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Both heart failure (HF) and insomnia are associated with high symptom burden that may be manifested in clustered symptoms. To date, studies of insomnia have focused only on its association with single symptoms. The purposes of this study were to: (1) describe daytime symptom cluster profiles in adults with insomnia and chronic HF; and (2) determine the associations between demographic and clinical characteristics, insomnia and sleep characteristics and membership in symptom cluster profiles.One hundred and ninety-five participants [We analyzed baseline data, including daytime symptoms (fatigue, pain, anxiety, depression, dyspnea, sleepiness) and insomnia (Insomnia Severity Index), and sleep characteristics (Pittsburgh Sleep Quality Index, wrist actigraphy). We conducted latent class analysis to identify symptom cluster profiles, bivariate associations, and multinomial regression.We identified three daytime symptom cluster profiles, physical (N = 73 participants; 37.4%), emotional (N = 12; 5.6%), and all-high symptoms (N = 111; 56.4%). Body mass index, beta blockers, and insomnia severity were independently associated with membership in the all-high symptom profile, compared with the other symptom profile groups.Higher symptom burden is associated with more severe insomnia in people with stable HF. There is a need to understand whether treatment of insomnia improves symptom burden as reflected in transition from symptom cluster profiles reflecting higher to lower symptom burden.

Background: The impact of do-not-resuscitate (DNR) order on patients with pancreatic cancer remains uncertain. In this study, we evaluated whether DNR status was associated with in-hospital mortality and costs for the inpatient stay among patients hospitalized with pancreatic cancer.Methods: Data were from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), and included 40,246 pancreatic cancer admissions between 2011 and 2016. Mortality was modeled using a logistic regression model; costs for the inpatient stay were modeled using a multivariable generalized linear regression model.Results: The sample included 6,041 (15%) patients with a documented DNR. After controlling for covariates, patients with a DNR order had approximately 6 times greater odds of mortality compared to patients without a DNR order (OR 5.90, pConclusions: The presence of a DNR order among patients with pancreatic cancer was significantly associated with higher mortality risk, as well as lower costs for the patients who died during the hospital stay. However, DNR status was not significantly associated with costs for patients with pancreatic cancer who were discharged alive.

Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was$33,900.Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Patients with long-standing carpal tunnel symptoms may develop transient and, paradoxically, worsened neuropathic pain immediately following release. The authors have termed this "reawakening phenomenon." The purpose of this study was to compare the characteristics of patients with this phenomenon to those with a standard postoperative course.A retrospective chart review was performed on all patients who underwent carpal tunnel release at a single institution between January of 2012 to December of 2017. Patients demonstrating increased neuropathic pain in the median nerve distribution postoperatively without evidence of complex regional pain syndrome were included. A comparison cohort was composed of the remaining patients identified. Demographic data, medical history, carpal tunnel history, and electromyogram and nerve conduction study findings were recorded.A total of 640 patients were identified; 440 met criteria. Seventeen patients were found to have symptoms consistent with median nerve reawakening phenomenon. The reawakening cohort was older (71.1 versus 56.8 years), more likely to have evidence of thenar muscle atrophy (58.8 percent versus 13.48 percent), and more likely to have fibrillations and sharp waves on electrodiagnostic studies. Although not statistically significant, they also had a longer duration of symptoms (4.9 versus 2.9 years). Of those patients with reawakening phenomenon, 14 had resolution of their symptoms at an average period of 4.4 months. Three remaining patients who were subjectively symptomatic had normal or improved postoperative electromyogram and nerve conduction studies.Reawakening of the median nerve has not been previously described but occurs in 3.9 percent of hands following routine carpal tunnel release. Preoperative counseling of patients at high risk for reawakening phenomenon is recommended.Risk, III.

Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol’s individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR). A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS. One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p

