Impact of risk factors on in-hospital mortality for octogenarians undergoing cardiac surgery.

BACKGROUND: Octogenarians undergoing cardiac surgery have higher mortality than their younger counterparts. OBJECTIVES: To determine if various risk factors have the same effect on mortality in octogenarians as in younger patients. METHODS: The National Inpatient Sample data set from 2004 to 2014 was queried to select patients aged 65 years and older who underwent either coronary artery bypass grafting (CABG), valvular heart surgery (VHS), or both (CABG + VHS) within 10 days of hospital admission. The patients were divided into two groups 65-79 years and 80 years and greater. Hospital mortality, patient demographics, comorbidities, and type of hospital admission was evaluated and compared using χ2 and multivariable logistic regressions. RESULTS: About 397,713 patients were identified including 86,345 (21.7%) aged 80 and above. Octogenarians had higher in-hospital mortality for all procedures: CABG (4.94% vs. 2.39%, p < .001), VHS (5.49% vs. 4.08%, p < .001), and CABG + VHS (7.59% vs. 5.95%, p < .001), and this relationship persisted when gender, race, comorbidities, and type of hospital admission were controlled for: CABG (odds ratio [OR] = 1.71; 95% confidence interval [CI] 1.62-1.81); VHS (OR = 1.18; 95% CI 1.11-1.27); and CABH + VHS (OR = 1.17; 95%CI 1.10-1.26). Female gender, renal, or heart failure, nonelective admission, and CABG + VHS were associated with increased risk of in-hospital mortality. Octogenarians had higher rates of these factors (p < .001). The effect size of renal and heart failure and type of surgery was smaller for octogenarians. CONCLUSIONS: Octogenarians undergoing cardiac surgery have higher rates of nonelective admissions, renal and heart failure, and female gender, which are most strongly associated with in-hospital mortality. Differing effect sizes suggest that certain risk factors, such as renal and heart failure, contribute more to mortality in younger patients.

Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy.

BACKGROUND: Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. METHODS: The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. RESULTS: A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64 years vs. 83.4% in patients aged ≥80 years, P < 0.0001) and with symptomatic presentation (odds ratio [OR] = 1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P < 0.002) and confirmed by multivariable analysis (OR = 1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115 minutes; Interquartile range (IQR): 89-145 versus median: 93 minutes; IQR: 76-119, respectively; P < 0.0001). Hospital length of stay was greater in GA than in RA (median: 1 day; IQR 1-2 vs. median: 1 day; IQR 1-1, respectively; P < 0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P = 0.02). CONCLUSIONS: Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.

Modified frailty index as an indicator for outcomes, discharge status, and readmission after lower extremity bypass surgery for critical limb ischemia.

Frailty has been associated with poor postoperative outcomes. This study evaluated the 5-factor modified frailty index (mFI-5) to assess complications, mortality, discharge disposition, and readmission in patients undergoing lower extremity (LE) bypass for critical limb ischemia (CLI).The National Surgical Quality Improvement Program vascular module (2011-2017) was utilized to identify patients undergoing LE bypass for CLI. Adverse events included infectious complications, bleeding complications, prolonged ventilation, amputation, readmission, and death. Patients were divided into groups based on mFI-5 scores: mFI1 (0), mFI2 (0.2), mFI3 (0.4), and mFI4 (0.6-1). Data were analyzed using the Cochran-Mantel-Haenszel statistic for general association and multivariable logistic regression. About 11,530 patients undergoing bypass for CLI were identified (42% rest pain and 58% tissue loss; 23% mFI1, 31% mFI2, 27% mFI3, and 19% mFI4; 64% men and 36% women). An increase in mFI-5 was associated with higher 30-day mortality (mFI1 = 0.62%; mFI12 = 1.45%; mFI13 = 1.35%; and mFI14 = 3.09%; P < .0001). After adjustment for age, mFI4 was associated with increased mortality compared with mFI1 (odds ratio, 3.80; 95% confidence interval, 1.69-8.54). Increased mFI-5 was associated with bleeding complications, wound infections, urinary tract infections, prolonged ventilation, sepsis, unplanned reoperations, and discharge to nonhome destination (all P < .01). Compared with mFI1 (13.5%), mFI4 was associated with increased 30-day readmission (24.8%, P < .0001). In patients undergoing LE bypass for CLI, higher mFI-5 was associated with increased postoperative complications, in-hospital and 30-day mortality, nonhome discharge, and 30-day readmission. The mFI-5 as an easily calculated tool can identify patients at high risk for inferior outcomes. It should be incorporated into discharge planning after LE bypass for CLI.

Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample.

Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005-2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.

Improved operative and recovery times with mini-thoracotomy aortic valve replacement.

BACKGROUND: The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy. METHODS: We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared. RESULTS: Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67-113) minutes; vs. 117 (93.5-139.5); vs. 102.5 (85.5-132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5-9) days; vs. 7 (5-14.5); vs 9 (6-15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)]. CONCLUSIONS: Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.

Contemporary Analysis of Calculous Nephrectomy Utilization and Outcomes in the United States.

Introduction: Calculous nephrectomy was a mainstay of treatment of complex upper tract stone disease up until the 1970s, but data on its contemporary utilization in the current era of rising rates of stone disease are lacking. We characterized the nationwide utilization and outcomes for calculous nephrectomy in the United States. Patients and Methods: The National/Nationwide Inpatient Sample databases for 2001 to 2014 were queried for adults with a principal diagnosis of upper urinary tract calculi (UUTCs), who underwent nephrectomy as well as other inpatient surgeries for UUTCs. Per-population trend in utilization of calculous nephrectomy was analyzed using negative binomial regression. The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTCs was analyzed using the Cochran-Armitage test. Patient demographics, hospital characteristics, perioperative outcomes, and complications were analyzed using appropriate statistical tests. Results: Of almost 1.42 million inpatient UUTC procedures performed over the study period, 9232 (0.65%) were calculous nephrectomies. Per-population utilization rate for calculous nephrectomy decreased significantly over time (incidence rate ratio = 0.82; 95% confidence interval = 0.73-0.91, p < 0.001). The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTC also decreased significantly over time (p < 0.0001). Majority of the procedures were performed in females, in urban teaching hospitals, and in the Southern United States. The overall complication rate was 38.3%, most commonly hemorrhage requiring transfusion (15.6%). Older age, female gender, and nonprivate insurance or lack of insurance were significant predictors of increased risk of complications, whereas hospitalization in urban hospitals was a predictor of lower risk. Conclusions: Despite increasing prevalence of stone disease in the United States in the contemporary era, utilization of calculous nephrectomy is low and is declining. Inpatient complication rates are moderately high and influenced by patient sociodemographic and hospital characteristics.

Children after motor vehicle crashes: Restraint utilization and injury severity.

BACKGROUND: Although injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity. METHODS: A retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0-7, 8-12, 13-16, 17-18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1-9], moderate [10-15], severe [16-25], and profound [>25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics. RESULTS: In all age groups head/neck injuries were most common (55-63%), while abdominal and pelvic injuries were least likely except group 8-12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0-7). It decreased with aging and children aged 17-18 years were significantly less likely to be IUR compared to those 0-7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35-0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2-14) and 5(1-9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39-0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48-7.43). CONCLUSION: Restraint quality has significant impact on injury severity in children after MVC. LEVEL OF EVIDENCE: Level III.

Contemporary trends and outcomes of thrombolytic therapy for acute lower extremity ischemia.

OBJECTIVE: Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia. METHODS: Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN). RESULTS: A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001). CONCLUSION: Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.

Impact of Patient Safety Indicators on readmission after abdominal aortic surgery.

Patient safety is a critical component of health-care quality and measures created by the Agency for Healthcare Research and Quality (AHRQ) to identify hospitalizations with potentially preventable adverse events. This analysis evaluated whether Patient Safety Indicator (PSI) events after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) were associated with increased risk of readmission. Patients undergoing elective repair of nonruptured AAA from 2009 to 2012 were selected in the Medicare Provider Analysis and Review files using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To identify PSI events, we used the AHRQ PSI International Classification of Diseases, Ninth Revision, Clinical Modification numerator codes. Chi-square test, multivariable logistic regression analysis, nonparametric Wilcoxon rank sum test, and Kaplan-Meier survival analysis were used for statistics. A total of 66,923 patients undergoing elective AAA repair were evaluated: (1) 9,315 with OSR and (2) 57,608 with EVAR. The most frequent PSI events after OSR versus EVAR were postoperative respiratory failure (PSI, 11; 17.7% vs 1.8%; P < .0001); perioperative hemorrhage/hematoma (PSI, 9; 3.6% vs 2.6%; P < .0001); postoperative sepsis (PSI, 13; 3.5% vs 0.4%; P < .0001); accidental puncture or laceration (PSI, 15; 2.1% vs 0.6%; P < .0001); and postoperative acute kidney injury requiring dialysis (PSI, 10; 1.4% vs 0.2%; P < .0001). The overall 30-day readmission rate was 10.5%. The occurrence of any PSI event overall significantly increased 30-day readmission compared with no event cases (odds ratio [OR] = 1.71; 95% confidence interval [CI], 1.57-1.86). Likelihood of 30-day readmission was greater for postoperative acute kidney injury requiring dialysis (OR = 1.66; 95% CI, 1.28-2.15), postoperative respiratory failure (OR = 1.36; 95% CI, 1.22-1.52), perioperative hemorrhage (OR = 1.34; 95% CI, 1.18-1.52), and postoperative pressure ulcer (OR = 2.88; 95% CI, 1.99-4.17). Occurrence of any PSI event was associated with an increased total hospital and intensive care unit length of stay and total hospital charges (all P < .001). In conclusion, AHRQ PSI events may be used to identify patients at the greatest risk for readmission after AAA repair. The risk for 30-day readmission was 71% higher when a PSI event occurred and was not associated with the type of repair. Minimizing preventable PSI events may be beneficial to reducing hospital readmissions after open and endovascular AAA repair and to improving hospital resource utilization.

Percutaneous Nephrolithotomy in Children: Analysis of Nationwide Hospitalizations and Short-Term Outcomes for the United States, 2001-2014.

OBJECTIVE: To describe population-wide utilization rates and outcomes of percutaneous nephrolithotomy (PCNL) in the management of pediatric upper urinary tract calculi (UUTC). PATIENTS AND METHODS: Patients <18 years with a diagnosis of UUTC, who underwent PCNL between 2001 and 2014 were identified from the National Inpatient Sample database. Annual PCNL rates, based on the at-risk population for each year, were estimated, and change in utilization rate was analyzed using negative binomial regression. Perioperative outcomes, hospital length of stay (LOS), and costs were determined; continuous and categorical variables were analyzed using nonparametric tests and Chi-squared tests, respectively. Trends tests and multivariable analyses (MVAs) were also performed where appropriate. RESULTS: An estimated 3206 pediatric PCNL procedures were performed. Mean annual PCNL rate increased significantly relative to 2001 (incidence rate ratio = 1.40; 95% confidence interval 1.15-1.71, p = 0.001). Proportion of PCNL as a fraction of all inpatient surgical procedures for UUTC also significantly increased over time, from 15.7% in 2001 to 26.4% in 2014 (p < 0.0001). Complications overall occurred in 20.7% of cases, with a significantly rising rate over time period (p < 0.0001). Complication rates were similar across hospital types and geographic regions. Median hospitalization cost was significantly higher for the West than for each of the other regions (p < 0.05 in each case). Median LOS was also highest for the West (4 days vs 3 days for each of the other regions). In MVA, significant predictors of both increased LOS and costs included black race, comorbidities of hypertension, diabetes, coagulopathy and neurologic disease, hospitalization in the South, and presence of complications. Race, gender, comorbidities, and treatment year were among the predictors of complications. CONCLUSIONS: PCNL utilization in the management of pediatric UUTC has significantly increased since 2001, with an associated increase in complication rates, although major complications were uncommon. Regional variations in costs and LOS were evident.

Injury patterns and outcomes in late middle age (55-65): The intersecting comorbidity with high-risk activity - A retrospective cohort study.

BACKGROUND: Late middle age (LMA), is a watershed between youth and old age, with unique physical and social changes and declines in vitality, but a desire to remain active despite increasing comorbidity. While post-injury outcomes in the elderly are well studied, little is known regarding LMA patients. We analyzed the injured LMA population admitted to a rural, regional Level 1 Trauma Center relative to outcomes for both younger and older patients. MATERIALS AND METHODS: Our registry was queried retrospectively for patients admitted 7/2008- 12/2015; they were divided into three cohorts: 18-54, 55-65, and >65 years. Demographics, injury details, comorbidities, and outcomes were compiled and compared using ANOVA and Chi-square; p < 0.05 was significant. RESULTS: During the study period, 10,543 were admitted; 1419 (14%) were LMA who experienced overall injury mechanisms, severities and patterns that mirrored the younger cohort. However comorbidity rates were high (56.4%) and comparable to the elderly. LMA patients had the highest rates of alcohol abuse, morbid obesity, and psychiatric illness (p < 0.0001) and suffered the poorest outcomes: highest complications and hospital charges, and longest ICU and hospital LOS. LMA mortality (4.1%) was 41% higher than younger patients (2.9%; p < 0.02) and similar to the older cohort (4.7%; p = 0.32). CONCLUSIONS: The LMA population has similar mechanisms and injury patterns to younger patients, while exhibiting comorbidity rates similar to the elderly. High-energy injuries exact a greater toll in LMA with poorer outcomes and greater resource utilization. Targeted outreach for injury prevention, and future studies, are needed to address high-risk behavior, substance abuse, and societal contributors.

Racial and Socioeconomic Disparities After Carotid Procedures.

BACKGROUND: Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established. MATERIALS AND METHODS: Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics. RESULTS: We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001). CONCLUSIONS: Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Disparities in the Use of Continent Urinary Diversions after Radical Cystectomy for Bladder Cancer.

BACKGROUND: Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. OBJECTIVE: Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC. METHODS: Using the National Inpatient Sample 2001-2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t-tests were used for analysis. RESULTS: Between 2001-2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 (p < 0.0001). Patients of all ages received ICs at a higher rate than CDs (40-59 years: 79.5% vs. 20.5%; 60-69 years: 88.0% vs. 12.0%; p < 0.0001). There was a difference in males vs. females (10.2% vs. 4.0%; OR 2.36) and Caucasians vs. African Americans (9.0% vs. 6.7%; OR 1.49) when comparing CD rates. CD rates were highest in the West, urban teaching centers, and large hospitals (p < 0.001). ICs were associated with higher rates of overall postoperative complications (p = 0.0185) including infection (p = 0.002) and mortality (p < 0.0001). In-hospital costs were greater for the CD group. CONCLUSIONS: The number of CDs has declined recently. Patients of all ages are more likely to receive ICs than CDs. Gender, racial, and geographic disparities exist among those receiving CDs. CDs are associated with lower rates of in-hospital complications and mortality, but higher in-hospital costs.

Pediatric hospitalizations for upper urinary tract calculi: Epidemiological and treatment trends in the United States, 2001-2014.

INTRODUCTION: The incidence of urolithiasis in the pediatric population in the United States has steadily been increasing over the past few decades. Few studies to date have examined trends in the hospitalization and inpatient surgical treatment of urolithiasis in the pediatric population using nationally representative data. OBJECTIVE: The aim was to evaluate nationwide trends in the rates of pediatric hospitalization and inpatient surgical activity for upper urinary tract calculi (UUTC) in the United States from 2001 to 2014. PATIENTS AND METHODS: The National Inpatient Sample (NIS) databases for 2001-2014 were queried. Hospitalizations for patients younger than age 18 (excluding newborns), with principal discharge diagnoses of kidney or ureteral calculi were selected. Surgical procedures during hospitalization were identified. Hospitalization and surgical activity data were analyzed using trends tests, chi-square statistics, and multivariable logistic regression as appropriate. RESULTS: Of an estimated 30.2 million pediatric hospitalizations during the study period, 44,369 overall (147 per 100,000) were for UUTC. The total number and proportion of UUTC hospitalizations per 100,000 all-cause admissions significantly decreased between 2001 and 2014 (p < 0.0001) (figure). Surgical intervention was undertaken in 19,946 (45%) of UUTC hospitalizations, with significantly increasing frequency over the study interval (p < 0.0001). Urinary tract drainage was the most frequently performed surgical intervention. On multivariable analysis, significant predictors of a higher likelihood of undergoing inpatient surgical intervention during hospitalization for UUTC included older age, female gender, deficiency anemias, hypertension, neurologic disorders, paralysis, and hospitalization after 2001. DISCUSSION: The declining trend in hospitalization for UUTC likely reflects a shift toward outpatient care for routine cases, reserving hospitalization for sicker patients or those with complications of urolithiasis. Similar to previous studies, we also observed that girls were significantly more likely than boys to be hospitalized for stone disease, and that majority of the stone activity in the pediatric population was in children aged 15-17 years. We also observed a sharp increase in the proportion of hospitalized patients who underwent surgical intervention between 2001 and 2014, but the primary driver of this trend remains uncertain. CONCLUSION: Pediatric hospitalizations for UUTC in US children significantly decreased between 2001 and 2014, while of those hospitalized the proportion who underwent stone-related surgical intervention significantly increased over the same period. A shift towards outpatient care, reserving hospitalization and inpatient surgical care for sicker patients, those with urolithiasis-related complications, or those who fail conservative management, is a possible explanation for these observed trends.

Diabetes control decreases morbidity and mortality after carotid endarterectomy.

BACKGROUND: Single-institution studies have demonstrated a negative effect of diabetes mellitus on outcomes after carotid endarterectomy (CEA). The aim of this study was to compare patients with explicitly controlled and uncontrolled diabetes at the population level. METHODS: Using the National Inpatient Sample 2006-2013, we selected patients undergoing CEA. Rates of stroke, myocardial infarction (MI), and hospital mortality, as well as duration of stay and cost were compared among patients with uncontrolled diabetes (UCDM), well-controlled diabetes (WCDM), and those without diabetes (NDM). RESULTS: We reviewed data from 614,190 patients undergoing CEA. Patients with UCDM, compared with those with WCDM and NDM, had higher rates of stroke (3.27%, 0.93%, and 0.94%, respectively; P < .0001), MI (3.35%, 1.10%, and 0.87%, respectively; P < .0001), and higher hospital mortality (1.43%, 0.25%, and 0.27%, respectively; P < .0001). On multivariate analysis, patients with UCDM compared with WCDM were more likely to develop stroke (odds ratio[OR], 1.45; 95% confidence interval [CI], 1.23-1.71), and MI (OR, 2.26; 95% CI, 1.96-2.60) and were more likely to die (OR, 2.74; 95% CI, 2.19-3.42). Patients with WCDM compared with patients without diabetes had similar likelihoods of stroke (OR, 0.96; 95% CI, 0.90-1.02) and MI (OR, 1.04; 95% CI, 0.98-1.10) but were actually less likely to die (OR, 0.85; 95% CI, 0.76-0.95). CONCLUSION: Patients with uncontrolled diabetes had poorer outcomes after CEA than those with controlled diabetes, whose outcomes were comparable to if not better than individuals without diabetes.

The effect of preoperative liver dysfunction on cardiac surgery outcomes.

BACKGROUND: To determine the impact of preoperative Liver Dysfunction (LD) on outcomes after elective Coronary Artery Bypass Grafting (CABG) and Valvular surgery (VS). METHODS: The Nationwide Inpatient Sample (2002-2010) was queried to identify patients with LD who had elective CABG or VS utilizing ICD-9-CM diagnosis and procedure codes. These patients were matched with the similar patients without LD (controls) by propensity score matching. Chi-square and Wilcoxon rank sum tests were used for analysis. RESULTS: We identified 1197 patients with LD (CABG = 755; VS = 442) who were matched to 2394 controls. LD significantly increased hospital mortality after both CABG (OR = 5.19; 95%CI = 2.93-9.20) and VS (OR = 7.49; 95%CI = 3.12-17.96). Overall rates of complications after CABG with LD were greater than in non-complicated cases (OR = 1.73; 95%CI = 1.46-2.05). Among them, there was an increase in bleeding (OR = 1.81;95%CI = 1.44-2.28), respiratory (OR = 2.33;95%CI = 1.86-2.93), renal (OR = 2.79;95%CI = 2.04-3.81), and infectious (OR = 2.93;95%CI = 2.14-4.01) complications. In general, the rates of complications after VS with LD were also greater than in non-complicated cases (OR = 2.77;95%CI = 2.13-3.60), specifically for bleeding (OR = 3.07;95%CI = 2.17-4.34), respiratory (OR = 3.57;95%CI = 2.51-5.07), renal (OR = 4.40;95%CI = 2.80-6.92), and infectious (OR = 4.63;95%CI = 2.85-7.51) complications. The development of LD significantly increased mean hospital length of stay (LOS) and total hospital charges after both CABG (from7.0 ± 4.0 to 9.2 ± 9.1 days and from $100,265 ± 87,107 to $117,756 ± 99,320, respectively; P < 0.0001 for both) and VS (from 7.9 ± 5.0 to 11.4 ± 9.9 days and from $134,306 ± 114,216 to $176,620 ± 147,049, respectively; P < 0.0001 for both). CONCLUSIONS: LD worsened the outcomes after cardiac surgery. It increased rates of complications, hospital mortality, length of stay and total hospital charges after both procedures.

Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization.

OBJECTIVE: Angiotensin-converting enzyme inhibitors (ACEIs) have not been well evaluated in conjunction with lower extremity revascularization (LER). This study evaluated freedom from amputation in patients who underwent either an open (OPEN) or endovascular (ENDO) revascularization with and without utilization of an ACEI. MATERIALS AND METHODS: Patients who underwent LER were identified from 2007-2008 Medicare Provider Analysis and Review files. Demographics, comorbidities, and disease severity were obtained. Post-procedural use of an ACEI was confirmed using combining them with National Drug Codes and Part D Files. Outcomes were analyzed using chi-square analysis, Kaplan-Meier test, and Cox regression. RESULTS: We identified 22,954 patients who underwent LER: 8,128 (35.4%) patients with claudication, 3,056 (13.3%) with rest pain, and 11,770 (51.3%) with ulceration or gangrene. More patients underwent ENDO (14,353) than OPEN (8,601) revascularization and 38% of the cohort was taking an ACEI. Overall, ACEI utilization compared to patients not taking ACEI was not associated with lower amputation rates at 30 days (13.5% vs. 12.6%), 90 days (17.7% vs. 17.1%), or 1 year (23.9% vs. 22.8%) (P>0.05 for all). After adjustment for comorbidities, ACEI utilization was associated with higher amputation rates for patients with rest pain (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8). CONCLUSION: ACEI utilization was not associated with overall improved rates of amputation-free survival or overall survival in the vascular surgery population. However, an important finding of this study was that patients presenting with a diagnosis of rest pain and taking an ACEI who underwent a LER had statistically higher amputation rates and a lower amputation-free survival at 1 year. Further analysis is needed to delineate best medical management for patients with critical limb ischemia and taking ACEI who undergo vascular revascularization.

Outcomes after Motor Vehicle Trauma: Transfers to Level I Trauma Centers Compared with Direct Admissions.

BACKGROUND: The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services. OBJECTIVES: The objective of this study is to assess whether there is a difference in outcomes of patients transferred to Level I centers compared with direct admissions. METHODS: The Nationwide Inpatient Sample was queried to identify patients involved in motor vehicle accidents, using International Classification of Diseases, Ninth Revision, Clinical Modification E-codes. Patients that were admitted to Level I trauma centers were identified using American College of Surgeons or American Trauma Society designations. RESULTS: There were 343,868 patients that met inclusion criteria. Of these patients, 29.2% (100,297) were admitted to Level I trauma centers, 5.7% (5691) of which were identified as trauma transfers. The lead admitting diagnosis for transfers was pelvic fracture (11.5%). Caucasians were 2.62 times as likely to be transferred as African-Americans (confidence interval 2.32-2.97), and 3.71 times as likely as Hispanics (confidence interval 3.25-4.23). Despite transfer patients having higher adjusted severity scores and higher adjusted risk of mortality, there were no differences in mortality (p = 0.95). CONCLUSIONS: Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.

A contemporary evaluation of carotid endarterectomy outcomes in patients with chronic kidney disease in the United States.

Objectives Chronic kidney disease (CKD) has been identified as a significant risk factor for poor post-surgical outcomes. This study was designed to provide a contemporary analysis of carotid endarterectomy (CEA) outcomes in patients with CKD, end-stage renal disease (ESRD), and normal renal function (NF). Methods The Nationwide Inpatient Sample data 2006-2012 was queried to select patients aging 40 years old and above who underwent CEA during two days after admission and had a diagnosis of ESRD on long-term hemodialysis, patients with non-dialysis-dependent CKD, or NF. Patients with acute renal failure were excluded. We subsequently compared procedure outcomes and hospital resource utilization in these patients. Results Totally 573,723 CEA procedures were estimated: 4801 (ESRD)' 32,988 (CKD)' and 535,934 (NF). Mean age was 71.0 years, 57.7% were males, and 73.7% were white. Overall hospital mortality was 0.20%: 0.69% (ESRD), 0.35% (CKD), and 0.19% (NF), p < 0.0005 between groups. The overall stroke rate was 1.6%: 1.8% (ESRD), 2.0% (CKD), and 1.6% (NF). Comparing NF to CKD there was a significant difference: p < 0.0001. For CKD patients, compared to NF patients, there was an increased risk in cardiac complications (odds ratio = 1.2; 95% CI 1.15-1.32), respiratory complications (odds ratio = 1.2; 95% CI 1.15-1.32), and stroke (odds ratio = 1.1; 95% CI 1.04-1.23). For ESRD patients compared to NF patients there was an increased risk in respiratory complications (odds ratio = 1.3; 95% CI 1.08-1.47) and sepsis (odds ratio = 4.4; 95% CI 3.23-5.94). Mean length of stay and cost were: 2.8 d and $13,903 (ESRD), 2.2 d and $12,057 (CKD), and 1.8 d and $10,130 (NF), all p < 0.0001. Conclusions Patients with ESRD undergoing CEA had an increased risk of respiratory and septic complications, but not a higher risk of stroke compared to patients with normal renal function. The greatest risks of postoperative stroke, respiratory, and cardiac complications were found in patients with CKD. A diagnosis of ESRD and CKD were both found to significantly increase hospital mortality, length of stay and cost. Where clinicians typically consider ESRD patients the highest risk for CEA, further consideration should be given to patients with CKD not yet on dialysis as they had the higher risk of cardiac complications and stroke compared to the others evaluated.