we sought to analyze whether octogenarians benefit from infra-inguinal interventions in the same manner as their younger counterparts. METHODS: We identified all patients admitted for elective treatment of LLC from the Nationwide Inpatient Sample from 2003 to 2012, who received open surgical or endovascular intervention for infra-inguinal peripheral arterial disease. These patients were divided into two groups including those between the ages 60-80 years (younger cohort) and those older than 80 years (octogenarians). Primary end-points included morbidity and mortality and the secondary end-points were length of hospital stay (LOS) and disposition after dismissal. RESULTS: Among 59,323 discharges identified in the dataset, 34,658 (58%) were males. There were 50,323 (85%) patients in the younger cohort and 9,000 (15%) octogenarians. The mean age was 69.9 ± 5.7 years and 84.2 ± 3.0 years for the younger cohort and octogenarians, respectively. The mean Charlson comorbidity index (CCI) was higher in our younger cohort (2.1 ± 1.1, P < 0.001). Octogenarians mainly treated with open surgery prior to 2004 are now treated endovascularly and this trend has remained stable. The younger cohort's treatment modality has fluctuated through the study period and most recently is treated mainly with open surgery. The rate of acute kidney injury, exacerbation of congestive heart failure and mortality was higher in octogenarians (P < 0.001). The rate of infectious wound complications was higher in the younger cohort (P < 0.05). Octogenarians have longer LOS and are dismissed in higher percentage to a skilled nursing facility (P < 0.001). On binary logistic regression analysis, age over 80 years, female sex, higher CCI and having an open as opposed to an endovascular procedure are independent predictors of in-hospital mortality. CONCLUSIONS: Although endovascular techniques seem to dominate the care for octogenarians with LLC, the overall morbidity and mortality rates are significantly higher in this patient population. Other options such as medical management and/or supervised exercise therapy should be explored in this patient group.

The Early Impact of Medicaid Expansion on Uninsured Patients Undergoing Emergency General Surgery.

BACKGROUND: Under the Affordable Care Act, eligibility for Medicaid coverage was expanded to all adults with incomes up to 138% of the federal poverty level in states that participated. We sought to examine the national impact Medicaid expansion has had on insurance coverage for patients undergoing emergency general surgery (EGS) and the cost burden to patients. MATERIALS AND METHODS: The National Inpatient Sample (NIS) was used to identify adults ≥18 y old who underwent the 10 most burdensome EGS operations (defined as a combination of frequency, cost, and morbidity). Distribution of insurance type before and after Medicaid expansion and charges to uninsured patients was evaluated. Weighted averages were used to produce nationally representative estimates. RESULTS: A total of 6,847,169 patients were included. The percentage of uninsured EGS patients changed from 9.4% the year before Medicaid expansion to 7.0% after (P < 0.01), whereas the percentage of patients on Medicaid increased from 16.4% to 19.4% (P < 0.01). The cumulative charges to uninsured patients for EGS decreased from $1590 million before expansion to $1211 million after. CONCLUSIONS: In the first year of Medicaid expansion, the number of uninsured EGS patients dropped by 2.4%. The cost burden to uninsured EGS patients decreased by over $300 million.

Trends of ureteral stent usage in surgery for diverticulitis.

BACKGROUND: Many believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing. MATERIALS: Patients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (n = 811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined. RESULTS: Usage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (P < 0.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, P < 0.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] P < 0.0001, South OR 0.60 [0.45-0.80] P = 0.0004, West OR 0.30 [0.22-0.41], P < 0.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], P < 0.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55 days, P < 0.0001) and cost ($1,983, P < 0.0001). CONCLUSIONS: The use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.

The influence of sociodemographic factors on operative decision-making in small bowel obstruction.

BACKGROUND: Current guidelines for small bowel obstruction (SBO) recommend a limited trial of nonoperative management of no more than 3-5 d. For patients requiring surgery, it is uncertain if sociodemographic factors are associated with disparities in the duration of the trial of nonoperative therapy. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 was queried for discharges with a primary diagnosis of SBO. Primary outcomes of interest were the effects of sociodemographic factors, including race, insurance status, and income on the rate of receiving any operative management for SBO, and subsequently, among patients managed surgically, the risk of operative delay, defined as operative management ≥ 5 d after admission. We did this by using logistic hierarchical generalized linear models, accounting for hospital clustering and adjusted for sex, age, comorbidity, and hospital factors. RESULTS: Of the 589,850 admissions for SBO between 2012 and 2014, 22.0% underwent operations. Overall, 26.2% were non-White, including 12.2% Black and 8.6% Hispanic patients, and the majority (56.0%) had Medicare insurance coverage. Income quartiles were evenly distributed across the overall study population. In adjusted logistic regression, operative delay was associated with increased odds of in-hospital mortality (odds ratio 1.30 95% confidence interval [1.10, 1.54]). Adjusted for patient and hospital factors, Black patients were significantly more likely to receive operations for SBO, whereas Medicaid and Medicare patients were significantly less likely. However, Black, Medicaid, and Medicare patients who were managed operatively were significantly more likely to have an operative delay of 5 or more d. There was no significant association between income and operative management in adjusted regression models. CONCLUSIONS: Significant disparities in the operative management were based on race and insurance status. Further research is warranted to understand the causes of, and solutions to, these sociodemographic disparities in care.