Background Observational research on the advance care planning (ACP) process is limited by a lack of easily accessible ACP variables in many large datasets. The objective of this study was to determine whether International Classification of Disease (ICD) codes for do-not-resuscitate (DNR) orders are valid proxies for the presence of a DNR recorded in the electronic medical record (EMR). Methods We studied 5,016 patients over the age of 65 who were admitted to a large, mid-Atlantic medical center with a primary diagnosis of heart failure. DNR orders were identified in billing records from ICD-9 and ICD-10 codes. DNR orders were also identified in the EMR by a manual search of physician notes. Sensitivity, specificity, positive predictive value and negative predictive value were calculated as well as measures of agreement and disagreement. In addition, estimates of associations with mortality and costs were calculated using the DNR documented in EMR and the DNR proxy identified in ICD codes. Results Relative to the gold standard of the EMR, DNR orders identified in ICD codes had an estimated sensitivity of 84.6%, specificity of 96.6%, positive predictive value of 90.5%, and negative predictive value of 94.3%. The estimated kappa statistic was 0.83, although McNemar’s test suggested there was some systematic disagreement between the DNR from ICD codes and the EMR. Conclusions ICD codes appear to provide a reasonable proxy for DNR orders among hospitalized older adults with heart failure. Further research is necessary to determine if billing codes can identify DNR orders in other populations.

Introduction:Additional preoperative safety checklist requirements at Penn State Health were recently implemented on the morning of surgery. We evaluate whether this added safety policy imp...

Surveillance guidelines for kidney cancer following surgery are heterogeneous, making it unclear what factors influence surveillance intensity in practice. Thus, we assessed the patterns of surveillance intensity in kidney cancer after primary surgery among patients ≥ 66 years. Non-metastatic kidney cancer patients after primary surgery (n = 2433) from 2007 to 2011 were identified in SEER-Medicare. Surveillance intensity was measured as the number of unique inpatient and outpatient claims made for kidney cancer starting 60 days after primary surgery. Multivariable linear regressions assessed relationships between patient factors and surveillance intensity (log-transformed). Parameters were reported using risk ratios (RRs). Patients diagnosed in contemporary years experienced 10% more surveillance visits/12 months (RR 1.10 for every 1-year increase, 95% CI 1.07–1.13, p

OBJECTIVE: Examine the bidirectional relationships between within-person day-to-day fluctuations in physical activity (PA) and sleep characteristics among people with heart failure (HF) and insomnia. PARTICIPANTS: Ninety-seven community-dwelling adults [median age 61.9 (interquartile range 55.3,70.9) years, female 41%] with stable HF and insomnia (insomnia severity index >7). METHODS: This sub-study longitudinally analyzed 15 consecutive days and nights of wrist actigraphy recordings, that were collected for baseline data prior to participation in a randomized controlled trial of cognitive behavioral therapy for insomnia. We used two-level mixed models of within- (daily) and between-participants variation to predict daytime PA counts/min from sleep variables (total sleep time, sleep efficiency) and predict sleep variables from PA. RESULTS: PA counts/min were low compared to prior cohorts that did not have HF (209 (166,259)) and negatively associated with NYHA class (standardized coefficient β(s)=−0.14, p

ObjectivesTo evaluate sex differences in demographic and clinical characteristics, treatments and outcomes for patients with diagnosed obstructive hypertrophic cardiomyopathy (oHCM) in the USA.SettingRetrospective observational study of administrative claims data from MarketScan Commercial Claims and Encounters Database from IBM Watson Health.ParticipantsOf the 28 million covered employees and family members in MarketScan, 9306 patients with oHCM were included in this analysis.Main outcome measuresoHCM-related outcomes included heart failure, atrial fibrillation, ventricular tachycardia/ fibrillation, sudden cardiac death, septal myectomy, alcohol septal ablation (ASA) and heart transplant.ResultsAmong 9306 patients with oHCM, the majority were male (60.5%, pConclusionWomen were less likely to be prescribed beta blockers, ACE inhibitors, anticoagulants, undergo implantable cardioverter-defibrillator and have ventricular tachycardia/fibrillation. Men were more likely to have atrial fibrillation. Future research using large, clinical real-world data are warranted to understand the root cause of these potential treatment disparities in women with oHCM.

Objective An interdisciplinary pain team was established at our institution to explore options for improving pain control in patients undergoing orthopedic surgery by identifying traits that put a patient at increased risk for inadequate pain control postoperatively. Materials and methods The interdisciplinary pain team identified 7 potential risk factors that may lead to inadequate pain control postoperatively including (1) history of physical, emotional, or sexual abuse; (2) history of anxiety; (3) history of drug or alcohol abuse; (4) preoperative nonsteroidal anti-inflammatory drug, or disease-modifying antirheumatic drug use; (5) current opioid use; (6) psychological conditions other than anxiety; and (7) current smoker. Statistical analysis determined which risk factors were associated with increased preoperative and postoperative pain scores. Results A total of 1923 patients undergoing elective orthopedic surgery were retrospectively identified. Hip, knee, and shoulder replacements accounted for 76.0% of the procedures. 78.5% of patients had 3 or fewer risk factors and 17.1% had no risk factors. Anxiety, other psychological conditions, current opioid use, and current smoking were significantly associated with higher preoperative and postoperative pain scores. Discussion We found a significant association between anxiety, current smoking, psychological conditions, and current opioid use with increased preoperative and postoperative reported pain score. We propose that identification of these risk factors should prompt more attention to postoperative pain control plans and will improve communication with patients and providers. We recommend a multimodal approach to postoperative pain control, and developed a pain orderset to help guide providers.

