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Background: Minimally invasive esophagectomy is associated with decreased postoperative complications compared with open esophagectomy. However, the risks of complications for minimally invasive esophagectomy compared with open esophagectomy may be affected by operative time. The objectives of this study are to (1) compare the incidence of postoperative complications for minimally invasive esophagectomy and open esophagectomy and (2) evaluate the association of postoperative complications on operative approach and operative time., Methods: A retrospective cohort analysis of patients who underwent an esophagectomy in the American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Data File was performed from 2016 to 2020. For analysis, minimally invasive esophagectomy and open esophagectomy were stratified into tertiles of operative time. A bivariate analysis of postoperative complications comparing minimally invasive esophagectomy with open esophagectomy was performed. Multivariable Poisson regression models were estimated evaluating the association of the likelihood of postoperative complications with operative approach and operative time., Results: In total, 8,574 patients who underwent esophagectomy were included: 5,369 patients underwent minimally invasive esophagectomy, and 3,205 patients underwent open esophagectomy. Median operative time was 402 minutes for minimally invasive esophagectomy and 321 minutes for open esophagectomy. The incidence of postoperative complications and 30-day mortality was lower in the minimally invasive esophagectomy group than the open esophagectomy group within the same tertiles of operative time. When we compared patients who underwent short open esophagectomy with those who underwent long minimally invasive esophagectomy, there were no significant differences in complications., Conclusion: There is no significant association of postoperative complications for short open esophagectomy compared with long minimally invasive esophagectomy. Patients should be selected for minimally invasive esophagectomy when there is appropriate surgeon experience and hospital resources., (Published by Elsevier Inc.)

Importance: Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown., Objective: To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs., Design, Setting, and Participants: This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023., Exposures: Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter., Main Outcomes and Measures: The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state., Results: There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients., Conclusions and Relevance: In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.

Problem: Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures., Aims: The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses., Methods: The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure., Results: A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs ( p  < 0.001)., Conclusions: The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors have no relevant financial disclosures to declare. The ultrasound machines were provided to the facility by FUJIFILM-Sonosite. The simulators were donated to the facility by Simulab Corporation.

Introduction: The COVID-19 pandemic caused interruptions in the delivery of medical care across a wide range of conditions including cancer. Trends in surgical treatment for cancer during the pandemic have not been well described. We sought to characterize associations between the pandemic and access to surgical treatment for breast, colorectal, and lung cancer in Illinois., Methods: We performed a retrospective cohort study evaluating inpatient admissions at Illinois hospitals providing surgical care for lung cancer (n = 1913 cases, n = 64 hospitals), breast cancer (n = 910 cases, n = 108 hospitals), and colorectal cancer (n = 5339 cases, n = 144 hospitals). Using discharge data from the Illinois Health and Hospital Association's Comparative Health Care and Hospital Data Reporting Services database, average monthly surgical case volumes were compared from 2019 to 2020. We also compared rates of cancer surgery for each cancer type, by patient characteristics, and hospital type across the three time periods using Pearson chi-squared and ANOVA testing as appropriate. Three discrete time periods were considered: prepandemic (7-12/2019), primary pandemic (4-6/2020), and pandemic recovery (7-12/2020). Hospital characteristics evaluated included hospital type (academic, community, safety net), COVID-19 burden, and baseline cancer surgery volume., Results: There were 2096 fewer operations performed for breast, colorectal, and lung cancer in 2020 than 2019 in Illinois, with the greatest reductions in cancer surgery volume occurring at the onset of the pandemic in April (colorectal, -48.3%; lung, -13.1%) and May (breast, -45.2%) of 2020. During the pandemic, breast (-14.6%) and colorectal (-13.8%) cancer surgery experienced reductions in volume whereas lung cancer operations were more common (+26.4%) compared to 2019. There were no significant differences noted in gender, race, ethnicity, or insurance status among patients receiving oncologic surgery during the primary pandemic or pandemic recovery periods. Academic hospitals, hospitals with larger numbers of COVID-19 admissions, and those with greater baseline cancer surgery volumes were associated with the greatest reduction in cancer surgery during the primary pandemic period (all cancer types, P < 0.01). During the recovery period, hospitals with greater baseline breast and lung cancer surgery volumes remained at reduced surgery volumes compared to their counterparts (P < 0.01)., Conclusions: The COVID-19 pandemic was associated with significant reductions in breast and colorectal cancer operations in Illinois, while lung cancer operations remained relatively consistent. Overall, there was a net reduction in cancer surgery that was not made up during the recovery period. Academic hospitals, those caring for more COVID-19 patients, and those with greater baseline surgery volumes were most vulnerable to reduced surgery rates during peaks of the pandemic and to delays in addressing the backlog of cases., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Patient navigation programs have shown promise for improving health but are not widely used in obstetric care. Our objective was to understand obstetric provider perspectives on how to implement patient navigation to optimize care during the postpartum period for low-income patients., Method: Focus groups were conducted with obstetric physicians, nurses, and social workers who care for low-income pregnant and postpartum patients in an academic medical center. Semistructured interview guides were developed to elicit conversations about the potential value of patient navigators, recommendations for navigator training, and how navigators could be most effective in improving postpartum care. Analysis of themes was based on the constant comparative method., Results: Twenty-six obstetric providers (six focus groups) discussed elements for a successful obstetric navigation program. Successful implementation themes included selecting navigators with appropriate interpersonal attributes, arranging navigator training, and identifying the most valuable services navigators could render. Desirable navigator attributes included persistence in patient advocacy, consistency, relatability, and a supportive manner. Training recommendations included learning the health care system, identifying where to obtain health system and community resources, and learning how be effective health educators. Suggested services were broad, ranging from traditional care coordination to specific educational and resource-driven tasks., Conclusions: Obstetric providers perceive patient navigation to be a potentially beneficial resource to support low-income patients and offered recommendations for navigation implementation. These included suggestions for patient-centered navigators, with specific training and services focused on promoting care continuity and coordination.

