A ruptured mycotic aortic aneurysm in a patient with urinary retention: A case report.

Symptomatic abdominal aortic aneurysm (AAA) is a diagnosis that is a true emergency. Since AAAs are typically asymptomatic prior to rupturing, they can easily be missed. When an abdominal aortic aneurysm becomes symptomatic and ruptures, the ramifications can be catastrophic for the patient. We present a case of a 55-year-old male who presented with urinary retention and suprapubic pain. Computerized tomography demonstrated a rapidly expanding AAA and signs of impending rupture. Emergent vascular surgical repair was performed successfully. There was concern for mycotic nature of the AAA with recent COVID-19 infection and possible bacteremia. This case demonstrates the need for maintaining a wider differential when examining patients and avoiding anchoring bias and serves as a point of discussion for potential complications of COVID-19 infection.

Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms.

Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

Fifteen-year experience with renal cell carcinoma with associated venous tumor thrombus.

BACKGROUND: For patients with renal cell carcinoma with venous tumor thrombus (VTT), the importance of the extent of the VTT on survival has inconsistent published results. The aim of the study was to evaluate the prognostic value of the VTT on morbidity and mortality of our patients with renal cell carcinoma. METHODS: This was a single institution review of all patients who underwent resection of renal cell carcinoma with VTT over a 15-year period. RESULTS: Thirty-seven patients (26 men, 11 women) with a mean age of 61 years were analyzed. The majority of the cohort were of Neves level II (n = 19), while 8 were of Neves 0 (only renal vein) or I, and 10 were of Neves III (extending into retrohepatic cava) or IV (extending supradiaphragmatically). When compared with Neves 0-II patients, there were more Neves III-IV patients with operative time >3 hours (70% vs 30%), blood loss >2,000 mL (70% vs 33%), and intensive care unit stay longer than one day (60% vs 30%) (P ≤ .05 each). Mean follow-up was 58 months. The overall 5-year survival was 71%, and all 10 patients with Neves III-IV had survived since the operation. CONCLUSION: We found advanced tumor thrombus involvement did not impact long-term survival; however, cases with suprahepatic VTT had increased operative time, blood loss, and duration of hospital stay.

Development of a Novel Composite Process Measure for Venous Thromboembolism Prophylaxis.

BACKGROUND: Postoperative venous thromboembolism (VTE) is important clinically, and VTE quality metrics are used in public reporting and pay-for-performance programs. However, current VTE outcome measures are not valid due to surveillance bias, and the Surgical Care Improvement Project (SCIP-VTE-2) process measure only requires prophylaxis within 24 hours of surgery. OBJECTIVES: We sought to (1) develop a novel measure of VTE prophylaxis that requires early ambulation, mechanical prophylaxis, and chemoprophylaxis throughout the hospitalization, and (2) compare hospital performance on the SCIP-VTE-2 process measure to this novel measure. RESEARCH DESIGN: A new composite measure of ambulation, sequential compression device (SCD), and chemoprophylaxis component measures was developed. The ambulation component required daily ambulation, the SCD component required documentation of continuous use, and the chemoprophylaxis component required patient-appropriate and medication-appropriate dosing and administration. Requirements could also be met with component-specific exceptions. Surgical patients at an academic center from 2012 to 2013 were assessed for SCIP-VTE-2 and composite measure adherence. RESULTS: Of 786 patients, 589 (74.9%) passed the ambulation measure, 494 (62.8%) passed the SCD measure, and 678 (86.3%) passed the chemoprophylaxis measure. A total of 268 (91.8%) SCD failures and 46 (42.6%) chemoprophylaxis failures were ordered but not administered. When comparing the 2 measures, 784 (99.7%) passed SCIP-VTE-2, whereas only 364 (46.3%) passed the composite measure (P<0.001). CONCLUSIONS: This new measure incorporates the critical aspects of VTE prevention to ensure defect-free care. After additional evaluation, this composite VTE prophylaxis measure with appropriate exclusion criteria may be a better alternative to existing VTE process and outcome measures.

National evaluation of hospital readmission after pulmonary resection.

OBJECTIVES: Our objectives were to (1) assess readmission rates and timing after pulmonary resection, (2) report the most common reasons for rehospitalization, and (3) identify risk factors for unplanned readmission after pulmonary resection. METHODS: Patients who underwent pulmonary resection were identified from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. We examined readmission within 30 days of surgery for all resections and 3 subgroups: open lobectomy, video-assisted thoracoscopic lobectomy, and pneumonectomy. Regression models were developed to identify factors associated with readmission. RESULTS: In 1847 patients, there were 899 open lobectomies (49%), 724 video-assisted thoracoscopic lobectomies (39%), and 85 pneumonectomies (5%). The overall readmission rate was 9.3% with no significant difference found among patients undergoing open lobectomy (9.1%), video-assisted thoracoscopic lobectomy (8.4%), or pneumonectomy (11.8%) (P = .576). The median time from operation to readmission was similar among patients undergoing open (14 days) or video-assisted thoracoscopic lobectomy (13 days). The most common cause of readmission for all groups examined was pulmonary related. In multivariable analyses, the strongest factor associated with readmission was an inpatient complication after the initial surgery in all resections (hazard ratio [HR], 4.29; 95% confidence interval [CI], 3.05-6.04), open lobectomy (HR, 4.36; 95% CI, 2.75-6.94), and video-assisted thoracoscopic lobectomy (HR, 4.60; 95% CI, 2.65-7.97). Surgical approach was not associated with readmission (video-assisted thoracoscopic vs open lobectomy: HR, 1.07; 95% CI, 0.75-1.52). CONCLUSIONS: Experiencing a postoperative complication was strongly associated with unplanned readmission. Increased attention toward reducing postoperative complications and earlier outpatient follow-up in these patients may be a viable strategy for decreasing readmissions after pulmonary resection.

Underlying reasons associated with hospital readmission following surgery in the United States.

IMPORTANCE: Financial penalties for readmission have been expanded beyond medical conditions to include surgical procedures. Hospitals are working to reduce readmissions; however, little is known about the reasons for surgical readmission. OBJECTIVE: To characterize the reasons, timing, and factors associated with unplanned postoperative readmissions. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing surgery at one of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, had clinically abstracted information examined. Readmission rates and reasons (ascertained by clinical data abstractors at each hospital) were assessed for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass. MAIN OUTCOMES AND MEASURES: Unplanned 30-day readmission and reason for readmission. RESULTS: The unplanned readmission rate for the 498,875 operations was 5.7%. For the individual procedures, the readmission rate ranged from 3.8% for hysterectomy to 14.9% for lower extremity vascular bypass. The most common reason for unplanned readmission was surgical site infection (SSI) overall (19.5%) and also after colectomy or proctectomy (25.8%), ventral hernia repair (26.5%), hysterectomy (28.8%), arthroplasty (18.8%), and lower extremity vascular bypass (36.4%). Obstruction or ileus was the most common reason for readmission after bariatric surgery (24.5%) and the second most common reason overall (10.3%), after colectomy or proctectomy (18.1%), ventral hernia repair (16.7%), and hysterectomy (13.4%). Only 2.3% of patients were readmitted for the same complication they had experienced during their index hospitalization. Only 3.3% of patients readmitted for SSIs had experienced an SSI during their index hospitalization. There was no time pattern for readmission, and early (≤7 days postdischarge) and late (>7 days postdischarge) readmissions were associated with the same 3 most common reasons: SSI, ileus or obstruction, and bleeding. Patient comorbidities, index surgical admission complications, non-home discharge (hazard ratio [HR], 1.40 [95% CI, 1.35-1.46]), teaching hospital status (HR, 1.14 [95% CI 1.07-1.21]), and higher surgical volume (HR, 1.15 [95% CI, 1.07-1.25]) were associated with a higher risk of hospital readmission. CONCLUSIONS AND RELEVANCE: Readmissions after surgery were associated with new postdischarge complications related to the procedure and not exacerbation of prior index hospitalization complications, suggesting that readmissions after surgery are a measure of postdischarge complications. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission.

A comparison of 2 surgical site infection monitoring systems.