Objective Little is known about the relationship between case volume and patient outcomes of those treated for ruptured abdominal aortic aneurysm (rAAA) after either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR). This study evaluated the impact of hospital case volume on outcomes after rAAA. Methods Patients with rAAA were identified in the Society for Vascular Surgery Vascular Quality Initiative database from 2003 to 2017, excluding patients from years in which a limited number of hospitals were included (2003-2009, 2017). Patients were stratified according to type of aneurysm repair and further stratified according to aortic surgical volume of the treating facility. Univariate and multivariable analyses were performed. Results Between 2010 and 2016, of 2895 patients who presented emergently with rAAA, 1246 underwent ruptured OAR (rOAR) and 1649 underwent ruptured EVAR (rEVAR). Before adjustment for demographics, comorbidities, and clinical characteristics, there were no differences in 1-year patient survival based on hospital OAR or EVAR volumes among patients undergoing rOAR or rEVAR. After adjustment for confounding variables, patients treated with rOAR at the highest volume OAR hospitals had a 33% lower hazard of mortality at 1 year relative to patients treated with rOAR at the lowest volume OAR hospitals. Preoperative interfacility transfer was associated with a 27% lower hazard of mortality after rOAR. There was no significant difference in hazard of mortality among patients undergoing rEVAR when they were stratified according to hospital EVAR volumes after adjustment for all other covariates. Conclusions Outcomes after rAAA repair are associated with hospital volume among patients undergoing rOAR but not among patients undergoing rEVAR. Thus, centralization of care may have an important impact on outcomes when OAR is indicated, suggesting a benefit for preoperative interfacility transfer of care when it is feasible.

Controversy remains regarding the impact of anti-TNFα agents on postoperative outcomes in Crohn’s disease. Patients (≥ 18 years) with Crohn’s disease (ICD-9, 555.0–555.2, 555.9) undergoing ileocolectomy between 2005 and 2013 were identified using the Truven MarketScan® database and stratified by receipt of anti-TNFα therapy. Multivariable logistic regression was performed to evaluate anti-TNFα use on emergency department (ED) visits, postoperative complications, and readmissions at 30 days, adjusting for potential confounders. Relationships between timing of anti-TNFα administration and outcomes were examined. The sample contained 2364 patients with Crohn’s disease undergoing ileocolectomy, with 28.5% (n = 674) who received biologic therapy. Median duration between anti-TNFα therapy and surgery was 33 days. Postoperative ED visits and readmission rates did not significantly differ among those receiving biologics and those that did not. Overall 30-day complication rates were higher among those receiving biologic therapy, namely related to wound and infectious complications. In multivariable analysis, anti-TNFα inhibitors were associated with increased odds of postoperative complications at 30 days (aggregate complications [OR 1.6], infectious complications [OR 1.5]). There was no significant association between timing of anti-TNFα administration and occurrence of postoperative outcomes. Anti-TNFα therapy is independently associated with increased postoperative infectious complications following ileocolectomy in Crohn’s disease. However, in patients receiving anti-TNFα therapy within 90 days of operative intervention, further delaying surgery may not attenuate risk of postoperative complications.

Women with substance use disorders have high incidences of psychiatric and mood disorders, which may affect their ability to cope with an infant with neonatal abstinence syndrome (NAS), particularly one with a protracted NICU course, exacerbating symptoms of mental health disorders. We examined the incidence of mental health diagnoses in the first 12 postpartum months in mothers of an NAS infant compared to mothers of an infant without NAS. In this retrospective, cohort study, data were extracted from MarketScan® database (2005–2013). NAS newborns were identified using ICD-9 codes. Each mother of an NAS newborn was matched to a mother of a newborn without NAS on age at delivery, birth year, gestational age, NICU stay and maternal mental health diagnoses in the 9 months prior to delivery. Primary outcomes were claims for major depression, postpartum depression, anxiety, adjustment reaction, post-traumatic stress disorder, and suicidal ideation. 338 mother-infant pairs met all inclusion/exclusion criteria and were matched 1-to-1 with controls. 245 (73%) of the NAS infants had a NICU admission. Median length of stay for these infants was 10 days compared to 3 days for infants with no NICU admission (p

Aims: Patients with chronic kidney disease (CKD) not on dialysis frequently have vitamin D insufficiency (VDI) and secondary hyperparathyroidism (SHPT), which are associated with an increased risk ...

