Clinical factors associated with ultrashort length of stay in patients undergoing lower extremity bypass for peripheral arterial disease.

BACKGROUND: Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery pathways challenging. The aim of this study was to use a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease. METHODS: All patients undergoing LEB for peripheral artery disease in the National Surgical Quality Improvement Project database from 2011 to 2018 were included. Patients were divided into two groups based on the postoperative length of stay : ultrashort (≤2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS. RESULTS: Overall, 17,510 patients were identified who underwent LEB, of which 2678 patients (15.3%) had an ultrashort postoperative LOS (mean, 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean, 7.1 days). When compared to patients with a standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%; P < .001), undergo elective surgery (86.1% vs 59.1%; P < .001), and be active smokers (52.1% vs 40.4%; P < .001). Patients with an ultrashort LOS were also more likely to have claudication as the indication for LEB (53.1% vs 22.5%; P < .001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%; P < .001), and have a prosthetic conduit (40.0% vs 29.9%; P < .001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%; P = .21); however, patients with an ultrashort LOS had a lower frequency of unplanned readmission (10.7% vs 18.8%; P < .001) and need for major reintervention (1.9% vs 5.6%; P < .001). On multivariable analysis, elective status (odds ratio , 2.66; 95% confidence interval [CI], 2.33-3.04), active smoking (OR, 1.18; 95% CI, 1.07-1.30), and lack of vein harvest (OR, 1.55; 95% CI, 1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR, 0.57; 95% CI, 0.51-0.63), tissue loss (OR, 0.30; 95% CI, 0.27-0.34), and totally dependent functional status (OR, 0.54; 95% CI, 0.35-0.84) were associated negatively with an ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR, 0.38; 95% CI, 0.19-0.75) and partially dependent (OR, 0.53; 95% CI, 0.32-0.88) functional status were persistently negatively associated with ultrashort LOS. CONCLUSIONS: Ultrashort LOS (≤2 days) after LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.

The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS: This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS: During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS: Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Diverticulitis in Older Adults: Is Cognitive Impairment Associated With Outcomes?

INTRODUCTION: Older age is associated with increased prevalence of both diverticulitis and cognitive impairment. The association between cognitive impairment and outcomes among older adults presenting to the emergency department (ED) for diverticulitis is unknown. METHODS: Adults aged ≥65 y presenting to an ED with a primary diagnosis of colonic diverticulitis were identified using the Nationwide Emergency Department Sample (2016-2019) and stratified by cognitive impairment status in this retrospective cohort study. Multivariable Poisson regression models adjusted for patient age, sex, Elixhauser Comorbidity Index, primary payer status, and presence of complicated diverticulitis quantified relative risk of a) inpatient admission, b) operative intervention, and c) in-hospital mortality comparing patients with or without a diagnosis code suggestive of cognitive impairment. RESULTS: Among 683,444 older adults with an ED encounter for diverticulitis from 2016 to 2019, there were 468,226 patients with isolated colonic diverticulitis and 26,388 (5.6%) with comorbid cognitive impairment. After adjustment, the risk of inpatient admission for those with cognitive impairment was 18% higher than for those without cognitive impairment (adjusted relative risks [aRR]: 1.18, 95% confidence interval [CI]: 1.17-1.20). Those with cognitive impairment were 34% more likely to undergo colectomy than those without cognitive impairment (aRR: 1.34, 95% CI: 1.24-1.44). Older adults with cognitive impairment had a 32% greater mortality than those without cognitive impairment (aRR: 1.32, 95% CI: 1.05-1.67). CONCLUSIONS: Among older adults presenting for ED care with a primary diagnosis of colonic diverticulitis, individuals with cognitive impairment had higher rates of hospitalization, operative intervention, and in-hospital mortality than those without cognitive impairment.

Patient-centered clinical success after lower extremity revascularization for complex diabetic foot wounds treated in a multidisciplinary setting.