IMPORTANCE: Surgical site infection (SSI) has emerged as the leading publicly reported surgical outcome and is tied to payment determinations. Many hospitals monitor SSIs using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), in addition to mandatory participation (for most states) in the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN), which has resulted in duplication of effort and incongruent data. OBJECTIVE: To identify discrepancies in the implementation of the NHSN and the ACS NSQIP at hospitals that may be affecting the respective SSI rates. DESIGN, SETTING, AND PARTICIPANTS: A pilot sample of hospitals that participate in both the NHSN and the ACS NSQIP. INTERVENTIONS: For each hospital, observed rates and risk-adjusted observed to expected ratios for year 2012 colon SSIs were collected from both programs. The implementation methods of both programs were identified, including telephone interviews with infection preventionists who collect data for the NHSN at each hospital. MAIN OUTCOMES AND MEASURES: Collection methods and colon SSI rates for the NHSN at each hospital were compared with those of the ACS NSQIP. RESULTS: Of 16 hospitals, 11 were teaching hospitals with at least 500 beds. The mean observed colon SSI rates were dissimilar between the 2 programs, 5.7% (range, 2.0%-14.5%) for the NHSN vs 13.5% (range, 4.6%-26.7%) for the ACS NSQIP. The mean difference between the NHSN and the ACS NSQIP was 8.3% (range, 1.6%-18.8%), with the ACS NSQIP rate always higher. The correlation between the observed to expected ratios for the 2 programs was nonsignificant (Pearson product moment correlation, ρ = 0.4465; P = .08). The NHSN collection methods were dissimilar among interviewed hospitals. An SSI managed as an outpatient case would usually be missed under the current NHSN practices. CONCLUSIONS AND RELEVANCE: Colon SSI rates from the NHSN and the ACS NSQIP cannot be used interchangeably to evaluate hospital performance and determine reimbursement. Hospitals should not use the ACS NSQIP colon SSI rates for the NHSN reports because that would likely result in the hospital being an outlier for performance. It is imperative to reconcile SSI monitoring, develop consistent definitions, and establish one reliable method. The current state hinders hospital improvement efforts by adding unnecessary confusion to the already complex arena of perioperative improvement.

Effect of post-discharge venous thromboembolism on hospital quality comparisons following hip and knee arthroplasty.

BACKGROUND: Symptomatic pre-discharge venous thromboembolism (VTE) rates after total or partial hip or knee arthroplasty have been proposed as patient safety indicators. However, assessing only pre-discharge VTE rates may be suboptimal for quality measurement as the duration of stay is relatively short and the VTE risk extends beyond the inpatient setting. METHODS: Patients who underwent total or partial hip or knee arthroplasty were identified in the 2008 through 2010 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Outcomes of interest were the deep venous thrombosis (DVT), pulmonary embolism (PE), and overall VTE rates within thirty days after surgery and the rates during the pre-discharge and post-discharge portions of this time period. Risk-adjusted hospital rankings based on only pre-discharge (inpatient) events were compared with those based on both pre-discharge and post-discharge events within thirty days of surgery. RESULTS: A total of 23,924 patients underwent total or partial hip arthroplasty (8499) or knee arthroplasty (15,425) at ninety-five hospitals. For hip arthroplasty, the VTE rate was 0.9%, with 57.9% of the events occurring after discharge. For knee arthroplasty, the VTE rate was 1.9%, with 38.3% of the events occurring after discharge. The median time of VTE occurrence was eleven days postoperatively for hip arthroplasty and three days for knee arthroplasty. The median duration of stay was three days for both hip and knee arthroplasty. When hospitals were ranked according to VTE rates, hospital outlier status designations changed when post-discharge events were included (κ = 0.386; 44% false-positive rate for low outliers). The median change in hospital quality ranking was 7 (interquartile range, 2 to 17), with a rank correlation of r = 0.82. CONCLUSIONS: Nearly twice as many VTE complications were captured if both pre-discharge and post-discharge events were considered, and inclusion of post-discharge events changed hospital quality rankings. These data suggest that inclusion of post-discharge events should be considered when comparing the quality of hospitals on the basis of postoperative VTE rates. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association between hospital imaging use and venous thromboembolism events rates based on clinical data.

