Race, Insurance, and Sex-Based Disparities in Access to High-Volume Centers for Pancreatectomy.

BACKGROUND: With a large body of literature demonstrating positive volume-outcome relationships for most major operations, minimum volume requirements have been suggested for concentration of cases to high-volume centers (HVCs). However, data are limited regarding disparities in access to these hospitals for pancreatectomy patients. METHODS: The 2005-2018 National Inpatient Sample (NIS) was queried for all elective adult hospitalizations for pancreatectomy. Hospitals performing more than 20 annual cases were classified as HVCs. Mixed-multivariable regression models were developed to characterize the impact of demographic factors and case volume on outcomes of interest. RESULTS: Of an estimated 127,527 hospitalizations, 79.8% occurred at HVCs. Patients at these centers were more frequently white (79.0 vs 70.8%; p < 0.001), privately insured (39.4 vs 34.2%; p < 0.001), and within the highest income quartile (30.5 vs 25.0%; p < 0.001). Adjusted analysis showed that operations performed at HVCs were associated with reduced odds of in-hospital mortality (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.34-0.55), increased odds of discharge to home (AOR, 1.17; 95% CI, 1.04-1.30), shorter hospital stay (ß, -0.81 days; 95% CI, -1.2 to -0.40 days), but similar costs. Patients who were female (AOR, 0.88; 95% CI, 0.79-0.98), non-white (black: AOR, 0.66; 95% CI, 0.59-0.75; Hispanic: AOR, 0.56; 95% CI, 0.47-0.66; reference, white), insured by Medicaid (AOR, 0.63; 95% CI, 0.56-0.72; reference, private), and within the lowest income quartile (AOR, 0.73; 95% CI, 0.59-0.90; reference, highest) had decreased odds of treatment at an HVC. CONCLUSIONS: For those undergoing pancreatectomies, HVCs realize superior clinical outcomes but treat lower proportions of female, non-white, and Medicaid populations. These findings may have implications for improving access to high-quality centers.

A kinematic model-based analysis framework for 3D Cine-DENSE-validation with an axially compressed gel phantom and application in sheep before and after antero-apical myocardial infarction.

PURPOSE: Myocardial strain is increasingly used to assess left ventricular (LV) function. Incorporation of LV deformation into finite element (FE) modeling environment with subsequent strain calculation will allow analysis to reach its full potential. We describe a new kinematic model-based analysis framework (KMAF) to calculate strain from 3D cine-DENSE (displacement encoding with stimulated echoes) MRI. METHODS: Cine-DENSE allows measurement of 3D myocardial displacement with high spatial accuracy. The KMAF framework uses cine cardiovascular magnetic resonance (CMR) to facilitate cine-DENSE segmentation, interpolates cine-DENSE displacement, and kinematically deforms an FE model to calculate strain. This framework was validated in an axially compressed gel phantom and applied in 10 healthy sheep and 5 sheep after myocardial infarction (MI). RESULTS: Excellent Bland-Altman agreement of peak circumferential (Ecc ) and longitudinal (Ell ) strain (mean difference = 0.021 ± 0.04 and -0.006 ± 0.03, respectively), was found between KMAF estimates and idealized FE simulation. Err had a mean difference of -0.014 but larger variation (±0.12). Cine-DENSE estimated end-systolic (ES) Ecc , Ell and Err exhibited significant spatial variation for healthy sheep. Displacement magnitude was reduced on average by 27%, 42%, and 56% after MI in the remote, adjacent and MI regions, respectively. CONCLUSIONS: The KMAF framework allows accurate calculation of 3D LV Ecc and Ell from cine-DENSE.

Outcomes and resource use for liver transplantation in the United States: Insights from the 2009-2017 National Inpatient Sample.

INTRODUCTION: Liver transplantation (LT) is a life-saving treatment for end-stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use. METHODS: Using the National Inpatient Sample, we identified all patients undergoing LT from 2009 to 2017 and defined high-resource use (HRU) as having costs ≥ 90th percentile. Hierarchical regression models were used to assess factors associated with length of stay (LOS) and HRU. RESULTS: Over the study period, approximately 53,000 patients underwent LT, increasing from 5,582 in 2009 to 7,095 in 2017 (nptrend < 0.001). Morbidity and mortality were 42.2% and 3.9%, respectively, with a median post-LT LOS of 10 days. Hospitalization costs increased from $106,866 to $145,868 (nptrend < 0.001). Acute kidney injury (ß:4.7 days, P < .001) and end-stage renal disease (ESRD) with dialysis (ß:4.3 days, P < .001) were associated with greater LOS while the Northeast region (AOR:5.2, P < .001), ESRD with dialysis (AOR:3.4, P < .001), heart failure (AOR:2.5, P < .001), and fulminant liver disease (AOR:1.8, P = .01) were associated with HRU. CONCLUSION: The cost of LT has increased over time. Renal dysfunction, regional practice patterns, and patient acuity were associated with greater resource use. Transplanting patients before health deterioration may help contain costs, mitigate resource use, and improve LT outcomes.