Background: "One-minute preceptor" (OMP) is a well-established educational technique; however, primary literature on OMP lacks a tool to assess behavioral change after delivery of curricula.Primary aim of this pilot study was to design a checklist for direct observation of teachers using OMP on general medicine rounds and obtain inter-rater reliability evidence for the checklist., Methods: This study pilots an internally designed 6-item checklist to assess change in directly observed behavior. We describe the process of developing the checklist and training the observers. We calculated a percent agreement and Cohen's kappa to assess inter-rater reliability., Results: Raters had a high percent agreement ranging from 0.8 to 0.9 for each step of OMP. Cohen's kappa ranged from 0.49 to 0.77 for the five OMP steps. The highest kappa obtained was for getting a commitment (κ = 0.77) step, whereas the lowest agreement was for correcting mistakes (κ = 0.49)., Conclusion: We showed a percent agreement ≥0.8 and moderate agreement based on Cohen's kappa with most steps of OMP on our checklist. A reliable OMP checklist is an important step in further improving the assessment and feedback of resident teaching skills on general medicine wards., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2022 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Background and Objectives: Increasing suicide rates and emergency department (ED) mental health visits reflect deteriorating mental health among American youth. This population-based study analyzes trends in ED visits for suicidal ideation (SI) before and during the coronavirus disease 2019 (COVID-19) pandemic., Methods: We analyzed Illinois hospital administrative data for ED visits coded for SI from January 2016 to June 2021 for youth aged 5 to 19 years. We characterized trends in patient sociodemographic and clinical characteristics, comparing three equal 22 month periods and analyzed patient and hospital characteristics associated with the likelihood of hospitalization., Results: There were 81 051 ED visits coded for SI at 205 Illinois hospitals; 24.6% resulted in hospitalization. SI visits accounted for $785 million in charges and 145 160 hospital days over 66 months. ED SI visits increased 59% from 2016 through 2017 to 2019 through 2021, with a corresponding increase from 34.6% to 44.3% of SI principal diagnosis visits (both P < .001). Hospitalizations increased 57% between prepandemic fall 2019 and fall 2020 (P = .003). After controlling for demographic and clinical characteristics, youth were 84% less likely to be hospitalized if SI was their principal diagnosis and were more likely hospitalized if coded for severe mental illness, substance use, anxiety, or depression, or had ED visits to children's or behavioral health hospitals., Conclusions: This study documents child ED SI visits in Illinois spiked in 2019, with an additional surge in hospitalizations during the pandemic. Rapidly rising hospital use may reflect worsening mental illness and continued difficulty in accessing low cost, high-quality outpatient mental health services., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally., Methods: From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling., Results: The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89)., Conclusions: Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of interest: none declared.

Background: Changes to the healthcare system due to COVID-19 have altered care delivery during birth and the postpartum period, a transitional time that requires intensive healthcare support and that is complicated by well-established health disparities. Our objective was to identify additional challenges to healthcare interactions that emerged for low-income postpartum individuals during the pandemic., Methods: This is a qualitative investigation of low-income postpartum individuals enrolled in a trial of postpartum care, who gave birth in the United States in the first three months of the COVID-19 pandemic. Participants completed in-depth semi-structured interviews that addressed healthcare experiences during and after birth, both for in-person and telemedicine encounters. Transcripts were analyzed using the constant comparative method., Results: Of 46 eligible individuals, 87% (N = 40) completed an interview, with 50% identifying as non-Hispanic Black and 38% as Hispanic. Challenges were organized into three domains: unanticipated changes in the birth experience, delayed care, and perceived disadvantages of telemedicine. Changes in the birth experience addressed uncertainty about COVID-19 status, COVID-19 testing, separation from newborn, and visitor restrictions. Delayed care themes addressed logistical challenges, postpartum care, health maintenance, and pediatric care. Participants reported multiple telemedicine-related challenges, including difficulty establishing rapport with providers., Conclusions: Understanding the challenges experienced by low-income peripartum individuals as the COVID-19 pandemic evolves is critical to informing guidelines and diminishing inequities in healthcare delivery. Potential solutions that may mitigate limitations to care in the pandemic include emphasizing shared decision-making in care processes and developing communication strategies to improve telemedicine rapport., Competing Interests: The authors have declared that no competing interests exist.

