How to improve newborn outcomes in 60 s-delay clamping the umbilical cord.

Deferred umbilical cord clamping (DCC) has been employed with wide variation in the United States over the last few decades. This practice has the potential to improve infant health and outcomes at the population health level. Education campaigns and policy interventions can promote DCC use in a safe manner.

Association between diabetes mellitus and total hip arthroplasty outcomes: an observational study using the US National Inpatient Sample.

OBJECTIVES: To investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA). DESIGN: Retrospective cohort study using data from the US National Inpatient Sample (NIS). SETTING: Study cohort was hospitalisations for primary THA in the USA, identified from the 2016-2020 NIS. PARTICIPANTS: We identified 2 467 215 adults in the 2016-2020 NIS who underwent primary THA using International Classification of Diseases, 10th Revision codes. Primary THA hospitlizations were analysed as the overall group and also stratified by the underlying primary diagnosis for THA. OUTCOME MEASURES: Outcome measures of interest were the length of hospital stay>the median, total hospital charges>the median, inpatient mortality, non-routine discharge, need for blood transfusion, prosthetic fracture, prosthetic dislocation and postprocedural infection, including periprosthetic joint infection, deep surgical site infection and postprocedural sepsis. RESULTS: Among 2 467 215 patients who underwent primary THA, the mean age was 68.7 years, 58.3% were female, 85.7% were white, 61.7% had Medicare payer and 20.4% had a Deyo-Charlson index (adjusted to exclude diabetes mellitus) of 2 or higher. 416 850 (17%) patients had diabetes. In multivariable-adjusted logistic regression in the overall cohort, diabetes was associated with higher odds of a longer hospital stay (adjusted OR (aOR) 1.38; 95% CI 1.35 to 1.41), higher total charges (aOR 1.11; 95% CI 1.09 to 1.13), non-routine discharge (aOR 1.18; 95% CI 1.15 to 1.20), the need for blood transfusion (aOR 1.19; 95% CI 1.15 to 1.23), postprocedural infection (aOR 1.62; 95% CI 1.10 to 2.40) and periprosthetic joint infection (aOR 1.91; 95% CI 1.12 to 3.24). We noted a lack of some associations in the avascular necrosis and inflammatory arthritis cohorts (p>0.05). CONCLUSION: Diabetes was associated with increased healthcare utilisation, blood transfusion and postprocedural infection risk following primary THA. Optimisation of diabetes with preoperative medical management and/or institution of specific postoperative pathways may improve these outcomes. Larger studies are needed in avascular necrosis and inflammatory arthritis cohorts undergoing primary THA.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations.

OBJECTIVE: Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). METHODS: This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. RESULTS: One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2 years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N = 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. CONCLUSIONS: Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study.

BACKGROUND: Previous cross-sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. METHODS AND RESULTS: We conducted a retrospective analysis using 100% Medicare fee-for-service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilization and Medicare-allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office-based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare-allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. CONCLUSIONS: The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office-based laboratory settings, non-White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value-based care for the treatment of claudication.

Racial and Ethnic Disparities in Medicaid Disenrollment After the End of the COVID-19 Public Health Emergency.

This survey study reports the proportions of and reasons for Medicaid coverage loss among racially and ethnically minoritized individuals.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020).

PURPOSE: Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification. METHODS: Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS: A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis. CONCLUSION: Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Assessing the predictive value of the Risk Analysis Index for short-term outcomes in acute spinal cord injury surgery.

BACKGROUND: Acute traumatic spinal cord injury (tSCI) requires rapid surgical intervention to maximize neurological function. Older patients comprise an increasingly larger proportion of SCI patients annually, necessitating accurate preoperative risk stratification tools. This study utilized a frailty-based preoperative risk stratification score to predict adverse events following non-elective neurosurgical intervention for acute tSCI patients. METHODS: The National Inpatient Sample (NIS) was queried for acute tSCI patients aged ≥18 who underwent spine surgery in 2019-2020. The Risk Analysis Index (RAI) was implemented with crosstabulation, to analyze frailty scores with the following binary outcome measures: overall complications, non-home discharge (NHD), extended length of stay (eLOS) (>75th percentile), and mortality. Area Under the Receiver Operating Characteristic (AUROC) analysis assessed the discriminative threshold of RAI compared to the modified 5-item Frailty Index (mFI-5) for NHD and 30-day mortality. RESULTS: A total of 9995 SCI patients underwent non-elective spine surgery. There were 1525 perioperative complications (15.3%) and 510 (5.1%) mortalities. An increasing RAI score was significantly associated with increasing postoperative mortality rates: RAI 0-20 (1.5%, N.=45), RAI 21-30 (3.4%, N.=110), RAI 31-40 (6.8%, N.=115), and RAI>41 (11.8%, N.=240) (P<0.001). RAI demonstrated superior discrimination compared to the mFI-5 for mortality and NHD with a C-statistic >0.72. CONCLUSIONS: Increasing frailty, as measured by RAI, was a reliable predictor of non-home discharge and 30-day mortality for SCI patients who underwent non-elective spinal surgery and RAI demonstrated superior discrimination compared to the mFI-5 for NHD and mortality.

Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality.

PURPOSE: Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning. METHODS: IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS: A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis. CONCLUSION: Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.

Evaluating Patient and Surgeon Characteristics Associated with Care Cost and Outcomes for Knee and Hip Replacement Procedures: A National Medicare Cohort Study.

Background: The role of physician credentialing has been widely considered in quality and outcome improvement studies. However, the association between surgeon characteristics and health-care costs remains unclear. Methods: Our objective was to determine the association of orthopaedic surgeon characteristics with health outcomes and costs, utilizing Medicare data. We used 100% Fee-for-Service Medicare data from 2015 to 2019 to identify all patients ≥65 years of age who underwent 2 common orthopaedic surgical procedures, total hip and knee replacement. After determining whether the patients had been readmitted after discharge from their initial admission for surgery, we computed 3 metrics of total medical expenditure: the costs of the initial surgery admission and 30-day and 180-day episode-based bundles of care. Hierarchical linear regression and logistic regression models were used to evaluate patient and surgeon characteristics associated with care costs and the likelihood of readmission. Results: We identified 2,269 surgeons who performed total knee replacements on 298,934 patients and 1,426 surgeons who performed total hip replacements on 204,721 patients. Patient characteristics associated with higher initial surgery costs included increasing age, female sex, racial minority status, and a higher Charlson Comorbidity Index. Surgeon characteristics associated with lower readmission rates included practice in the Northeast region and a higher patient volume; having malpractice claims was associated with higher readmission rates. Conclusions: A higher volume of patients treated by the orthopaedic surgeon was associated with lower overall costs and readmission rates. Information on surgeons' malpractice claims and annual volume should be made publicly available to assist patients, payer networks, and hospitals in surgeon selection and oversight. These results could also inform the guidelines of physician credentialing organizations. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reported Variation in Hospital Billing Quality.

This study examines how US hospitals perform on billing quality measures, including legal actions taken by a hospital to collect medical debt, the timeliness of sending patients an itemized billing statement, and patient access to a qualified billing representative.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020).

BACKGROUND CONTEXT: Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSE: This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTING: Cross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURES: CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODS: Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTS: There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSION: Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Hypothyroidism Impacts Clinical and Healthcare Utilization Outcomes After Primary Total Hip Arthroplasty.

BACKGROUND: Our objective was to assess the association of hypothyroidism with outcomes of primary total hip arthroplasty (THA) overall and stratified by underlying diagnosis. METHODS: We identified patients undergoing primary THA in a national database from 2016 to 2020. We stratified them based on primary diagnoses into hip osteoarthritis (OA; N = 1,761,960), osteonecrosis (ON; N = 78,275), traumatic fracture (N = 532,910), inflammatory arthritis (IA; N = 3,520), and "other" (N = 90,550). We identified hypothyroidism and complications using secondary diagnoses. Among 2,467,215 patients undergoing primary THA, mean age was 68 years (range, 18 to 90), and 58.3% were women. Complications codes only included initial encounters. We performed time-trends analyses and multivariable-adjusted regression analyses adjusted for demographics, expected primary payer, a comorbidity score, elective versus non-elective admission, and hospital characteristic information, with clinical and healthcare utilization outcome as endpoints. RESULTS: Overall, hypothyroidism was significantly associated with increased LOS, total charges, non-routine discharges, blood transfusions, and prosthetic fractures. In the OA cohort, hypothyroidism was associated with increased LOS, total charges, and non-routine discharges (P < .001 for each), and blood transfusions (P = .02). Hypothyroidism was associated with increased total charges (P = .001) in the ON cohort and with increased LOS, non-routine discharge, and blood transfusion (P < .05 each) in the traumatic fracture cohort. CONCLUSIONS: Hypothyroidism was associated with blood transfusions, prosthetic fractures, and utilization outcomes in THA patients. Tailored intervention strategies for hypothyroidism should be tested for their efficacy to improve THA peri-operative outcomes.