OBJECTIVE: Physician-oriented outcomes, such as patency and amputation-free survival (AFS), have traditionally been markers of success after lower extremity revascularization. Previous studies have defined clinical success based on a composite of patient-centered outcomes and have shown this outcome to be achieved in less than 50% of patients, far lower than standard physician-oriented outcomes. The purpose of this study is to evaluate clinical success after lower extremity bypass (LEB) or peripheral vascular intervention (PVI) for tissue loss in diabetic patients treated in a multidisciplinary setting to better understand what factors are associated with success from a patient's perspective. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from July 2012 to January 2020 were enrolled in a prospective database. Patients who underwent either LEB or PVI for ulcer or gangrene were included in the analysis. Clinical success was defined as the composite outcome of secondary patency to the point of wound healing, limb salvage for 1 year, maintenance of ambulatory status for 1 year, and survival for 6 months. Secondary outcomes included 1-year wound healing, patency, and AFS. RESULTS: A total of 134 revascularizations were performed in 131 patients, including 91 (68%) PVI and 43 (32%) LEB. Patients were more frequently male (64%) and black (61%), and 16% were dialysis-dependent. All patients had tissue loss (53% ulcer, 47% gangrene). There were 5 (3.7%) wound, ischemia, and foot infection stage 1, 6 (6.0%) stage 2, 29 (22%) stage 3, and 92 (69%) stage 4 limbs at the time of revascularization. Overall, 76.9% of patients preserved secondary patency to the point of wound healing, 92.5% had limb salvage for 1 year, 90.3% had maintenance of ambulatory status for 1 year, and 96.3% survived for 6 months. The clinical success composite outcome was achieved in 71.6% of patients and was not statistically different between those undergoing PVI vs LEB (69.2% vs 76.7%, P = .37). Secondary patency, limb salvage, and AFS at 1 year were 80.8% ± 3.6%, 91.8% ± 2.3%, and 83.3% ± 3.1%, respectively. Wound healing at 1 year was 84.3% ± 3.4%. The only covariate associated with clinical failure on multivariable analysis was increased age (odds ratio, 0.95; 95% confidence interval, 0.91-0.99; P = .008). CONCLUSIONS: Among diabetic patients presenting with tissue loss, the composite outcome of patient-centered clinical success is lower than traditional physician-centered outcomes after lower extremity revascularization, mostly due to low rates of secondary patency to the point of wound healing. In the current study, clinical failure was only associated with older age and was no different after PVI compared with LEB.

Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients?

BACKGROUND: Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique. OBJECTIVE: This study aimed to assess the cost-effectiveness of extended prophylaxis in postoperative ulcerative colitis patients. DESIGN: A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon. SETTING: Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality. MAIN OUTCOME MEASURES: Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities. RESULTS: Using reference parameters, the individual expected societal total cost of care was $957 without and $1775 with prophylaxis (not cost-effective; $257,280 per quality-adjusted life year). Preventing a single mortality with prophylaxis would cost $5 million (number needed to treat: 6134 individuals). Adjusting across a range of scenarios upheld these conclusions 77% of the time. With further sensitivity testing, venous thromboembolism cumulative risk (>1.5%) and ePpx regimen pricing (<$299) were the 2 parameters most sensitive to uncertainty. LIMITATIONS: Recommendations of decision analysis methodology are limited to group decision-making, not an individual risk profile. CONCLUSION: Routine ePpx in postoperative ulcerative colitis patients is not cost-effective. This finding is sensitive to higher-than-average rates of venous thromboembolism and low-cost prophylaxis opportunities. See Video Abstract at http://links.lww.com/DCR/B818. SE APLICAN LAS LIMITACIONES DE COSTOS DE LA PROFILAXIS PROLONGADA DESPUS DE LA CIRUGA A LOS PACIENTES CON COLITIS ULCEROSA: ANTECEDENTES:Los pacientes de cirugía colorrectal con colitis ulcerosa tienen un mayor riesgo de tromboembolismo venoso posoperatorio. La profilaxis extendida para la prevención de la tromboembolia se ha utilizado en pacientes con cirugía colorrectal, aunque ha sido criticada por su falta de rentabilidad. Sin embargo, la rentabilidad de la profilaxis prolongada para los pacientes posoperados con colitis ulcerosa puede ser aceptable.OBJETIVO:Evaluar la rentabilidad de la profilaxis prolongada en pacientes posoperados con colitis ulcerosa.DISEÑO:Un análisis de decisiones comparó los costos y beneficios en pacientes posoperados con colitis ulcerosa con y sin profilaxis prolongada de por vida.AJUSTE:Los supuestos para el análisis de decisiones se identificaron a partir de la literatura disponible para el riesgo de trombosis de un paciente con colitis ulcerosa típica, la edad al momento de la cirugía, el tipo de trombosis, la reducción del riesgo con profilaxis, las complicaciones hemorrágicas y la mortalidad.PRINCIPALES MEDIDAS DE RESULTADO:Los costos ($) y los beneficios (año de vida ajustado por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la principal medida de resultado, la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilística multivariable modeló la incertidumbre en probabilidades, costos y desutilidades.RESULTADOS:Utilizando parámetros de referencia, el costo total de atención social esperado individual fue de $957 sin profilaxis y $1775 con profilaxis (no rentable; $257,280 por año de vida ajustado por calidad). La prevención de una sola mortalidad con profilaxis costaría $5.0 millones (número necesario a tratar: 6.134 personas). El ajuste en una variedad de escenarios mantuvo estas conclusiones el 77% de las veces. Con más pruebas de sensibilidad, el riesgo acumulado de TEV (>1,5%) y el precio del régimen de ePpx (<$299) fueron los dos parámetros más sensibles a la incertidumbre.LIMITACIONES:Las recomendaciones de la metodología de análisis de decisiones se limitan a la toma de decisiones en grupo, no a un perfil de riesgo individual.CONCLUSIÓN:La profilaxis extendida de rutina en pacientes posoperados con colitis ulcerosa no es rentable. Este hallazgo es sensible a tasas de TEV superiores al promedio y oportunidades de profilaxis de bajo costo. Consulted Video Resumen en http://links.lww.com/DCR/B818. (Traducción-Dr. Felipe Bellolio).

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time.

BACKGROUND: Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines. MATERIALS AND METHODS: We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included. RESULTS: The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001). CONCLUSIONS: Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.

Real-world comorbidities of atopic dermatitis in the US adult ambulatory population.

BACKGROUND: Atopic dermatitis (AD) is a pruritic, inflammatory skin disease associated with various comorbidities. However, comprehensive analyses of real-world comorbidities in adult patients with AD are limited. OBJECTIVE: To characterize the real-world comorbidities associated with adult AD in an ambulatory population. METHODS: We queried the MarketScan Commercial Claims and Encounters database from January 1, 2017 to December 31, 2017. Multivariable logistic regressions were performed to compare comorbidities in adult patients with AD versus age- and sex-matched controls. RESULTS: A total of 39,779 patients with AD and 353,743 controls were identified. Increased odds of psychiatric conditions, including anxiety (odds ratio [OR] 1.44) and mood disorders (OR 1.31), were observed in patients with AD. Patients with AD had higher likelihoods of autoimmune diseases, including vitiligo (OR 4.44) and alopecia areata (OR 6.01). Adult AD was also associated with infections, including impetigo (OR 9.72), methicillin-resistant Staphylococcus aureus (OR 3.92), and cellulitis (OR 2.52). Patients with AD were more likely to have systemic conditions, including lymphoid/hematopoietic malignancy (OR 1.91), atherosclerosis (OR 1.69), and metabolic syndrome (OR 1.47). For all the above, P < .001. LIMITATIONS: Retrospective analysis of health care claims data. CONCLUSION: Adult AD is associated with various psychiatric and systemic comorbidities, emphasizing the systemic nature of AD and the need for the collaborative management of these patients.

Epidemiologic Trends in Oculoplastics-Related Emergency Department Visits in the United States, 2006-2015.

