Clinical factors associated with ultrashort length of stay in patients undergoing lower extremity bypass for peripheral arterial disease.

INTRODUCTION: Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery (ERAS) pathways challenging. The aim of this study was to utilize a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease (PAD). METHODS: All patients undergoing LEB for PAD in the National Surgical Quality Improvement Project database from 2011-2018 were included. Patients were divided into two groups based on the length of postoperative stay: ultrashort (<=2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS. RESULTS: Overall, 17,510 patients were identified who underwent LEB, of which 2,678 (15.3%) patients had an ultrashort postoperative LOS (mean 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean 7.1 days). When compared to patients with standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%, p<0.001), undergo elective surgery (86.1% vs. 59.1%, p<0.001) and to be active smokers (52.1% vs. 40.4%, p<0.001). Ultrashort LOS patients were also more likely to have claudication as the indication for LEB (53.1% vs. 22.5%, p<0.001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%, p<0.001) and had a prosthetic conduit (40.0% vs. 29.9%, p<0.001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%, p=0.21); however ultrashort LOS patients had a lower frequency of unplanned readmission (10.7% vs. 18.8%, p<0.001) and need for major reintervention (1.9% vs. 5.6%, p<0.001). On multivariable analysis, elective status (OR:2.66, 95%CI:2.33-3.04), active smoking (OR:1.18, 95%CI:1.07-1.30) and lack of vein harvest (OR:1.55, 95%CI:1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR:0.57, 95%CI:0.51-0.63), tissue loss (OR:0.30, 95%CI:0.27-0.34) and totally dependent functional status (OR:0.54, 95%CI:0.35-0.84) were negatively associated with ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR:0.38 95%CI:0.19-0.75) and partially dependent (OR:0.53, 95%CI:0.32-0.88) functional status were persistently negatively associated with ultrashort LOS. CONCLUSIONS: Ultrashort LOS (<= 2 days) following LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.

Sex-Related Differences in Utilization and Outcomes of Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest.

Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 ± 16.9 years (mean ± standard deviation) and men's 54.7 ± 14.1 (p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men (p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men (p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.

The impact of undergoing elective pediatric lung resection during respiratory syncytial virus peak season on patient outcomes: A nationwide retrospective analysis.

OBJECTIVES: Observational data to support delaying elective pediatric thoracic surgery during peak respiratory viral illness season is lacking. This study evaluated whether lung surgery during peak viral season is associated with differences in postoperative outcomes and resource utilization. METHODS: A retrospective observational cohort study was performed using the Pediatric Health Information System (PHIS). Patients with a congenital lung malformation (CLM) who underwent elective lung resection between 1 January 2016 and 29 February 2020 were included. Respiratory syncytial virus (RSV) incidence was used as a proxy for respiratory viral illness circulation. Monthly hospital-specific RSV incidence was calculated from PHIS data, and peak RSV season was defined by Centers for Disease Control data. Multivariable regression models were built to identify predictors of postoperative mechanical ventilation, which was the main outcome measure, as well as secondary outcomes including 30-day readmission after lung resection, postoperative length of stay (LOS) and hospital billing charges. RESULTS: Of 1542 CLM patients identified, 344 (22.3%) underwent lung resection during peak RSV season. 38% fewer operations were performed per month during peak RSV season than during off-peak months (p < .001). Children who underwent surgery during peak RSV season did not differ from the off-peak group in terms of age at operation, race, or comorbid conditions (i.e., congenital heart disease, newborn respiratory distress, and preoperative pneumonia). There was no association between hospital-specific RSV incidence at the time of surgery and postoperative mechanical ventilation, postoperative LOS, 30-day readmission rate or hospital billing charges. DISCUSSION: Performing elective lung surgery in children with CLMs during peak viral season is not associated with adverse surgical outcomes or increased utilization of healthcare resources.

Epidemiology of ophthalmic trauma in the United States from 2009-2018: A Nationwide Emergency Department Sample Analysis.

PURPOSE: To determine the incidence, characteristics, disposition, and economic burden of emergency department (ED) visits for ophthalmic trauma in the United States (US). DESIGN: Retrospective study. METHODS: The Nationwide Emergency Department Sample was used to calculate and characterize ED visits for ophthalmic trauma in the US from 2009 to 2018. Linear regression was used to estimate trends in annual incidence and mean inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. RESULTS: There were over 7.3 million ED visits for ophthalmic trauma in the US over the 10 years, with an annual incidence of 233 per 100,000 population. Patients were predominantly male (65 %), 21-44 years old (39 %), and from low-income households (56 %). Only 1 % of patients were hospitalized. Older age, male sex, metropolitan teaching hospitals, and trauma centers were associated with significantly higher odds of inpatient admission. The mean inflation-adjusted ED charge per visit more than doubled over the decade ($1,333 to $3,187) with total charges exceeding $14 billion. Superficial injuries (44 %) and eyelid/orbit wounds (20 %) accounted for the majority of visits. Orbital floor fractures (4 %) and open globe injuries (2 %) accounted for a minority of visits but were responsible for most admissions (49 % and 29 %, respectively) and the highest mean ED charge ($7,157 and $6,808, respectively). CONCLUSIONS: Ophthalmic trauma represents an increasingly significant burden to EDs in the US. Preventive efforts should target young males from low socioeconomic backgrounds. Strategies to improve outpatient access and redirect non-urgent injuries may help alleviate costs.

Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward.

BACKGROUND: Enhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions. METHODS: We collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance. RESULTS: Enhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay. CONCLUSION: This study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.

More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery.

Background: Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery. Methods: We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue. Results: We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67). Conclusions: High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.

The association between severe maternal morbidity and mortality and race/ethnicity with community type in Maryland.

BACKGROUND: Severe maternal morbidity and mortality are increasing in the United States with continued healthcare disparities among Non-Hispanic Black women. However, there is sparse data on the disparities of severe maternal morbidity and mortality by race/ethnicity as it relates to community type. OBJECTIVE: To determine whether residing in rural communities increases the racial/ethnic disparities in severe maternal morbidity and mortality. DESIGN: This study is a cross-sectional analysis of women admitted for delivery from 2015 to 2020. A total of 204,140 adults who self-identified as women, were admitted for delivery, who resided in Maryland, and were between the ages 15 and 54 were included in our analysis. Community type was defined as either rural or urban. METHODS: A multivariable logistic regression, which included an interaction term between race/ethnicity and community type, was used to assess the effect of community type on the relationship between race/ethnicity and severe maternal morbidity and mortality. Data were obtained from the Maryland Health Service Cost Review Commission database. The primary outcome was a composite, binary variable of severe maternal morbidity and mortality. Exposures of interest were residence in either rural or urban counties in Maryland and race/ethnicity. RESULTS: Our study found that after adjusting for confounders, odds of severe maternal morbidity and mortality were 65% higher in Non-Hispanic Black women (odds ratio 1.65, 95% confidence interval: 1.46-1.88, p < 0.001) and 54% higher in Non-Hispanic Asian women (odds ratio 1.54, 95% confidence interval: 1.24-1.90, p < 0.001) compared to Non-Hispanic White women. The interaction term used to determine whether community type modified the relationship between race/ethnicity and severe maternal morbidity and mortality was not statistically significant for any race/ethnicity (Non-Hispanic Black women, p = 0.60; Non-Hispanic Asian women, p = 0.91; Hispanic women, p = 0.15; Other/Unknown race/ethnicity, p = 0.54). CONCLUSION: Although our study confirmed the known disparities in maternal outcomes by race/ethnicity, we found that residing in rural communities did not increase racial/ethnic disparities.

Diverticulitis in Older Adults: Is Cognitive Impairment Associated With Outcomes?

INTRODUCTION: Older age is associated with increased prevalence of both diverticulitis and cognitive impairment. The association between cognitive impairment and outcomes among older adults presenting to the emergency department (ED) for diverticulitis is unknown. METHODS: Adults aged ≥65 y presenting to an ED with a primary diagnosis of colonic diverticulitis were identified using the Nationwide Emergency Department Sample (2016-2019) and stratified by cognitive impairment status in this retrospective cohort study. Multivariable Poisson regression models adjusted for patient age, sex, Elixhauser Comorbidity Index, primary payer status, and presence of complicated diverticulitis quantified relative risk of a) inpatient admission, b) operative intervention, and c) in-hospital mortality comparing patients with or without a diagnosis code suggestive of cognitive impairment. RESULTS: Among 683,444 older adults with an ED encounter for diverticulitis from 2016 to 2019, there were 468,226 patients with isolated colonic diverticulitis and 26,388 (5.6%) with comorbid cognitive impairment. After adjustment, the risk of inpatient admission for those with cognitive impairment was 18% higher than for those without cognitive impairment (adjusted relative risks [aRR]: 1.18, 95% confidence interval [CI]: 1.17-1.20). Those with cognitive impairment were 34% more likely to undergo colectomy than those without cognitive impairment (aRR: 1.34, 95% CI: 1.24-1.44). Older adults with cognitive impairment had a 32% greater mortality than those without cognitive impairment (aRR: 1.32, 95% CI: 1.05-1.67). CONCLUSIONS: Among older adults presenting for ED care with a primary diagnosis of colonic diverticulitis, individuals with cognitive impairment had higher rates of hospitalization, operative intervention, and in-hospital mortality than those without cognitive impairment.

Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus: A Claims-Based Analysis.

PURPOSE: The purpose of this study was to report 1) demographic and clinical characteristics for US patients with keratoconus undergoing deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK) and 2) complication rates for the 2 procedures. METHODS: We performed a retrospective review of 2010 to 2018 health records for patients with keratoconus age younger than 65 years using the IBM MarketScan Database. A multivariable model adjusting for potential confounders was used to determine factors associated with receiving DALK over PK. Rates of complications 90 days and 1 year postoperatively were calculated. For select complications only (repeat keratoplasty, glaucoma surgery, and cataract surgery), Kaplan-Meier survival curves were additionally constructed over a period of up to 7 years. RESULTS: A total of 1114 patients with keratoconus (mean age: 40.5 ± 12.6 years) were included in the analysis. Hundred nineteen received DALK, and 995 received PK. Regional differences exist, with patients in the north central United States having greater odds of receiving DALK than northeastern patients (OR = 5.08, 95% confidence interval, 2.37-10.90). Rates of endophthalmitis, choroidal hemorrhage, infectious keratitis, graft failure, graft rejection, postoperative cataract, glaucoma, or retinal surgery were all low at 90 days and 1 year. Complication rates for DALK and PK were both low beyond 1 year for repeat keratoplasty, cataract, and glaucoma surgery. CONCLUSIONS: There are regional differences between DALK and PK utilization rates. In addition, DALK and PK complication rates in this nationally representative sample are low at 1 year and beyond, but further studies are needed to assess whether longer-term complications differ by procedure type.

Racial and Ethnic Disparities in Outcomes Among Newborns with Congenital Diaphragmatic Hernia.

Importance: There is some data to suggest that racial and ethnic minority infants with congenital diaphragmatic hernia (CDH) have poorer clinical outcomes. Objective: To determine what patient- and institutional-level factors are associated with racial and ethnic differences in CDH mortality. Design, Setting, and Participants: Multicenter cohort study of 49 US children's hospitals using the Pediatric Health Information System database from January 1, 2015, to December 31, 2020. Participants were patients with CDH admitted on day of life 0 who underwent surgical repair. Patient race and ethnicity were guardian-reported vs hospital assigned as Black, Hispanic (White or Black), or White. Data were analyzed from August 2021 to March 2022. Exposures: Patient race and ethnicity: (1) White vs Black and (2) White vs Hispanic; and institutional-level diversity (as defined by the percentage of Black and Hispanic patients with CDH at each hospital): (1) 30% or less, (2) 31% to 40%, and (3) more than 40%. Main Outcomes and Measures: The primary outcomes were in-hospital and 60-day mortality. The study hypothesized that hospitals managing a more racially and ethnically diverse population of patients with CDH would be associated with lower mortality among Black and Hispanic infants. Results: Among 1565 infants, 188 (12%), 306 (20%), and 1071 (68%) were Black, Hispanic, and White, respectively. Compared with White infants, Black infants had significantly lower gestational ages (mean [SD], White: 37.6 [2] weeks vs Black: 36.6 [3] weeks; difference, 1 week; 95% CI for difference, 0.6-1.4; P < .001), lower birthweights (White: 3.0 [1.0] kg vs Black: 2.7 [1.0] kg; difference, 0.3 kg; 95% CI for difference, 0.2-0.4; P < .001), and higher extracorporeal life support use (White: 316 patients [30%] vs Black: 69 patients [37%]; χ21 = 3.9; P = .05). Black infants had higher 60-day (White: 99 patients [9%] vs Black: 29 patients [15%]; χ21 = 6.7; P = .01) and in-hospital (White: 133 patients [12%] vs Black: 40 patients [21%]; χ21 = 10.6; P = .001) mortality . There were no mortality differences in Hispanic patients compared with White patients. On regression analyses, institutional diversity of 31% to 40% in Black patients (hazard ratio [HR], 0.17; 95% CI, 0.04-0.78; P = .02) and diversity greater than 40% in Hispanic patients (HR, 0.37; 95% CI, 0.15-0.89; P = .03) were associated with lower mortality without altering outcomes in White patients. Conclusions and Relevance: In this cohort study of 1565 who underwent surgical repair patients with CDH, Black infants had higher 60-day and in-hospital mortality after adjusting for disease severity. Hospitals treating a more racially and ethnically diverse patient population were associated with lower mortality in Black and Hispanic patients.

The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS: This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS: During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS: Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Risk of Tertiary, Quaternary, and Quinary Proliferative Vitreoretinopathy: Analysis of a Nationwide Database (2010-2017).

OBJECTIVE: Primary proliferative vitreoretinopathy (PVR) is established as an important cause of the failed repair of a fresh retinal detachment (RD) and the consequent need for secondary repair. However, the burden of multiple repairs beyond the initial failure has not been studied in detail. We aimed to determine the association between primary PVR and the occurrence of tertiary, quaternary, and quinary RD repairs, using a nationwide database. DESIGN: Retrospective cohort study of insurance claims. SUBJECTS: Cases of rhegmatogenous RD that underwent primary surgical repair. METHODS: Cases of primary RD repair from 2010 to 2017 were categorized based on the absence (P0 group) or presence (P1 group) of primary PVR. In each group, we analyzed the frequency of subsequent RD repair procedures with concurrent PVR. MAIN OUTCOME MEASURE: The risk of secondary and higher multiples of PVR-associated RD repair. RESULTS: A total of 27 137 cases were included, with 24 500 (90.3%) in the P0 group and 2637 (9.7%) in the P1 group. The frequency (%) of cases ultimately requiring secondary, tertiary, quaternary, and quinary repair in P0 versus P1 was 1.88 versus 10.24 (P < 0.001), 0.26 versus 2.50 (P < 0.001), 0.07 versus 0.64 (P < 0.001), and 0.03 versus 0.08 (P = 0.272), respectively. The risk of undergoing secondary repair was higher in the P1 than in the P0 group (hazard ratio [HR], 6.02; 95% confidence interval [CI], 5.24-6.92; P < 0.001). The risk of undergoing tertiary repair was also higher in the P1 than in the P0 group (HR, 1.67; CI, 1.23-2.28; P = 0.001). There was no difference in the risk of undergoing quaternary repair between the groups (HR, 0.76; CI, 0.41-1.40; P = 0.37). Senary repairs were not detected in this dataset. CONCLUSIONS: Primary PVR may increase the risk of requiring multiple sequential retinal reattachment surgeries beyond the initial repair failure. Retinal detachment cases with primary PVR at the initial presentation of RD were more likely to undergo secondary and tertiary repairs than cases without primary PVR. Health care claims analysis may be a useful tool to study population-based estimates for multiple recurrences of RD in cases with PVR. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Early Reexploration for Bleeding Is Associated With Improved Outcome in Cardiac Surgery.

BACKGROUND: Reexploration after cardiac surgery, most frequently for bleeding, is a quality metric used to assess surgical performance. This may cause surgeons to delay return to the operating room in favor of attempting nonoperative management. This study investigated the impact of the timing of reexploration on morbidity and mortality. METHODS: This study was a single-institution retrospective review of all adult cardiac surgery patients from July 2010 to June 2020. Time to reexploration was assessed, and outcomes were compared across increasing time intervals. Reported bleeding sites were classified into 5 groups, and bleeding rate (chest tube output) was compared across bleeding sites. Univariable analysis was performed using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic regression models were used for risk-adjusted analyses. RESULTS: Of 10 070 eligible patients, 251 (2.5%) required reexploration for postoperative bleeding. The most common site of bleeding was "any suture line" (n = 70; 28%). Interestingly, in 30% of cases (n = 75) "no active bleeding" site was reported. The highest rate of bleeding (mL/h) was observed in the "any mediastinal structure" group (median, 450; interquartile range [IQR], 185, 8878), and the lowest rate was noted in the "no active bleeding" group (median, 151.2; IQR, 102, 270). Both morbidity rates (0-4 hours, 12.3% vs 25-48 hours, 37.5%; P = .001) and mortality rates (0-4 hours, 3.1% vs 25-48 hours, 43.8%; P = .001) escalated significantly with increasing time to reexploration. CONCLUSIONS: Delayed reexploration for bleeding after cardiac surgery is associated with increased risk for morbidity and mortality. Early surgical intervention, particularly within 4 hours, may improve outcomes. Implications from using reoperation as a performance metric may lead to unnecessary delay and patient harm.

National emergency department trends for endogenous endophthalmitis: an increasing public health challenge.

BACKGROUND/OBJECTIVE: To characterize incidence rates and identify risk factors for admission and mortality in patients with endogenous endophthalmitis (EE) in the United States (US). SUBJECTS/METHODS: Patients with EE were identified using the Nationwide Emergency Department (NEDS) Database from 2006 to 2017 in this cross-sectional study. Subjects were required to have diagnoses of both endophthalmitis and septicaemia using contemporary International Classification of Diseases diagnosis codes. Incidence rates, mortality rates and demographics were evaluated. Risk factors for admission and mortality were identified using weighted logistic regression analysis. RESULTS: A total of 6400 patients with EE were identified. Incidence increased from 0.10 (95% confidence interval [CI]: 0.07-0.12) per 100,000 in the US population in 2006 to 0.25 (95% CI: 0.21-0.30) in 2017 (p < 0.05). Most were female (55.4%), insured with Medicare (53.5%), were in the first income quartile earnings (29.3%) [bottom 25% income bracket], lived in the South (40.5%), and presented to metropolitan teaching hospitals (66.6%). Mortality increased from 8.6% (95% CI: 3.8-18.3%) in 2006 to 13.8% (95% CI: 9.7-19.2%) in 2017 (p = 0.94). Factors predicting admission included older age (odds ratio [OR] 32.59; [95% CI 2.95-359.78]) and intravenous drug use (OR 14.90 [95% CI: 1.67-133.16]). Factors associated with increased mortality included: human immunodeficiency virus infection/immune deficiencies (OR 2.58 [95% CI: 1.26-5.28]), heart failure (OR 2.12 [95% CI: 1.47-3.05]), and hepatic infections/cirrhosis (OR 1.89 [95% CI: 1.28-2.79]). Pneumonia and renal/urinary tract infections (UTI) were associated with both increased hospital admission [(pneumonia OR 9.64 (95% CI: 1.25-74.35, p = 0.030), renal/UTI OR 4.09 (95% CI: 1.77-9.48)] and mortality [(pneumonia OR 1.64 (95% CI: 1.17-2.29, p = 0.030), renal/UTI OR 1.87 (95% CI: 1.18-2.97)]. Patients with diabetes mellitus (DM) had decreased odds ratio for mortality (OR 0.49 [95% CI: 0.33-0.73]). CONCLUSION: EE has increased in incidence throughout US. The two systemic factors that conferred both an increase in mortality and admission were pneumonia, and renal/UTI. Additional exploration of the potential protective association of DM with decreased mortality in this context is needed.

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Factors Associated with Length of Stay and Cost among Pediatric Hospitalizations with a Primary Ophthalmic Diagnosis.

PURPOSE: To investigate factors associated with prolonged length of stay and high cost among pediatric hospitalizations with a primary ophthalmic diagnosis. METHODS: This retrospective, cross-sectional study utilized data on pediatric admissions with a primary ophthalmic diagnosis from the multicenter 2016 Kids' Inpatient Database. Multivariable logistic regression models adjusted for demographic, hospital, and admission characteristics were used to evaluate factors associated with prolonged stay and high cost, defined as exceeding the 75th percentile (>4 days and $12,642, respectively). RESULTS: An estimated 6,811 pediatric hospitalizations with a primary ophthalmic diagnosis in the United States in 2016 were included. On adjusted analysis, a prolonged length of stay was more likely with Medicaid (vs. private insurance, OR = 1.19, 95% CI: [1.02, 1.40], p = .03), non-trauma (vs. trauma, OR = 2.77, 95% CI: [2.12, 3.63], p < .001) and urban teaching hospitals (vs. rural, OR = 3.48, 95% CI: [1.04, 11.69], p = .04). A high cost of stay was more likely with higher income levels (Quartile 3 vs. 1, OR = 1.30, 95% CI: [1.02, 1.67], p = .04; Quartile 4 vs. 1, OR = 1.49, 95% CI: [1.08, 2.05], p = .02), private insurance (vs. Medicaid, OR = 1.26, 95% CI: [1.04, 1.53], p = .02), Western hospitals (vs. South, OR = 2.74, 95% CI: [1.83, 4.12], p < .001), and trauma (vs. non-trauma, OR = 3.29, 95% CI: [2.57, 4.21], p < .001). Children and young adults had higher odds of prolonged stay, while adolescents and young adults had higher odds of high cost compared to toddlers (p < .05 for all). CONCLUSIONS: Additional work addressing the factors associated with higher resource utilization may help promote the delivery of quality inpatient pediatric eye care.

Association Between Early Speech-Language Pathology Consultation and Pneumonia After Cardiac Surgery.

PURPOSE: Patients undergoing cardiac surgery are reported to be at higher risk for oropharyngeal dysphagia and aspiration, which may predispose them to respiratory complications such as pneumonia. Speech-language pathology consultation facilitates early identification of swallowing difficulties providing appropriate and timely interventions during the postoperative period. This study explores the association between pneumonia and timing of speech-language pathology order entry and evaluation following cardiac surgery. METHOD: A retrospective study was performed on adults who underwent cardiac surgery in a tertiary care center, from July 2016 through December 2019. Patients with preexisting tracheostomy upon admission for cardiac surgery were excluded. The medical records of patients who had speech-language pathology consultation orders for swallowing concerns were analyzed in order to compare the timing of speech-language pathology order entry, completion of speech-language pathology evaluation, and incidence of pneumonia during hospitalization following cardiac surgery. RESULTS: During the study period, 3,168 patients underwent cardiac surgery, of which 2,864 patients met the inclusion criteria. Speech-language pathology was ordered for 473 cases (16.5%), and clinical swallow evaluation (CSE) was completed by speech-language pathology in 419 patients (88.6%), of which 309 patients were suspected to have dysphagia (73.7%). Among the 2,391 patients without speech-language pathology consultation, pneumonia was reported in 34 patients (1.42%). Pneumonia was reported in 53 patients in the speech-language pathology cohort, of which 43 patients (13.9%) were suspected to have dysphagia. Patients with pneumonia had significantly longer median time (20.0 hr, range: 4.9-26.7) from speech-language pathology orders to completion of CSE, compared to those without pneumonia (13.2 hr, range: 3.2-22.4, p = .025). There was no significant difference in the median time from extubation to speech-language pathology consultation order time in patients with pneumonia versus those without pneumonia. Patients with pneumonia were observed to have prolonged, although not statistically significant, median time from extubation to CSE (70.4 hr, range: 21.2-215) compared to those without pneumonia (42.2 hr, range: 19.5-105.8, p = .066). CONCLUSIONS: Patients without pneumonia in the postoperative period were observed to have shorter median time from extubation to speech-language pathology evaluation. Future studies are needed to further understand the impact of early speech-language pathology consultation and incidence of pneumonia in this population.

Accuracy of Chest Computed Tomography in Distinguishing Cystic Pleuropulmonary Blastoma From Benign Congenital Lung Malformations in Children.

Importance: The ability of computed tomography (CT) to distinguish between benign congenital lung malformations and malignant cystic pleuropulmonary blastomas (PPBs) is unclear. Objective: To assess whether chest CT can detect malignant tumors among postnatally detected lung lesions in children. Design, Setting, and Participants: This retrospective multicenter case-control study used a consortium database of 521 pathologically confirmed primary lung lesions from January 1, 2009, through December 31, 2015, to assess diagnostic accuracy. Preoperative CT scans of children with cystic PPB (cases) were selected and age-matched with CT scans from patients with postnatally detected congenital lung malformations (controls). Statistical analysis was performed from January 18 to September 6, 2020. Preoperative CT scans were interpreted independently by 9 experienced pediatric radiologists in a blinded fashion and analyzed from January 24, 2019, to September 6, 2020. Main Outcomes and Measures: Accuracy, sensitivity, and specificity of CT in correctly identifying children with malignant tumors. Results: Among 477 CT scans identified (282 boys [59%]; median age at CT, 3.6 months [IQR, 1.2-7.2 months]; median age at resection, 6.9 months [IQR, 4.2-12.8 months]), 40 cases were extensively reviewed; 9 cases (23%) had pathologically confirmed cystic PPB. The median age at CT was 7.3 months (IQR, 2.9-22.4 months), and median age at resection was 8.7 months (IQR, 5.0-24.4 months). The sensitivity of CT for detecting PPB was 58%, and the specificity was 83%. High suspicion for malignancy correlated with PPB pathology (odds ratio, 13.5; 95% CI, 2.7-67.3; P = .002). There was poor interrater reliability (κ = 0.36 [range, 0.06-0.64]; P < .001) and no significant difference in specific imaging characteristics between PPB and benign cystic lesions. The overall accuracy rate for distinguishing benign vs malignant lesions was 81%. Conclusions and Relevance: This study suggests that chest CT, the current criterion standard imaging modality to assess the lung parenchyma, may not accurately and reliably distinguish PPB from benign congenital lung malformations in children. In any cystic lung lesion without a prenatal diagnosis, operative management to confirm pathologic diagnosis is warranted.

Risk of Cystoid Macular Edema after Cataract Surgery in Retinitis Pigmentosa: An Analysis of United States Claims from 2010 to 2018.

PURPOSE: Cataract surgery is commonly performed to improve vision in patients with retinitis pigmentosa (RP). However, the risk of postoperative cystoid macular edema (CME) in RP remains unclear. Here, we leveraged a large multiyear claims database to estimate the risk of CME after cataract surgery in patients with and without RP. DESIGN: Retrospective multicenter cohort. SUBJECTS: Patients aged 18 to 65 years who underwent single-phase cataract surgery between January 1, 2020, and December 31, 2018. Identified using the IBM MarketScan claims database. METHODS: We evaluated the baseline characteristics and outcomes and estimated the hazard ratio (HR) using a multivariable mixed-effects approach. The eyes of patients with RP were categorized as group R1, and those without diagnoses of RP by the time of surgery were categorized as group R0. MAIN OUTCOME MEASURES: Incident postoperative CME in the same eye that underwent cataract extraction within 12 months of the procedure. RESULTS: We included 468 123 patients and 615 645 eyes. This included 124 eyes with RP (R1) and 615 521 without RP (R0). The mean ages were 50.5 ± 9.8 years in R1 and 57.9 ± 6.1 years in R0. The cumulative incidence of CME at 12 months was 5.8% (95% confidence interval [CI] 1.2%-10.3%) in R1, and it was 1.1% (95% CI 1.1%-1.2%) in R0. On average, CME was reported in R1 subjects 3.9 weeks later than in R0 subjects (95% CI 2.04-6.5 weeks; P <0.001). The subjects in R1 had 4.83 (95% CI 2.13-10.93, P <0.001) times the risk of CME compared to the subjects in R0. A stratified analysis showed that epiretinal membrane (ERM) decreased the risk of CME in R1 (HR 0.12 [95% CI 0.48-0.97; P = 0.004]) but increased it in R0 (HR, 4.32 [95% CI 3.13-5.95; P <0.001]). CONCLUSIONS: The cataract surgery-related risk of CME among patients with RP may be >4 times that among people without RP. Men and individuals aged 18 to 34 and 55 to 65 years may be at the greatest risk, whereas ERM may lower the risk. Further study is warranted to stratify the risk by RP genotype and phenotype and illuminate the natural history, angiographic features, and functional consequences of postoperative CME.

Preoperative Opioid Dose and Surgical Outcomes in Colorectal Surgery.

BACKGROUND: The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients. METHODS: Adult colectomy patients in the IBM MarketScan database (2010-2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression. RESULTS: Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1-49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose-response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1-49 MME: OR 1.19, 95% CI 1.08-1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20-2.24, p = 0.002). Similar dose-response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all). CONCLUSIONS: Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.