Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 8.656
Filtrar
1.
JAMA ; 323(11): 1077-1084, 2020 Mar 17.
Artículo en Inglés | MEDLINE | ID: mdl-32181848

RESUMEN

Importance: Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience. Objective: To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system. Design, Setting, and Participants: Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017. Exposures: Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement. Main Outcomes and Measures: The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions. Results: Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08). Conclusions and Relevance: Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.


Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Cementos para Huesos , Fracturas del Cuello Femoral/cirugía , Prótesis de Cadera , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Tempo Operativo , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Estudios Retrospectivos , Riesgo , Estados Unidos
2.
Am Surg ; 86(2): 116-120, 2020 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-32167042

RESUMEN

Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.


Asunto(s)
Trasplante de Riñón/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Basiliximab/efectos adversos , Diabetes Mellitus/epidemiología , Femenino , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Inmunosupresores/efectos adversos , Incidencia , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Análisis de Regresión , Reoperación/efectos adversos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo
3.
Medicine (Baltimore) ; 99(10): e19363, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32150080

RESUMEN

Hospital readmission rates are used as a metric to measure quality patient care. While several tools predict readmissions based on patient-specific characteristics, this study assesses if physician characteristics correlate with hospital readmission rates.In a 5-year retrospective electronic record review at a single institution, 31 internal medicine attending physicians' discharges were tracked for a total of 70 physician years, and 15,933 hospital discharges. Each physician's yearly 7-day, 8 to 30-day, and 30-day readmission rates were compared. Each rate was also correlated with years of post-graduate clinical experience, discharge volume, physician sex, and fiscal year.Individual physicians had significantly different 7-day, 8 to 30-day, and 30-day readmission rates from each other. The rates were not related to sex, years after post-graduate training, or fiscal year. However, physician patient volume correlated with 7-day readmission rates. Physicians who discharged ≤100 patients per year had a higher 7-day readmission rate than physicians who discharged >100 patients per year. This correlation with patient volume did not hold for the 8 to 30-day and 30-day readmission rates.Individual physicians differ in their patient readmission rates in 7-day, 8 to 30-day, and 30-day categories. A critical level of a physician's hospital activity, as reflected by the number of patient discharges per year (>100), results in lower 7-day readmission rates. Sex, post-graduate years of clinical experience, and fiscal year did not play a role. The lack of correlation between each physicians' 7-day and 8 to 30-day readmission rates suggests that different physician factors are involved in these 2 rates.


Asunto(s)
Readmisión del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/normas , Alta del Paciente/estadística & datos numéricos , Pennsylvania , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Retrospectivos
4.
Anaesthesia ; 75 Suppl 1: e62-e74, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31903563

RESUMEN

Critical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri-operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30-day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. A systematic review of MEDLINE, Embase, CINAHL, Web of Science, the Cochrane database and the grey literature identified 44 studies assessing risk factors for unplanned critical care admission in adult populations undergoing non-cardiac, non-thoracic and non-neurological surgery. Comparative, quantitative analysis of the admission criteria was not feasible due to heterogeneity in study design. Age, anaemia, ASA physical status, body mass index, comorbidity burden, emergency surgery, high-risk surgery, male sex, obstructive sleep apnoea, increased blood loss and operative duration were all independent risk factors for unplanned critical care admission. Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.


Asunto(s)
Cuidados Críticos/métodos , Readmisión del Paciente/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos , Humanos , Factores de Riesgo
5.
N Engl J Med ; 382(5): 405-415, 2020 01 30.
Artículo en Inglés | MEDLINE | ID: mdl-31995686

RESUMEN

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).


Asunto(s)
Tratamiento Conservador , Drenaje , Neumotórax/terapia , Adolescente , Adulto , Tubos Torácicos , Drenaje/métodos , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Neumotórax/diagnóstico por imagen , Complicaciones Posoperatorias , Radiografía Torácica , Recurrencia , Resultado del Tratamiento , Espera Vigilante , Adulto Joven
6.
Dis Colon Rectum ; 63(2): 217-225, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31914114

RESUMEN

BACKGROUND: The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood. OBJECTIVE: The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database. DESIGN: This was a retrospective cohort study. SETTINGS: A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included. PATIENTS: Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included. INTERVENTIONS: Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage. MAIN OUTCOME MEASURES: Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured. RESULTS: In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis. LIMITATIONS: The study was limited by residual confounding from missing covariates and its observational study design. CONCLUSIONS: The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).