OBJECTIVE: The objective was to assess the presence and extent of venous thromboembolic (VTE) surveillance bias using high-quality clinical data. BACKGROUND: Hospital VTE rates are publicly reported and used in pay-for-performance programs. Prior work suggested surveillance bias: hospitals that look more for VTE with imaging studies find more VTE, thereby incorrectly seem to have worse performance. However, these results have been questioned as the risk adjustment and VTE measurement relied on administrative data. METHODS: Data (2009-2010) from 208 hospitals were available for analysis. Hospitals were divided into quartiles according to VTE imaging use rates (Medicare claims). Observed and risk-adjusted postoperative VTE event rates (regression models using American College of Surgeons National Surgical Quality Improvement Project data) were examined across VTE imaging use rate quartiles. Multivariable linear regression models were developed to assess the impact of hospital characteristics (American Hospital Association) and hospital imaging use rates on VTE event rates. RESULTS: The mean risk-adjusted VTE event rates at 30 days after surgery increased across VTE imaging use rate quartiles: 1.13% in the lowest quartile to 1.92% in the highest quartile (P < 0.001). This statistically significant trend remained when examining only the inpatient period. Hospital VTE imaging use rate was the dominant driver of hospital VTE event rates (P < 0.001), as no other hospital characteristics had significant associations. CONCLUSIONS: Even when examined with clinically ascertained outcomes and detailed risk adjustment, VTE rates reflect hospital imaging use and perhaps signify vigilant, high-quality care. The VTE outcome measure may not be an accurate quality indicator and should likely not be used in public reporting or pay-for-performance programs.

Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices.

BACKGROUND: Recent research suggests that hospital rates of postoperative venous thromboembolism (VTE) are subject to surveillance bias: the more hospitals 'look for' VTE, the more VTE they find. However, little is known about what drives variation in hospital VTE imaging rates. We conducted an observational study to examine hospital and market characteristics that were associated with hospital-level rates of postoperative VTE imaging, focusing on hospitals with particularly high rates. METHODS: For Medicare beneficiaries undergoing 11 major operations (2009-2010) at 2820 hospitals, hospital-level postoperative VTE imaging use rates were calculated. Hospital characteristics associated with hospital VTE imaging use rates were examined including case severity, size, ownership, VTE process measure adherence, accreditations, staffing, malpractice environment, and county market factors. Associations between explanatory variables and VTE imaging rates were assessed using quantile regressions at the 25th, median, 75th and 90th quantiles. RESULTS: Mean postoperative VTE imaging rates ranged from 85.26 (SD=67.38) per 1000 discharges in the lowest quartile of hospitals ranked by VTE imaging rates to 168.86 (SD=76.70) in the highest quartile. Drivers of high imaging rates at the 90th quantile were high resident-to-bed ratio (coefficient=51.35, p<0.01), Joint Commission accreditation (coefficient=19.05, p<0.01), presence of other hospitals in the same market with high imaging rates (coefficient=15.29, p<0.01), average case severity (coefficient=11.97, p<0.01), local malpractice costs (coefficient=11.29, p<0.01), and market competition (coefficient=11.03, p<0.01). CONCLUSIONS: Hospital teaching status, resident-to-bed ratio, malpractice environment and local market factors drive hospital postoperative VTE imaging use, suggesting that non-clinical forces predominantly drive hospital VTE imaging practices.

Effect of wound classification on risk adjustment in American College of Surgeons NSQIP.

BACKGROUND: Surgical wound classification has been used in risk-adjustment models. However, it can be subjective and could potentially improperly bias hospital quality comparisons. The objective is to examine the effect of wound classification on hospital performance risk-adjustment models. STUDY DESIGN: Retrospective review of the 2011 American College of Surgeons NSQIP database was conducted for the following wound classification categories: clean, clean-contaminated, contaminated, and dirty-infected. To assess the influence of wound classification on risk adjustment, 2 models were developed for all outcomes: 1 including and 1 excluding wound classification. For each model, hospital postoperative complications were estimated using hierarchical multivariable regression methods. Absolute changes in hospital rank, correlations of odds ratios, and outlier status agreement between models were examined. RESULTS: Of the 442,149 cases performed in 315 hospitals: 53.6% were classified as clean; 34.2% as clean-contaminated; 6.7% as contaminated; and 5.5% as dirty-infected. The surgical site infection rate was highest in dirty-infected (8.5%) and lowest in clean (1.8%) cases. For overall surgical site infection, the absolute change in risk-adjusted hospital performance rank between models, including vs excluding wound classification, was minimal (mean 4.5 of 315 positions). The correlations between odds ratios of the 2 performance models were nearly perfect (R = 0.9976, p < 0.0001), and outlier status agreement was excellent (κ = 0.95ss08, p < 0.0001). Similar findings were observed in models of subgroups of surgical site infections and other postoperative outcomes. CONCLUSIONS: In circumstances where alternate information is available for risk adjustment, there appear to be minimal differences in performance models that include vs exclude wound classification. Therefore, the American College of Surgeons NSQIP is critically evaluating the continued use of wound classification in hospital performance risk-adjustment models.