Recurrent Falls Among Elderly Patients and the Impact of Anticoagulation Therapy.

BACKGROUND: Falls are the leading source of injury and trauma-related hospital admissions for elderly adults in the USA. Elderly patients with a history of a fall have the highest risk of falling again, and the decision on whether to continue anticoagulation after a fall is difficult. To inform this decision, we evaluated the rate of recurrent falls and the impact of anticoagulation on outcomes. METHODS: All patients of age ≥ 65 years and hospitalized for a fall in the first 6 months of 2013 and 2014 were identified in the nationwide readmission database, a nationally representative all-payer database tracking patient readmissions. Readmissions for a recurrent fall within 6 months, and mortality and bleeding injuries (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission were identified. Logistic regression evaluated factors associated with mortality on repeat falls. RESULTS: Of the 331,982 patients admitted for a fall, 15,565 (4.7%) were admitted for a recurrent fall within 6 months. The median time to repeat fall was 57 days (IQR 19-111 days), and 9.0% (1406) of repeat fallers were on anticoagulation. The rate of bleeding injury was similar regardless of anticoagulation status (12.8 vs. 12.7% not on anticoagulation, p = 0.97); however, among patients with a bleeding injury, those on anticoagulation had significantly higher mortality (21.5 vs. 6.9% not on anticoagulation, p < 0.01). CONCLUSION: Among patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months. Patients on anticoagulation with repeat falls do not have increased rates of bleeding injury but do have significantly higher rates of death with a bleeding injury. This information is essential to discuss with patients when deciding to restart their anticoagulation.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction.

BACKGROUND: Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. MATERIALS AND METHODS: The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. RESULTS: A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). CONCLUSIONS: This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

Association of timing and agent for VTE prophylaxis in patients with severe traumatic brain injury on VTE, mortality, neurosurgical intervention, and discharge disposition.

BACKGROUND: Trauma patients are at increased risk for venous thromboembolism events (VTE). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI). METHODS: This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (AIS Head = 3,4, or 5). Data was collected at 35 Level 1 and 2 trauma centers from January 1, 2017 to June 1, 2022. Patients were placed into analysis cohorts: No VTEP, low-molecular weight heparin (LMWH) ≤ 48 hours, LMWH>48 hours, Heparin≤48 hours, Heparin>48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTE events, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage. RESULTS: Of 12,879 patients, 32% had no VTEP, 36% LMWH, and 32% Heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH≤48 hours (4.1%). VTE rates were lower with use of LMWH (1.6 vs 4.5%, OR 2.98, 95% CI 1.40-6.34, p = 0.005) without increasing mortality or neurosurgical interventions. VTE rates were lower with early prophylaxis (2.0 vs 3.5%, OR 1.76, 95% CI 1.15-2.71, p = 0.01) without increasing mortality (p = 1.0). Early VTEP was associated with more non-fatal intracranial operations (p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition (p = 0.7, p = 0.1, p = 0.5). CONCLUSIONS: In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP≤48 hours decreased VTE incidence and increased non-fatal neurosurgical interventions without affecting mortality. LMWH is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III.

Driving Safety Among Surgical Residents in the Era of Duty Hour Restrictions.

OBJECTIVE: Fatigued driving is a known contributor to adverse motor vehicle events (AMVEs), defined as crashes and near misses. Surgical trainees work long and irregular hours; the safety of work-related driving since the introduction of work hour regulations has not yet been studied in this population. We aimed to assess the impact of fatigue on driving safety and explore perceptions of a funded rideshare program. DESIGN: An electronic survey was delivered and inquired in retrospective fashion about fatigue and sleepiness while driving, occurrences of AMVEs, and projected use of a funded rideshare program as a potential solution to unsafe driving. Chi-square testing determined categorical differences between response choices. SETTING: Yale University School of Medicine, Department of Surgery, New Haven, CT-a general surgery program with 4 urban clinical sites positioned along a roughly twenty mile stretch of interstate highway in Southeastern Connecticut. PARTICIPANTS: General Surgery residents at the Yale University School of Medicine. RESULTS: Of 58 respondents (81% response rate), 97% reported that fatigue compromised their safety while driving to or from work. Eighty-three percent reported falling nearly or completely asleep, and 22% reported AMVEs during work-related driving. Junior residents were more likely than Seniors to drive fatigued on a daily-to-weekly basis (69% vs 47%, p = 0.02) and twice as likely to fall asleep on a weekly-to-monthly basis (67% vs 33%, p = 0.02). Despite this, only 7% of residents had ever hired a ride service when fatigued, though 88%, would use a free rideshare service if provided. CONCLUSIONS: Work-related fatigue impairs the driving safety of nearly all residents, contributing to frequent AMVEs. Currently, few residents hire rideshare services. Eliminating the cost barrier by funding a rideshare and encouraging its routine use may protect surgical trainees and other drivers.

Toward Dynamic Risk Prediction of Outcomes After Coronary Artery Bypass Graft: Improving Risk Prediction With Intraoperative Events Using Gradient Boosting.

BACKGROUND: Intraoperative data may improve models predicting postoperative events. We evaluated the effect of incorporating intraoperative variables to the existing preoperative model on the predictive performance of the model for coronary artery bypass graft. METHODS: We analyzed 378 572 isolated coronary artery bypass graft cases performed across 1083 centers, using the national Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2014 and 2016. Outcomes were operative mortality, 5 postoperative complications, and composite representation of all events. We fitted models by logistic regression or extreme gradient boosting (XGBoost). For each modeling approach, we used preoperative only, intraoperative only, or pre+intraoperative variables. We developed 84 models with unique combinations of the 3 variable sets, 2 variable selection methods, 2 modeling approaches, and 7 outcomes. Each model was tested in 20 iterations of 70:30 stratified random splitting into development/testing samples. Model performances were evaluated on the testing dataset using the C statistic, area under the precision-recall curve, and calibration metrics, including the Brier score. RESULTS: The mean patient age was 65.3 years, and 24.7% were women. Operative mortality, excluding intraoperative death, occurred in 1.9%. In all outcomes, models that considered pre+intraoperative variables demonstrated significantly improved Brier score and area under the precision-recall curve compared with models considering pre or intraoperative variables alone. XGBoost without external variable selection had the best C statistics, Brier score, and area under the precision-recall curve values in 4 of the 7 outcomes (mortality, renal failure, prolonged ventilation, and composite) compared with logistic regression models with or without variable selection. Based on the calibration plots, risk restratification for mortality showed that the logistic regression model underestimated the risk in 11 114 patients (9.8%) and overestimated in 12 005 patients (10.6%). In contrast, the XGBoost model underestimated the risk in 7218 patients (6.4%) and overestimated in 0 patients (0%). CONCLUSIONS: In isolated coronary artery bypass graft, adding intraoperative variables to preoperative variables resulted in improved predictions of all 7 outcomes. Risk models based on XGBoost may provide a better prediction of adverse events to guide clinical care.

Earlier Is Better: Evaluating the Timing of Tracheostomy After Liver Transplantation.

BACKGROUND: Respiratory failure after orthotopic liver transplantation is associated with increased mortality and prolonged hospitalization. METHODS: A retrospective analysis was conducted through the query of the National In-patient Sample for subjects who underwent orthotopic liver transplantation and tracheostomy after transplantation from 2000 to 2011. Tracheostomies by post-transplantation day 14 were considered "early," whereas those after day 14 were "routine." A Cox proportional hazards model was used to evaluate the impact of early tracheostomy on post-tracheostomy length of stay. RESULTS: There were 2,149 weighted discharges. Of these, 783 (36.4%) had early tracheostomy after transplantation. The subjects who received an early tracheostomy after transplantation were more likely to have a Charlson Comorbidity index22 score of ≥3 (early 71.1% vs late 60.0%; P = .038). Early tracheostomy after transplantation had lower in-hospital mortality (early 26.4% vs late 36.7%; P = .01). Unadjusted median post-tracheostomy length of stay was 31 d for early tracheostomy after transplantation versus 39 d for late tracheostomy after transplantation (P = .034). Early tracheostomy after transplantation was associated with 20% decreased odds of in-hospital mortality (hazard ratio 0.80; P = .01). Early tracheostomy had 41% higher daily rate of discharge alive (hazard ratio 1.41; P < .001). CONCLUSIONS: Early tracheostomy after transplantation was associated with lower in-hospital mortality, shorter post-tracheostomy length of stay, and quicker discharge alive. These results supported our hypothesis that, among subjects with respiratory failure after orthotopic liver transplantation, early tracheostomy after transplantation may be associated with more favorable outcomes than a delayed approach.

The effect of sociodemographic factors on outcomes and time to discharge after bariatric operations.

INTRODUCTION: Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS: The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS: The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION: Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.