Asunto(s)
Diverticulitis/terapia , Manejo de Atención al Paciente/tendencias , Readmisión del Paciente/estadística & datos numéricos , Enfermedad Aguda , Anciano , Bases de Datos Factuales , Diverticulitis/epidemiología , Drenaje/métodos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento/estadística & datos numéricos , Insuficiencia del Tratamiento , Estados Unidos/epidemiología
7.
N Engl J Med ; 382(1): 51-59, 2020 01 02.
Artículo en Inglés | MEDLINE | ID: mdl-31893515

RESUMEN

BACKGROUND: The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. METHODS: Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. RESULTS: The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. CONCLUSIONS: Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).


Asunto(s)
Instituciones Asociadas de Salud , Hospitales , Calidad de la Atención de Salud , Anciano , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Medicare , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Medición de Resultados Informados por el Paciente , Indicadores de Calidad de la Atención de Salud , Estados Unidos
10.
Bone Joint J ; 102-B(1): 82-89, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31888355

RESUMEN

AIMS: The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). METHODS: In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. RESULTS: Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. CONCLUSION: These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82-89.


Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Actividades Cotidianas , Anciano , Estudios de Casos y Controles , Femenino , Fracturas de Cadera/cirugía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Fracturas Periprotésicas/cirugía , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios
11.
Ann R Coll Surg Engl ; 102(1): 54-61, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31891669

RESUMEN

INTRODUCTION: Studies have attempted to identify prognostic indicators for successful outcomes following bariatric surgery for obesity. The aim of this study was to determine whether the degree of obesity affects outcomes in patients who are morbidly obese (basal metabolic index, BMI, 40-49.9 kg/m2), super-obese (BMI 50-59.9 kg/m2) and super-super-obese (BMI greater than 60 kg/m2) undergoing restrictive or malabsorptive bypass procedures. MATERIAL AND METHODS: Retrospective analysis of a prospectively maintained database was undertaken to include all consecutive laparoscopic adjustable gastric bands (LAGB), laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures since 2010. Patients with at least two years of follow-up were included. At each visit, the patient's weight, BMI, excess weight loss and comorbidity status were recorded. RESULTS: A total of 353 patients (75% women) were included in the analysis; 65 (18.4%) underwent LAGB; 70 (19.8%) LSG and 218 (61.8%) LRYGB. At presentation, the median BMI for the morbidly obese sub-group was 47.2 kg/m2 for LAGB, 46.4 kg/m2 for LSG and 46.6 kg/m2 for LRYGB (P = 0.625); for the super-obese sub-group it was 53.2 kg/m2 for LAGB, 52.9 kg/m2 for LSG and 52.4 kg/m2 for LRYGB (P = 0.481); and for the super-super-obese sub-group 66.9 kg/m2 for (LAGB, 66.7 kg/m2 for LSG and 61.5 kg/m2 for LRYGB (P = 0.169). Percentage of excess weight loss at the end of two years was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB (median 68.5% and 69.5%, respectively; P < 0.001) than in the sub-groups undergoing LAGB and LSG. This was also reflected in the reduction of BMI achieved with bypass in the two sub-groups (P < 0.001). Complete diabetes remission was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB treatment (P < 0.05). Sleep apnoea, asthma and exercise tolerance had significantly improved in the super-morbidly obese undergoing LRYGB (P < 0.05). There was no significant difference between the three treatment groups in remission of hypertension; dyslipidaemia; gastro-oesophageal reflux disease and depression in all three BMI sub-groups. CONCLUSION: The mid-term results for weight loss and resolution of obesity-related comorbidities is best achieved in super-obese patients undergoing LRYGB, without any significant increase in complications with this procedure as compared with LAGB and LSG.


Asunto(s)
Cirugía Bariátrica/métodos , Peso Corporal/fisiología , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Adulto , Cirugía Bariátrica/estadística & datos numéricos , Femenino , Humanos , Laparoscopía/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de Peso/fisiología
12.
Lancet ; 395(10217): 33-41, 2020 01 04.
Artículo en Inglés | MEDLINE | ID: mdl-31908284

RESUMEN

BACKGROUND: Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS: We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS: Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION: Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING: Dutch Adhesion Group and Nordic Pharma.


