scholarly journals SURG-09. SURGICAL AND PERI-OPERATIVE CONSIDERATIONS FOR BRAIN METASTASES: A NATIONWIDE ANALYSIS

2019 ◽  
Vol 1 (Supplement_1) ◽  
pp. i32-i32
Author(s):  
Saksham Gupta ◽  
Alexandra Giantini Larsen ◽  
Hassan Dawood ◽  
Luis Fandino ◽  
Erik Knelson ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Cohort Analysis ◽  
Medical Complications ◽  
Unplanned Readmission ◽  
Cardiac Events ◽  
Post Discharge ◽  
Improvement Project ◽  
Improve Risk Stratification ◽  
Cerebrospinal Fluid Diversion ◽  
Tract Infections

Abstract BACKGROUND: Brain metastases are the most frequent brain tumors in adults, whose management remains nuanced. We aim to improve risk stratification for brain metastases patients who might be candidates for surgical resection. METHODS: We conducted a nationwide, retrospective cohort analysis of adult patients who received craniotomy for resection of brain metastasis using the 2012–2015 American College of Surgeons National Surgical Quality Improvement Project databases. Our primary outcomes of interest were post-operative medical complications, reoperation, readmission, and mortality. RESULTS: 3500 cases were included, of which 17% were considered frail and 24% were infratentorial. The most common 30-day medical complications were pneumonia (4%), venous thromboembolism (VTE;3%), and urinary tract infections (2%). Cardiac events and cerebrovascular accidents tended to occur in the early post-operative period, while VTEs and infections occurred in a more delayed fashion. Reoperation and unplanned readmission occurred in 5% and 12% of patients, respectively. Infratentorial approach and frailty were associated with reoperation before discharge (OR 2.0 for both; p=0.01 and p=0.03 respectively), but not after discharge. Frail patients were especially at risk for surgical evacuation of hematoma (OR 3.6). Infratentorial approaches conferred heightened risk for readmission for hydrocephalus (OR 5.1, p=0.02) and reoperation for cerebrospinal fluid diversion (OR 7.1, p< 0.001). Overall 30-day mortality was 4%, with nearly three-quarters occurring after discharge. Pre-frailty and frailty were associated with increased odds for post-discharge mortality (OR 1.7 and 2.7, p< 0.05), but not pre-discharge mortality. We developed a model to predictors of death, which identified frailty, thrombocytopenia, and high American Society of Anesthesiologists score as the strongest predictors of 30-day mortality (AUROC 0.75). CONCLUSION: Optimization of metrics contributing to patient frailty and heightened surveillance in patients with infratentorial metastases may be considered in the peri-operative period.

30-day readmission among gastrointestinal cancer patients in Texas.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 121-121
Author(s):  
Joanna-Grace Manzano ◽  
Ruili Luo ◽  
Linda S. Elting ◽  
Maria Suarez-Almazor
Keyword(s):  
Cancer Patients ◽  
Claims Data ◽  
Healthcare Delivery ◽  
The Elderly ◽  
Unplanned Readmission ◽  
Electrolyte Disorders ◽  
Post Discharge ◽  
Readmission Rates ◽  
Early Readmission ◽  
Tract Infections

121 Background: 30 day readmission has become an important metric in healthcare delivery. Policymakers have started to factor in readmission rates in their recommendations on reimbursement algorithms. It is unclear whether these methods are applicable to cancer patients. More studies are needed in order to understand readmission in the context of cancer patients. A few studies have found that the elderly and those with gastrointestinal (GI) malignancies are at risk. Methods: We conducted a retrospective cohort study using linked Texas Cancer Registry and Medicare claims data to describe the patterns of 30 day unplanned readmission among GI cancer patients in Texas. Only short stays to acute care hospitals were included in the study. Claims data were analyzed for a period of 2 years from the date of cancer diagnosis. Modified Poisson regression model was used to identify factors associated with the outcome. Results: 30,199 patients aged 66 and above were included in our study. The incidence of unplanned readmission in our cohort was 15%. The top 10 reasons for readmission were fluid and electrolyte disorders, secondary malignancies, complications of surgical procedures and medical care, congestive heart failure, intestinal obstruction, pneumonia, sepsis, GI hemorrhage, urinary tract infections, and complications of device, implant or graft. After multivariate analysis, age >80 (OR 0.79, 0.73-0.85), regional (1.19, 1.11-1.27) and distant disease (1.16, 1.07-1.25), living in less affluent neighborhoods (1.10, 1.01-1.19), and increasing comorbidity index (p<0.0001) were associated with 30 day readmission. Esophageal cancer carried the highest risk for 30 day readmission (1.53, 1.38-1.70). Conclusions: Most of the top reasons for readmission appear to be cancer-related. This means that most of these readmissions are likely not preventable. This should be taken into consideration by policymakers when making recommendations. There are, however, some that may be amenable to outpatient management. This further underlines the importance of primary care involvement in the management of cancer patients. Risk factors identified can help risk–stratify patients who may need early follow up post-discharge, in order to prevent early readmission.

scholarly journals Prospective cohort study on hospitalised patients with suspected urinary tract infection and risk factors por multidrug resistance

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Victor Garcia-Bustos ◽  
Ana Isabel Renau Escrig ◽  
Cristina Campo López ◽  
Rosario Alonso Estellés ◽  
Koen Jerusalem ◽  
...  
Keyword(s):  
Risk Factors ◽  
Urinary Incontinence ◽  
Multidrug Resistance ◽  
Urinary Tract ◽  
Prospective Cohort ◽  
Bacterial Infections ◽  
Cohort Analysis ◽  
Term Care ◽  
Hospitalised Patients ◽  
Tract Infections

AbstractUrinary tract infections (UTIs) are among the most common bacterial infections and a frequent cause for hospitalization in the elderly. The aim of our study was to analyse epidemiological, microbiological, therapeutic, and prognostic of elderly hospitalised patients with and to determine independent risk factors for multidrug resistance and its outcome implications. A single-centre observational prospective cohort analysis of 163 adult patients hospitalized for suspected symptomatic UTI in the Departments of Internal Medicine, Infectious Diseases and Short-Stay Medical Unit of a tertiary hospital was conducted. Most patients currently admitted to hospital for UTI are elderly and usually present high comorbidity and severe dependence. More than 55% met sepsis criteria but presented with atypical symptoms. Usual risk factors for multidrug resistant pathogens were frequent. Almost one out of five patients had been hospitalized in the 90 days prior to the current admission and over 40% of patients had been treated with antibiotic in the previous 90 days. Infection by MDR bacteria was independently associated with the previous stay in nursing homes or long-term care facilities (LTCF) (OR 5.8, 95% CI 1.17–29.00), permanent bladder catheter (OR 3.55, 95% CI 1.00–12.50) and urinary incontinence (OR 2.63, 95% CI 1.04–6.68). The degree of dependence and comorbidity, female sex, obesity, and bacteraemia were independent predictors of longer hospital stay. The epidemiology and presentation of UTIs requiring hospitalisation is changing over time. Attention should be paid to improve management of urinary incontinence, judicious catheterisation, and antibiotic therapy.

Surgical Indication Optimization of Brain Metastases Based on the Evolutionary Analysis of Karnofsky Performance Status

2021 ◽  
Author(s):  
Jorge Rasmussen ◽  
Pablo Ajler ◽  
Daniela Massa ◽  
Pedro Plou ◽  
Matteo Baccanelli ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Functional Status ◽  
Surgical Resection ◽  
Pharmacological Treatment ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Cohort Analysis ◽  
Surgical Indication ◽  
Evolutionary Analysis ◽  
Survival Curves

Abstract Background and Objective Surgical resection of brain metastases (BM) offers the highest rates of local control and survival; however, it is reserved for patients with good functional status. In particular, the presence of BM tends to oversize the detriment of the overall functional status, causing neurologic deterioration, potentially reversible following symptomatic pharmacological treatment. Thus, a timely indication of surgical resection may be dismissed. We propose to identify and quantify these variations in the functional status of patients with symptomatic BM to optimize the indication of surgical resection. Patients and Methods Historic, retrospective cohort analysis of adult patients undergoing BM microsurgical resection, consecutively from January 2012 to May 2016, was conducted. The Karnofsky performance status (KPS) variation was recorded according to the symptomatic evolution of each patient at specific moments of the diagnostic–therapeutic algorithm. Finally, survival curves were delineated for the main identified factors. Results One hundred and nineteen resection surgeries were performed. The median overall survival was 243 days, while on average it was 305.7 (95% confidence interval [CI]: 250.6–360.9) days. The indication of surgical resection of 10% of the symptomatic patients in our series (7.5% of overall) could have been initially rejected due to pharmacologically reversible neurologic impairment. Survival curves showed statistically significant differences when KPS was stratified following pharmacological symptomatic treatment (p < 0.0001), unlike when they were estimated at the time of BM diagnosis (p = 0.1128). Conclusion The preoperative determination of the functional status by KPS as an evolutive parameter after the nononcologic symptomatic pharmacological treatment allowed us to optimize the surgical indication of patients with symptomatic BM.