PURPOSE: To characterize demographics and trends in oculoplastics-related emergency department (ED) visits. METHODS: The authors conducted a retrospective, multiyear study of the nationwide ED sample database. The nationwide ED sample was queried for oculoplastics-related International Classification of Disease-ninth revision codes identified from a comprehensive list and categorized based on anatomic location, urgency, and trauma status. Demographics, clinical characteristics, procedure requirement, and cost data were analyzed. Variables associated with inpatient admission were assessed using univariate and multivariate logistic regression. RESULTS: The authors identified an estimated 4.2 million ED visits in the United States with oculoplastics-related primary diagnoses, of which pathology was 80.8% eyelid/adnexal, 17.4% orbital, and 1.74% lacrimal. Overall, 31.3% of the visits were deemed to be nonurgent. Orbital pathology was more likely to be caused by trauma (70.6%), to be urgent (98.0%), and to require a procedure (45.6%) (p < 0.001). While less than 5% of all patients required hospitalization, predictors for inpatient admission were urgent diagnoses (odds ratio, 14.9; CI, 13.7-16.1), presentation to a level 1 trauma center (odds ratio, 3.19; CI, 2.7-3.79), and presence of orbital pathology (odds ratio, 6.09; CI 5.73-6.47). Incidence of ED visits decreased in all categories; however, total inflation-adjusted charges increased. CONCLUSIONS: Over half of oculoplastics-related ED visits are for trauma, with orbital pathology being less common but requiring a high level of care. Although trends show a potentially decreasing incidence of oculoplastics-related ED visits, increasing costs and high proportion of nonurgent visits pose an opportunity for mitigating periocular trauma and increasing outpatient access to care, respectively.

Sex diversity within U.S. residencies: a cross-sectional study of trends from 2011 to 2019.

BACKGROUND: Despite females comprising 50.8% of the U.S. population, the percentage of females in the physician workforce is only 36.3%. Studies have examined sex trends within select specialties, however there is insufficient literature studying trends across all specialties. In this study, the authors examined trends in the proportion of female residents from 2011 to 2019 across all specialties, including both surgical and non-surgical.  METHODS: Data on the proportion of female residents from 2011 to 2019 in all specialties was extracted from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books and analyzed with the chi-square test for trend. RESULTS: From 2011 to 2019, there was a statistically significant increase in the percentage of female residents in surgical specialties (p < 0.001) and no significant change in the percentage of female residents in non-surgical specialties. In the same time period, the specialty with the highest percentage of females was Obstetrics & Gynecology (81.3%), and the specialty with the lowest percentage of females was Orthopedic Surgery (13.8%). CONCLUSIONS: Although there has been a positive overall trend in the percentage of females entering medical and surgical specialties, the percentage of females in medicine overall still lies below that of the entire population. Increased efforts are needed to increase female representation in medicine, especially in the U.S. in specialties where they are traditionally underrepresented.

Exploring the Collateral Damage of the COVID-19 Pandemic on Stroke Care: A Statewide Analysis.

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Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation.

OBJECTIVES: To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation. DESIGN: A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0-3 defined as a good neurologic outcome, and a score of 4-6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes. SETTING: The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01-1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04-1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06-1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08-1.29; p < 0.001). CONCLUSIONS: In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.

Characteristics of Orbital Floor Fractures in the United States from 2006 to 2017.