RAI-measured frailty predicts non-home discharge following metastatic brain tumor resection: national inpatient sample analysis of 20,185 patients.

PURPOSE: Preoperative risk stratification for patients undergoing metastatic brain tumor resection (MBTR) is based on established tumor-, patient-, and disease-specific risk factors for outcome prognostication. Frailty, or decreased baseline physiologic reserve, is a demonstrated independent risk factor for adverse outcomes following MBTR. The present study sought to assess the impact of frailty, measured by the Risk Analysis Index (RAI), on MBTR outcomes. METHODS: All MBTR were queried from the National Inpatient Sample (NIS) from 2019 to 2020 using diagnosis and procedural codes. The relationship between preoperative RAI frailty score and our primary outcome - non-home discharge (NHD) - and secondary outcomes - complication rates, extended length of stay (eLOS), and mortality - were analyzed via univariate and multivariable analyses. Discriminatory accuracy was tested by computation of concordance statistics in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS: There were 20,185 MBTR patients from the NIS database from 2019 to 2020. Each patient's frailty status was stratified by RAI score: 0-20 (robust): 34%, 21-30 (normal): 35.1%, 31-40 (very frail): 13.9%, 41+ (severely frail): 16.8%. Compared to robust patients, severely frail patients demonstrated increased complication rates (12.2% vs. 6.8%, p < 0.001), eLOS (37.6% vs. 13.2%, p < 0.001), NHD (52.0% vs. 20.6%, p < 0.001), and mortality (9.9% vs. 4.1%, p < 0.001). AUROC curve analysis demonstrated good discriminatory accuracy of RAI-measured frailty in predicting NHD after MBTR (C-statistic = 0.67). CONCLUSION: Increasing RAI-measured frailty status is significantly associated with increased complication rates, eLOS, NHD, and mortality following MBTR. Preoperative frailty assessment using the RAI may aid in preoperative surgical planning and risk stratification for patient selection.

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards.

This Viewpoint discusses new standards proposed by the Centers for Medicare & Medicaid Services for ensuring that Medicare managed care networks meet enrollees' needs.

Eligibility and Prevalence of the American Heart Association Heart Check Certification Program in the US Packaged Food and Beverage Supply: A Cross-Sectional Study.

Objective: Consumers in the US make choices within a food supply dominated by processed packaged foods and beverage products. Front-of-package nutrition labels (FOPL) equip consumers to make healthier choices, but further evaluation and regulation regarding FOPL format, scope, and display have been recommended by the World Health Organization. As a leader in consumer FOPL guidance, the American Heart Association's (AHA) Heart Check programme certifies food companies seeking to add an AHA Heart Check logo as a FOPL for qualifying heart healthy products. A cross-sectional assessment of the AHA Heart Check Standard Certification was conducted within the US packaged food and beverage supply to assess the eligibility and prevalence of the programme as a FOPL. Methods: Data were derived from Label Insight's Open Data initiative, which is the largest publicly-available US branded food composition database. The proportions of products that were certified and eligible to be certified for the Standard Certification were reported by nutrient attributes, grocery aisles and food brands. Results: Among 153,453 products examined, fewer than 1% exhibited the Heart Check certification on their label. Among products that were not Heart Check certified,13.8% were eligible for Standard Certification. The most common reason for ineligibility was the saturated fat content (52%), followed by total fat content (47%) and sodium content (47%). Heart Check certification and eligibility differed substantially across grocery aisle categories. Conclusions: The abundance of unhealthy products in the US packaged food and beverage supply and absence of harmonized FOPL policies suggest the need for FOPL like the Heart Check label to promote adherence to healthy diets. There are opportunities for food manufacturers and the AHA to certify more heart healthy foods and beverages. However, more consistent criteria and transparent labelling could enhance Heart Check certification to facilitate consumers' ability to make more informed and healthful purchases.

A Predictive Model of Failure to Rescue After Thoracolumbar Fusion.

OBJECTIVE: Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients. METHODS: Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011-2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR. RESULTS: The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21-25, 1.3 [0.8-2.2]; RAI 26-30, 4.0 [2.4-6.6]; RAI 31-35, 7.0 [3.8-12.7]; RAI 36-40, 10.0 [4.9-20.2]; RAI 41- 45, 21.5 [9.1-50.6]; RAI ≥ 46, 45.8 [14.8-141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89-0.95). CONCLUSION: Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication.