Screening and Prophylaxis for Venous Thromboembolism in Pediatric Surgery: A Systematic Review.

OBJECTIVE: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY: Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE: Level 3-4.

Classification and Surgical Management of Anorectal Malformations: A Systematic Review and Evidence-based Guideline From the APSA Outcomes and Evidence-based Practice Committee.

OBJECTIVE: Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS: A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS: Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee.

BACKGROUND: Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS: Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS: The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION: Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

Frequency and predictors of complication clustering within 30 days of spinal fusion surgery: a study of children with neuromuscular scoliosis.

PURPOSE: There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. METHODS: In this retrospective database cohort study, we identified children (ages 10-18 years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30 days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. RESULTS: Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400 min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. CONCLUSION: Longer surgical time (≥ 400 min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. LEVEL OF EVIDENCE: Level IV evidence.

Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility.

INTRODUCTION: Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS: This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS: There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS: Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.

Frequency and predictors of concurrent complications in multi-suture release for syndromic craniosynostosis.

PURPOSE: Understanding the complication profile of craniosynostosis surgery is important, yet little is known about complication co-occurrence in syndromic children after multi-suture craniosynostosis surgery. We examined concurrent perioperative complications and predictive factors in this population. METHODS: In this retrospective cohort study, children with syndromic diagnoses and multi-suture involvement who underwent craniosynostosis surgery in 2012-2020 were identified from the National Surgical Quality Improvement Program-Pediatric database. The primary outcome was concurrent complications; factors associated with concurrent complications were identified. Correlations between complications and patient outcomes were assessed. RESULTS: Among 5,848 children identified, 161 children (2.75%) had concurrent complications: 129 (2.21%) experienced two complications and 32 (0.55%) experienced ≥ 3. The most frequent complication was bleeding/transfusion (69.53%). The most common concurrent complications were transfusion/superficial infection (27.95%) and transfusion/deep incisional infection (13.04%) or transfusion/sepsis (13.04%). Two cardiac factors (major cardiac risk factors (odds ratio (OR) 3.50 [1.92-6.38]) and previous cardiac surgery (OR 4.87 [2.36-10.04])), two pulmonary factors (preoperative ventilator dependence (OR 3.27 [1.16-9.21]) and structural pulmonary/airway abnormalities (OR 2.89 [2.05-4.08])), and preoperative nutritional support (OR 4.05 [2.34-7.01]) were independently associated with concurrent complications. Children who received blood transfusion had higher odds of deep surgical site infection (OR 4.62 [1.08-19.73]; p = 0.04). CONCLUSIONS: Our results indicate that several cardiac and pulmonary risk factors, along with preoperative nutritional support, were independently associated with concurrent complications but procedural factors were not. This information can help inform presurgical counseling and preoperative risk stratification in this population.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee.

INTRODUCTION: Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. METHODS: Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment. CONCLUSIONS: The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention. LEVEL OF EVIDENCE: Level 4. TYPE OF STUDY: Systematic Review of Level 1-4 studies.

Upper Gastrointestinal Series in the Workup for Pediatric Gastrostomy Placement: Does it Delay Care?

INTRODUCTION: Upper gastrointestinal (UGI) series is often part of the workup prior to the placement of gastrostomy tubes in children. Prior studies have suggested UGI to be limited in utility and an extra financial burden. The goal of this study was to investigate the utility and cost of UGI studies. METHODS: A retrospective, case control study of patients aged < 18 y receiving gastrostomy tubes at a free-standing children's hospital between 2012 and 2017. Total costs were obtained from the Pediatric Health Information System. RESULTS: Six hundred eighty five patients underwent gastrostomy placement during the study period. UGI was obtained in 90.8% of patients; 23.6% of studies were abnormal. The most common abnormal findings were reflux (13.8%) and abnormal anatomy (5.8%). The median time to obtain a UGI was 0.82 d (interquartile range 0.22-1.05). Obtaining a UGI was associated with delayed care in 104 patients (15.2%). If a delay was encountered, median time was 2.47 d (interquartile range 1.86-2.99). Ladd's procedures were performed in 12 patients (1.7%) found to have malrotation on UGI. None of the 63 patients who did not undergo UGI required a Ladd's procedure. Patients that had a UGI did not experience an increase in overall length of stay (14.3 versus 15.6 d, excluding intensive care unit patients), operative time (34 versus 39 min), or a change in rate of operative complications (11.5% versus 14.3%). In addition, UGI did not have a significant impact on total adjusted costs ($49,844 versus $83,438 without UGI, P = 0.12) but did slightly increase total adjusted costs per day ($2212 versus $1999 without UGI, P = 0.01). CONCLUSIONS: UGI prior to gastrostomy placement in children rarely identified abnormal findings that changed the operative plan, was associated with delayed care in 15% of patients, and was associated with slightly increased costs per day. Further analyses to identify subsets of children that may benefit from routine UGI are warranted.

