The Impact of Higher Surgical Volume on the Adoption of Outpatient Setting for Minimally Invasive Hysterectomy for Medicare Patients in the U.S.

Introduction: We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions. Materials and Methods: Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists–Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis. Results: In the present study, preoperative anemia was not associated with longer LOS ( P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb ( P = .05*) and postoperative nadir Hgb ( P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS ( P = .36); however, greater perioperative Hgb decrement predicted longer LOS ( P < .0001*). Older age ( P = .01*) and greater number of levels fused ( P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS ( P < .0001*). Discussion: Postoperative nadir Hgb ( P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb ( P = .05*). There is a perioperative Hgb decrement associated with longer LOS ( P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration. Conclusion: Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

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The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2018.09.003 ◽

2018 ◽

Vol 219 (5) ◽

pp. 490.e1-490.e8 ◽

Cited By ~ 2

Author(s):

C. Emi Bretschneider ◽

Pamela Frazzini Padilla ◽

Deepanjana Das ◽

J. Eric Jelovsek ◽

Cecile A. Unger

Keyword(s):

Adverse Events ◽

Minimally Invasive ◽

Surgeon Volume ◽

Large Uterus ◽

The Impact ◽

Minimally Invasive Hysterectomy

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Impact of inpatient hospitalization on opiate usage for minimally invasive hysterectomy amongst gynecologic oncology patients.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e18109 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e18109-e18109

Author(s):

Amy Dawn Gee ◽

Shannon Michelle Grabosch ◽

Jeffrey Gavard

Keyword(s):

Minimally Invasive ◽

Gynecologic Oncology ◽

Hospitalized Patients ◽

Categorical Variables ◽

Psychiatric Disease ◽

Same Day Discharge ◽

The Impact ◽

Minimally Invasive Hysterectomy ◽

Chronic Use ◽

At Home

e18109 Background: The overdose death rate related to opiates has quadrupled in the last two decades. Up to 27% of chronic opiate users report initiation in the post-op period. Among cancer patients, 10% of opioid-naive patients continue chronic use one year after surgery. Restrictive opiate prescribing has demonstrated promise in other studies. However, lacking from current literature is an analysis of the effect that same day discharge (SDD) has on post-op opiate usage at home. The objective of this study is to evaluate the impact of SDD versus physician-elected observation for 1 to 2 days on acute post-op opiate usage and safety following minimally-invasive hysterectomy (MIH). Methods: This is a prospective observational study of women undergoing MIH. Sixty patients were assigned to either the SDD or hospitalization group at provider discretion based on practice pattern, distance from hospital, or comorbidities. One patient was lost to follow up. Patients were followed through 30 days after surgery. Total opiate usage included the inpatient usage (if hospitalized) and home usage assessed at the post-op visit. Anonymous surveys were used to collect home opiate usage practices, satisfaction, and self-reported risk factors for continued use. Continuous variables were analyzed by independent Student’s t-test and the Mann-Whitney U test. Categorical variables were analyzed using Chi-square test and Fisher's Exact test. Results: 29 SDD and 30 hospitalized patients were available for review. Demographics including age, BMI, tobacco use, and procedure indication were well matched. SDD patients used a median 5.0 (1.5-13.5) versus 8.5 (2.25-14.25) 5mg oxycodone tabs (p 0.33). SDD patients used opiates less for non-pain indications including to sleep (4 vs 9, p 0.24) or relax (3 vs 5, p 0.71). One SDD patient had a complication of a cuff hematoma, which spontaneously drained. There were no readmissions. Only one SDD patient felt she would have benefited from longer stay due to nausea. All hospitalized patients took their own opiates at home while 7 SDD had a family member dispense. Psychiatric disorders were the highest comorbidities in both groups (depression n = 12 and 10, anxiety n = 10 and 12). Conclusions: SDD demonstrated a trend towards less opiate usage, although not statistically significant. Patients did not feel that they needed to stay longer in the hospital. The safety of SDD is supported by lack of readmissions and one minor post-op complication. The high rates of psychiatric disease are a concerning risk factor for chronic use.

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