Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study.

BACKGROUND: Anesthesiologists' contribution to perioperative healthcare disparities remains unclear because patient and surgeon preferences can influence care choices. Postoperative nausea and vomiting is a patient- centered outcome measure and a main driver of unplanned admissions. Antiemetic administration is under the sole domain of anesthesiologists. In a U.S. sample, Medicaid insured versus commercially insured patients and those with lower versus higher median income had reduced antiemetic administration, but not all risk factors were controlled for. This study examined whether a patient's race is associated with perioperative antiemetic administration and hypothesized that Black versus White race is associated with reduced receipt of antiemetics. METHODS: An analysis was performed of 2004 to 2018 Multicenter Perioperative Outcomes Group data. The primary outcome of interest was administration of either ondansetron or dexamethasone; secondary outcomes were administration of each drug individually or both drugs together. The confounder-adjusted analysis included relevant patient demographics (Apfel postoperative nausea and vomiting risk factors: sex, smoking history, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use; as well as age) and included institutions as random effects. RESULTS: The Multicenter Perioperative Outcomes Group data contained 5.1 million anesthetic cases from 39 institutions located in the United States and The Netherlands. Multivariable regression demonstrates that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (290,208 of 496,456 [58.5%] vs. 2.24 million of 3.49 million [64.1%]; adjusted odds ratio, 0.82; 95% CI, 0.81 to 0.82; P < 0.001). Black as compared to White patients were less likely to receive any dexamethasone (140,642 of 496,456 [28.3%] vs. 1.29 million of 3.49 million [37.0%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.78; P < 0.001), any ondansetron (262,086 of 496,456 [52.8%] vs. 1.96 million of 3.49 million [56.1%]; adjusted odds ratio, 0.84; 95% CI, 0.84 to 0.85; P < 0.001), and dexamethasone and ondansetron together (112,520 of 496,456 [22.7%] vs. 1.0 million of 3.49 million [28.9%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.79; P < 0.001). CONCLUSIONS: In a perioperative registry data set, Black versus White patient race was associated with less antiemetic administration, after controlling for all accepted postoperative nausea and vomiting risk factors.

Impact of Intraoperative Data on Risk Prediction for Mortality After Intra-Abdominal Surgery.

BACKGROUND: Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models. METHODS: With IRB approval, an institutional retrospective cohort of intra-abdominal surgery patients in the 2005 to 2015 American College of Surgeons National Surgical Quality Improvement Program was identified. Intraoperative data were obtained from the electronic health record. The primary outcome was 30-day mortality. We evaluated the performance of machine learning algorithms to predict 30-day mortality using: 1) baseline variables and 2) baseline + intraoperative variables. Algorithms evaluated were: 1) logistic regression with elastic net selection, 2) random forest (RF), 3) gradient boosting machine (GBM), 4) support vector machine (SVM), and 5) convolutional neural networks (CNNs). Model performance was evaluated using the area under the receiver operator characteristic curve (AUROC). The sample was randomly divided into a training/testing split with 80%/20% probabilities. Repeated 10-fold cross-validation identified the optimal model hyperparameters in the training dataset for each model, which were then applied to the entire training dataset to train the model. Trained models were applied to the test cohort to evaluate model performance. Statistical significance was evaluated using P < .05. RESULTS: The training and testing cohorts contained 4322 and 1079 patients, respectively, with 62 (1.4%) and 15 (1.4%) experiencing 30-day mortality, respectively. When using only baseline variables to predict mortality, all algorithms except SVM (area under the receiver operator characteristic curve [AUROC], 0.83 [95% confidence interval {CI}, 0.69-0.97]) had AUROC >0.9: GBM (AUROC, 0.96 [0.94-1.0]), RF (AUROC, 0.96 [0.92-1.0]), CNN (AUROC, 0.96 [0.92-0.99]), and logistic regression (AUROC, 0.95 [0.91-0.99]). AUROC significantly increased with intraoperative variables with CNN (AUROC, 0.97 [0.96-0.99]; P = .047 versus baseline), but there was no improvement with GBM (AUROC, 0.97 [0.95-0.99]; P = .3 versus baseline), RF (AUROC, 0.96 [0.93-1.0]; P = .5 versus baseline), and logistic regression (AUROC, 0.94 [0.90-0.99]; P = .6 versus baseline). CONCLUSIONS: Postoperative mortality is predicted with excellent discrimination in intra-abdominal surgery patients using only preoperative variables in various machine learning algorithms. The addition of intraoperative data to preoperative data also resulted in models with excellent discrimination, but model performance did not improve.