Surgical outcomes in children with Trisomy 13: An ACS NSQIP - Pediatric review.

BACKGROUND: Trisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls. METHODS: Using the ACS NSQIP Pediatric 2012-2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity. RESULTS: The median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87-1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28-8.61, p<0.001). CONCLUSIONS: We conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.

The Impact of the Maritime Deployment Cycle on the Surgeon's Knowledge, Skills, and Abilities.

INTRODUCTION: The U.S. Navy routinely deploys aircraft carriers and amphibious assault ships throughout the world in support of U.S. strategic interests, each with an embarked single surgeon team. Surgeons and their teams are required to participate in lengthy pre-deployment shipboard certifications before each deployment. Given the well-established relationship of surgeon volume to patient outcome, we aim to compare the impact of land vs. maritime deployments on Navy general surgeon practice patterns. MATERIALS AND METHODS: Case logs and pre-deployment training initiation of land-based (n = 8) vs. maritime-based (n = 7) U.S. Navy general surgeons over a 3-year period (2017-2020) were compared. Average cases per week were plotted over 26 weeks before deployment. Student's t-test was utilized for all comparisons. RESULTS: Cases declined for both groups in the weeks before deployment. At 6 months (26 weeks) before deployment, land-based surgeons performed significantly more cases than their maritime colleagues (50.3 vs. 14.0, P = .009). This difference persisted at 16 weeks (13.1 vs. 1.9, P = .011) and 12 weeks (13.1 vs. 1.9, P = .011). Overall, surgeon operative volume fell off earlier for maritime surgeons (16 weeks) than land-based surgeons (8 weeks). Within 8 weeks of deployment, both groups performed a similarly low number of cases as they completed final deployment preparations. CONCLUSIONS: Surgeons are a critical component of combat causality care teams. In this analysis, we have demonstrated that both land- and maritime-based U.S. Navy surgeons have prolonged periods away from clinical care before and during deployments; for shipboard surgeons, this deficit is large and may negatively impact patient outcomes in the deployed maritime environment. The authors describe this discrepancy and provide practical doctrinal solutions to close this readiness gap.

Regional air transportation of ovarian tissue for cryopreservation in a prepubertal female with cancer.

Ovarian tissue cryopreservation is the only fertility preservation (FP) option available to prepubescent females receiving gonadotoxic therapy, but it has limited availability. A 6-year-old female was diagnosed with high-risk rhabdomyosarcoma, and the planned treatment carried an 80% risk of ovarian failure. Her parents desired FP, but the nearest center was 500 miles away. The patient underwent oophorectomy at the cancer center with air transport of the tissue to the oncofertility center, where it was successfully cryopreserved. Formation of networks between full-service and limited oncofertility centers in a hub-and-spoke model would increase access to FP services, particularly in children.

Respiratory Syncytial Virus Bronchiolitis Complicated by Necrotizing Enterocolitis: A Case Series.

In rare instances, severe respiratory syncytial virus (RSV) infections of the lower respiratory tract can cause life-threatening extrapulmonary complications. In this report, we describe 4 previously healthy, term and late-preterm infants admitted to the PICU with respiratory failure due to RSV bronchiolitis who developed necrotizing enterocolitis shortly after admission. All infants exhibited progressive abdominal distention, had typical radiographic findings, and developed simple or complex ascites. In addition to being managed with broad-spectrum antibiotics and bowel rest, 1 infant was treated with colon resection and ileostomy, 2 had peritoneal drainage procedures for ascites, and one of those later developed small bowel strictures treated with delayed resection and anastomosis. Three were discharged from the hospital without further complications; 1 died of septic shock. In this case series, we describe development of necrotizing enterocolitis in otherwise healthy neonates with severe RSV disease in the absence of traditional risk factors. We hypothesize that a dysregulated proinflammatory response associated with severe RSV disease may alter intestinal blood flow and compromise barriers to bacterial translocation. Enteral feeding intolerance, septic ileus, and/or complex ascites may represent important clinical corollaries in these patients.

Poisson Probability of Failing to Meet Minimum Case Volumes in Pediatric Surgery Fellowships.

INTRODUCTION: With the expansion of pediatric surgery fellowships from 2008 to 2018, there is concern for the dilution of training experience, especially for rare index cases. The Accreditation Council for Graduate Medical Education (ACGME) established required minimum case numbers by case type, but this is a program requirement rather than an individual trainee requirement. The American Board of Surgery (ABS) is considering instituting minimum case requirements across 5 broad categories for individuals to be board-eligible in pediatric surgery. METHODS: The ACGME National Data Report summary case logs were obtained for graduating fellows in pediatric surgery from 2008 to 2018. Median case volumes were compared to minimum ACGME case numbers and proposed ABS individual requirements. Using Poisson distributions, probabilities of individual fellows failing to meet minimum case numbers were calculated. RESULTS: The average annual probability that a median program would fail to meet minimum ACGME case numbers in at least 1 category was estimated at 16.6%. Using the proposed ABS system, the probability of failure was estimated at 44.1%. No temporal trend was found in the annual probability of failure in either the ACGME or the proposed ABS system. CONCLUSIONS: There is significant risk of a fellow failing to meet case minimums in the ACGME system and the proposed ABS system. This probability is increased for the half of programs below median. If the ABS institutes case minimums as a requirement for certification in pediatric surgery, the current training paradigm may be impacted at some programs.

Surgical and anesthetic management for hepatectomy in two pediatric patients with trisomy 18, pulmonary hypertension, and hepatoblastoma.

Children with trisomy 18 are surviving longer and undergoing more aggressive life-sustaining therapy. This report describes two patients with trisomy 18 and hepatoblastoma (HB) successfully resected in the setting of significant pulmonary hypertension. Forty-four previously published cases of the association between HB and trisomy 18 are reviewed. With careful multidisciplinary preoperative planning, successful resection of HB in children with trisomy 18 who have significant pulmonary hypertension is feasible. Because HB and trisomy 18 are increasing in prevalence, the need for timely liver tumor resection in the setting of pulmonary hypertension will be more common.

NSQIP Analysis: Increased Immediate Reconstruction in the Treatment of Breast Cancer.

Immediate reconstruction after the surgical treatment of breast cancer has increased in the last decade. The purpose of this study is to use the National Surgical Quality Improvement Program database to analyze long-term trends in breast reconstruction. Women who underwent mastectomy for invasive or in situ breast cancer or prophylaxis between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Trends and predictors for reconstruction were explored. In 44,410 women identified, immediate reconstruction increased from 30.0 to 39.6 per cent from 2005 to 2011 (P < 0.001). This trend persisted after adjustment for patient characteristics using multivariate logistic regression [odds ratio (OR) 1.09/year, 95% confidence interval (CI) 1.07-1.10]. Reconstruction type was 77.9 per cent implant, 13.3 per cent pedicle flap, 5.5 per cent free flap, and 3.3 per cent other. Pedicle flaps decreased from 27.1 to 9.2 per cent (P < 0.001), implant-based reconstruction increased from 66.3 to 81.3 per cent (P < 0.001), and free flaps remained stable between 4 and 7 per cent. Independent predictors for reconstruction were young age (stepwise decrease in OR from 1 to 0.02 by decade as age increased from 40 to 80, all P < 0.001), carcinoma in situ (OR 1.51, 95% CI 1.42-1.61), prophylaxis (OR 1.89, 95% CI 1.63-2.19), bilateral resection (OR 2.55, 95% CI 2.42-2.69), and non-Hispanic white race (OR 0.67 for other races, 95% CI 0.64-0.70). Immediate breast reconstruction has steadily increased since 2005 with an associated rise in implant-based reconstruction. Based on these trends, discussion with a reconstructive surgeon should be an early part of the newly diagnosed breast cancer patient's treatment algorithm.

Packed red blood cell transfusion after surgery: are we "overtranfusing" our patients?

BACKGROUND: Data on the hemoglobin (Hb) after transfusion, or the "target," which reflects the "dose" of blood given are not well studied. We sought to examine the incidence and causes of "over transfusion" of red blood cells after surgery. METHODS: Data on blood utilization including Hb triggers and targets were obtained for patients undergoing colorectal, pancreas, or liver surgery between 2010 and 2013. RESULTS: A total of 2,905 patients were identified, of which 895 (31%) were transfused (median age 64, interquartile range: 53 to 72; 51% men; median American Society of Anesthesiologists class 3, interquartile range: 3-3; 51% pancreatic, 14% hepatobiliary, 21% colorectal, and 14% other). Among these, 512 (57%) were overtransfused (final Hb target after transfusion ≥9.0 g/dL). Among patients who were overtransfused, 171 (33%) were transfused at too high an initial trigger (>8.0 g/dL), whereas 304 (59%) had an appropriate trigger but received ≥2 packed red blood cell (PRBC) units, suggesting an opportunity to have transfused fewer units. There was significant variation in overtransfusion among surgeons (range 0% to 80%, P = .003). CONCLUSIONS: Excess use of blood transfusion is common and was due to PRBC utilization for too high a transfusion trigger, as well as too many units transfused.

Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery.

BACKGROUND: The effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures. METHODS: Patients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity. RESULTS: Among 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3-4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98-1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88-1.22; P = 0.65). CONCLUSIONS: Liberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.

Understanding Variation in 30-Day Surgical Readmission in the Era of Accountable Care: Effect of the Patient, Surgeon, and Surgical Subspecialties.

IMPORTANCE: Readmission is a target area of quality improvement in surgery. While variation in readmission is common, to our knowledge, no study has specifically examined the underlying etiology of this variation among a variety of surgical procedures performed in a large academic medical center. OBJECTIVE: To quantify the variability in 30-day readmission attributable to patient, surgeon, and surgical subspecialty levels in patients undergoing a major surgical procedure. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of administrative claims data of patients discharged following a major surgical procedure at a tertiary care center between January 1, 2009, and, December 31, 2013. A total of 22,559 patients were included in this study and underwent a major surgical procedure performed by 56 surgeons practicing in 8 surgical subspecialties. MAIN OUTCOMES AND MEASURES: In-hospital morbidity, 30-day readmission, and proportional variation in 30-day readmission at patient, surgeon, and surgical subspecialty levels. RESULTS: Among the 22,559 patients in this study, patient age, race/ethnicity, and payer type differed across surgical subspecialties. Preoperative comorbidity was common and noted in 65.1% of patients. Postoperative complications were noted in 21.6% of patients varying from 2.1% following breast, melanoma or endocrine surgery to 37.0% following cardiac surgery. The overall 30-day readmission was 13.2% (n = 2975). Readmission varied considerably across the 8 different surgical subspecialties, ranging from 24.8% following transplant surgery (n = 557) to 2.1% following breast, melanoma, or endocrine surgery (n = 32). After adjusting for patient- and surgeon-level variables, factors associated with readmission included African American race/ethnicity (odds ratio, 1.23; 95% CI, 1.11-1.36; P < .001), increasing comorbidity (Charlson Comorbidity Index score of 1: odds ratio, 1.16; 95% CI, 1.02-1.32; P = .02; and a Charlson Comorbidity Index score of ≥2 : odds ratio, 1.38; 95% CI, 1.24-1.53; P < .001), postoperative complication (odds ratio, 1.19; 95% CI, 1.08-1.32; P = .001), and an extended length of stay (odds ratio, 1.78; 95% CI, 1.61-1.96; P < .001). The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%. CONCLUSIONS AND RELEVANCE: Readmission occurred in more than 1 in 10 patients, with considerable variation across surgical subspecialties. Variation in readmission was overwhelmingly owing to patient-level factors while only a minority of the variation was attributable to factors at the surgical subspecialty and individual surgeon levels.

Early versus late readmission after surgery among patients with employer-provided health insurance.

OBJECTIVES: To define the incidence of 90-day readmission and characterize the factors associated with 90-day readmission after 10 major surgical procedures. BACKGROUND: Most data on readmission focus solely on same hospital readmission (index hospitals) within 30 days of discharge. These studies may underestimate readmission, as patients may be readmitted beyond 30 days of discharge or to other non-index hospitals. METHODS: Patients discharged after 10 major surgical procedures (coronary artery bypass grafting, abdominal aortic aneurysm repair, carotid endarterectomy, aortic valve replacement, esophagectomy, pancreatectomy, pulmonary resection, hepatectomy, colectomy, and cystectomy) between 2010 and 2012 were identified from the Truven Health MarketScan Commercial Claims and Encounters database. Multivariable logistic regression analysis was performed to identify determinants of early (≤30 days) and late (31-90 days) readmission. RESULTS: A total of 158,753 patients were identified; 60.3% were male, and 42.3% had a Charlson Comorbidity Index of 2 or more. A total of 26,817 (16.9%) patients were readmitted within 90 days [early: 16,419 (10.4%) vs late: 10,398 (6.5%)]. Among readmitted patients, 38.3% were readmitted to a different hospital than the index hospital. Both early and late readmissions were more common at the index versus non-index hospital (early: 83.9% vs 16.1%; late: 75.0% vs 25.0%; both P < 0.001). In-hospital mortality after early readmission and late readmission was found to be lower at index hospitals than that at non-index hospitals (early; 0.7% vs 2.5%, P = 0.04; late; 0.2% vs 2.0%, P = 0.02). CONCLUSIONS: More than one-third of readmission occurred after 30 days of index discharge. Approximately 20% of patients were readmitted to non-index hospitals. Assessment of 30 day same hospital readmissions underestimated the true incidence of readmission.