scholarly journals Creating a culture of quality: our experience with providing feedback to frontline hospitalists

2021 ◽  
Vol 10 (1) ◽  
pp. e001141
Author(s):  
Brittany Becker ◽  
Sneha Nagavally ◽  
Nicholas Wagner ◽  
Rebekah Walker ◽  
Yogita Segon ◽  
...  
Keyword(s):  
Performance Feedback ◽  
Rank Order ◽  
Quality Metrics ◽  
Faculty Members ◽  
Feedback Report ◽  
Full Time ◽  
Academic Medical Centre ◽  
Improvement Project ◽  
Tract Infections ◽  
Culture Of Quality

BackgroundOne way to provide performance feedback to hospitalists is through the use of dashboards, which deliver data based on agreed-upon standards. Despite the growing trend on feedback performance on quality metrics, there remain limited data on the means, frequency and content of feedback that should be provided to frontline hospitalists.ObjectiveThe objective of our research is to report our experience with a comprehensive feedback system for frontline hospitalists, as well as report the change in our quality metrics after implementation.Design, setting and participantsThis quality improvement project was conducted at a tertiary academic medical centre among our hospitalist group consisting of 46 full-time faculty members.Intervention or exposureA monthly performance feedback report was distributed to provide ongoing feedback to our hospitalist faculty, including an individual dashboard and a peer comparison report, complemented by coaching to incorporate process improvement tactics into providers’ daily workflow.Main outcomes and measuresThe main outcome of our study is the change in quality metrics after implementation of the monthly performance feedback reportResultsThe dashboard and rank order list were sent to all faculty members every month. An improvement was seen in the following quality metrics: length of stay index, 30-day readmission rate, catheter-associated urinary tract infections, central line-associated bloodstream infections, provider component of Healthcare Consumer Assessment of Healthcare Providers and Systems scores, attendance at care coordination rounds and percentage of discharge orders placed by 10:00.ConclusionsImplementation of a monthly performance feedback report for hospitalists, complemented by peer comparison and guidance on tactics to achieve these metrics, created a culture of quality and improvement in the quality of care delivered.

scholarly journals SURG-26. READMISSION FOLLOWING RESECTION FOR PATIENTS WITH BRAIN METASTASES IN THE UNITED STATES

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi245-vi245
Author(s):  
Rupesh Kotecha ◽  
Muni Rubens ◽  
Sergio Gonzalez-Arias ◽  
Vitaly Siomin ◽  
Matthew Hall ◽  
...  
Keyword(s):  
Brain Metastasis ◽  
Brain Metastases ◽  
Systemic Disease ◽  
Significant Proportion ◽  
The United States ◽  
Patient Specific ◽  
Unplanned Readmission ◽  
Readmission Rates ◽  
Operative Care ◽  
Nationally Representative