Asunto(s)
Laparoscopía/efectos adversos , Readmisión del Paciente/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/efectos adversos , Adherencias Tisulares/etiología , Abdomen/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pelvis/cirugía , Complicaciones Posoperatorias/epidemiología , Reoperación/efectos adversos , Estudios Retrospectivos , Adherencias Tisulares/cirugía , Adulto Joven
13.
BMJ ; 368: l6831, 2020 01 15.
Artículo en Inglés | MEDLINE | ID: mdl-31941686

RESUMEN

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Asunto(s)
Unidades de Observación Clínica/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca , Infarto del Miocardio , Neumonía , Atención Subaguda , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Humanos , Revisión de Utilización de Seguros , Masculino , Uso Excesivo de los Servicios de Salud/prevención & control , Medicare/estadística & datos numéricos , Mortalidad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Neumonía/mortalidad , Neumonía/terapia , Estudios Retrospectivos , Atención Subaguda/métodos , Atención Subaguda/organización & administración , Atención Subaguda/tendencias , Estados Unidos/epidemiología
14.
N Engl J Med ; 382(2): 152-162, 2020 01 09.
Artículo en Inglés | MEDLINE | ID: mdl-31914242

RESUMEN

BACKGROUND: There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services. METHODS: We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge. RESULTS: The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group. CONCLUSIONS: In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).


Asunto(s)
Enfermedad Crónica/terapia , Hospitalización/estadística & datos numéricos , Manejo de Atención al Paciente/métodos , Readmisión del Paciente/estadística & datos numéricos , Adulto , Anciano , Atención Ambulatoria/estadística & datos numéricos , Costos de la Atención en Salud , Visita Domiciliaria , Humanos , Modelos Lineales , Persona de Mediana Edad , New Jersey , Manejo de Atención al Paciente/organización & administración , Resumen del Alta del Paciente , Estudios Prospectivos , Factores Socioeconómicos , Estados Unidos
15.
J Surg Res ; 246: 457-463, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31706537

RESUMEN

BACKGROUND: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.


Asunto(s)
Colostomía/efectos adversos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Transferencia de Pacientes/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Estados Unidos/epidemiología
16.
J Trauma Acute Care Surg ; 88(2): 219-229, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31804415

RESUMEN

BACKGROUND: We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality. METHODS: The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality. RESULTS: Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million). CONCLUSIONS: Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs. LEVEL OF EVIDENCE: Epidemiological, level III.


Asunto(s)
Costos de Hospital/estadística & datos numéricos , Mortalidad Hospitalaria , Readmisión del Paciente/estadística & datos numéricos , Tiempo de Tratamiento/economía , Heridas y Traumatismos/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de Tiempo , Tiempo de Tratamiento/estadística & datos numéricos , Estados Unidos , Heridas y Traumatismos/economía , Heridas y Traumatismos/mortalidad , Adulto Joven
17.
J Surg Res ; 246: 123-130, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31569034

RESUMEN

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Asunto(s)
Organizaciones Responsables por la Atención/estadística & datos numéricos , Fijación de Fractura/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Fracturas de la Columna Vertebral/cirugía , Organizaciones Responsables por la Atención/economía , Anciano , Anciano de 80 o más Años , Grupos de Población Continentales/estadística & datos numéricos , Ahorro de Costo/economía , Ahorro de Costo/estadística & datos numéricos , Grupos Étnicos , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/economía , Gastos en Salud/estadística & datos numéricos , Disparidades en Atención de Salud/organización & administración , Mortalidad Hospitalaria , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad/estadística & datos numéricos , Factores Socioeconómicos , Fracturas de la Columna Vertebral/economía , Estados Unidos/epidemiología
18.
J Surg Res ; 246: 131-138, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31580983

RESUMEN

BACKGROUND: Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS: Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS: There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.


Asunto(s)
Procedimientos Quirúrgicos Operativos/clasificación , Infección de la Herida Quirúrgica/epidemiología , Herida Quirúrgica/clasificación , Factores de Edad , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Herida Quirúrgica/complicaciones , Infección de la Herida Quirúrgica/etiología
19.
J Surg Res ; 246: 395-402, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31629495

