Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation.

OBJECTIVE: The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation. BACKGROUND: Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated. METHODS: All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS: Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001). CONCLUSIONS: Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.

Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer.

BACKGROUND: Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available. METHODS: The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations. RESULTS: Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [ß: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (ß: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (ß: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (ß: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001). DISCUSSION: PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation.

INTRODUCTION: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking. METHODS: This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator. RESULTS: Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge. CONCLUSIONS: Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Association of Frailty With Clinical and Financial Outcomes Following Liver Transplantation.

INTRODUCTION: Frailty, a measure of physiological aging and reserve, has been validated as a prognostic indicator of mortality in patients with cirrhosis. However, large-scale analyses of the independent association of frailty with clinical and financial outcomes following liver transplantation (LT) are lacking. METHODS: Adults (≥18 years) undergoing LT were identified in the 2016-2020 National Readmissions Database. Frailty was defined using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable linear and logistic regression models were developed to evaluate the independent association of frailty with in-hospital mortality, perioperative complications, and costs. RESULTS: Of an estimated 34 442 patients undergoing LT, 8265 (24%) were frail. After adjustment, frailty was associated with greater odds of mortality (adjusted odds ratio [AOR] 1.80; 95% Confidence Interval [CI]: 1.49-1.18), postoperative length of stay (ß + 11 days; 95% CI: +10, +12), and hospitalization costs (+$86 880; 95% CI: +75 660, +98 100), as well as a two-fold increase in relative risk of nonhome discharge (AOR 2.17, 95% CI: 1.90-2.49). CONCLUSIONS: Frailty is associated with an increased risk of in-hospital mortality, complications, and resource utilization among LT recipients. As the proportion of frail LT patients continues to rise, our findings underscore the need for novel risk-stratification and individualized care protocols for such vulnerable patients.

Radiomics for precision medicine in glioblastoma.

INTRODUCTION: Being the most common primary brain tumor, glioblastoma presents as an extremely challenging malignancy to treat with dismal outcomes despite treatment. Varying molecular epidemiology of glioblastoma between patients and intra-tumoral heterogeneity explains the failure of current one-size-fits-all treatment modalities. Radiomics uses machine learning to identify salient features of the tumor on brain imaging and promises patient-specific management in glioblastoma patients. METHODS: We performed a comprehensive review of the available literature on studies investigating the role of radiomics and radiogenomics models for the diagnosis, stratification, prognostication as well as treatment planning and monitoring of glioblastoma. RESULTS: Classifiers based on a combination of various MRI sequences, genetic information and clinical data can predict non-invasive tumor diagnosis, overall survival and treatment response with reasonable accuracy. However, the use of radiomics for glioblastoma treatment remains in infancy as larger sample sizes, standardized image acquisition and data extraction techniques are needed to develop machine learning models that can be translated effectively into clinical practice. CONCLUSION: Radiomics has the potential to transform the scope of glioblastoma management through personalized medicine.

Heart Transplantation After Donation After Circulatory Death: Early United States Experience.

BACKGROUND: Given the renewed interest in heart transplantation after donation after circulatory death (DCD), a contemporary analysis of trends and longer-term survival is warranted. METHODS: Adult heart transplant recipients (December 2019-September 2023) were identified in the Organ Procurement and Transplantation Network. Recipients were stratified as donation after brain death (DBD) or DCD. DCD procurements were further classified as direct procurement and perfusion (DCD-DPP) or normothermic regional perfusion (DCD-NRP), based on the declaration of death to cross-clamp interval (≥40 minutes DCD-NRP). The main outcome was posttransplant survival at 1 and 3 years. RESULTS: Of 11,625 transplantations, 792 (7%) involved DCD allografts (249 DCD-NRP, 543 DCD-DPP). The proportion of transplants involving DCD allografts significantly increased from 2% (December 2019) to 11% (January-September 2023, P < .001). Upon adjusted analysis, 1-year posttransplant survival was similar for DBD vs DCD-DPP (hazard ratio [HR], 1.00; 95% CI, 0.66-1.66) or DCD-NRP (HR, 0.92; 95% CI, 0.49-1.72). This remained true at 3 years for DCD-DPP (HR, 1.07; 95% CI, 0.77-1.48) and DCD-NRP (HR, 1.04; 95% CI, 0.62-1.73). Incidence of postoperative stroke, dialysis, acute graft rejection, and primary graft dysfunction were similar across groups. Across various strata of recipient risk and center volume, survival was equivalent between the DBD and DCD cohorts. CONCLUSIONS: Rates of DCD heart transplantation continue to rise. Across various recipient risk and center volume categories, DCD and DBD recipients show comparable posttransplant survival up to 3 years. These findings encourage broader use of such donors in attempts to expand the organ pool.

Care fragmentation is associated with increased mortality after ileostomy creation.

BACKGROUND: Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures. METHODS: All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures. RESULTS: Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5). CONCLUSION: Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.

Cost variation of nonelective surgery for ulcerative colitis across the United States.

BACKGROUND: Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS: All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS: An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION: The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.

National analysis of racial disparities in emergent surgery for colorectal cancer.

Background: Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery. Methods: All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends. Results: Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type. Conclusion: Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.

Outcomes following major thoracoabdominal cancer resection in adults with congenital heart disease.

BACKGROUND: While advances in medical and surgical management have allowed >97% of congenital heart disease (CHD) patients to reach adulthood, a growing number are presenting with non-cardiovascular malignancies. Indeed, adults with CHD are reported to face a 20% increase in cancer risk, relative to others, and cancer has become the fourth leading cause of death among this population. Surgical resection remains a mainstay in management of thoracoabdominal cancers. However, outcomes following cancer resection among these patients have not been well established. Thus, we sought to characterize clinical and financial outcomes following major cancer resections among adult CHD patients. METHODS: The 2012-2020 National Inpatient Sample was queried for all adults (CHD or non-CHD) undergoing lobectomy, esophagectomy, gastrectomy, pancreatectomy, hepatectomy, or colectomy for cancer. To adjust for intergroup differences in baseline characteristics, entropy balancing was applied to generate balanced patient groups. Multivariable models were constructed to assess outcomes of interest. RESULTS: Of 905,830 patients undergoing cancer resection, 1,480 (0.2%) had concomitant CHD. The overall prevalence of such patients increased from <0.1% in 2012 to 0.3% in 2012 (P for trend<0.001). Following risk adjustment, CHD was linked with greater in-hospital mortality (AOR 2.00, 95%CI 1.06-3.76), as well as a notable increase in odds of stroke (AOR 8.94, 95%CI 4.54-17.60), but no statistically significant difference in cardiac (AOR 1.33, 95%CI 0.69-2.59) or renal complications (AOR 1.35, 95%CI 0.92-1.97). Further, CHD was associated with a +2.39 day incremental increase in duration of hospitalization (95%CI +1.04-3.74) and a +$11,760 per-patient increase in hospitalization expenditures (95%CI +$4,160-19,360). CONCLUSIONS: While a growing number of patients with CHD are undergoing cancer resection, they demonstrate inferior clinical and financial outcomes, relative to others. Novel screening, risk stratification, and perioperative management guidelines are needed for these patients to provide evidence-based recommendations for this complex and unique cohort.

Trends, outcomes, and factors associated with in-hospital opioid overdose following major surgery.

Background: With the growing opioid epidemic across the US, in-hospital utilization of opioids has garnered increasing attention. Using a national cohort, this study sought to characterize trends, outcomes, and factors associated with in-hospital opioid overdose (OD) following major elective operations. Methods: We identified all adult (≥18 years) hospitalizations entailing select elective procedures in the 2016-2020 National Inpatient Sample. Patients who experienced in-hospital opioid overdose were characterized as OD (others: Non-OD). The primary outcome of interest was in-hospital OD. Multivariable logistic and linear regression models were developed to evaluate the association between in-hospital OD and mortality, length of stay (LOS), hospitalization costs, and non-home discharge. Results: Of an estimated 11,096,064 hospitalizations meeting study criteria, 5375 (0.05 %) experienced a perioperative OD. Compared to others, OD were older (66 [57-73] vs 64 [54-72] years, p < 0.001), more commonly female (66.3 vs 56.7 %, p < 0.001), and in the lowest income quartile (26.4 vs 23.2 %, p < 0.001). After adjustment, female sex (Adjusted Odds Ratio [AOR] 1.68, 95 % Confidence Interval [CI] 1.47-1.91, p < 0.001), White race (AOR 1.19, CI 1.01-1.42, p = 0.04), and history of substance use disorder (AOR 2.51, CI 1.87-3.37, p < 0.001) were associated with greater likelihood of OD. Finally, OD was associated with increased LOS (ß +1.91 days, CI [1.60-2.21], p < 0.001), hospitalization costs (ß +$7500, CI [5900-9100], p < 0.001), and greater odds of non-home discharge (AOR 2.00, CI 1.61-2.48, p < 0.001). Conclusion: Perioperative OD remains a rare but costly complication after elective surgery. While pain control remains a priority postoperatively, protocols and recovery pathways must be re-examined to ensure patient safety.

National analysis of outcomes in timing of cholecystectomy for acute cholangitis.

BACKGROUND: The present study aimed to compare outcomes between cholecystectomy on index versus delayed admission for acute cholangitis. METHODS: The 2011-2020 Nationwide Readmissions Database was used to identify adult patients admitted for acute cholangitis who underwent cholecystectomy. Study cohorts were defined based on timing of surgery. Multivariable regressions and Royston-Parmar time-adjusted analysis were used to evaluate the association of cholecystectomy timing and outcomes. RESULTS: Of 65,753 patients, 82.0 â€‹% received surgery on Index and 18.0 â€‹% on Delayed admissions. Following adjustment, Delayed operation was associated with significantly increased odds of mortality (AOR 1.67 [95 â€‹% CI 1.10-2.54]), complications (1.25 [1.13-1.40]), repair of bile duct injury (1.66 [1.15-2.41]), conversion to open (1.69 [1.48-1.93]), and 30-day readmission (3.52 [3.21-3.86]). The Delayed cohort experienced a +$14,200 increment in hospitalization costs relative to Index. CONCLUSIONS: Delayed cholecystectomy for acute cholangitis is significantly associated with adverse postoperative outcomes, suggesting that index cholecystectomy may be safe to perform.

Application of machine learning to predict in-hospital mortality after transcatheter mitral valve repair.

INTRODUCTION: Transcatheter mitral valve repair offers a minimally invasive treatment option for patients at high risk for traditional open repair. We sought to develop dynamic machine-learning risk prediction models for in-hospital mortality after transcatheter mitral valve repair using a national cohort. METHODS: All adult hospitalization records involving transcatheter mitral valve repair were identified in the 2016-2020 Nationwide Readmissions Database. As a result of initial class imbalance, undersampling of the majority class and subsequent oversampling of the minority class using Synthetic Minority Oversampling TEchnique were employed in each cross-validation training fold. Machine-learning models were trained to predict patient mortality after transcatheter mitral valve repair and compared with traditional logistic regression. Shapley additive explanations plots were also developed to understand the relative impact of each feature used for training. RESULTS: Among 2,450 patients included for analysis, the in-hospital mortality rate was 1.8%. Naïve Bayes and random forest models were the best at predicting transcatheter mitral valve repair postoperative mortality, with an area under the receiver operating characteristic curve of 0.83 ± 0.05 and 0.82 ± 0.04, respectively. Both models demonstrated superior ability to predict mortality relative to logistic regression (P < .001 for both). Medicare insurance coverage, comorbid liver disease, congestive heart failure, renal failure, and previous coronary artery bypass grafting were associated with greater predicted likelihood of in-hospital mortality, whereas elective surgery and private insurance coverage were linked with lower odds of mortality. CONCLUSION: Machine-learning models significantly outperformed traditional regression methods in predicting in-hospital mortality after transcatheter mitral valve repair. Furthermore, we identified key patient factors and comorbidities linked with greater postoperative mortality. Future work and clinical validation are warranted to continue improving risk assessment in transcatheter mitral valve repair .

Discharge against medical advice in trauma patients: Trends, risk factors, and implications for health care management strategies.

OBJECTIVE: Given the nonelective nature of most trauma admissions, patients who experience trauma are at a particular risk of discharge against medical advice. Despite the risk of unplanned readmission and financial burden on the health care system, discharge against medical advice among hospitalized patients continues to rise. The present study aimed to assess evolving trends and outcomes associated in patients with discharge against medical advice among patients hospitalized for traumatic injury. METHODS: The 2016-2020 Nationwide Readmissions Database was queried to identify all hospitalizations for traumatic injuries. The patient cohort was stratified into those who had discharge against medical advice and those who did not. Temporal trends of discharge against medical advice and associated costs over time were evaluated using nonparametric tests. Multivariable regression models were developed to assess factors associated with discharge against medical advice. Associations of discharge against medical advice with length of stay, hospitalization costs, and unplanned 30-day readmission were subsequently evaluated. RESULTS: Of an estimated 4,969,717 patients, 65,354 (1.3%) had discharge against medical advice after hospitalization for traumatic injury. Over the study period, the incidence of discharge against medical advice increased (nptrend <0.001). After risk adjustment, older age (adjusted odds ratio, 0.98/per year; 95% confidence interval, 0.97-0.98), female sex (adjusted odds ratio, 0.65; 95% confidence interval, 0.64-0.67), and management at high-volume trauma center (adjusted odds ratio, 0.71; 95% confidence interval, 0.69-0.74) were associated with lower odds of discharge against medical advice. Compared with others, discharge against medical advice was associated with decrements in length of stay by 1.3 days (95% confidence interval, 1.1-1.5 days) and index hospitalization costs by $2,200 (5% confidence interval, $1,600-2,900), while having a greater risk of unplanned 30-day readmission (adjusted odds ratio, 2.21; 95% confidence interval, 2.06-2.36). CONCLUSION: The incidence of discharge against medical advice and its associated cost burden have increased in recent years. Community-level interventions and institutional efforts to mitigate discharge against medical advice may improve the quality of care and resource allocation for patients with traumatic injuries.