Background: Evaluate patient outcomes after endovascular aortic interventions performed for nonruptured aortic aneurysms by physician specialties., Methods: Endovascular aortic repair (EVAR), fenestrated or branched repair (F-BEVAR), and thoracic endovascular aortic repair (TEVAR) procedures were obtained from the Illinois Hospital Association Comparative Health Care and Hospital Data Reporting Services database from 2016 to 2019. Logistic and Poisson regression were used to determine outcomes by patient, physician, and hospital characteristics., Results: A total of 4,935 procedures, 3,666 (74.3%) EVAR, 567 (11.5%) F-BEVAR, and 702 (14.2%) TEVAR were performed by vascular surgeons, interventional radiologists, interventional cardiologists, and cardiac surgeons. Vascular surgeons performed interventions equally between hospital types while interventional radiologists primarily performed interventions in teaching hospitals (68.1%) and interventional cardiologists and cardiac surgeons typically performed interventions in community hospitals (91.8% and 82.1%, respectively; P < .001). No differences in inpatient mortality were noted between specialties. Patients treated by interventional radiologists had increased odds of staying in the hospital ≥8 days (odd ration [OR] 1.95, 95% confidence interval [CI] 1.19-3.19) and patients treated by interventional cardiologists had lower odds of being admitted to the intensive care unit [ICU] (OR 0.42, 95% CI 0.18-0.95)., Conclusion: Differences in practice patterns among specialties performing endovascular aortic aneurysm repair for nonruptured aneurysms suggest opportunities for collaboration to optimize quality of care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Research on maternal birth outcomes rarely includes postpartum complications with longitudinally linked patient data. We analyze characteristics associated with delivery complications and postpartum hospital use., Methods: This population-based cohort study is based on administrative data from California. International Classification of Diseases, 10th Revision, codes were used to categorize the incidence of severe maternal morbidity and other route-specific delivery complications as well as preexisting and pregnancy-related conditions and principal diagnoses for postpartum hospital visits. Postpartum hospital use is a composite outcome defined as emergency department visit or hospital readmission within 90 days of birth admission discharge. Multivariable modified Poisson regression analyses were used to estimate the association of patient-level and hospital-level characteristics with the likelihood of postpartum hospital use., Results: In 2017, 457,498 birth admissions occurred in California-licensed hospitals, of which 348,828 index births with linked data were analyzed. Among linked births, 34,825 (10.0%) had an inpatient admission (4,206 [1.2%]) or an emergency department visit (30,371 [9.2%]) within 90 days of birth admission discharge. Birth complications included a 1.7% severe maternal morbidity rate, 7.9% rate of vaginal birth complications, 10.0% rate of cesarean birth complications, and 2.9% frequency of long lengths of stay, all of which were significantly associated with postpartum hospital use. Other significant risk factors for postpartum hospital use were preexisting and pregnancy-related conditions, undergoing cesarean birth, being younger than 18 years old, being non-Hispanic Black, living in a high poverty ZIP code, and having Medicaid., Conclusion: One in 10 birthing persons had a hospital visit within 90 days postpartum. Improving postpartum care is an urgent public health priority., (Copyright © 2021 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to assess the association between United States county-level COVID-19 mortality and changes in presidential voting between 2016 and 2020., Study Design: The study design is a county-level ecological study., Methods: We analysed county-level population-weighted differences in partisan vote change, voter turnout and sociodemographic and health status characteristics across pre-election COVID-19 mortality quartiles. We estimated a population-weighted linear regression of the 2020-2016 Democratic vote change testing the significance of differences between quartiles of COVID-19 mortality, controlling for other county characteristics., Results: The overall change in the 2020-2016 Democratic vote was +2.9% but ranged from a +4.3% increase in the lowest mortality quartile counties to +0.9% in the highest mortality quartile counties. Change in turnout ranged from +9.1% in the lowest mortality counties to only +6.2% in highest mortality counties. In regression estimates, the highest mortality quartile was associated with a -1.26% change in the Democratic 2020-2016 vote compared with the lowest quartile (P < 0.001)., Conclusions: Higher county-level COVID-19 mortality was associated with smaller increases in Democratic vote share in 2020 compared with 2016. Possible explanations to be explored in future research could include fear of in-person voting in heavily Democratic, high-mortality counties, fear of the economic effects of perceived Democratic support for tighter lockdowns and stay-at-home orders and general exhaustion that lowered political participation in hard-hit counties., (Copyright © 2021 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Recent paradigm shifts in postpartum care have conceptualized the "fourth trimester" as a critical transitional period requiring tailored, ongoing health care. However, this concept presents challenges for providers, especially in low-resource settings. Our objective was to understand providers' perspectives on challenges in postpartum care to highlight strategies for optimizing care. Methods: Focus groups were conducted using a semistructured interview guide to elicit perspectives on barriers and facilitators to postpartum care. Participants included physicians, nurses, and social workers who care for low-income postpartum individuals. Interviews explored the provider experience of postpartum care, with a focus on barriers experienced by patients and providers, and tools for maintaining engagement. Analysis was performed using the constant comparative method and framed by the Social Ecological Model. Results: Participants ( N  = 26) all acknowledged the importance of the "fourth trimester" but identified multiple barriers to providing optimal postpartum care. Challenges providers perceived for patients and those they perceived for themselves often overlapped, including difficulty with appointment scheduling, insurance limitations, lack of provider continuity, and knowledge gaps. Providers identified ease of referrals to specialists, access to tangible services ( e.g. , contraception), and enhanced care coordination ( e.g. , patient navigation) as potential facilitators of improved postpartum care. Conclusions: Obstetric providers recognize the importance of postpartum care yet highlighted significant systems- and patient-based barriers to achieving optimal care. The development and implementation of postpartum care delivery system redesign, such as the use of patient navigators to improve health care utilization and resource attainment, may enhance care during this critical time. Clinical Trial No.: NCT03922334., Competing Interests: No competing financial interests exist., (© Rachel S. Ruderman et al., 2021; Published by Mary Ann Liebert, Inc.)

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Understanding factors in internal medicine (IM) resident career choice may reveal important needed interventions for recruitment and diversity in IM primary care and its subspecialties. Self-reported learner confidence is higher in men than in women in certain areas of practicing medicine, but has never been explored as a factor in career choice., Objective: The purpose of this study is to elucidate associations between confidence, gender, and career choice., Design: IM residents completed a 31-item survey rating confidence in procedural, clinical, and communication skills on a 9-point Likert scale. Residents also reported anticipated career choice and rated influence of factors. Associations between gender and confidence scale scores, gender and career choice, and confidence and career choice were analyzed using t tests, ANOVA, and multiple linear regression controlled for postgraduate year (PGY), institution, and specialty choice., Participants: 292 IM residents at Northwestern and University of Texas (UT) Southwestern MAIN MEASURES: Resident gender, self-reported confidence, career choice KEY RESULTS: Response rate was 79.6% (n = 292), of them 50.3% women. Overall self-reported confidence increased with training (PGY-1 4.9 (1.1); PGY-2 6.2 (1.0); PGY-3 7.4 (1.0); p < 0.001). Men had higher confidence than women (men 6.6 (1.5); women 6.3 (1.4), p = 0.06), with the greatest difference in procedures. High confidence in men was associated with choice of procedural careers, whereas there was no association between confidence and career in women., Conclusions: This is the first study demonstrating a gender difference in self-reported confidence and career choice. There is a positive correlation in men: higher self-reported confidence with procedural specialties, lower with general internal medicine. Women's self-reported confidence had no association. Further investigation is needed to elucidate causative factors for differences in self-reported confidence by gender, and whether alterations in level of self-reported confidence produce a downstream effect on career choice.

