Development and validation of a point-of-care clinical risk score to predict surgical site complication-associated readmissions following open spine surgery.

Background: Surgical site complications (SSCs) contribute to increased healthcare costs. Predictive analytics can aid in identifying high-risk patients and implementing optimization strategies. This study aimed to develop and validate a risk-assessment score for SSC-associated readmissions (SSC-ARs) in patients undergoing open spine surgery. Methods: The Premier Healthcare Database (PHD) of adult patients (n=157,664; 3,182 SSC-ARs) between January 2019 and September 2020 was used for retrospective data analysis to create an SSC risk score using mixed effects logistic regression modeling. Full and reduced models were developed using patient-, facility-, or procedure-related predictors. The full model used 37 predictors and the reduced used 19. Results: The reduced model exhibited fair discriminatory capability (C-statistic =74.12%) and demonstrated better model fit [Pearson chi-square/degrees of freedom (DF) =0.93] compared to the full model (C-statistic =74.56%; Pearson chi-square/DF =0.92). The risk scoring system, based on the reduced model, comprised the following factors: female (1 point), blood disorder [2], congestive heart failure [2], dementia [3], chronic pulmonary disease [2], rheumatic disease [3], hypertension [2], obesity [2], severe comorbidity [2], nicotine dependence [1], liver disease [2], paraplegia and hemiplegia [3], peripheral vascular disease [2], renal disease [2], cancer [1], diabetes [2], revision surgery [2], operative hours ≥5 [4], emergency/urgent surgery [2]. A final risk score (sum of the points for each surgery; range, 0-40) was validated using a 1,000-surgery random hold-out sample (C-statistic =85.16%). Conclusions: The resulting SSC-AR risk score, composed of readily obtainable clinical information, could serve as a robust predictive tool for unplanned readmissions related to wound complications in the preoperative setting of open spine surgery.

Comparative Effectiveness of Negative Pressure Wound Therapy With and Without Oxidized Regenerated Cellulose (ORC)/Collagen/Silver-ORC Dressing.

OBJECTIVE: Negative pressure wound therapy (NPWT) and oxidized regenerated cellulose (ORC)/collagen/silver-ORC (OCSO) dressings have individually demonstrated effectiveness in supporting wound healing, but few studies have examined their combined use. This retrospective data analysis compared wound outcomes following outpatient NPWT with and without OCSO dressings. APPROACH: A search of de-identified records from the U.S. Wound Registry resulted in 485 cases of wounds managed with NPWT with OCSO dressings. A matched cohort of patients who received NPWT without any collagen dressing (n=485) was created using propensity scoring. For patients in the NPWT+OCSO group, OCSO was applied topically on or after the day of NPWT initiation and stopped on or before the day of NPWT termination. RESULTS: Wounds managed with NPWT+OCSO were significantly more likely to improve and/or heal compared to wounds that received NPWT alone (p=0.00029). The relative wound area reduction was 40% for patients receiving NPWT+OCSO, compared to 9% for patients receiving only NPWT (p=0.0099). The median time to achieve 75-100% granulation coverage with no measurable wound depth was shorter by 8 days with NPWT+OCSO in all wound types (p=0.00034), and by 14 days in surgical wounds (p=0.0010), than with NPWT alone. INNOVATION: This is the first study examining the clinical outcomes associated with the integration of NPWT and OCSO dressings compared to the use of NPWT alone. These data support the novel practice of applying NPWT concurrently with OCSO dressings. CONCLUSION: This retrospective comparative analysis using real world data demonstrated improved healing outcomes with integrated use of NPWT with OCSO dressings versus NPWT alone.

Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs.

Chlorhexidine gluconate (CHG)-containing dressings are recommended to prevent central line associated bloodstream infections (CLABSIs) and other catheter-related infections. This study compared the effect of 2 CHG dressings on CLABSI, cost of care, and contact dermatitis. A retrospective analysis was conducted using the Premier Healthcare Database of hospitalized patients (n = 53 149) with central venous catheters (CVCs) and receiving either a transparent CHG gel dressing (n = 14 488) or an opaque CHG sponge dressing (n = 38 661) between January 2019 and September 2020. Two cohorts (n = 14 488 each), CHG-Gel and CHG-Sponge, were matched 1:1 using a propensity score method on 33 patient and facility characteristics. CLABSI and contact dermatitis rates, hospital length of stay (LOS), and hospitalization costs were compared using mixed-effect multiple regression. This approach effectively controlled for random clustering effects across hospitals and patients' Diagnosis-Related Group (DRG) classifications. CHG gel dressings were associated with a 41% decrease in CLABSI rates (P = .0008) compared to CHG sponge dressings (0.35%vs 0.60%). A 0.4-day shorter LOS (9.53vs 9.90 days, P = .0001) and a cost saving of $3576 per hospital stay ($40 197 vs $43 774, P = .0179) was observed with CHG gel dressing use. There was no statistically significant difference in contact dermatitis rates (P = .7854) between the CHG-Gel and CHG-Sponge cohorts. The findings of this study suggest that the use of CHG gel dressings may be more effective in reducing the risk of CLABSIs and associated clinical costs compared to CHG sponge dressings in hospitalized patients. Moreover, there appears to be no significant discrepancy in contact dermatitis rates between CHG gel and CHG sponge dressings. Healthcare providers may consider using CHG gel dressings as a standard practice for patients with CVCs to reduce the risk of infections and improve patient outcomes.

Corrigendum to "Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures" [Surg Open Sci (2023) 1-18/ISSN 2589-8450].

[This corrects the article DOI: 10.1016/j.sopen.2022.10.004.].

Incidence and impact of surgical site complications on length of stay and cost of care for patients undergoing open procedures.

Background: Surgical site complications (SSCs) can have serious and life-threatening consequences for patients; however, their frequency and impact on healthcare utilization across surgical procedures, particularly for non-infectious SSCs, are unknown. This study examined incidence of overall SSCs and non-infectious SSCs in patients undergoing open surgical procedures in the United States and their effect on length of stay (LOS) and costs. Methods: This retrospective study utilizing 2019-2020 data from Medicare and Premier Health Database identified patients with SSCs during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSCs. Mean LOS and costs attributable to SSCs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSC on LOS and costs across healthcare settings. Results: Overall and non-infectious SSC rates were 7.3 % and 5.3 % respectively for 2,696,986 Medicare and 6.7 % and 5.0 % for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSC were 7.8 days and $15,339 for Medicare patients and 6.2 days and $17,196 for Premier patients. Incremental LOS and cost attributable to non-infectious SSCs were 6.5 days and $12,703 and 5.2 days and $14,477 for Medicare and Premier patients respectively. Conclusions: This study utilizing two large national databases provides strong evidence that SSCs, particularly non-infectious SSCs, are not uncommon in open surgeries and result in increased healthcare utilization and costs. These findings demonstrate the need for increased adoption of evidence-based interventions that can reduce SSC rates.

Effectiveness of Disinfecting Caps for Intravenous Access Points in Reducing Central Line-Associated Bloodstream Infections, Clinical Utilization, and Cost of Care During COVID-19.

Purpose: Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic. Methods: The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively. Results: The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group. Conclusion: This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.

Development and validation of a point-of-care clinical risk score to predict surgical site infection following open spinal fusion.

Background: Surgical site infection (SSI) after open spine surgery increases healthcare costs and patient morbidity. Predictive analytics using large databases can be used to develop prediction tools to aid surgeons in identifying high-risk patients and strategies for optimization. The purpose of this study was to develop and validate an SSI risk-assessment score for patients undergoing open spine surgery. Methods: The Premier Healthcare Database of adult open spine surgery patients (n = 157,664; 2,650 SSIs) was used to create an SSI risk scoring system using mixed effects logistic regression modeling. Full and reduced multilevel logistic regression models were developed using patient, surgery or facility predictors. The full model used 38 predictors and the reduced used 16 predictors. The resulting risk score was the sum of points assigned to 16 predictors. Results: The reduced model showed good discriminatory capability (C-statistic = 0.75) and good fit of the model ([Pearson Chi-square/DF] = 0.90, CAIC=25,517) compared to the full model (C-statistic = 0.75, [Pearson Chi-square/DF] =0.90, CAIC=25,578). The risk scoring system, based on the reduced model, included the following: female (5 points), hypertension (4), blood disorder (8), peripheral vascular disease (9), chronic pulmonary disease (6), rheumatic disease (16), obesity (12), nicotine dependence (5), Charlson Comorbidity Index (2 per point), revision surgery (14), number of ICD-10 procedures (1 per procedure), operative time (1 per hour), and emergency/urgent surgery (12). A final risk score as the sum of the points for each surgery was validated using a 1,000-surgery random hold-out (independent from the study cohort) sample (C-statistic = 0.77). Conclusions: The resulting SSI risk score composed of readily obtainable clinical information could serve as a strong prediction tool for SSI in preoperative settings when open spine surgery is considered.

Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures.

Background: Surgical site infections (SSIs) are associated with increased morbidity and mortality; however, current SSI rates across open procedures and their effect on healthcare delivery are unknown. The objective of this study was to examine incidence of SSIs for open surgical procedures in the United States and impact on length of stay (LOS) and costs. Methods: This retrospective study utilizing 2019-2020 data from Medicare and Premier identified patients with SSIs occurring during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSIs. Mean LOS and costs attributable to SSIs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSI on LOS and costs across healthcare settings. Results: SSI rates were 2.0% for 2,696,986 Medicare and 1.8% for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSI, including index admission, readmissions, and outpatient visits were 9.3 days and $18,626 for Medicare patients and 7.8 days and $20,979 for Premier patients. SSI rates were higher for urgent/emergency surgeries compared to overall SSI rates. Although less common that superficial SSIs, deep SSIs resulted in higher incremental LOS and index costs for the index admission and for SSI-related readmissions. Conclusions: This study of SSIs utilizing two large national databases provides robust data and analytics reinforcing and bolstering current evidence that SSIs occur infrequently but are detrimental to patients in terms of increased LOS and care costs.

Medical students' learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES.

BACKGROUND: There is a paucity of evidence on how to train medical students to provide equitable, high quality care to racial and ethnic minority patients. We test the hypothesis that medical schools' ability to foster a learning orientation toward interracial interactions (i.e., that students can improve their ability to successfully interact with people of another race and learn from their mistakes), will contribute to white medical students' readiness to care for racial minority patients. We then test the hypothesis that white medical students who perceive their medical school environment as supporting a learning orientation will benefit more from disparities training. METHODS: Prospective observational study involving web-based questionnaires administered during first (2010) and last (2014) semesters of medical school to 2394 white medical students from a stratified, random sample of 49 U.S. medical schools. Analysis used data from students' last semester to build mixed effects hierarchical models in order to assess the effects of medical school interracial learning orientation, calculated at both the school and individual (student) level, on key dependent measures. RESULTS: School differences in learning orientation explained part of the school difference in readiness to care for minority patients. However, individual differences in learning orientation accounted for individual differences in readiness, even after controlling for school-level learning orientation. Individual differences in learning orientation significantly moderated the effect of disparities training on white students' readiness to care for minority patients. Specifically, white medical students who perceived a high level of learning orientation in their medical schools regarding interracial interactions benefited more from training to address disparities. CONCLUSIONS: Coursework aimed at reducing healthcare disparities and improving the care of racial minority patients was only effective when white medical students perceived their school as having a learning orientation toward interracial interactions. Results suggest that medical school faculty should present interracial encounters as opportunities to practice skills shown to reduce bias, and faculty and students should be encouraged to learn from one another about mistakes in interracial encounters. Future research should explore aspects of the medical school environment that contribute to an interracial learning orientation.

Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care.

PURPOSE: The purpose of this study was to describe the prevalence, incidence, and effectiveness of home health care (HHC) agencies' services with and without a WOC nurse related to wounds, incontinence, and urinary tract infection (UTI) patient outcomes. SUBJECTS AND SETTING: There were 449,243 episodes of care from a national convenience sample of 785 HHC agencies representing nonmaternity patients who were aged 18 years or older and receiving skilled home health services between October 1, 2008, and December 31, 2009. DESIGN: This study employed descriptive and comparative designs for data collection and analysis. We analyzed data from HHC agencies' electronic health records and conducted an Internet-based survey of HHC agencies. INSTRUMENTS: Data for this study were documented by HHC clinicians using the Outcome and Assessment Information Set. An Internet survey identified if a WOC nurse provided care or consultations within an HHC agency. RESULTS: The majority of HHC agencies (88.5%) had some influence of a WOC nurse. The incidence of wounds, incontinence, and UTIs was higher for agencies with no WOC nurse. Home health care agencies with WOC nurses had significantly better improvement outcomes for pressure ulcers, lower extremity ulcers, surgical wounds, urinary incontinence, bowel incontinence, and UTIs as well as significantly better stabilization outcomes for these outcomes except lower extremity ulcers. Virtually all patients in HHC agencies with and without a WOC nurse had stabilization of their lower extremity ulcers. CONCLUSIONS: Findings of this study suggest that influence of a WOC nurse is effective in achieving several important positive outcomes of HHC agencies' services for wounds, incontinence, and UTIs.

Effectiveness of wound, ostomy and continence-certified nurses on individual patient outcomes in home health care.

PURPOSE: To assess whether there was a significant improvement and stabilization (not worse at discharge) in pressure ulcers, lower extremity venous ulcers, surgical wounds, urinary incontinence, bowel incontinence, and urinary tract infections in home health care (HHC) patients cared for by a certified WOC nurse. SUBJECTS AND SETTING: There were 449,170 episodes of care from a national convenience sample of 785 HHC agencies with 447,309 nonmaternity, adult patients between October 1, 2008, and December 31, 2009. DESIGN: Descriptive and comparative. INSTRUMENTS AND METHODS: Data from the Outcome and Assessment Information Set documented by HHC clinicians were analyzed using mixed-effects logistic regression, propensity score analysis, and appropriate parametric and nonparametric tests. An Internet survey identified whether WOC nurses provided care to patients in an HHC agency. Home health care agencies identified records of patients receiving WOC nurse visits/consults. RESULTS: An HHC patient assigned to a WOC nurse had surgical wounds, pressure ulcers, and incontinence problems that were significantly worse than HHC patients not assigned to a WOC nurse. Patients cared for by a WOC nurse showed significant improvement and stabilization of the number of pressure ulcers and surgical wounds and the frequency of urinary and bowel incontinence, despite having problems that were more severe than other patients. Home health care patients not cared for by WOC nurses, with less-severe wound and incontinence problems, also got better. CONCLUSIONS: WOC nurses are effective in achieving positive health outcomes for pressure ulcers, surgical wounds, and incontinence in HHC patients with severe health problems.

Effectiveness of wound, ostomy and continence-certified nurses on individual patient outcomes in home health care.

PURPOSE: To assess whether there was a significant improvement and stabilization (not worse at discharge) in pressure ulcers, lower extremity venous ulcers, surgical wounds, urinary incontinence, bowel incontinence, and urinary tract infections in home health care (HHC) patients cared for by a certified WOC nurse. SUBJECTS AND SETTING: There were 449,170 episodes of care from a national convenience sample of 785 HHC agencies with 447,309 nonmaternity, adult patients between October 1, 2008, and December 31, 2009. DESIGN: Descriptive and comparative. INSTRUMENTS AND METHODS: Data from the Outcome and Assessment Information Set documented by HHC clinicians were analyzed using mixed-effects logistic regression, propensity score analysis, and appropriate parametric and nonparametric tests. An Internet survey identified whether WOC nurses provided care to patients in an HHC agency. Home health care agencies identified records of patients receiving WOC nurse visits/consults. RESULTS: An HHC patient assigned to a WOC nurse had surgical wounds, pressure ulcers, and incontinence problems that were significantly worse than HHC patients not assigned to a WOC nurse. Patients cared for by a WOC nurse showed significant improvement and stabilization of the number of pressure ulcers and surgical wounds and the frequency of urinary and bowel incontinence, despite having problems that were more severe than other patients. Home health care patients not cared for by WOC nurses, with less-severe wound and incontinence problems, also got better. CONCLUSIONS: WOC nurses are effective in achieving positive health outcomes for pressure ulcers, surgical wounds, and incontinence in HHC patients with severe health problems.

Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care.

PURPOSE: The purpose of this study was to describe the prevalence, incidence, and effectiveness of home health care (HHC) agencies' services with and without a WOC nurse related to wounds, incontinence, and urinary tract infection (UTI) patient outcomes. SUBJECTS AND SETTING: There were 449,243 episodes of care from a national convenience sample of 785 HHC agencies representing nonmaternity patients who were aged 18 years or older and receiving skilled home health services between October 1, 2008, and December 31, 2009. DESIGN: This study employed descriptive and comparative designs for data collection and analysis. We analyzed data from HHC agencies' electronic health records and conducted an Internet-based survey of HHC agencies. INSTRUMENTS: Data for this study were documented by HHC clinicians using the Outcome and Assessment Information Set. An Internet survey identified if a WOC nurse provided care or consultations within an HHC agency. RESULTS: The majority of HHC agencies (88.5%) had some influence of a WOC nurse. The incidence of wounds, incontinence, and UTIs was higher for agencies with no WOC nurse. Home health care agencies with WOC nurses had significantly better improvement outcomes for pressure ulcers, lower extremity ulcers, surgical wounds, urinary incontinence, bowel incontinence, and UTIs as well as significantly better stabilization outcomes for these outcomes except lower extremity ulcers. Virtually all patients in HHC agencies with and without a WOC nurse had stabilization of their lower extremity ulcers. CONCLUSIONS: Findings of this study suggest that influence of a WOC nurse is effective in achieving several important positive outcomes of HHC agencies' services for wounds, incontinence, and UTIs.

The development of preschool children's (Homo sapiens) uses of objects and their role in peer group centrality.

The ways in which objects were used by preschool children (Homo sapiens) was examined by directly observing them across one school year. In the first objective we documented the relative occurrence of different forms of object use and their developmental growth curves. Second, we examined the role of different types of object use, as well as novel and varied uses of objects, in predicting peer group centrality. Results indicated that noninstrumental object play was the most frequently observed category, followed by tool use, exploration, and construction; sex moderated the growth curve of children's exploration. Noninstrumental object play, not other types of object use, was significantly related to novel and varied object uses and only the latter category predicted peer group centrality. Results are discussed in terms of the social transmission of novel object use.

A longitudinal study of preschool children's (Homo sapiens) sex segregation.

In this 2-year longitudinal study, we hypothesized that sex of the human child (Homo sapiens), differences in physical activity, and time of the year would interact to influence preschool children's sex segregation. We also hypothesized that activity would differentially relate to peer rejection for boys and girls. Consistent with the first hypothesis, high-activity girls started off as the most integrated group but became more segregated with time, whereas high-activity boys remained the most segregated group across the duration of the study. The second hypothesis was also supported: For girls only, activity was significantly related to peer rejection during Year 1 only, the time when high-activity girls also interacted frequently with boys. Results are discussed in terms of sexual selection theory and gender boundary violations.