Association of prior bariatric surgery with outcomes following emergency general surgery.

BACKGROUND: Despite the favorable outcomes and safety profile associated with metabolic and bariatric surgery (MBS), complications may occur postoperatively, necessitating emergency general surgery (EGS) intervention. OBJECTIVES: To evaluate the association of outcomes in patients with prior MBS following EGS interventions. SETTING: Academic, University-affiliated; USA. METHODS: All adults undergoing nonelective EGS operations were identified using the 2016 to 2020 Nationwide Readmission Database. Patients with a history of MBS were subsequently categorized as Bariatric, with the remainder of patients as NonBariatric. The primary outcome of interest was in-hospital mortality, while perioperative complications, length of stay (LOS), hospitalization costs, non-home discharge, and 30-day readmission were secondarily assessed. Multivariable regression models were developed to evaluate the association of history of MBS with outcomes of interest. RESULTS: Of an estimated 632,375 hospitalizations for EGS operations, 29,112 (4.6%) had a history of MBS. Compared to Nonbariatric, Bariatric were younger, more frequently female and more commonly had severe obesity. Following risk adjustment, Bariatric had significantly lower odds of in-hospital mortality (AOR .83, 95%CI .71-.98). Compared to others, Bariatric had reduced LOS by .5 days (95%CI .4-.7) and hospitalization costs by $1600 (95%CI $900-2100). Patients with prior MBS had reduced odds of nonhome discharge (AOR .89, 95%CI .85-.93) and increased likelihood of 30-day readmissions (AOR 2.32, 95%CI 1.93--2.79) following EGS. CONCLUSIONS: Prior MBS is associated with decreased mortality and perioperative complications as well as reduced resource utilization in select EGS procedures. Our findings suggest that patients with a history of MBS can be managed effectively by acute surgical interventions.

Mortality and resource utilization in surgical versus transcatheter repeat mitral valve replacement: A national analysis.

BACKGROUND: Transcatheter mitral valve replacement (TMVR) has garnered interest as a viable alternative to the traditional surgical mitral valve replacement (SMVR) for high-risk patients requiring redo operations. This study aims to evaluate the association of TMVR with selected clinical and financial outcomes. METHODS: Adults undergoing isolated redo mitral valve replacement were identified in the 2016-2020 Nationwide Readmissions Database and categorized into TMVR or SMVR cohorts. Various regression models were developed to assess the association between TMVR and in-hospital mortality, as well as additional secondary outcomes. Transseptal and transapical catheter-based approaches were also compared in relation to study endpoints. RESULTS: Of an estimated 7,725 patients, 2,941 (38.1%) underwent TMVR. During the study period, the proportion of TMVR for redo operations increased from 17.8% to 46.7% (nptrend<0.001). Following adjustment, TMVR was associated with similar odds of in-hospital mortality (AOR 0.82, p = 0.48), but lower odds of stroke (AOR 0.44, p = 0.001), prolonged ventilation (AOR 0.43, p<0.001), acute kidney injury (AOR 0.61, p<0.001), and reoperation (AOR 0.29, p = 0.02). TMVR was additionally correlated with shorter postoperative length of stay (pLOS; ß -0.98, p<0.001) and reduced costs (ß -$10,100, p = 0.002). Additional analysis demonstrated that the transseptal approach had lower adjusted mortality (AOR 0.44, p = 0.02), shorter adjusted pLOS (ß -0.43, p<0.001), but higher overall costs (ß $5,200, p = 0.04), compared to transapical. CONCLUSIONS: In this retrospective cohort study, we noted TMVR to yield similar odds of in-hospital mortality as SMVR, but fewer complications and reduced healthcare expenditures. Moreover, transseptal approaches were associated with lower adjusted mortality, shorter pLOS, but higher cost, relative to the transapical. Our findings suggest that TMVR represent a cost-effective and safe treatment modality for patients requiring redo mitral valve procedures. Nevertheless, future studies examining long-term outcomes associated with SMVR and TMVR in redo mitral valve operations, are needed.

Persistent Racial Disparities in Morbidity Following Major Elective Operations.

Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.

Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States.

BACKGROUND: While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations. METHODS: Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations. RESULTS: Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured. CONCLUSION: Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.