PURPOSE: To examine the incidence, characteristics, and economic burden of orbital floor fractures in the United States. DESIGN: Retrospective, longitudinal study of the Nationwide Emergency Department Sample (NEDS). PARTICIPANTS: Patients in the Emergency Department (ED). METHODS: The NEDS, a representative sample of all hospital-based EDs in the US, was used to identify and describe ED visits with a primary diagnosis of orbital floor fracture from 2006 to 2017. Linear regression was used to estimate the trends in annual incidence and inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. MAIN OUTCOME MEASURES: Incidence, injury mechanisms, demographics, clinical characteristics, disposition, and economic burden. RESULTS: From 2006 to 2017, there were an estimated 350 379 ED visits in the US with a primary diagnosis of orbital floor fracture. The incidence increased by 47% over the study period (P < 0.001): from 7.7 (95% confidence interval [CI], 6.9-8.5) to 11.3 (95% CI, 10.0-12.6) per 100 000 population. The majority were male (67%), aged 21 to 44 years (46%), and from low-income households (32%). The most common cause was assault (43%), which was most frequent in young adults (65%) and increased modestly over time (3.5 to 4.5 per 100 000 population; P = 0.02). The second most common cause was falls (26%), most frequent in patients aged ≥65 years (86%) and more than doubled over time (1.6 to 3.5 per 100 000 population; P < 0.001). The rate of inpatient admission was 14%, with a higher likelihood for patients aged ≥65 years (odds ratio [OR], 2.21; 95% CI, 1.99-2.46; P < 0.001) and falls (OR, 1.54; 95% CI, 1.27-1.86; P < 0.001). The total inflation-adjusted ED charges over the study period exceeded $2 billion, with the mean charge per visit increasing 48% (P < 0.001): from $5881 (95% CI, 5499-6263) to $8728 (95% CI, 8074-9382). CONCLUSIONS: Orbital floor fractures are becoming an increasingly common and costly injury in the United States. Preventive strategies aimed at reducing assault and falls will be crucial to mitigate the burden of orbital floor fractures on the healthcare system.

Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients.

OBJECTIVE: Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation. METHODS: Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses. RESULTS: A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.

Incidence and risk factors of sepsis in hemodialysis patients in the United States.

BACKGROUND: Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States. METHODS: All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ2, and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate. RESULTS: A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001). CONCLUSIONS: Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD.

Evaluation of revascularization benefit quartiles using the Wound, Ischemia, and foot Infection classification system for diabetic patients with chronic limb-threatening ischemia.

OBJECTIVE: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system was developed to stratify the risk of 1-year major amputation. Recently, the WIfI scores were used to define the estimated revascularization benefit quartiles ranging from high benefit (Q1) to questionable benefit (Q4). The aim of our study was to evaluate the revascularization benefit quartiles in a cohort of diabetic patients presenting with chronic limb-threatening ischemia (CLTI). METHODS: All diabetic patients presenting to our multidisciplinary diabetic foot and wound clinic (June 2012 to May 2020) who underwent lower extremity revascularization for CLTI were included. The affected limbs were graded using the WIfI system and assigned to an estimated benefit of revascularization quartile as previously published. One-year major amputation, complete foot healing, secondary patency, and amputation-free survival were calculated among the quartiles using Kaplan-Meier curve analyses and compared using Cox proportional hazards models. RESULTS: Overall, 136 diabetic patients underwent revascularization of 187 limbs (mean age, 64.9 ± 11.2 years; 63.2% male; 58.8% black). The limbs were revascularized using an endovascular approach for 66.8% and open surgery for 33.2%. Of the 187 limbs, 27.3% had a high estimated benefit of revascularization (Q1), 31.6% had a moderate estimate benefit of revascularization (Q2), 20.3% had a low estimated benefit of revascularization (Q3), and 20.9% had a questionable benefit of revascularization (Q4). The estimated 1-year major amputation rates were 7.2% ± 4.1% for Q1, 3.8% ± 2.6% for Q2, 7.0% ± 4.8% for Q3, and 25.7% ± 7.5% for Q4 (P = .006). The estimated 1-year foot healing rates were 87.3% ± 5.7% for Q1, 84.8% ± 5.6% for Q2, 83.8% ± 7.4% for Q3, and 68.2% ± 9.1% for Q4 (P = .06). The overall secondary patency (P = .23) and amputation-free survival (P = .33) did not significantly differ among the groups. Using Cox proportional hazard modeling, the Q4 group had a significantly greater risk of major amputation compared with Q1 (hazard ratio, 4.26; 95% confidence interval, 1.15-15.70). Of the 14 limbs requiring major amputation, 9 (56.3%) had a patent revascularization at the time of amputation, including one of three limbs in Q1, two of two limbs in Q2, no limb in Q3, and six of nine limbs in Q4. CONCLUSIONS: The questionable estimated revascularization benefit quartile using the WIfI classification system is significantly associated with 1-year major amputation in diabetic patients presenting with CLTI. Limbs with a questionable benefit of revascularization (Q4) will frequently require major amputation despite a patent revascularization, suggesting that the wound size and infection burden are the driving factors behind the elevated risk of major amputation in this group. Our findings support the previously described use of the WIfI classification system to predict revascularization benefit among diabetic patients with CLTI.

