Emergency Department Visit Rates After Ambulatory Surgery.

This cohort study compares the rates of emergency department visits after cholecystectomy, transurethral resection of the prostate, and knee arthroplasty at freestanding ambulatory surgery centers vs hospital-owned surgery centers.

Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty.

Importance: In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown. Objectives: To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs. Design, Setting, and Participants: This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022. Main Outcomes and Measures: Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared. Results: A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001). Conclusions: This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research.

Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals.

BACKGROUND: Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay. METHODS: We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay. RESULTS: We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001). CONCLUSION: Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.

Full-Thickness Chemical Burn From Trifluoroacetic Acid: A Case Report and Review of the Literature.

Trifluoroacetic acid (TFA) burns are an ill-defined entity due to a lack of reported sizable burns from this chemical. In this case report of the largest reported burn from TFA, we demonstrate that TFA causes extensive, progressive full-thickness tissue injury that may initially appear superficial. Trifluoroacetic acid does not seem to involve the systemic toxicities that result from hydrofluoric acid burns, and there is no role for calcium gluconate in acute management based on this case. Operative intervention should be staged because wound beds may initially seem healthy yet demonstrate continued necrosis.

Self-inflicted gunshot wounds: readmission patterns.

BACKGROUND: Self-inflicted gunshot wounds (SI-GSWs) are often fatal, but roughly 20% of individuals survive. What happens to survivors after the initial hospitalization is unknown. We hypothesized that the SI-GSW survivors are frequently readmitted and that the pattern of readmission is different from that of the survivors of non-GSW self-harm (SH). METHODS: We conducted a retrospective cohort analysis using the 2013 and 2014 Nationwide Readmission Database. Patients with any diagnosis indicating deliberate SH in the first 6 months of the year were included. This group was divided into those who had SI-GSW as their mechanism and those who did not. Weighted numbers are reported. RESULTS: A total of 1987 patients were admitted for SI-GSW in the study period. Many (n = 506, 26%) experienced at least one readmission in 6 months. When compared with non-GSW SH patients, readmission rates were not statistically different (26% versus 26%, P = 0.60). However, readmissions for repeat SH were lower for the SI-GSW cohort (3% versus 7%, P = 0.004). Readmission for the SI-GSW cohort less frequently had a primary diagnosis of psychiatric illness (28% versus 57%, P < 0.001). In multivariate analysis, there was no difference in odds ratios (OR) of all-cause readmission between the two groups. SI-GSW was associated with a lower OR of repeat SH readmission compared with non-GSW SH (OR 0.65, P = 0.039). CONCLUSIONS: Readmissions after an SI-GSW are frequent, highlighting the burden of this injury beyond the index hospitalization. There are differences in readmission patterns for SI-GSW patients versus non-GSW SH patients, and this suggests that prevention and follow-up strategies may differ between the two groups.