Background: COVID-19 is associated with hypercoagulability and increased incidence of thrombosis. We compared the clinical outcomes of adults hospitalized with COVID-19 who were on therapeutic anticoagulants to those on prophylactic anticoagulation., Materials and Methods: We performed an observational study of adult inpatients' with COVID-19 from March 9 to June 26, 2020. We compared patients who were continued on their outpatient prescribed therapeutic anticoagulation and those who were newly started on therapeutic anticoagulation for COVID-19 (without other indication) to those who were on prophylactic doses. The primary outcome was overall death while secondary outcomes were critical illness (World Health Organization Ordinal Scale for Clinical Improvement score ≥5), mechanical ventilation, and death among patients who first had critical illness. We adjusted for age, sex, race, body mass index (BMI), Charlson score, glucose on admission, and use of antiplatelet agents., Results: Of 1716 inpatients with COVID-19, 171 patients were continued on their therapeutic anticoagulation and 78 were started on new therapeutic anticoagulation for COVID-19. In patients continued on home therapeutic anticoagulation, there were no differences in overall death, critical illness, mechanical ventilation, or death among patients with critical illness compared to patients on prophylactic anticoagulation. In patients receiving new therapeutic anticoagulation for COVID-19, there was increased death (OR 5.93; 95% CI 3.71-9.47), critical illness (OR 14.51; 95% CI 7.43-28.31), need mechanical ventilation (OR 11.22; 95% CI 6.67-18.86), and death after first having critical illness (OR 5.51; 95% CI 2.80-10.87)., Conclusions: Therapeutic anticoagulation for inpatients with COVID-19 was not associated with improved outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Author(s).)

Background: In November 2019, Centers for Medicare and Medicaid Services announced total hip arthroplasty (THA) will be removed from the inpatient-only list. This may lead to avoidance of patients who have prolonged hospitalizations and discharge to skilled nursing facilities or push providers to unsafely push patients to outpatient surgery centers. Disparities in hip arthroplasty may worsen as patients are "risk stratified" preoperatively to minimize cost outliers. We aimed to evaluate which patient characteristics are associated with extended length of stay (eLOS)-greater than 2 days-and nonhome discharge in patients undergoing hip arthroplasty., Methods: The Illinois COMPdata administrative database was queried for THA admissions from January 2016 to June 2018. Variables included age, sex, race and ethnicity, median household income, Illinois region, insurance status, principal diagnosis, Charlson comorbidity index, obesity, discharge disposition, and LOS. Hospital characteristics included bundled payment participation and arthroplasty volume. Using multiple Poisson regression, we examined the association between these factors and the likelihood of nonhome discharge and eLOS., Results: There were 41,832 THA admissions from January 2016 to June 2018. A total of 36% had LOS greater than 2 midnights and 25.3% of patients had nonhome discharges. Female patients, non-Hispanic black patients, patients older than 75, obese patients, Medicaid or uninsured status, Charlson comorbidity index > 3, and hip arthroplasty for fracture were associated with increased risk of eLOS and/or nonhome discharge (P < .05)., Conclusion: With the Centers for Medicare and Medicaid Services emphasis on cost containment, patients at risk of extended stay or nonhome discharge may be deemed "high risk" and have difficulty accessing arthroplasty care. These are potentially vulnerable groups during the transition to the bundled payment model., (Copyright © 2020. Published by Elsevier Inc.)

Background: Bundled payment programs and the Centers for Medicare and Medicaid Services removal of total knee arthroplasty (TKA) from the inpatient-only list potentially incentivize avoiding patients with extended length of stay (eLOS) and nonhome discharge (NHD). We aimed to describe which patients are most at risk of eLOS (>2 days), very eLOS (veLOS; >4 days), and NHD., Methods: Admissions for unilateral TKAs at 151 Illinois nonfederal hospitals from January 2016 to June 2018 were selected from the Illinois Hospital and Health Systems Association COMPdata administrative hospital discharge database. Records included patient age, race and ethnicity, Illinois region, insurance status, principal diagnosis, and date of procedure. Zip code level median household income, Charlson comorbidity index, and obesity status were computed. Hospitals were characterized through their bundled payment participation status, academic status, and annual knee replacement volume. Poisson regression was used to test the associations between patient and hospital characteristics and the likelihood of eLOS, veLOS, and NHD., Results: Of the 72,359 admissions included, 25.0% had an NHD, 41.1% had eLOS, and 4.0% veLOS. Female patients, those 75 years old or more as compared to those 65-74 years old, non-Hispanic blacks, Hispanics and Asians versus non-Hispanic whites, Medicaid/uninsured patients versus those privately insured, obese patients, those with nonzero Charlson comorbidity index, and those treated at low-volume hospitals (<200 TKAs/year vs >600 TKAs/year) were more likely to have eLOS, veLOS, and/or NHD (P < .05)., Conclusion: Arthroplasty surgeons may be incentivized to avoid the abovementioned patient groups due to bundled payment programs and recent Centers for Medicare and Medicaid Services legislation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To identify the medical, demographic, and behavioral factors associated with a reduction of body mass index percent of the 95th percentile (BMIp95) after 1 year for patients receiving care at a tertiary care obesity management clinic., Study Design: A retrospective review of data from first and 12 ± 3-month follow-up visits of subjects aged 8-17 years with obesity. Data included anthropometrics, demographics, medical/psychological history, reported diet patterns, and participation in moderate/vigorous physical activity. After analyzing factors associated with 1-year follow-up, we used a forward conditional logistic regression model, controlling for subject's sex, to examine associations with a BMIp95 ≥5-point decrease at 1 year., Results: Of 769 subjects, 184 (23.9%) had 1-year follow-up. Boys more often had follow-up (28.4% vs girls, 19.1%; P = .003). The follow-up sample was 62.0% male, 65.8% Hispanic, and 77.7% with public insurance; 33.2% achieved a ≥5-point decrease in BMIp95. In regression results, the ≥5-point decrease group was more likely to have completed an initial visit in April-September (OR 2.0, 95% CI 1.1-3.9); have increased physical activity by 1-2 d/wk (OR 3.4, 95% CI 1.4-7.8) or increased physical activity by ≥ 3 d/wk at 1 year (OR 2.7, 95% CI 1.1-6.3); and less likely to have been depressed at presentation (OR 0.4, 95% CI 0.2-0.9). Demographic and dietary factors were not significantly associated with BMIp95 group status., Conclusions: Strategies improving follow-up rates, addressing mental health concerns, and promoting year-round physical activity are needed to increase the effectiveness of obesity management clinics., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The study objective was to evaluate trends in the use of surgical therapy for patients with early-stage (IA-IIA) non-small cell lung cancer when stereotactic ablative radiotherapy was introduced in the United States., Methods: Patients with clinical stage IA to IIA non-small cell lung cancer diagnosed from January 1, 2004, to December 31, 2013, were identified in the National Cancer Data Base. The Cochran-Armitage trend test was used to evaluate the change in the proportion of patients undergoing surgery over time. Logistic regression was used to identify the factors associated with receipt of surgery compared with radiation., Results: Of 200,404 eligible patients from 1235 hospitals, 79.8% (n = 159,943) underwent surgery. For all stages combined, the rate of surgery decreased from 83.9% in 2004 to 75.1% in 2013 (P < .0001), with the largest decrease seen in patients with stage IIA: stage IA 86.5% to 77.1% (P < .0001); stage IB 79.6% to 71.5% (P < .0001); and stage IIA 94.7% to 70.3% (P < .001). Patients were more likely to undergo surgery if they were younger and white, had higher income, or had private or Medicare insurance., Conclusions: From 2004 to 2013, there was an overall decrease in the use of surgical therapy for lung cancer in early-stage disease. Because resection remains the standard of care for most patients with early-stage disease, these data suggest a potentially significant quality gap in the treatment of patients with non-small cell lung cancer., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: The aim of this study is to determine whether simulation-based education (SBE) translates into reduced procedure time, radiation, and contrast use in actual clinical care., Background: As a high volume procedure often performed by novice cardiology fellows, diagnostic coronary angiography represents an excellent target for SBE. Reports of SBE in interventional cardiology are limited and there is little understanding of the potential downstream clinical impact of these interventions., Methods: All diagnostic coronary angiograms performed at a single center between January 1, 2011 and June 30, 2015 were analyzed. Random effects linear regression models were used to compare outcomes between procedures performed by 12 cardiology fellows who underwent simulation-based training and those performed by 20 traditionally trained fellows., Results: Thirty-two cardiology fellows performed 2,783 diagnostic coronary angiograms. Procedures performed by fellows trained with SBE were shorter (mean of 23.98 min vs. 24.94 min, P = 0.034) and were performed with decreased radiation (mean of 56,348 mGycm 2 vs. 66,120 mGycm 2 , P < 0.001). After controlling for year in training, procedure year, access site, and supervising attending physician, training on the simulator was independently associated with 117 fewer seconds of fluoroscopy time per procedure (P = 0.04)., Conclusions: Diagnostic coronary angiography SBE is associated with decreased use of fluoroscopy in downstream clinical care. SBE may be a useful tool to reduce radiation exposure in the cardiac catheterization laboratory., (© 2017 Wiley Periodicals, Inc.)

Background: Understanding the characteristics of men who initially present with metastatic prostate cancer (mPCa) can better enable directed improvement initiatives. The objective of this study was to assess the relationship between socioeconomic status (SES) and newly diagnosed mPCa., Materials Methods: All men diagnosed with PCa in the National Cancer Data Base from 2004 to 2013 were identified. Characteristics of men presenting with and without metastatic disease were compared. A 4-level composite metric of SES was created using Census-based income and education data. Multivariable logistic regression was used to evaluate the association between SES, race/ethnicity, and insurance and the risk of presenting with mPCa at the time of diagnosis., Results: Of 1,034,754 patients diagnosed with PCa, 4% had mPCa at initial presentation. Lower SES (first vs. fourth quartile; odds ratio [OR] = 1.39, 95% CI: 1.35-1.44), black and Hispanic race/ethnicity (vs. white; OR = 1.47, 95% CI: 1.43-1.51 and OR = 1.22, 95% CI: 1.17-1.28, respectively), and having Medicaid or no insurance (vs. Medicare or private; OR = 3.91, 95% CI: 3.78-4.05) were each independently associated with higher odds of presenting with mPCa after adjusting for all other covariates., Conclusions: Lower SES, race/ethnicity, and having Medicaid or no insurance were each independently associated with higher odds of presenting with metastases at the time of PCa diagnosis. Our findings may partially explain current PCa outcomes disparities and inform future efforts to reduce disparities., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This corrects the article DOI: 10.1038/pcan.2017.5.

Objective: To evaluate adherence to a delayed cord clamping protocol for preterm births in the first 2 years after its introduction, perform a quality improvement assessment, and determine neonatal outcomes associated with protocol implementation and adherence., Methods: This is a retrospective cohort study of women delivering singleton neonates at 23-32 weeks of gestation in the 2 years before (preprotocol) and 2 years after (postprotocol) introduction of a 30-second delayed cord clamping protocol at a large-volume academic center. This policy was communicated to obstetric and pediatric health care providers and nurses and reinforced with intermittent educational reviews. Barriers to receiving delayed cord clamping were assessed using χ tests and multivariable logistic regression. Neonatal outcomes then were compared between all neonates in the preprotocol period and all neonates in the postprotocol period and between all neonates in the preprotocol period and neonates receiving delayed cord clamping in the postprotocol period using multivariable linear and logistic regression analyses., Results: Of the 427 eligible neonates, 187 were born postprotocol. Of these, 53.5% (n=100) neonates received delayed cord clamping according to the protocol. The rate of delayed cord clamping preprotocol was 0%. Protocol uptake and frequency of delayed cord clamping increased over the 2 years after its introduction. In the postprotocol period, cesarean delivery was the only factor independently associated with failing to receive delayed cord clamping (adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.25-0.96). In comparison with the preprotocol period, those who received delayed cord clamping in the postprotocol period had significantly higher birth hematocrit (β=2.46, P=.007) and fewer blood transfusions in the first week of life (adjusted OR 0.49, 95% CI 0.25-0.96)., Conclusion: After introduction of an institutional delayed cord clamping protocol followed by continued health care provider education and quality feedback, the frequency of delayed cord clamping progressively increased. Compared with historical controls, performing delayed cord clamping in eligible preterm neonates was associated with improved neonatal hematologic indices, demonstrating the effectiveness of delayed cord clamping in a large-volume maternity unit.

Background: Current guidelines recommend postmastectomy radiotherapy (PMRT) for patients with ≥4 positive lymph nodes and suggest strong consideration of PMRT in those with 1-3 positive nodes. These recommendations were incorporated into a Commission on Cancer quality measure in 2014. However, national adherence with these recommendations is unknown. Our objectives were to describe PMRT use in the United States in patients with stage I to III invasive breast cancer and to examine possible factors associated with the omission of PMRT., Methods: From the National Cancer Data Base, 753,536 mastectomies at 1123 hospitals were identified from 1998 to 2011. PMRT use over time was examined using random effects logistic regression analyses, adjusting for patient, tumor, and hospital characteristics. Analyses were stratified by nodal status (≥4 nodes positive, 1-3 nodes positive, node negative)., Results: The proportion of patients receiving PMRT increased from 1998 to 2011 (>4 positive nodes: 56.2 to 66.6 %; 1-3 positive nodes: 28.0 to 39.1 %; node-negative: 8.3 to 10.0 %, p < 0.001 for all). In adjusted analyses, patients with ≥4 positive nodes were more likely to have PMRT omitted if they had smaller tumors. Patients with 1-3 positive nodes were more likely to have PMRT omitted if they had lower grade or smaller tumors. Irrespective of patients' nodal status, PMRT utilization rates decreased as age increased., Conclusions: Though PMRT rates increased over time in patients with ≥4 and 1-3 positive nodes, PMRT in patients with ≥4 positive nodes remains underutilized. Feedback to hospitals using the new Commission on Cancer PMRT measure may help to improve adherence rates.

Objective: To evaluate factors associated with delayed surgical treatment among women with endometrial cancer., Methods: Using the National Cancer Database (NCDB), we analyzed time to first surgery for epithelial endometrial cancer patients who underwent surgical treatment from 2003 to 2011. Poisson regression was used to examine delays >6weeks between diagnosis and surgery, controlled for patients' sociodemographic and clinical characteristics. Survival for women diagnosed between 2003 and 2006 with timely versus delayed surgery was compared using Cox proportional hazards regression., Results: The study included 112,041 women diagnosed at 1108 continuously reporting NCDB hospitals. Survival through 2011 was available for 40,184 women. All patients underwent hysterectomy. Twenty-eight percent of patients underwent surgery >6weeks after diagnosis. Poisson regression estimates indicated that being younger than 40years old, being black or Hispanic, having Medicaid or being uninsured, or being from the lowest education quartile were associated with a significantly higher likelihood of surgical wait time>6weeks. Patients diagnosed in 2010-2011 were more likely (IRR 1.32, 95% CI 1.24-1.40) to undergo surgery >6weeks after diagnosis compared to patients treated in 2003. Survival for women with surgical wait times >6weeks was worse than those treated within 6weeks of diagnosis (HR 1.14, 95% CI 1.09-1.20)., Conclusions: Being a minority patient and having lower socioeconomic status or poor insurance coverage were associated with an increased likelihood of delayed surgical treatment. Wait times >6weeks from diagnosis of endometrial cancer to definitive surgery may have a negative impact on survival., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Ambulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preventable with timely and effective outpatient care. Approximately 75% of all ACSHs occur through the emergency department (ED). ACSHs through the ED (ED ACSHs) have significant implications for costs and ED crowding., Objective: This study compares rates of ED ACSHs for 2003 and 2009 among patients 18 to 64 years of age with private insurance, Medicaid, or no insurance., Methods: Nationally representative estimates of ED ACSHs, defined by the Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs), were generated from the 2003 and 2009 Nationwide Inpatient Samples. Census data were used to calculate direct age- and sex-standardized ACSH rates by non-Medicare payers for both years., Results: Between 2003 and 2009, the overall rate of ED ACSHs decreased from 7.6 (95% confidence interval [CI] 7.57-7.75) to 7.3 (95% CI 7.2-7.4) per 1000 18- to 64-year-old non-Medicare patients. ED ASCH rates declined significantly from 42.4 (95% CI 42.0-42.8) to 25.3 (95% CI 25.0-25.6) per 1000 patients with Medicaid, and declined modestly from 3.8 (95% CI 3.8-3.9) to 3.3 (95% CI 3.2-3.4) per 1000 patients with private insurance. However, the ED ACSH rate increased for the uninsured population from 5.4 (95% CI 5.2-5.7) to 6.2 (95% CI 5.9-6.4) per 1000 patients., Conclusion: Expansion of Medicaid over the study period was not associated with an increase in ED ACSHs for Medicaid patients. However, an increase in the uninsured population was associated with an increase in the rate of ED ACSH for uninsured patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To describe the risk factors for acquiring functional or cognitive disabilities during admission to a PICU., Design: Retrospective analysis of a multicenter PICU database., Setting: Twenty-four PICUs in the Virtual PICU Performance System network from January 1, 2009, through December 31, 2010., Patients: Consecutive patients, who are 1 month to 18 years old, who survived to discharge., Interventions: None., Measurements and Main Results: Primary outcomes were acquired global functional disability and cognitive disability during admission to a PICU, measured by change in Pediatric Overall Performance Category or in Pediatric Cerebral Performance Category scores, respectively. The primary analysis cohort consisted of 29,352 admissions to the 24 Virtual PICU Performance System sites which collected the main outcome variables. Respectively, 10.3% and 3.4% of the cohort acquired global functional or cognitive disability. Trauma diagnosis (odds ratio, 4.50; 95% CI, 3.83-5.29; odds ratio, 3.91; 95% CI, 3.07-4.98), unscheduled admission to the PICU (odds ratio, 2.67; 95% CI, 2.27-3.12; odds ratio, 1.52; 95% CI, 1.16-2.00), highest risk of mortality category (odds ratio, 1.19; 95% CI, 1.02-1.39; odds ratio, 2.70; 95% CI, 2.15-3.40), oncologic primary diagnoses (odds ratio, 5.61; 95% CI, 4.56-6.91; odds ratio, 4.30; 95% CI, 2.97-6.24), and neurologic primary diagnoses (odds ratio, 2.04, 95% CI, 1.70-2.44; odds ratio, 4.29, 95% CI, 3.18-5.78) were independently associated with acquiring both functional and cognitive disability. Intervention risk factors for acquiring both functional and cognitive disability included invasive mechanical ventilation (odds ratio, 1.79; 95% CI, 1.60-2.00; odds ratio, 2.83; 95% CI, 2.36-3.39), renal replacement therapy (odds ratio, 2.43; 95% CI, 1.73-3.42; odds ratio, 1.76, 95% CI, 1.08-2.85), cardiopulmonary resuscitation (odds ratio, 1.91; 95% CI, 1.24-2.95; odds ratio, 1.81; 95% CI, 1.02-3.23), and extracorporeal membrane oxygenation (odds ratio, 7.40, 95% CI, 4.10-13.36; odds ratio, 14.04, 95% CI, 7.51-26.26)., Conclusions: We identified a subset of patients whose potential for acquiring global functional and cognitive disability during admission to the PICU is high. This population may benefit from interventions that could mitigate this risk and from focused follow-up after discharge from the PICU.