Adrenalectomy is an operation performed by both urologists and general surgeons; however, the majority are performed by general surgeons. We investigated whether there was a difference in outcomes based on surgical specialty performing the procedure. If no differences exist, an argument can be made that urologists should be doing more adrenalectomies. The National Surgical Quality Improvement Project (NSQIP) Participant Use File (PUF) was queried to extract all cases of adrenalectomies performed from 2011 to 2015. Current Procedural Technology (CPT) codes 60540 and 60650 were used. The data were stratified by surgical specialty performing the adrenalectomy (urology or general surgery). Our outcomes of interest included post-surgical complications, reoperations, 30-day readmission, mortality, and hospital length of stay. A total of 3358 patients who underwent adrenalectomy between 2011 and 2015 were included. General surgeons performed 90% of these (n = 3012) and urologists performed 10% (n = 334). Differences in number of post-surgical complications, length of stay, rate of reoperation, 30-day readmission, and mortality were not statistically significant between general surgeons and urologists (p = 0.76, p = 0.29, p = 0.37, p = 0.98, and p = 0.59, respectively). Small complication rates disallowed multivariable analyses, but unadjusted rates for reoperation, presence of any post-operative complication, readmission within 30 days, and mortality were similar between specialties. Surgical specialty did not make a difference in outcomes for patients undergoing adrenalectomy, despite a large disparity in the number of procedures performed by general surgeons versus urologists. Urologists should continue performing adrenalectomies and, given their familiarity with the retroperitoneum, perhaps perform more than is the current trend.

Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis.A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters.In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective.Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.

PURPOSE: With the introduction of the Oncology Care Model and plans for the transition to Oncology Care First, alternative payment models (APMs) are an increasingly important piece of the oncology care landscape. Evidence is mixed on the Oncology Care Model's impact on utilization and costs, but as policymakers consider expansion of similar models, it is critical to understand the characteristics of hospitals that may be differentially affected. METHODS: We used 2007-2016 SEER-Medicare data to identify patients with breast and prostate cancer receiving chemotherapy, endocrine therapy (breast), or androgen deprivation therapy (prostate). For each hospital, we calculated 6-month expected mortality, emergency department (ED) visits, inpatient admissions, and costs, all commonly collected APM outcomes. After calculating observed-to-expected rates for each outcome by hospital, we estimated the association between observed-to-expected rates and characteristics of each hospital to understand hospital characteristics that might be associated with higher- or lower-than-expected rates of each outcome. RESULTS: Hospitals with > 15% rural patients had significantly higher-than-expected mortality (0.31 points higher, P < .001) and ED visit rates (0.10 points higher, P = .029) as well as significantly lower costs (0.06 points lower, P = .004). Hospitals unaffiliated with a medical school also experienced significantly higher-than-expected mortality and ED visits. Hospitals eligible for disproportionate share hospital payment experienced significantly higher ED visits but lower costs. For-profit hospitals experienced higher-than-expected mortality. CONCLUSION: Rural hospitals and those unaffiliated with a medical school may require special consideration as APMs expand in oncology care. Designated cancer centers and larger hospitals may be advantaged.