RESUMEN

BACKGROUND: Laparoscopic appendectomy is a preferred approach in children with appendicitis. Patient characteristics associated with open appendectomy are poorly characterized, although such information can help optimize the care. MATERIAL AND METHODS: To characterize the factors associated with open appendectomy, we performed a retrospective analysis using the 2014 Nationwide Readmissions Database, capturing 49.3% of US hospitalizations. We identified surgically managed appendicitis using International Classification of Diseases, Ninth Revision, Clinical Modification among patients aged 18 or younger. Factors associated with open appendectomy, 30-d readmission rate, and hospitalization length were assessed using logistic regression, Cox proportional hazards regression, and Poisson regression, respectively. RESULTS: Of 46,147 children with surgically managed appendicitis, 85.2% had laparoscopic appendectomy. Low-volume hospitals (odds ratio, OR: 3.01 [95% confidence interval, CI: 1.81-5.01]), rural hospitals (OR: 2.36 [95%CI: 1.63-3.40]), public insurance (OR: 1.19 [95%CI: 1.03-1.36]), lower-income neighborhood residence (OR: 1.40 [95%CI: 1.06-1.86]), younger age (OR: 5.00 [95%CI: 3.64-6.86] in <5 year-old), and abscess complicating appendicitis (OR: 1.91 [95%CI: 1.58-2.31]) were associated with open appendectomy. Laparoscopic appendectomy was associated with shorter hospitalization (incidence rate ratio: 0.77 [95%CI: 0.69-0.87]) and less readmission with wound infection, but not with 30-d readmission, or readmission with intraabdominal abscess. CONCLUSIONS: Along with clinical factors, non-clinical factors including appendicitis volume and rural/teaching status of the treating hospitals play a role in the choice of surgical approach. Awareness of the patient- and hospital-level factors associated with open appendectomy may allow for future resource distribution or improvement in access to care, resulting in population-level impact.


Asunto(s)
Absceso Abdominal/epidemiología , Apendicectomía/efectos adversos , Apendicitis/cirugía , Readmisión del Paciente/estadística & datos numéricos , Infección de la Herida Quirúrgica/epidemiología , Absceso Abdominal/etiología , Absceso Abdominal/cirugía , Adolescente , Factores de Edad , Apendicectomía/métodos , Apendicitis/complicaciones , Niño , Preescolar , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Factores Socioeconómicos , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/cirugía
20.
J Surg Res ; 246: 100-105, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31563829

RESUMEN

BACKGROUND: Surgical site infection (SSI) is an established quality indicator and predictor for adverse patient outcomes. Multiple strategies have been established to reduce SSI; however, optimum protocol remains unclear. The aim of the study was to assess the impact of established protocol on SSI after colon surgery. METHODS: We established a colon SSI bundle in 2017, which includes a chlorhexidine prescrub followed by chloraPrep, betadine wound wash, antibiotic infused irrigation, use of closure tray, and incision coverage with silver impregnated dressing. Retrospective analysis of a 2-y (2016-2017) prospectively collected before and after analysis of all patients undergoing elective colon surgery was performed. Patients were divided into two groups: preprotocol (PP: year 2016) and postprotocol (PoP: year 2017). Patients in the two groups were matched using propensity score matching for age, gender, comorbidities, Anesthesiology Severity Score, indication of procedure, and procedure type. Outcome measures were SSI, hospital length of stay, and readmission rate. RESULTS: A total of 328 patients were analyzed, and after propensity matching, 94 patients (PP:47 and PoP:47) were included. The mean age was 63.7 ± 16.4 y, 43.6% male, and 44.6% of procedures were performed laparoscopically. There was no difference in demographics, comorbidities, and procedure details between two groups. PoP patients had significantly lower superficial (odds ratio: 0.91 [0.74-0.98]; P = 0.045) and deep SSI (odds ratio:0.97 [0.65-0.99]; P = 0.048) than PP patients. PoP patient had shorter length of stay (P = 0.049) and trend toward lower readmission rate (P = 0.098) compared with PP patients and an 85% reduction in the Centers for Medicare and Medicaid Services standardized infection rate. CONCLUSIONS: Protocol-driven patient care improves patient outcomes. SSI bundle reduced SSI in patient undergoing colon surgery. Establishing national SSI bundles will help standardize care and help optimize patient outcomes.


Asunto(s)
Protocolos Clínicos , Colon/cirugía , Procedimientos Quirúrgicos Electivos/efectos adversos , Cuidados Preoperatorios/métodos , Infección de la Herida Quirúrgica/prevención & control , Anciano , Antibacterianos/administración & dosificación , Antiinfecciosos Locales/administración & dosificación , Profilaxis Antibiótica/métodos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Resultado del Tratamiento , Estados Unidos
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA