Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation.

OBJECTIVE: The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation. BACKGROUND: Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated. METHODS: All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS: Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001). CONCLUSIONS: Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation.

INTRODUCTION: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking. METHODS: This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator. RESULTS: Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge. CONCLUSIONS: Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Association of time to resection with survival in patients with colon cancer.

PURPOSE: Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS: This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS: Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS: Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Race, Insurance, and Sex-Based Disparities in Access to High-Volume Centers for Pancreatectomy.

BACKGROUND: With a large body of literature demonstrating positive volume-outcome relationships for most major operations, minimum volume requirements have been suggested for concentration of cases to high-volume centers (HVCs). However, data are limited regarding disparities in access to these hospitals for pancreatectomy patients. METHODS: The 2005-2018 National Inpatient Sample (NIS) was queried for all elective adult hospitalizations for pancreatectomy. Hospitals performing more than 20 annual cases were classified as HVCs. Mixed-multivariable regression models were developed to characterize the impact of demographic factors and case volume on outcomes of interest. RESULTS: Of an estimated 127,527 hospitalizations, 79.8% occurred at HVCs. Patients at these centers were more frequently white (79.0 vs 70.8%; p < 0.001), privately insured (39.4 vs 34.2%; p < 0.001), and within the highest income quartile (30.5 vs 25.0%; p < 0.001). Adjusted analysis showed that operations performed at HVCs were associated with reduced odds of in-hospital mortality (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.34-0.55), increased odds of discharge to home (AOR, 1.17; 95% CI, 1.04-1.30), shorter hospital stay (ß, -0.81 days; 95% CI, -1.2 to -0.40 days), but similar costs. Patients who were female (AOR, 0.88; 95% CI, 0.79-0.98), non-white (black: AOR, 0.66; 95% CI, 0.59-0.75; Hispanic: AOR, 0.56; 95% CI, 0.47-0.66; reference, white), insured by Medicaid (AOR, 0.63; 95% CI, 0.56-0.72; reference, private), and within the lowest income quartile (AOR, 0.73; 95% CI, 0.59-0.90; reference, highest) had decreased odds of treatment at an HVC. CONCLUSIONS: For those undergoing pancreatectomies, HVCs realize superior clinical outcomes but treat lower proportions of female, non-white, and Medicaid populations. These findings may have implications for improving access to high-quality centers.

Association of postoperative length of stay with outcomes following orthotopic heart transplantation-A national analysis.

BACKGROUND: In the absence of standardized recovery protocols, there is little evidence to guide postoperative care to ensure optimal in-hospital and long-term outcomes following heart transplantation (HT). Using two national databases, we examined the association between postoperative length of stay (LOS) with patient/graft survival, index hospitalization costs, and non-elective readmissions. METHODS: Adult HT recipients from 2010 to 2019 were identified and analyzed within the Organ Procurement and Transplantation Network (OPTN) Database and Nationwide Readmissions Database (NRD). The risk-adjusted relationship between 1-year mortality and LOS was assessed with restricted cubic splines and subsequently used to stratify patients into Expedited (7-11 days), Routine (12-16 days), and Delayed (>16) discharge groups. Survival outcomes were analyzed using Restricted Means Survival Time analysis (RMST) and multivariable Cox models. RESULTS: Of 9995 HT recipients within the OPTN, 3777 (38%) were categorized as Expedited, and 3040 (30%) as Routine. After adjustment, expedited discharge was not associated with inferior 90-day (ΔRMST -.01, p = .91) and 1-year patient survival (ΔRMST -.02, p = .53). Additionally, expedited was not associated with increased odds of non-elective readmission at 90-days (HR 1.04, CI .77-1.43) relative to Routine discharge. Counterfactual analysis revealed an estimated cost saving of $50 million if all Routine patients received an expedited discharge. CONCLUSION: Expedited discharge after HT seems to be cost-effective and is not associated with inferior outcomes. Institutional-level outcome analyses should be performed to identify patients that would benefit from expedited discharge, and future studies should analyze the feasibility of implementing standardized discharge protocols following HT.

Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes.

BACKGROUND: Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking. METHODS: This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts. RESULTS: Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors. CONCLUSIONS: Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.

Impact of surgeon specialty on clinical outcomes following esophagectomy for cancer.

BACKGROUND: The impact of surgeon and hospital operative volume on esophagectomy outcomes is well-described; however, studies examining the influence of surgeon specialty remain limited. Therefore, we evaluated the impact of surgeon specialty on short-term outcomes following esophagectomy for cancer. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) was queried to identify all patients undergoing esophagectomy for esophageal cancer. Surgeon specialty was categorized as general (GS) or thoracic (TS). Entropy balancing was used to generate sample weights that adjust for baseline differences between GS and TS patients. Weights were subsequently applied to multivariable linear and logistic regressions, which were used to evaluate the independent association of surgeon specialty with 30-day mortality, complications, and postoperative length of stay. RESULTS: Of 2657 esophagectomies included for analysis, 54.1% were performed by TS. Both groups had similar distributions of age, sex, and body mass index. TS patients more frequently underwent transthoracic esophagectomy, while GS patients more commonly received minimally invasive surgery. After adjustment, surgeon specialty was not associated with altered odds of 30-day mortality (adjusted odds ratio [AOR] 1.10 p = 0.73) or anastomotic leak (AOR 0.87, p = 0.33). However, TS patients exhibited a 40-min reduction in operative duration and faced greater odds of perioperative transfusion, relative to GS. CONCLUSION: Among ACS NSQIP participating centers, surgeon specialty influenced operative duration and blood product utilization, but not mortality and anastomotic leak. Our results support the relative safety of esophagectomy performed by select GS and TS.

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database. METHODS: Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis. RESULTS: Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (ß -0.10, 95% -0.13, -0.07), reduced costs (ß -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96). CONCLUSIONS: Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Outcomes of Expedited Discharge After Isolated Coronary Artery Bypass Grafting.

OBJECTIVES: Expedited discharge after coronary artery bypass grafting (CABG) has been postulated as a possible solution for reducing hospitalization costs. This study aimed to evaluate the impact of expedited postoperative discharge on readmissions and costs in patients undergoing isolated CABG. DESIGN: Adults (≥18 years) who underwent isolated CABG were identified using the 2016-to-2019 Nationwide Readmission Database. Patients were classified as expedited or routine, with expedited patients being discharged on or before postoperative day 4. Those who experienced perioperative complications were excluded. SETTING: The Nationwide Readmissions Database. PARTICIPANTS: Patients ≥18 years old who underwent isolated CABG. MEASUREMENTS AND MAIN RESULTS: Of an estimated 187,591 patients meeting study criteria, 37.2% (n = 69,861) experienced expedited discharge. Expedited patients experienced lower index hospitalization costs ($28,543 v $34,114, p < 0.001), and were less likely to experience 30-day nonelective readmission (4.6% v 7.3%, p < 0.001) and 90-day nonelective readmission (5.6% v 8.7%, p < 0.001). After adjustment, expedited discharge remained independently associated with reduced odds of both 30-day (adjusted odds ratio [AOR]: 0.78, 95% CI: 0.71-0.85) and 90-day (AOR: 0.80, 95% CI: 0.74-0.87) nonelective readmission. In addition, expedited discharge was associated with an incremental decrease in index hospitalization costs (ß: -5,661, 95% CI: -5,894 to -5,429). CONCLUSIONS: Expedited discharge immensely decreases costs of care for patients undergoing isolated CABG, as well as readmission risks. Expedited discharge may be considered a strategy to both improve postoperative patient care and reduce hospitalization costs within the United States healthcare system.

Heart Transplantation After Donation After Circulatory Death: Early United States Experience.

BACKGROUND: Given the renewed interest in heart transplantation after donation after circulatory death (DCD), a contemporary analysis of trends and longer-term survival is warranted. METHODS: Adult heart transplant recipients (December 2019-September 2023) were identified in the Organ Procurement and Transplantation Network. Recipients were stratified as donation after brain death (DBD) or DCD. DCD procurements were further classified as direct procurement and perfusion (DCD-DPP) or normothermic regional perfusion (DCD-NRP), based on the declaration of death to cross-clamp interval (≥40 minutes DCD-NRP). The main outcome was posttransplant survival at 1 and 3 years. RESULTS: Of 11,625 transplantations, 792 (7%) involved DCD allografts (249 DCD-NRP, 543 DCD-DPP). The proportion of transplants involving DCD allografts significantly increased from 2% (December 2019) to 11% (January-September 2023, P < .001). Upon adjusted analysis, 1-year posttransplant survival was similar for DBD vs DCD-DPP (hazard ratio [HR], 1.00; 95% CI, 0.66-1.66) or DCD-NRP (HR, 0.92; 95% CI, 0.49-1.72). This remained true at 3 years for DCD-DPP (HR, 1.07; 95% CI, 0.77-1.48) and DCD-NRP (HR, 1.04; 95% CI, 0.62-1.73). Incidence of postoperative stroke, dialysis, acute graft rejection, and primary graft dysfunction were similar across groups. Across various strata of recipient risk and center volume, survival was equivalent between the DBD and DCD cohorts. CONCLUSIONS: Rates of DCD heart transplantation continue to rise. Across various recipient risk and center volume categories, DCD and DBD recipients show comparable posttransplant survival up to 3 years. These findings encourage broader use of such donors in attempts to expand the organ pool.

Short-term outcomes of bariatric surgery in patients with inflammatory bowel disease: a national analysis.

BACKGROUND: While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD). OBJECTIVES: The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery. SETTING: Academic, university-affiliated; United States. METHODS: All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest. RESULTS: Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 ± 1.4; CD: 3.1 ± 1.5; non-IBD: 2.7 ± 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD. CONCLUSIONS: Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.

Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis.

Background: Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations. Methods: All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes. Results: Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (ß + 0.90 days, CI +0.68-1.12) and costs (ß + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70). Conclusions: Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.

Outcomes following major thoracoabdominal cancer resection in adults with congenital heart disease.

BACKGROUND: While advances in medical and surgical management have allowed >97% of congenital heart disease (CHD) patients to reach adulthood, a growing number are presenting with non-cardiovascular malignancies. Indeed, adults with CHD are reported to face a 20% increase in cancer risk, relative to others, and cancer has become the fourth leading cause of death among this population. Surgical resection remains a mainstay in management of thoracoabdominal cancers. However, outcomes following cancer resection among these patients have not been well established. Thus, we sought to characterize clinical and financial outcomes following major cancer resections among adult CHD patients. METHODS: The 2012-2020 National Inpatient Sample was queried for all adults (CHD or non-CHD) undergoing lobectomy, esophagectomy, gastrectomy, pancreatectomy, hepatectomy, or colectomy for cancer. To adjust for intergroup differences in baseline characteristics, entropy balancing was applied to generate balanced patient groups. Multivariable models were constructed to assess outcomes of interest. RESULTS: Of 905,830 patients undergoing cancer resection, 1,480 (0.2%) had concomitant CHD. The overall prevalence of such patients increased from <0.1% in 2012 to 0.3% in 2012 (P for trend<0.001). Following risk adjustment, CHD was linked with greater in-hospital mortality (AOR 2.00, 95%CI 1.06-3.76), as well as a notable increase in odds of stroke (AOR 8.94, 95%CI 4.54-17.60), but no statistically significant difference in cardiac (AOR 1.33, 95%CI 0.69-2.59) or renal complications (AOR 1.35, 95%CI 0.92-1.97). Further, CHD was associated with a +2.39 day incremental increase in duration of hospitalization (95%CI +1.04-3.74) and a +$11,760 per-patient increase in hospitalization expenditures (95%CI +$4,160-19,360). CONCLUSIONS: While a growing number of patients with CHD are undergoing cancer resection, they demonstrate inferior clinical and financial outcomes, relative to others. Novel screening, risk stratification, and perioperative management guidelines are needed for these patients to provide evidence-based recommendations for this complex and unique cohort.

Trends, outcomes, and factors associated with in-hospital opioid overdose following major surgery.

Background: With the growing opioid epidemic across the US, in-hospital utilization of opioids has garnered increasing attention. Using a national cohort, this study sought to characterize trends, outcomes, and factors associated with in-hospital opioid overdose (OD) following major elective operations. Methods: We identified all adult (≥18 years) hospitalizations entailing select elective procedures in the 2016-2020 National Inpatient Sample. Patients who experienced in-hospital opioid overdose were characterized as OD (others: Non-OD). The primary outcome of interest was in-hospital OD. Multivariable logistic and linear regression models were developed to evaluate the association between in-hospital OD and mortality, length of stay (LOS), hospitalization costs, and non-home discharge. Results: Of an estimated 11,096,064 hospitalizations meeting study criteria, 5375 (0.05 %) experienced a perioperative OD. Compared to others, OD were older (66 [57-73] vs 64 [54-72] years, p < 0.001), more commonly female (66.3 vs 56.7 %, p < 0.001), and in the lowest income quartile (26.4 vs 23.2 %, p < 0.001). After adjustment, female sex (Adjusted Odds Ratio [AOR] 1.68, 95 % Confidence Interval [CI] 1.47-1.91, p < 0.001), White race (AOR 1.19, CI 1.01-1.42, p = 0.04), and history of substance use disorder (AOR 2.51, CI 1.87-3.37, p < 0.001) were associated with greater likelihood of OD. Finally, OD was associated with increased LOS (ß +1.91 days, CI [1.60-2.21], p < 0.001), hospitalization costs (ß +$7500, CI [5900-9100], p < 0.001), and greater odds of non-home discharge (AOR 2.00, CI 1.61-2.48, p < 0.001). Conclusion: Perioperative OD remains a rare but costly complication after elective surgery. While pain control remains a priority postoperatively, protocols and recovery pathways must be re-examined to ensure patient safety.

Machine learning based predictive modeling of readmissions following extracorporeal membrane oxygenation hospitalizations.

Background: Despite increasing utilization and survival benefit over the last decade, extracorporeal membrane oxygenation (ECMO) remains resource-intensive with significant complications and rehospitalization risk. We thus utilized machine learning (ML) to develop prediction models for 90-day nonelective readmission following ECMO. Methods: All adult patients receiving ECMO who survived index hospitalization were tabulated from the 2016-2020 Nationwide Readmissions Database. Extreme Gradient Boosting (XGBoost) models were developed to identify features associated with readmission following ECMO. Area under the receiver operating characteristic (AUROC), mean Average Precision (mAP), and the Brier score were calculated to estimate model performance relative to logistic regression (LR). Shapley Additive Explanation summary (SHAP) plots evaluated the relative impact of each factor on the model. An additional sensitivity analysis solely included patient comorbidities and indication for ECMO as potential model covariates. Results: Of ∼22,947 patients, 4495 (19.6 %) were readmitted nonelectively within 90 days. The XGBoost model exhibited superior discrimination (AUROC 0.64 vs 0.49), classification accuracy (mAP 0.30 vs 0.20) and calibration (Brier score 0.154 vs 0.165, all P < 0.001) in predicting readmission compared to LR. SHAP plots identified duration of index hospitalization, undergoing heart/lung transplantation, and Medicare insurance to be associated with increased odds of readmission. Upon sub-analysis, XGBoost demonstrated superior disclination compared to LR (AUROC 0.61 vs 0.60, P < 0.05). Chronic liver disease and frailty were linked with increased odds of nonelective readmission. Conclusions: ML outperformed LR in predicting readmission following ECMO. Future work is needed to identify other factors linked with readmission and further optimize post-ECMO care among this cohort.

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis.

BACKGROUND: Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort. METHODS: All non-elective pediatric (<18 years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE). RESULTS: Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]). CONCLUSION: Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Early discharge following colectomy for colon cancer: A national perspective.

BACKGROUND: Although early discharge after colectomy has garnered significant interest, contemporary, large-scale analyses are lacking. OBJECTIVE: The present study utilized a national cohort of patients undergoing colectomy to examine costs and readmissions following early discharge. METHODS: All adults undergoing elective colectomy for primary colon cancer were identified in the 2016-2019 Nationwide Readmissions Database. Patients with perioperative complications or prolonged length of stay (>8 days) were excluded to enhance cohort homogeneity. Patients discharged by postoperative day 3 were classified as Early, and others as Routine. Entropy balancing and multivariable regression were used to assess the risk-adjusted association of early discharge with costs and non-elective readmissions. Importantly, we compared 90-day stroke rates to examine whether our results were influenced by preferential early discharge of healthier patients. RESULTS: Of an estimated 153,996 patients, 45.5% comprised the Early cohort. Compared to Routine, the Early cohort was younger and more commonly male. Patients in the Early group more commonly underwent left-sided colectomy and laparoscopic operations. Following multivariable adjustment, expedited discharge was associated with a $4,500 reduction in costs as well as lower 30-day (adjusted odds ratio [AOR] 0.74, p<0.001) and 90-day non-elective readmissions (AOR 0.74, p<0.001). However, among those readmitted within 90 days, Early patients were more commonly readmitted for gastrointestinal conditions (45.8 vs 36.4%, p<0.001). Importantly, both cohorts had comparable 90-day stroke rates (2.2 vs 2.1%, p = 0.80). CONCLUSIONS: The present work represents the largest analysis of early discharge following colectomy for cancer and supports its relative safety and cost-effectiveness.

Nationwide Trends in Utilization of Minimally Invasive Techniques for Blunt Abdominal Trauma.

BACKGROUND: Despite increasing use of minimally invasive surgical (MIS) techniques for trauma, limited large-scale studies have evaluated trends, outcomes, and resource utilization at centers that utilize MIS modalities for blunt abdominal trauma. METHODS: Operative adult admissions after blunt assault, falls, or vehicular collisions were tabulated from the 2016-2020 National Inpatient Sample. Patients who received diagnostic laparoscopy or other laparoscopic and robotic intervention were classified as MIS. Institutions with at least one MIS trauma operation in a year were defined as an MIS Performing Institution (MPI; rest: non-MPI). The primary endpoint was mortality, with secondary outcomes of reoperation, complication, postoperative length of stay (LOS), and hospitalization costs. Mixed regression models were used to determine the association of MPI status on the outcomes of interest. RESULTS: Throughout the study period, the proportion of MIS operations and MPI significantly increased from 22.6 to 29.8% and 45.9 to 58.8%, respectively. Of an estimated 77,480 patients, 66.7% underwent care at MPI. After adjustment, MPI status was not associated with increased odds of mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] [.96,1.24]), reoperation (AOR 1.02, CI [.87,1.19]), or any of the tabulated complications. There was additionally no difference in adjusted LOS (ß-.18, CI [-.85, +.49]) or costs (ß+$1600, CI [-1600, +4800]), between MPI and non-MPI. DISCUSSION: The use of MIS operations in blunt abdominal trauma has significantly increased, with performing centers experiencing no difference in mortality or resource utilization. Prospectively collected data on outcomes following MIS trauma surgery is necessary to elucidate appropriate applications.

Association of socioeconomic vulnerability with clinical and financial outcomes following emergent hernia repair.

BACKGROUND: While race and insurance have been linked with greater likelihood of hernia incarceration and emergent presentation, the association of broader social determinants of health (SDOH) with outcomes following urgent repair remains to be elucidated. STUDY DESIGN: All adult hospitalizations entailing emergent repair for strangulated inguinal, femoral, and ventral hernias were identified in the 2016-2020 Nationwide Readmissions Database. Socioeconomic vulnerability was ascertained using relevant diagnosis codes. Multivariable models were developed to consider the independent associations between socioeconomic vulnerability and study outcomes. RESULTS: Of ∼236,215 patients, 20,306 (8.6 â€‹%) were Vulnerable. Following risk-adjustment, socioeconomic vulnerability remained associated with greater odds of in-hospital mortality, any perioperative complication, increased hospitalization expenditures and higher risk of non-elective readmission. CONCLUSIONS: Among patients undergoing emergent hernia repair, socioeconomic vulnerability was linked with greater morbidity, expenditures, and readmission. As part of patient-centered care, novel screening, postoperative management, and SDOH-informed discharge planning programs are needed to mitigate disparities in outcomes.