Supplemental Digital Content is available in the text., Background. Renal dysfunction is associated with poor long-term outcomes after liver transplantation. We examined the renal sparing effect of everolimus (EVR) compared to standard calcineurin inhibitor (CNI) immunosuppression with direct measurements of renal function over 24 months. Methods. This was a prospective, randomized, open-label trial comparing EVR and mycophenolic acid (MPA) with CNI and MPA immunosuppression. An Investigational New Drug Application (IND # 113882) was obtained with the Food and Drug Administration as EVR is only approved for use with low-dose tacrolimus. Serum creatinine, 24-hour urine creatinine clearance, iothalamate clearance, Cockcroft-Gault creatinine clearance (CrCl), and Modification of Diet in Renal Disease estimated glomerular filtration rate were prospectively measured at 4 study visits. Nonparametric statistical tests were used for analyses, including the Mann-Whitney U test for continuous outcomes and Pearson’s chi-square test for binary outcomes. Effect size was measured using Cohen’s d. Patients also completed quality of life surveys using the FACT-Hep instrument at each study visit. Comparison between the 2 groups was performed using the Student t test. Results. Each arm had 12 subjects; 4 patients dropped out in the EVR arm and 1 in the CNI arm by 24 months. Serum creatinine (P = 0.015), Modification of Diet in Renal Disease estimated glomerular filtration rate (P = 0.013), and 24-hour urine CrCL (P = 0.032) were significantly better at 24 months with EVR. Iothalamate clearance showed significant improvement at 12 months (P = 0.049) and a trend toward better renal function (P = 0.099) at 24 months. There was no statistical significance with Cockcroft-Gault CrCl. Adverse events were not significantly different between the 2 arms. The EVR group also showed significantly better physical, functional, and overall self-reported quality of life (P = 0.01) at 24 months. Conclusions. EVR with MPA resulted in significant long-term improvement in renal function and quality of life at 24 months after liver transplantation compared with standard CNI with MPA immunosuppression.

As the incidence of autism spectrum disorder (ASD) increases, otolaryngologists are more likely to encounter patients from this population during tonsillectomy. The purpose of this study was to examine whether outcomes differ between pediatric patients with and without ASD in a national cohort of children undergoing tonsillectomy. Understanding these differences may be used to inform future approaches to improve clinical outcomes and healthcare costs.Data for this study were obtained from the Kids Inpatient Database (KID) of the Healthcare Cost Utilization Project. We studied pediatric patients who underwent tonsillectomy during 2003, 2006, 2009, and 2012. Tonsillectomy was identified using ICD-9-CM diagnosis codes 28.2 (tonsillectomy without adenoidectomy) and 28.3 (tonsillectomy with adenoidectomy). ASD was identified using ICD-9-CM diagnosis code 299 (autism). Outcomes including complications, length of hospital stay, and total hospitalization costs. Analyses were performed using multivariable models. Propensity score matching was used to control for covariate imbalance between patients with and without ASD.In our sample of 27,040 patients, 322 (1.2%) had a diagnosis of ASD. After controlling for potential confounders, multivariable modeling suggested patients with ASD had a shorter LOS of 0.50 days (p 0.0001), were less likely to experience complications (odds ratio 0.57, p = 0.001), and had lower associated costs of $1308 less (p 0.0001). Propensity score matching confirmed the findings of the multivariable modeling.Although ASD alone does not appear to confer additional costs or morbidity, differences between children with and without ASD suggest the need for providers to address patients with ASD uniquely.

Minimally invasive surgical approaches for gastric adenocarcinoma are increasing in prevalence. Although recent studies suggest such approaches are associated with improvements in short-term outcomes, long-term outcomes have not been well studied. This study aimed to evaluate the impact of minimally invasive gastrectomy on long-term survival. The National Cancer Database (NCDB) was used to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. Patient characteristics were stratified by open and minimally invasive approaches and compared using chi-square and t tests. Unadjusted survival functions were estimated using Kaplan-Meier methodology. Multivariable modeling of risks factors for survival was analyzed with Cox proportional hazard models. Covariate imbalance was controlled using propensity score matching. The study included 17,449 patients who underwent gastrectomy. Cox proportional hazard modeling demonstrated that minimally invasive surgery improved survival (hazard ratio = 0.86, P

Background Intrapleural lytic therapy has been established as an important modality of treatment for many pleural disorders, including hemothorax and empyema. Retained traumatic hemothorax is a common and understudied subset of pleural disease. The current standard of care for retained traumatic hemothorax is operative management. The use of lytic therapy for avoidance of operative intervention in the trauma population has not been well established. Methods Randomized controlled trials (RCTs) and non-RCTs reporting operative intervention following the use of intrapleural lytic treatment for retained traumatic hemothorax were identified in the literature. The primary outcome was avoidance of surgery following treatment with any lytic agent. Meta-analysis was performed to pool the results of those studies. Subgroup analysis by type of lytic therapy and analysis of length of stay were also performed. Results One RCT and nine non-RCTs including 162 patients were pooled in the analysis. Avoidance of surgery following treatment with any lytic agent was found to be 87% (95% CI, 81%-92%). Tissue plasminogen activator resulted in 83% operative avoidance (95% CI, 71%-94%), and other, non-tissue plasminogen activator lytic agents resulted in 87% operative avoidance (95% CI, 82%-93%). The average length of stay for patients undergoing lytic therapy was 14.88 days (95% CI, 12.88-16.88). Conclusions Lytic therapy could reduce the need for operative intervention in trauma patients with retained traumatic hemothorax. RCTs are indicated to definitively evaluate the benefit of this approach.