Chronic common femoral vein occlusion secondary to endometriosis.

Venous occlusion is sometimes caused by external compression due to adjacent masses. Endometriosis, the presence of functioning endometrial tissue outside the uterine cavity, is a rare cause of venous occlusion. We report a case of chronic common femoral vein occlusion due to endometrioma causing severe leg edema and groin pain that was treated with resection and venous bypass.

Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure.

IMPORTANCE: Postoperative venous thromboembolism (VTE) rates are widely reported quality metrics soon to be used in pay-for-performance programs. Surveillance bias occurs when some clinicians use imaging studies to detect VTE more frequently than other clinicians. Because they look more, they find more VTE events, paradoxically worsening their hospital's VTE quality measure performance. A surveillance bias may influence VTE measurement if (1) greater hospital VTE prophylaxis adherence fails to result in lower measured VTE rates, (2) hospitals with characteristics suggestive of higher quality (eg, more accreditations) have greater VTE prophylaxis adherence rates but worse VTE event rates, and (3) higher hospital VTE imaging utilization use rates are associated with higher measured VTE event rates. OBJECTIVE: To examine whether a surveillance bias influences the validity of reported VTE rates. DESIGN, SETTING, AND PARTICIPANTS: 2010 Hospital Compare and American Hospital Association data from 2838 hospitals were merged. Next, 2009-2010 Medicare claims data for 954,926 surgical patient discharges from 2786 hospitals who were undergoing 1 of 11 major operations were used to calculate VTE imaging (duplex ultrasonography, chest computed tomography/magnetic resonance imaging, and ventilation-perfusion scans) and VTE event rates. MAIN OUTCOMES AND MEASURES: The association between hospital VTE prophylaxis adherence and risk-adjusted VTE event rates was examined. The relationship between a summary score of hospital structural characteristics reflecting quality (hospital size, numbers of accreditations/quality initiatives) and performance on VTE prophylaxis and risk-adjusted VTE measures was examined. Hospital-level VTE event rates were compared across VTE diagnostic imaging rate quartiles and with a quantile regression. RESULTS: Greater hospital VTE prophylaxis adherence rates were weakly associated with worse risk-adjusted VTE event rates (r2 = 4.2%; P = .03). Hospitals with increasing structural quality scores had higher VTE prophylaxis adherence rates (93.3% vs 95.5%, lowest vs highest quality quartile; P < .001) but worse risk-adjusted VTE rates (4.8 vs 6.4 per 1000, lowest vs highest quality quartile; P < .001). Mean VTE diagnostic imaging rates ranged from 32 studies per 1000 in the lowest imaging use quartile to 167 per 1000 in the highest quartile (P < .001). Risk-adjusted VTE rates increased significantly with VTE imaging use rates in a stepwise fashion, from 5.0 per 1000 in the lowest quartile to 13.5 per 1000 in the highest quartile (P < .001). CONCLUSIONS AND RELEVANCE: Hospitals with higher quality scores had higher VTE prophylaxis rates but worse risk-adjusted VTE rates. Increased hospital VTE event rates were associated with increasing hospital VTE imaging use rates. Surveillance bias limits the usefulness of the VTE quality measure for hospitals working to improve quality and patients seeking to identify a high-quality hospital.

Stepwise age-related outcomes of elective endovascular abdominal aortic aneurysm repair: 11-year institutional review.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysms (EVAR) has largely supplanted open surgery over the past 2 decades. Faced with an aging population, the outcomes of EVAR among various age groups were examined. METHOD: Retrospective review of elective EVAR cases was performed at a single institution from 1998 to 2009. Patients were separated into 4 age groups for easy comparison. Perioperative data were analyzed using Fisher's exact test. RESULTS: Demographics were similar among the groups except for sex, BMI, and smoking status. The 30-day morbidity and mortality data were not statistically different among groups. From EVAR to end of the study, there was a 10.9% all-cause mortality rate (with no difference among groups) and an 8.0% reintervention rate (with the oldest age group having a lower reintervention rate; P < .03). CONCLUSIONS: EVAR remains a good treatment option for elective aneurysm repair despite advanced age, which alone does not appear to be an independent predictor of outcome.