Penetrating Trauma in Baltimore: An Analysis of the Effect of a Rise in Localized Violence by Age Group.

BACKGROUND: Incidence of firearm mortality in the United States is increasing. Baltimore, MD saw a substantial increase in violence in April 2015. We analyzed the effect of this localized surge in violence on the pediatric population. METHODS: Using the Maryland Health Services Cost Review Commission database, initial hospital encounters for gunshot wound (GSW) or stab wound (SW) were identified. Baltimore Police Department victim-based crime data and homicide data on GSW and SW assault were used to capture those not seen at hospitals. Changes in incidence rate ratios from before/after April 2015 were analyzed using Poisson regression. RESULTS: No change in mortality was seen in hospital-evaluated GSW patients. The pediatric population showed decreased incidence of SW (P < 0.001) and increase in GSW (P < 0.001) but no change in total penetrating trauma (tPT). The young adult population had decreased SW incidence (P < 0.001) without change in GSW or tPT. The pediatric populations saw no difference in SW/GSW deaths or homicide rate. However, in young adults, there were increased homicides (P < 0.001) and GSW deaths (P < 0.001) with unchanged SW deaths. CONCLUSIONS: After a surge in violence, the shifted mechanism of penetrating trauma in the pediatric population did not increase mortality or tPT. By contrast, GSW incidence is increasing in young adults with more lethal injuries. Intervention could be aimed at gun control and targeted education/intervention in the at-risk younger age group.

Comparative Effectiveness of Roux-en Y Gastric Bypass Versus Vertical Sleeve Gastrectomy for Sustained Remission of Type 2 Diabetes Mellitus.

BACKGROUND: Bariatric surgery results in rapid weight loss and resolution of comorbidities such as type 2 diabetes mellitus (T2DM). We aimed to determine whether the type of surgical procedure-vertical sleeve gastrectomy (VSG) versus Roux-en-Y gastric bypass (RYGB)-was associated with sustained remission from T2DM, and to identify other independent predictors of sustained remission. METHODS: Using the IBM MarketScan database of privately insured patients in the United States, we performed a retrospective cohort study on individuals aged 18-65 y with T2DM on hypoglycemic medication, who underwent either VSG or RYGB from 2010 to 2016. Remission was defined as no refill of antidiabetic medication 180 d after a patient's medication was expected to run out and recurrence as medication refill after at least 180 d of remission. RESULTS: Of 5119 patients in our cohort, 4127 (81%) experienced remission of T2DM, and 816 (19.8%) of the 4127 patients experienced recurrence. Patients who underwent RYGB had a 24% (HR = 1.24, 95% CI: 1.16, 1.32) increased probability of achieving remission compared with VSG. RYGB had a 36% (HR = 0.64, 95% CI: 0.55, 0.74) decreased risk of recurrence compared with VSG. A higher number of diabetic medications at the time of surgery and a higher Charlson index score were associated with decreased probability of remission and an increased risk of recurrence of T2DM. CONCLUSIONS: While both procedures are initially effective, RYGB may be better than VSG at providing lasting remission of T2DM.

Specialty Mediated 30-Day Complications in First Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data. RESULTS: Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P = 0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68). CONCLUSIONS: The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS.

Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes.

BACKGROUND: Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS: Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS: A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.

Trauma Center Outcomes After Transition From Level 2 to Level 1: A National Trauma Data Bank Analysis.

BACKGROUND: Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition. STUDY DESIGN: We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year. RESULTS: Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition. CONCLUSIONS: Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.