Background Because of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. Materials and methods Data were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. Results Thirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). Conclusions Carotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Background Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. Objective The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. Design This was a retrospective cohort study. Settings Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. Patients Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. Main outcome measures Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. Results A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p Limitations This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. Conclusions After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

Introduction Implant based breast reconstructions has become widely accepted as an appropriate reconstruction method following mastectomy for breast cancer. The two most common techniques include immediate reconstruction and implantation (single-stage procedure) or the use of a tissue expander with delayed insertion of implant and reconstruction (two-stage procedure). Using existing studies and available data, a meta-analysis was performed analyzing reoperation rates and postoperative complications between these two methods based upon available literature. Methods A literature search was performed by two individual investigators using the databases PubMed, Cochrane, and Medline. All articles comparing implant based single and two stage breast reconstructions outcomes between 2006 and 2016 were utilized. The primary endpoint of interest was reoperation rates. Secondary endpoints included postoperative complications such as infection, seroma, hematoma, and necrosis. Results A total of five studies met the inclusion criteria, for a total of 12,357 breast reconstructions. 2,281 breast reconstructions were singlestage and 10,076 were two-staged. The primary endpoint of reoperation was increased reoperation rate in the single-stage breast reconstruction (OR=0.78, CI 0.67-0.91; p

Chiari I malformation is a common entity in pediatric neurosurgery. Prior studies have shown that surgical treatment at children’s hospitals (CH) is associated with higher costs compared to non-children’s hospitals (NCH) for other diagnoses. Therefore, we hypothesized that costs would be increased for the treatment of Chiari I malformation at a CH. Data were extracted from the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). Patients who underwent surgery for Chiari I malformation were identified using International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. Univariate statistical tests, multivariable linear regression models, and propensity score matching were utilized to determine differences in hospital length of stay (LOS) and costs between patients treated at CH versus NCH. Treatment at a CH was associated with significantly higher costs compared to treatment at an NCH while hospital LOS and mortality were similar. In the multivariable linear regression model, the adjusted average cost for surgical treatment of Chiari I malformation was $13,716, and treatment at a CH was associated with an additional $6,343 (p

The risk of instability, dislocation, and revision following total hip arthroplasty (THA) is increased in patients with abnormal spinopelvic mobility. Seated and standing lateral lumbar spine imaging can identify patients with stiff/hypermobile spine (SHS) to guide interventions such as changes in acetabular cup placement or use of a dual-mobility hip construct aimed at reducing dislocation risk.A Markov decision model was created to compare routine preoperative spinal imaging (PSI) to no screening in patients with and without SHS. Screened patients with SHS were assumed to receive dual-mobility hardware while those without SHS and nonscreened patients were assumed to receive conventional THA. Cost-effectiveness was determined by estimating the incremental cost-effectiveness ratio. Effectiveness measured as quality-adjusted life years (QALYs), with $100,000 per additional QALY as the threshold for cost-effectiveness. Sensitivity analyses were performed to determine the robustness of the base-case result.The screening strategy with PSI had a lifetime cost of $12,515 and QALY gains of 16.91 compared with no-screening ($13,331 and 16.77). The PSI strategy reached cost-effectiveness at 5 years and was dominant (ie, less costly and more effective) at 11 years following THA. In sensitivity analyses, PSI remained the dominant strategy if prevalence of SHS was1.9%, the cost of PSI was$925, and the cost of dual-mobility hardware exceeded the cost of conventional hardware by$2850.Screening patients for SHS prior to THA with PSI is both less costly and more effective and should be considered as part of standard presurgical workup.