Background: In order to manage the increasing worldwide problem of obesity, medical students will need to acquire the knowledge and skills necessary to assess and counsel patients with obesity. Few educational intervention studies have been conducted with medical students addressing stigma and communication skills with patients who are overweight or obese. The purpose of this study was to evaluate changes in students' attitudes and beliefs about obesity, and their confidence in communication skills after a structured educational intervention that included a clinical encounter with an overweight standardized patient (SP)., Methods: First year medical students (n = 127, 47% female) enrolled in a communications unit were instructed to discuss the SPs' overweight status and probe about their perceptions of being overweight during an 8 minute encounter. Prior to the session, students were asked to read two articles on communication and stigma as background information. Reflections on the readings and their performance with the SP were conducted prior to and after the encounter when students met in small groups. A newly constructed 16 item questionnaire was completed before, immediately after and one year after the session. Scale analysis was performed based on a priori classification of item intent., Results: Three scales emerged from the questionnaire: negative obesity stereotyping (7 items), empathy (3 items), and counseling confidence (3 items). There were small but significant immediate post-intervention improvements in stereotyping (p = .002) and empathy (p < .0001) and a very large mean improvement in confidence (p < .0001). Significant improvement between baseline and immediate follow-up responses were maintained for empathy and counseling at one year after the encounter but stereotyping reverted to the baseline mean. Percent of students with improved scale scores immediately and at one year follow up were as follows: stereotyping 53.1% and 57.8%; empathy 48.4% and 47.7%; and confidence 86.7% and 85.9%., Conclusions: A structured encounter with an overweight SP was associated with a significant short-term decrease in negative stereotyping, and longer-term increase in empathy and raised confidence among first year medical students toward persons who are obese. The encounter was most effective for increasing confidence in counseling skills.

Background: Medication discrepancies are common as patients transition from hospital to home. Errors with post-discharge medication regimens may play a role in hospital readmissions., Objectives: To determine whether primary care physician (PCP) contact with patients at hospital discharge impacts the frequency of medication discrepancies at 24 hours post-discharge., Design: With the PCP-Enhanced Discharge Communication Intervention, PCPs were asked to speak with treating hospitalists and contact patients within 24 hours of hospital discharge (either in person or by phone) to discuss any hospital medication changes. Research staff enrolled subjects during their hospitalization and telephoned subjects 48 hours post-discharge to determine medication discrepancies and PCP contact., Participants: One hundred fourteen community-dwelling adults, admitted to acute medicine services >24 hours on ≥ 5 medications., Results: Of the 114 subjects enrolled in the hospital, 75 subjects completed 48 hours postdischarge phone interviews. Of the 75 study patients, 39 patients (50.6%) experienced a total of 84 medication discrepancies (mean, 2.1 discrepancies/patient). Subjects who were contacted by their PCP at discharge were 70% less likely to have a discrepancy when compared with those not contacted (P = 0.04). Males were 4.34 times more likely to have a discrepancy (P = 0.02)., Conclusion: PCP communication with patients within 24 hours of discharge was associated with decreased medication discrepancies. Our results further demonstrate the importance of PCP involvement in the hospital discharge process., (© 2013 Society of Hospital Medicine.)

Background: Despite the availability of first trimester abortion services in urban settings, many women request abortion in the second trimester. We identified protective and risk factors associated with women who delay requesting abortions until the second trimester., Study Design: The study was a cross-sectional survey of 247 patients requesting surgical abortion at an urban family planning clinic. Survey and medical records data were analyzed for associations between 18 risk factors and incidence of second trimester request., Results: Thirty-two percent of subjects presented in the second trimester. Chi-square analyses revealed that first trimester participants were more often employed (p<.0001), privately insured (p=.01), or had previous abortions (p=.04). Second trimester patients were younger (p<.0001), more often primigravid (p=.04), experienced more difficulty financing the procedure (p<.0001) and finding a surgeon (p<.0001), traveled longer distances (p=.005), and more often feared the procedure (p=.03). Using multiple logistic regression, women requesting second trimester abortions were more likely to report: obstacles financing the abortion (OR 2.34, 95% CI 1.28-4.28); traveling long distances (OR 2.88, 95% CI 1.31-6.31); and fear (OR 2.45, 95% CI 1.17-5.17). These women were less often employed outside the home (OR 0.35, 95% CI 0.19-0.64)., Conclusions: Physicians and advocates must strive to reduce abortion costs, increase access to trained surgeons, and allay women's fears of abortion procedures.