Patient care in rapid-expansion intensive care units during the COVID-19 pandemic crisis.

BACKGROUND: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. METHODS: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. RESULTS: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. CONCLUSIONS: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU.

Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model.

BACKGROUND: Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. METHODS: With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. RESULTS: Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. CONCLUSIONS: Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

The Disparity of Care and Outcomes for Medicaid Patients Undergoing Colectomy.

BACKGROUND: Colectomies are one of the most common surgeries in the United States with about 275,000 performed annually. Studies have shown that insurance status is an independent risk factor for worse surgical outcomes. This study aims to analyze the effect of insurance on health outcomes of patients undergoing colectomy procedures. METHODS: We examined hospital discharge data from the State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, from 2009 to 2014 in California, Florida, New York, Maryland, and Kentucky. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), total hospital charges, and 30- and 90-d readmissions. RESULTS: A total of 444,877 patients were included in the analysis. Bivariate analysis showed that open surgeries were more common in Medicaid patients (50.5%), whereas robotic and laparoscopic surgeries were more common in private insurance holders (50.4% and 21.7%, respectively). In the adjusted multivariate models, when compared with private insurance patients, Medicaid patients had the highest odds ratio (OR) for mortality (OR, 1.96; 95% confidence interval [CI], 1.78-2.15), complication rates (OR, 1.43; 95% CI, 1.38-1.49), 30-d readmission (OR, 1.47; 95% CI, 1.40-1.55), 90-d readmission (OR, 1.44; 95% CI, 1.37-1.51), longer LOS (coefficient, 1.26; 95% CI, 1.24-1.28), and higher total hospital charges (coefficient, 1.15; 95% CI, 1.13-1.17). CONCLUSIONS: We identified Medicaid insurance status as a predictor of open colectomies and of higher mortality, LOS, complications, readmission rates, and charges after colectomy. Further research and initiatives are necessary to meet the specific needs of patients with different payer types.

Implementation of Postoperative Nausea and Vomiting Guidelines for Female Adult Patients Undergoing Anesthesia During Gynecologic and Breast Surgery in an Ambulatory Setting.

PURPOSE: Postoperative nausea and vomiting (PONV) is one of the most common complications after anesthesia. This evidence-based quality improvement (QI) project describes the implementation of a PONV guideline and the impact on providers' compliance with PONV risk assessment using the Apfel PONV score. DESIGN: A retrospective preimplementation and postimplementation QI project. METHODS: This evidence-based QI project sample included 294 adult female patients scheduled for gynecologic or breast surgery in the ambulatory setting. They were observed for PONV in the postanesthesia care unit. In addition, compliance of Apfel risk-assessment score documentation on the preanesthesia evaluation form was assessed. FINDINGS: Postimplementation of the guideline, the overall incidence of PONV was significantly lower (9.5% vs 21.1%, P = .009) and anesthesia providers' adherence to Apfel risk score documentation significantly increased (63.3% vs 49%, P = .019). CONCLUSIONS: A PONV guideline for gynecologic and breast surgery can reduce the PONV incidence and improve anesthesia providers' compliance with PONV risk assessment and its documentation.

Perioperative outcomes and anesthetic considerations of robotic bariatric surgery in a propensity-matched cohort of super obese and super-super obese patients.

BACKGROUND: The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort. METHODS: Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type. RESULTS: A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1-92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1-48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8-3.2 vs. 1.8 days, IQR 1.2-2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60-92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset. CONCLUSIONS: Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.

The Disparities of Coronary Artery Bypass Grafting Surgery Outcomes by Insurance Status: A Retrospective Cohort Study, 2007-2014.