Introduction Insomnia is common among adults with chronic heart failure (HF), often not explained by sleep apnea (SA), and associated with daytime symptoms and poor daytime function. The purpose of this randomized controlled trial was to evaluate the sustained effects of cognitive behavioral therapy for insomnia (CBT-I) on insomnia severity and sleep characteristics over 6 months among adults with stable chronic HF. Methods We included adults with HF who had at least mild insomnia [Insomnia Severity Index (ISI) > 8] and no more than mild SA or SA treated with continuous positive airway pressure. We randomized in groups to 8 weeks of group CBT-I (Healthy Sleep: HS) [4 group sessions + calls on alternate weeks] or attention control (Healthy Hearts: HH) [HF self-management education + brief sleep hygiene] in the same format. We administered the ISI, the Pittsburgh Sleep Quality Index (PSQI), the Dysfunctional Beliefs & Attitudes about Sleep Scale (DBAS), and the Sleep Disturbance Questionnaire (SDQ) at baseline (T0), 2 weeks after treatment ended (T1) and at 6 months (T2). Statistical analysis included descriptive statistics and mixed effects models with random intercepts and slopes. Results The sample include 175 participants (HS: N = 91; 62 + 13 years; 58% Male; 15% Black; 68% NY Heart Class II-III) (HH: N = 84; 64 + 12.5 years; 56% Male; 17% Black; 70% NY Heart Class II-III). There was no significant difference at baseline in demographic characteristics or the mean ISI [HS: 15.3 (4.5); HH: 14.4 (4.5)], but a greater percentage in the HS group had clinical/moderate-severe insomnia (ISI > 15) (HS: 60.4% vs. HH: 47%). The CBT-I intervention (HS) was associated with significant improvement in insomnia severity (ISI: p = .001), sleep quality (PSQI: p = .002), and sleep-related cognitions (DBAS: p = .0006; SDQ: p = .0138), and a modest effect on self-reported sleep duration (46 vs. 20 mins, p = .054), but no effect on sleep efficiency. At 6 months, 12.9% of the HS group, compared with 24.9% of the HH group had clinical insomnia. Conclusion CBT-I has sustained effects on insomnia, sleep-quality, and sleep-related cognitions in people with HF. Support (if any) R01NR01691 (NSR, PI)

Background Nurse staffing impacts patient outcomes, but little is known about the relationship between nurse staffing and outcomes for lung cancer patients undergoing pulmonary lobectomy. Objectives To examine the association between nurse staffing and outcomes following lobectomy for lung cancer. Methods Patients (N = 16,994) with lung cancer between who underwent lobectomy between 2008–2011 were identified in the National Inpatient Sample. Nurse staffing was quantified using registered nurse full-time equivalents per adjusted patient days. Multivariable models were used to estimate the effect of RN FTEs on mortality, length of stay, and costs, controlling for covariates. Results Patients treated at hospitals using 5.6 or more RN FTEs had shorter hospitals stays by 0.37 days (p = 0.008), had 36% lower odds of mortality (OR = 0.64, p = 0.014), but incurred $4,388 (p Conclusions Hospital administrators face a troubling trade-off between costs and outcomes in decisions about nurse staffing mix for pulmonary lobectomy.

Background:. The U.S. Patient Protection and Affordable Care Act created the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition Reduction Program (HACRP). Under these programs, hospitals face reimbursement reductions for having high rates of readmission and hospital-acquired conditions. This study investigated whether readmission following total joint arthroplasty (TJA) under the HRRP was associated with reimbursement penalties under the HACRP. Methods:. Hospital-level data on hospital-acquired conditions, readmissions, and financial penalties were obtained from Definitive Healthcare. Outcomes included receipt of an HACRP penalty and the associated losses in revenue in 2018. Logistic regression and linear regression models were used to determine whether the all-cause, 30-day readmission rate following TJA was associated with the receipt or magnitude of an HACRP penalty. Results:. Among 2,135 private, acute care hospitals, 477 (22.3%) received an HACRP penalty. After controlling for other patient and hospital characteristics, hospitals with a 30-day readmission rate of >3% after TJA had over twice the odds of receiving an HACRP penalty (odds ratio, 2.20; p = 0.043). In addition, hospitals with a readmission rate of >3% after TJA incurred $77,519 more in revenue losses due to HACRP penalties (p = 0.011). These effects were magnified in higher-volume hospitals. Conclusions:. Acute care hospitals in the United States with higher 30-day readmission rates following TJA are more likely to be penalized and to have greater revenue losses under the HACRP than hospitals with lower readmission rates after TJA. This strengthens the incentive to invest in the prevention of readmissions after TJA, for example, through greater efforts to reduce surgical site infections and other modifiable risk factors.