Background: Quality improvement efforts have demonstrated considerable hospital-to-hospital variation in surgical outcomes. However, information about the quality of emergency surgical care is lacking. The objective of this study was to assess whether hospitals have comparable outcomes for emergency and nonemergency operations., Study Design: Patients undergoing colorectal resections were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2005 to 2007 dataset. Logistic regression models for 30-day morbidity and mortality after emergency and nonemergency colorectal resections were constructed. Hospital risk-adjusted outcomes as measured by observed to expected (O/E) ratios, outlier status, and rank-order differences were compared., Results: Of 25,710 nonemergency colorectal resections performed at 142 ACS NSQIP hospitals, 6,138 (23.9%) patients experienced at least 1 complication, and 492 (1.9%) patients died. There were 5,083 emergency colorectal resections; 2,442 (48%) patients experienced at least 1 complication, and 780 (15.3%) patients died. Outcomes for nonemergency versus emergency operations were weakly correlated for morbidity and mortality (Pearson correlation coefficient: 0.28 versus 0.13). Median differences in hospital rankings based on O/E ratios between nonemergency and emergency performance were 30.5 ranks (interquartile range [IQR] 13 to 59) for morbidity and 34 ranks (interquartile ratio 17 to 61) for mortality., Conclusions: Hospitals with favorable outcomes after nonemergency colorectal resections do not necessarily have similar outcomes for emergency operations. Hospitals should specifically examine their performance on emergency surgical procedures to identify quality improvement opportunities and focus quality improvement efforts appropriately.

Background: Liver transplantation (LT) from donation after cardiac death (DCD) donors is increasingly being used to address organ shortages. Despite encouraging reports, standard survival metrics have overestimated the effectiveness of DCD livers. We examined the mode, kinetics, and predictors of organ failure and resource utilization to more fully characterize outcomes after DCD LT., Methods: We reviewed the outcomes for 32 DCD and 237 donation after brain death (DBD) LT recipients at our institution., Results: Recipients of DCD livers had a 2.1 times greater risk of graft failure, a 2.5 times greater risk of relisting, and a 3.2 times greater risk of retransplantation compared with DBD recipients. DCD recipients had a 31.6% higher incidence of biliary complications and a 35.8% higher incidence of ischemic cholangiopathy. Ischemic cholangiography was primarily implicated in the higher risk of graft failure observed after DCD LT. DCD recipients with ischemic cholangiography experienced more frequent rehospitalizations, longer hospital stays, and required more invasive biliary procedures., Conclusion: Related to higher complication rates, DCD recipients necessitated greater resource utilization. This more granular data should be considered in the decision to promote DCD LT. Modification of liver allocation policy is necessary to address those disadvantaged by a failing DCD graft.

Emerging evidence suggests that current fluoroquinolone dosing strategies may be inadequate to treat bloodstream infections caused by organisms classified as sensitive. This study sought to determine if differences in MICs for levofloxacin-susceptible gram-negative organisms correlate with differences in patient outcomes. A retrospective cohort study evaluated patients treated with levofloxacin for bloodstream infections caused by susceptible gram-negative organisms. Patients infected with gram-negative organisms for which MICs indicated susceptibility were categorized into three groups: those with organisms for which MICs were low (

The consequences of inactive empiric antimicrobial therapy are not well-described and may cause prolonged hospitalization or infection-related mortality. In vitro susceptibility results for 884 patients hospitalized at an academic medical center with gram-negative bloodstream infections (GNBI) from 2001 to 2003 were matched to antimicrobial orders within 24 h of culture. Clinical characteristics, organism, inpatient mortality, and length of stay after culture for patients with GNBI were compared between patients receiving active versus inactive empiric antimicrobial therapy. A total of 14.1% of patients with GNBI received inactive empiric therapy, defined as no antimicrobial therapy within 24 h of the culture active against the identified organism based on in vitro microbiology reports. Patients who received inactive therapy were more likely to be younger, to be infected with Pseudomonas aeruginosa, to have a nosocomial infection, and to receive antimicrobial monotherapy but less likely to be bacteremic with Escherichia coli or to have sepsis (P < 0.05). There were no significant differences in mortality between patients receiving active versus inactive empiric therapy (16.1% versus 13.6%, respectively) or in length of stay after positive culture (11.5 days versus 12.6 days, respectively). Only 45 patients had greater than 2 days of exposure to inactive therapy; however, 8/30 patients (26.7%) who never received active antimicrobial therapy died while in the hospital. Inactive empiric therapy was more common in healthier patients. Inactive antimicrobial therapy in the first 24 h did not significantly impact average outcomes for GNBI among hospitalized patients but may have caused harm to specific individuals.

Background. We examined patient outcomes for colon resection to determine if they varied according to surgeon-specific factors including: (1) American Board of Surgery (ABS) certification, (2) colorectal surgery subspecialty certification, (3) site of residency training (university-based vs nonuniversity-based), and (4) years of experience since ABS certification. Methods. We performed a retrospective study of 15,427 admissions of northern Illinois residents who underwent segmental colon resection as their primary operation from 1994 to 1997 at 76 nonfederal Illinois hospitals. There were 514 surgeons. Main outcome measures were inpatient mortality, complications, and hospital length of stay. Regression analyses with mixed effects were used to assess the significance of surgeon-specific variables as a predictor of outcomes after risk adjustment for patient age, gender, emergency admission, surgeon volume, hospital site, colon pathology, and comorbid illnesses. Results. ABS-certification was associated with reduced mortality and morbidity. Increasing years of experience was associated with reduced mortality. Colorectal surgery certification and site of residency training did not significantly affect outcomes. Conclusion. We were able to link patient outcomes with surgeon's training. Certification was an important determinant of patient outcomes for colon resection. Increasing surgeon experience also had a favorable effect on outcomes, suggesting a continued learning curve subsequent to residency. (Surgery 2002;132:663-72).