Factors associated with high-cost hospitalizations in elderly ovarian cancer patients.

OBJECTIVE: To characterize factors associated with high-cost inpatient admissions for ovarian cancer. METHODS: Operative hospitalizations for ovarian cancer patients ≥65 years of age were identified using the 2010-2017 National Inpatient Sample. Admissions with high-cost were defined as those incurring ≥90th percentile of hospitalization costs each year, while the remainder were considered low-cost. Multivariable logistic regression models were developed to assess independent predictors of being in the high-cost cohort. RESULTS: During the study period, an estimated 58,454 patients met inclusion criteria. 5827 patient admissions (9.98%) were classified as high-cost. Median hospitalization cost for this high-cost group was $55,447 (interquartile range (IQR) $46,744-$74,015) compared to $16,464 (IQR $11,845-$23,286, p < 0.001) for the low-cost group. Patients with high-cost admissions were more likely to have received open (adjusted odds ratio (AOR) 2.23, 1.31-3.79) or extended (AOR 5.64, 4.79-6.66) procedures and be admitted non-electively (AOR 3.32, 2.74-4.02). Being in the top income quartile (AOR 1.77, 1.39-2.27) was also associated with high-cost. Age and hospital factors, including bed size and volume of gynecologic oncology surgery, did not affect cost group. CONCLUSION: High-cost ovarian cancer admissions were three times more expensive than low-cost admissions. Fewer open and extended procedures with subsequently shorter lengths of stay may have contributed to decreasing inpatient costs over the study period. In this cohort of patients largely covered by Medicare, clinical factors outweigh socioeconomic factors as cost drivers. Understanding the relationship of disease-specific and social factors to cost will be important in informing future value-based quality improvement efforts in gynecologic cancer care.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017.

BACKGROUND: Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS: We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS: Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS: Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States.

INTRODUCTION: Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy. MATERIAL AND METHODS: We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality. RESULTS: Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01). CONCLUSIONS: Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.

Outcomes and Resource Utilization in Robotic Mitral Valve Repair: Beyond the Learning Curve.

BACKGROUND: After the initial learning curve associated with mastering a robotic procedure, there is a plateau where operative time and complication rates stabilize. Our objective was to evaluate one surgeon's experience with robotic mitral valve repairs (MVRep) beyond the learning curve and to compare its effectiveness against the traditional open approach. METHODS: Data from Ronald Reagan University of California, Los Angeles Medical Center was prospectively collected from January 2008 to March 2016 to identify adult patients undergoing robotic MVRep. Operative times, complication rates, and cost for robotic versus open MVRep were compared using multivariate regressions, adjusting for comorbidities and previous cardiac surgeries. RESULTS: During the study period, 175 robotic (41%) and 259 open (59%) MVRep cases were performed at our institution. As the surgeon performed more robotic operations, there was a decrease in room time (554-410 min, P < 0.001), surgery time (405-271 min, P < 0.001), and cross-clamp times (179-93 min, P < 0.001). After application of a multivariate regression model, robotic MVRep was associated with lower odds of complications (odds ratio = 0.42, P = 0.001), shorter length of stay (ß = -2.51, P < 0.001), and a reduction of 11% in direct (P = 0.003) and 24% in room costs (P < 0.001), but a 51% increase in surgery cost (P < 0.001). CONCLUSIONS: As the surgeon gained experience with robotic MVRep, operative times decreased in a steady manner. Robotic MVRep had comparable outcomes to open MVRep and lower overall cost. The observed difference in costs is likely related to shorter length of stay and lower room cost with the robotic approach.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization.

BACKGROUND: Depression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery. METHODS: A retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression. RESULTS: During the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02). CONCLUSIONS: New-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Assessment of Differential Pressures in Chest Drainage Systems: Is What You See What You Get?

BACKGROUND: Dry-suction chest drainage systems are used to achieve proper drainage of the pleural space after cardiothoracic operations. Data on the actual intrapleural pressure during the use of these systems is lacking. The present study was performed to evaluate pressure differences across the circuit using an ex vivo model. METHODS: An ex vivo apparatus coupled to a hospital-grade pleural drainage system was devised to provide calibrated levels of suction and air leak. Simultaneous pressure measurements were obtained at the system outlet and the simulated patient entry site. Trials were conducted with increasing levels of water between the patient and drainage modules at various levels of suction and leak pressures. Signals were recorded at 100 Hz and analyzed using two-way ANOVA. RESULTS: With no obstruction, the drainage system provided precise levels of negative pressure at the patient level (10-40 cm H2O). Addition of fluid in the drainage tubing caused significant differences in transmitted suction (P < 0.001). With increasing air leakage and fluid volume, the pressure differential between the system and patient increased significantly (1.14 to 36.69 cm H2O, P < 0.001). In the off-suction setting, increasing levels of obstruction to 22 cm of water led to development of positive intrapleural pressures (2.6 to 11.1 cm H2O, P < 0.001). CONCLUSIONS: While commercially available chest drainage systems are able to provide predictable levels of suction at the device, intrapleural pressures can be highly variable and depend on complete patency of connecting tubes. Systems capable of modulating the level of suction based on actual intrapleural pressures may enhance recovery after procedures requiring tube thoracotomy.

National trends in volume-outcome relationships for extracorporeal membrane oxygenation.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) has emerged as a common therapy for severe cardiopulmonary dysfunction. We aimed to describe the relationship of institutional volume with patient outcomes and examine transfer status to tertiary ECMO centers. MATERIALS AND METHODS: Using the National Inpatient Sample, we identified adult patients who received ECMO from 2008 to 2014. Individual hospital volume was calculated as tertiles of total institutional discharges for each year independently. RESULTS: Of the total 18,684 adult patients placed on ECMO, 2548 (13.6%), 5278 (28.2%), and 10,858 (58.1%) patients were admitted to low-, medium-, and high-volume centers, respectively. Unadjusted mortality at low-volume hospitals was less than that of medium- (43.7% versus 50.3%, P = 0.03) and high-volume hospitals (43.7% versus 55.6%, P < 0.001). Length of stay and cost were reduced at low-volume hospitals compared to both medium- and large-volume institutions (all P < 0.001). In high-volume institutions, transferred patients had greater postpropensity-matched mortality (58.5% versus 53.7%, P = 0.05) and cost ($190,299 versus $168,970, P = 0.009) compared to direct admissions. On exclusion of transferred patients from propensity analysis, mortality remained greater in high-volume compared to low-volume centers (50.2% versus 42.8%, P = 0.04). Predictors of mortality included treatment at high-volume centers, respiratory failure, and cardiogenic shock (all P < 0.001). CONCLUSIONS: Our findings show increased in-hospital mortality in high-volume institutions and in patients transferred to tertiary centers. Whether this phenomenon represents selection bias or transfer from another facility deserves further investigation and will aid with the identification of surrogate markers for quality of high-risk interventions.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies.

BACKGROUND: Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy. METHODS: Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies. RESULTS: An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches. CONCLUSIONS: Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort.

Importance: Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. Objective: To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. Design, Setting, and Participants: This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Exposures: Undergoing HP vs PAPD. Main Outcomes and Measures: Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. Results: During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11 514 patients [35.6%]; P < .001). In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30 851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). Conclusions and Relevance: This study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with patients who underwent HP. These findings suggest that further delineation of criteria for appropriate application of PAPD in the urgent setting are warranted.

Impact of frailty on short term outcomes, resource use, and readmissions after transcatheter mitral valve repair: A national analysis.

BACKGROUND: Treatment options for mitral regurgitation range from diuretic therapy, to surgical and interventional strategies including TMVR in high-risk surgical candidates. Frailty has been associated with inferior outcomes following hospitalizations for heart failure and in open cardiac surgery. OBJECTIVE: The purpose of the present study was to evaluate the impact of frailty on clinical outcomes and resource use following transcatheter mitral valve repair (TMVR). METHODS: Adults undergoing TMVR were identified using the 2016-2018 Nationwide Readmissions Database, and divided into Frail and Non-Frail groups. Frailty was defined using a derivative of the Johns Hopkins Adjusted Clinical Groups frailty indicator. Generalized linear models were used to assess the association of frailty with in-hospital mortality, complications, nonhome discharge, hospitalization costs, length of stay, and non-elective readmission at 90 days. Average marginal effects were used to quantify the impact of frailty on predicted mortality. RESULTS: Of 18,791 patients undergoing TMVR, 11.6% were considered frail. The observed mortality rate for the overall cohort was 2.2%. After adjustment, frailty was associated with increased odds of in-hospital mortality (AOR 1.8, 95% CI 1.2-2.6), corresponding to an absolute increase in risk of mortality of 1.1%. Frailty was associated with a 2.7-day (95% CI 2.1-3.2) increase in postoperative LOS, and $18,300 (95% CI 14,400-22,200) increment in hospitalization costs. Frail patients had greater odds (4.4, 95% CI 3.6-5.4) of nonhome discharge but similar odds of non-elective 90-day readmission. CONCLUSIONS: Frailty is independently associated with inferior short-term clinical outcomes and greater resource use following TMVR. Inclusion of frailty into existing risk models may better inform choice of therapy and shared decision-making.

