Risks of adverse events in colorectal patients: population-based study.

BACKGROUND: Postoperative (PO) outcomes are rapidly being integrated into value-based purchasing programs and associated penalties are slated for inclusion in the near future. Colorectal surgery procedures are extremely common and account for a high proportion of morbidity among general surgery. We sought to assess adverse events in colorectal surgical patients. METHODS: We performed a retrospective study using the Nationwide Inpatient Sample database, 2008-2012. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and classified based on procedure indication: colon cancer, benign polyps, diverticulitis, inflammatory bowel disease, and ischemic colitis. The outcome of interest was inpatient adverse event identified by Agency for Healthcare Research and Quality's patient safety indicators (PSIs). RESULTS: We identified 1,100,184 colorectal patients who underwent major surgery; 2.7% developed a PSI during their hospital stay. Compared to all colorectal patients, those with ischemic colitis had significantly higher risk-adjusted rates per 1000 case for pressure ulcer (50.20), failure to rescue (211.30), central line bloodstream infection (2.33) and PO DE/deep vein thrombosis (16.02), and sepsis (46.99), whereas benign polyps were associated with significantly lower risk-adjusted rates per 1000 cases for pressure ulcer (11.48), failure to rescue (84.79), central line bloodstream infection (0.97) and PO pulmonary embolism/deep vein thrombosis (4.81), and sepsis (11.23). Compared to both patient demographic and clinical characteristics, the procedure indication was the strongest predictor of any PSI relevant to colorectal surgery; patients with ischemic colitis had higher odds of experiencing a PSI (odds ratio, 1.84; 95% confidence interval, 1.71-1.99) compared with cancer patients. CONCLUSIONS: Among colorectal surgery patients, inpatient events were not uncommon. We found important differential rates of adverse events by diagnostic category, with the highest odds ratio occurring in patients undergoing surgery for ischemic colitis. Our work elaborates the need for rigorous risk adjustment, quality improvement strategies for high-risk populations, and attention to detail in calculating financial incentives in emerging value-based purchasing programs.

Efficacy of Topical Treatments for Chrysaora chinensis Species: A Human Model in Comparison with an In Vitro Model.

OBJECTIVES: This study sought to create a model for testing topical treatment of jellyfish stings. It sought to determine which treatments 1) stimulate/inhibit nematocyst discharge; 2) decrease pain; and 3) decrease skin inflammation; it also sought to discover whether there is a clinical correlation between stimulated nematocyst discharge observed in vitro to the pain and erythema experienced by humans stung by a particular species of jellyfish, C chinensis. METHODS: Chrysaora chinensis stung 96 human subjects, who were then treated with isopropyl alcohol, hot water, acetic acid, papain meat tenderizer, lidocaine, or sodium bicarbonate. Pain and erythema were measured. In a separate experiment, nematocysts were examined microscopically after exposure to the same topical treatments used in the human experiment. RESULTS: Forearms treated with papain showed decreased mean pain over the first 30 minutes after being stung, relative to placebo, although only by a small amount. The other topical treatments tested did not reach statistical significance. Sodium bicarbonate may reduce erythema after 30 minutes of treatment; sodium bicarbonate and papain may reduce erythema at 60 minutes. The other topical treatments tested did not reach statistical significance. Nematocyst discharge in vitro occurred when tentacles of C chinensis were exposed to acetic acid or isopropyl alcohol. Sodium bicarbonate, papain, heated water, and lidocaine did not induce nematocyst discharge. CONCLUSIONS: Papain-containing meat tenderizer used as a topical treatment for C chinensis stings may decrease pain. Although there is published experimental support for the concept that in vitro nematocyst discharge correlates with in vivo human pain perception, no definitive randomized controlled trial, including ours, has yet provided incontrovertible evidence of this assertion. Despite this study's limitations, it presents a viable basis for future human studies looking at the efficacy of topical treatments for jellyfish stings.

Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: Patients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization. METHODS: We linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality. RESULTS: Of 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred. CONCLUSIONS: The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.