BACKGROUND: Coronary artery bypass grafting (CABG) surgery is the gold standard treatment for complex coronary artery disease. Social determinants of health, including primary payer status, are disproportionately associated with adverse outcomes following surgical operations. We sought to examine associations between insurance status, in particular having Medicaid public insurance, and postoperative outcomes following isolated CABG surgeries. METHODS: A retrospective review was performed using Florida, California, New York, Maryland, and Kentucky State Inpatient Databases (2007-2014) for isolated CABG patients ≥ 18 years. Multivariate regression for postsurgical inpatient mortality, postsurgical complications, 30- and 90-day readmission rates, total charges, and length of stay yielded adjusted odds ratios (ORs) reported for outcomes by insurance status. RESULTS: Among 312,018 individuals, patients with Medicaid insurance and those designated as Uninsured incurred increased adjusted ORs of postsurgical inpatient mortality (56 and 64%, respectively) compared to Private Insurance. Additionally, Medicaid had the highest adjusted OR for 30-day readmission (OR 1.52, 95% CI 1.45-1.59), 90-day readmission (OR 1.53, 95% CI 1.47-1.59), postsurgical complications (OR 1.10, 95% CI 1.07-1.14) including pulmonary and infectious complications, postoperative length of stay, and total hospital charges (2016 dollars). CONCLUSIONS: Medicaid insurance, compared to Private Insurance, is significantly associated with worse outcomes after isolated CABG. Our results demonstrate that Medicaid as a patient's primary insurance payer is an independent predictor of perioperative risks. Further research may help explain the reasons for the differences in payer groups.

Predictive Value of Emergency Designation on Outcomes of Moribund Patients.

BACKGROUND: Anesthesiologists are increasingly encountering sicker patients that require potentially life-saving surgical interventions, and assess risk using the American Society of Anesthesiology Physical Status (ASA PS) classification system. Here, we examined long-term mortality along with hospital length of stay (LoS) and discharge disposition for survivors in ASA PS 5 and 5E patients. METHODS: Adult surgeries were extracted from New York-Presbyterian Hospital/Weill Cornell Medical Center's Electronic Medical Record (EMR) for cases between January 1, 2013 and December 31, 2017; outcomes were collected from EMRs and the Social Security Death Index Master File. RESULTS: 194,947 cases were identified. Mortality correlated with increasing ASA PS; the same trend was observed within both emergent and non-emergent sub-populations. Two hundred seventy-six cases were identified as 5/5E. This patient population had a higher rate of mortality at 30 days than at 48 hours (25.9% vs. 13.4%, respectively, p < 0.01); there was no difference between survivor functions at 30 or 90 days (p = 0.63, p = 0.09, respectively). Survivors within the 5 or 5E subpopulations did not have significantly different LoSs. Further, survivors after 90 days typically had a disposition of hospice, long-term facilities, inpatient rehabilitation, or self-discharged. CONCLUSIONS: Mortality increases with increases in ASA PS classifications. There is no difference in outcomes for 5 vs 5E at 30- or 90-day postoperatively. Similarly, emergency status did not play a role in LoS. Most 5 or 5E patients are not discharged home but to another facility. These outcomes should be considered during the informed consent process in this high-risk surgical population.

Adoption of video laryngoscopy by a major academic anesthesia department.

Aim: To describe the adoption patterns of intubating devices used at a major teaching and research facility. Materials & methods: Retrospective analysis of 2012-2019 data on frequency and trends in airway management devices collected from our anesthesia information management system. Results: Use of direct laryngoscopy was more frequent, but there was a downward trend in use over time (p < 0.008) in favor of video laryngoscopy (VL), which increased significantly (p < 0.008). The largest growth among devices was the McGrath VL, which increased from 0.2% in 2012 to 36.2% of cases in 2019. Conclusion: Our study shows a clear increase in VL usage which has implications in quality of care and medical education.

Sickle Cell Disease is Associated with Increased Morbidity, Resource Utilization, and Readmissions after Common Abdominal Surgeries: A Multistate Analysis, 2007-2014.

INTRODUCTION: Sickle cell disease (SCD), the most commonly inherited hemoglobinopathy in the United States, increases the likelihood of postoperative complications, resulting in higher costs and readmissions. We used a retrospective cohort study to explore SCD's influence on postoperative complications and readmissions after cholecystectomy, appendectomy, and hysterectomy. METHODS: We used an administrative database's 2007-2014 data from California, Florida, New York, Maryland, and Kentucky. RESULTS: 1,934,562 patients aged ≥18 years were included. Compared to non-SCD patients, SCD patients experienced worse outcomes: increased odds of blood transfusion and major and minor complications, higher adjusted odds of 30- and 90-day readmissions, longer length of stay, and higher total hospital charges. CONCLUSION: Sickle cell disease patients are at high risk for poor outcomes based on their demographic characteristics. Therefore, perioperative physicians including hematologists, anesthesiologists, and surgeons need to take this knowledge into consideration for management and counselling of SCD patients on the risks of surgery and recovery.

Medicaid payer status is associated with increased mortality and morbidity after inpatient shoulder arthroplasty: a multistate analysis, 2007-2014.

BACKGROUND AND OBJECTIVES: Inpatient shoulder arthroplasty is widely performed around the USA at an increasing rate. Medicaid insurance has been identified as a risk factor for inferior surgical outcomes. We sought to identify the impact of being Medicaid-insured on in-hospital mortality, readmission, complications, and length of stay (LOS) in patients who underwent inpatient shoulder arthroplasty. METHODS: We analyzed 89 460 patient discharge records for inpatient total, partial, and reverse shoulder arthroplasties using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We compared patient demographics, present-on-admission comorbidities, and hospital characteristics by insurance payer. We estimated multilevel mixed-effect multivariate logistic regression models and generalized linear models to assess insurance's effect on in-hospital mortality, readmission, infectious complications, cardiac complications, and LOS; models controlled for patient and hospital characteristics. RESULTS: Medicaid-insured patients had greater odds than patients with private insurance, other insurance, and Medicare of inpatient mortality (OR: 4.61, 95% CI 2.18 to 9.73, p<0.001) and 30-day and 90-day readmissions (OR: 1.94, 95% CI 1.57 to 2.38, p<0.001; OR: 1.65, 95% CI 1.42 to 2.38, p<0.001, respectively). Compared with private insurance, other insurance, and Medicare patients, Medicaid patients had increased likelihood of developing infectious complications and were expected to have longer LOS. CONCLUSIONS: Our study supports our hypothesis that among inpatient shoulder arthroplasty patients, those with Medicaid insurance have worse outcomes than patients with private insurance, other insurance, and Medicare. These results are relatively consistent with previous findings in the literature.

Medicaid insurance status predicts postoperative mortality after total knee arthroplasty in state inpatient databases.

Aim: Medicaid versus private primary insurance status may predict in-hospital mortality and morbidity after total knee arthroplasty (TKA). Materials & methods: Regression models were used to test our hypothesis in patients in the State Inpatient Database (SID) from five states who underwent primary TKA from January 2007 to December 2014. Results: Medicaid patients had greater odds of in-hospital mortality (odds ratio [OR]: 1.73; 95% CI: 1.01-2.95), greater odds of any postoperative complications (OR: 1.25; 95% CI: 1.18-1.33), experience longer lengths of stay (OR: 1.09; 95% CI: 1.08-1.10) and higher total charges (OR: 1.03; 95% CI: 1.02-1.04). Conclusion: Medicaid insurance status is associated with higher in-hospital mortality and morbidity in patients after TKA compared with private insurance.

Assessing the value of preoperative medical clearance in patients with primary rhegmatogenous retinal detachment.

PURPOSE: To determine rates of intraoperative and postoperative systemic and ocular adverse events and establish the value of preoperative medical assessment in patients undergoing surgery for primary rhegmatogenous retinal detachment repair at a single academic center. PATIENTS AND METHODS: Retrospective cohort study of 185 patients undergoing surgery for repair of primary rhegmatogenous retinal detachment (RRD) at a single academic center. Medical records were reviewed for medical comorbidities, completion of preoperative medical examination, anesthesia used during surgery, intraoperative adverse medical events, intraoperative ocular complications, and systemic and ocular postoperative complications. The main outcome of interest was the association of comorbidities and preoperative medical evaluation with intraoperative and postoperative complications. RESULTS: Approximately 48% of the patients presented with no medical comorbidities of interest. Formal preoperative evaluation by an independent medical provider was completed in 36% of the patients. Overall, intraoperative and postoperative systemic complications (5.7% and 1%, respectively) and intraoperative and postoperative ocular complications (0.5% for both) were uncommon. Patients with a history of chronic heart failure (OR 24.5, P=0.02) or who received general anesthesia (OR 9.56, P<0.001) had increased risk of having experienced any intraoperative or postoperative complication. No relationship between preoperative medical evaluation and intraoperative and postoperative complications was observed. CONCLUSION: Patients undergoing surgery for RRD repair presented with fewer medical comorbidities than previously reported in patients undergoing all vitreoretinal surgeries. Intraoperative and postoperative complications were uncommon and were increased in patients with chronic heart failure or who received general anesthesia. Complications were not significantly associated with preoperative evaluation by an independent medical provider.

Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status.

BACKGROUND: Total hip replacements (THRs) are the sixth most common surgical procedure performed in the USA. Readmission rates are estimated at between 4.0 and 10.9%, and mean costs are between $10,000 and $19,000. Readmissions are influenced by the quality of care received. We sought to examine differences in readmissions by insurance payer, race and ethnicity, and income status. METHODS: We analyzed all THRs from 2007 to 2011 in California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Primary outcomes were readmission at 30 and 90 days after THR. Descriptive statistics were calculated, and multivariate logistic regression analysis was used to estimate adjusted odds ratio (OR) for readmissions. Statistical significance was evaluated at the < 0.05 alpha level. RESULTS: A total of 274,851 patients were included in the analyses. At 30 days (90 days), 5.6% (10.2%) patients had been readmitted. Multivariate logistic regression analysis showed that patients insured by Medicaid (OR 1.23, 95%CI 1.17-1.29) and Medicare (OR 1.58, 95%CI 1.44-1.73) had increased odds of 30-day readmission, as did patients living in areas with lower incomes, Black patients, and patients treated at lower volume hospitals. Ninety-day readmissions showed similar significant results. CONCLUSIONS: The present study has shown that patients on public insurance, Black patients, and patients who live in areas with lower median incomes have higher odds of readmission. Future research should focus on further identifying racial and socioeconomic disparities in readmission after THR with an eye towards implementing strategies to ameliorate these differences.

Coronary artery bypass graft readmission rates and risk factors - A retrospective cohort study.

BACKGROUND: Hospital readmissions contribute substantially to the overall healthcare cost. Coronary artery bypass graft (CABG) is of particular interest due to its relatively high short-term readmission rates and mean hospital charges. METHODS: A retrospective review was performed on 2007-2011 data from California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project. All patients ≥18 years of age who underwent isolated CABG and met inclusion/exclusion criteria were included. Insurance status was categorized by Medicaid, Medicare, Private Insurance, Uninsured, and Other. Primary outcomes were unadjusted rates and adjusted odds of readmission at 30- and 90-days. Secondary outcomes included diagnosis at readmission. RESULTS: A total of 177,229 were included in the analyses after assessing for exclusion criteria. Overall 30-day readmission rate was 16.1%; rates were highest within Medicare (18.4%) and Medicaid (20.2%) groups and lowest in the private insurance group (11.7%; p < 0.0001). Similarly, 90-day rates were highest in Medicare (27.3%) and Medicaid (29.8%) groups and lowest in the private insurance group (17.6%), with an overall 90-day rate of 24.0% (p < 0.0001). The most common 30-day readmission diagnoses were atrial fibrillation (26.7%), pleural effusion (22.5%), and wound infection (17.7%). Medicare patients had the highest proportion of readmissions with atrial fibrillation (31.7%) and pleural effusions (23.3%), while Medicaid patients had the highest proportion of readmissions with wound infections (21.8%). Similar results were found at 90 days. Risk factors for readmission included non-private insurance, age, female sex, non-white race, low median household income, non-routine discharge, length of stay, and certain comorbidities and complications. CONCLUSIONS: CABG readmission rates remain high and are associated with insurance status and racial and socioeconomic markers. Further investigation is necessary to better delineate the underlying factors that relate racial and socioeconomic disparities to CABG readmissions. Understanding these factors will be key to improving healthcare outcomes and expenditure.

Anesthesia for the patient undergoing total knee replacement: current status and future prospects.

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.

Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York.

STUDY OBJECTIVE: To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements. DESIGN: Retrospective cohort study. SETTING: Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. PATIENTS: 295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51). INTERVENTIONS: Patients underwent total hip replacement. MEASUREMENTS: Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data. MAIN RESULTS: Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS. CONCLUSIONS: We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.