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting.

BACKGROUND: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression. RESULTS: Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001). CONCLUSIONS: Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

BACKGROUND: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. METHODS: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. RESULTS: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40). CONCLUSIONS: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States.

BACKGROUND: Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS: We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS: During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS: High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

National Analysis of Coronary Artery Bypass Grafting in Autoimmune Connective Tissue Disease.

BACKGROUND: Autoimmune connective tissue diseases (CTDs) are associated with accelerated atherosclerosis and inflammation, while often requiring immunosuppression. Large-scale outcomes of coronary artery bypass graft (CABG) surgery in this population have not been reported thus far. This study characterized trends in use of CABG in patients with CTDs and the impact of the disease on mortality, in-hospital complications, length of stay, and costs. METHODS: The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing isolated CABG. The CTDs cohort included rheumatoid arthritis, lupus erythematosus, and antiphospholipid syndrome (APLS), among others. Hierarchical multivariable logistic models were used to calculate the independent impact of CTDs on clinical outcomes and costs. RESULTS: Of an estimated 2,101,591 patients, 41,567 (1.8%) were diagnosed with CTDs (rheumatoid arthritis, 58%; systemic lupus erythematosus, 12%; APLS, 11%) Although the overall annual use of CABG decreased, the proportion of patients with CTDs receiving the operation significantly increased. After adjusting for patient and hospital characteristics, CTDs were not associated with increased mortality (adjusted odds ratio [AOR], 0.91; P = .34) but were protective against cardiovascular (AOR, 0.92; P < .003), neurologic (AOR, 0.81; P = .01), and infectious (AOR, 0.80; P = .01) complications. The diagnosis of CTDs was also predictive of reduced length of hospital stay (ß-coefficient = -0.40; P < .001) and costs (ß-coefficient, -$1200; P = .01). On subgroup analysis patients with APLS had significantly increased odds of mortality (AOR, 1.5) and increased renal (AOR, 1.3), infectious (AOR, 1.7), and thromboembolic (AOR, 4.3) complications (all P < .05). CONCLUSIONS: CABG in patients with CTDs provides acceptable outcomes and paradoxically improved resource use. However CABG in patients with APLS warrants careful consideration given inferior outcomes.

National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest.

INTRODUCTION: Extracorporeal life support (ECLS) has shown promise in the management of cardiac arrest. The purpose of this study was to examine temporal trends and predictors of ECLS utilization and survival to discharge among inpatients with cardiac arrest in the United States. METHODS: All patients admitted after out-of-hospital cardiac arrest (OHCA) and those who experienced in-hospital cardiac arrest (IHCA) from 2005 to 2014 were identified in the National Inpatient Sample. Patients carrying a pregnancy as well as those with do-not-resuscitate orders or trauma-related diagnoses were excluded. Multivariable logistic regression was used to identify predictors of ECLS utilization and survival to discharge. RESULTS: An estimated 1,624,827 patients were identified. During the study period, use of ECLS increased from 77 to 564 per 100,000 arrests for OHCA, and 60 to 632 per 100,000 arrests for IHCA. Survival among patients on ECLS for OHCA and IHCA increased from 34.2% to 54.2% and from 4.7% to 19.2%, respectively. Age, year of arrest, cardiac rhythm, and the presence of a potentially reversible etiology including myocardial infarction and pulmonary embolism, were predictive of ECLS utilization. Among patients placed on ECLS, age, rhythm at arrest, and location of arrest were predictive of survival to discharge. CONCLUSIONS: Mortality after cardiac arrest for those on ECLS has substantially decreased. Younger age, shockable rhythm, and out-of-hospital arrest location were predictive of survival or utilization. As ECLS use increases, it is critical to define selection criteria that maximize the benefits of ECLS.