Abstract OBJECTIVE Up to 30% of cancer patients will develop brain metastasis during the course of their systemic disease with a significant proportion undergoing resection of at least one lesion. The objective of the present study was to characterize the rates, predictors, and costs of 30-day readmissions following craniotomy for brain metastases using a nationally representative database. METHODS This study was a retrospective analysis of data from the Nationwide Readmissions Database (NRD) from 2010–2014. We included patients who underwent craniotomy for brain metastasis, identified using ICD-9-CM diagnosis (198.3) and procedure (01.59) codes. The primary outcome of the study was unplanned 30-day all-cause readmission rates. Secondary outcomes included predictors and costs of readmissions. RESULTS During the study period, there were 44,846 index hospitalizations for patients who underwent resection of brain metastasis. Among this cohort, 17.8% (n=7,965) had unplanned readmissions within the first 30 days after discharge from the index hospitalization. The readmission rate did not change significantly during the study period (P=0.286). The odds of unplanned readmission were significantly greater in patients with thromboembolic complications (aOR, 1.53; 95% CI: 1.18–2.01), patients with Elixhauser comorbidities >3 (aOR, 1.35; 95% CI: 1.22–1.50), male patients (adjusted odds ratio [aOR], 1.29; 95% CI: 1.17–1.42), patients with an initial length of stay ≥5 days (aOR, 1.02; 95% CI: 1.01–1.03). The median per-patient cost for 30-day unplanned readmission was $11,109 and this accounted for a total cost of $132.1 million during the study period. CONCLUSIONS Unplanned readmissions after resection for brain metastases involve substantial healthcare expenditures. Though there have been many interventions for improving surgical quality, post-operative care, and cost metrics, unplanned readmission rates have not changed. Key patient-specific variables and high rates of comorbidities should be considered to focus our efforts on patient selection for resection, and for strengthening existing interventions for high-risk patients.

scholarly journals Age Based Trends for Unplanned Pediatric Rehospitalizations in the United States

2021 ◽  
Author(s):  
Nupur Amritphale ◽  
Amod Amritphale ◽  
Deepa Vasireddy ◽  
Mansi Batra ◽  
Mukul Sehgal ◽  
...  
Keyword(s):  
Hospital Readmission ◽  
Readmission Rate ◽  
Age Groups ◽  
The United States ◽  
Unplanned Readmission ◽  
Post Discharge ◽  
Readmission Rates ◽  
Discharge Care ◽  
Hospital Readmission Rate ◽  
Bowel Diseases

BACKGROUND AND OBJECTIVES: Hospital readmission rate helps to highlight the effectiveness of post- discharge care. There remains a paucity of plausible age based categorization especially for ages below one year for hospital readmission rates. METHODS: Data from 2017 Healthcare cost and utilization project National readmissions database was analyzed for ages 0-18 years. Logistic regression analysis was performed to identify predictors for unplanned early readmissions. RESULTS: We identified 5,529,389 inpatient pediatric encounters which were further divided into age group cohorts. The overall rate of readmissions was identified at 3.2%. Beyond infancy, the readmission rate was found to be 6.7%. Across all age groups, the major predictors of unplanned readmission were cancers, diseases affecting transplant recipients and sickle cell patients. It was determined that reflux, milk protein allergy, hepatitis and inflammatory bowel diseases were significant comorbidities leading to readmission. Anxiety, depression and suicidal ideation depicted higher readmission rates in those older than 13 years. Across ages 1-4 yrs, dehydration, asthma and bronchitis were negative predictors of unplanned readmission. CONCLUSIONS: Thirty-day unplanned readmissions remain a problem leading to billions of tax-payer-dollars lost per annum. Effective strategies for mandatory outpatient follow-up may help the financial aspect of care while also enhancing the quality of care.

2204Predicting the trajectory of depression following an acute coronary syndrome: the role of resilience

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J H C Smith ◽  
S Toukhsati ◽  
A J P Francis ◽  
V Stavropoulos ◽  
D L Hare
Keyword(s):  
Acute Coronary Syndrome ◽  
Risk Stratification ◽  
Depression Scale ◽  
Post Discharge ◽  
Chi Square ◽  
Coronary Syndrome ◽  
Improve Risk Stratification ◽  
Treatment Implementation ◽  
Cardiac Depression ◽  
Class B

Abstract Background Depression is common in patients following an Acute Coronary Syndrome (ACS) substantially increases the risk of future events and mortality. Post-ACS depression typically resembles one of four longitudinal trajectories: chronic; absent; recovered, or delayed depression. Early identification of a patient's post-ACS depression trajectory will improve risk stratification, treatment implementation and risk management. Purpose To explore whether stable psychosocial traits, such as resilience, predict the trajectory of depression one month and 6 months following an ACS admission. Method Consecutive adult ACS patients (STEMI/NSTEMI) admitted to a large general hospital completed the Cardiac Depression Scale (CDS) and the Sense of Coherence scale during their admission, then one and six months following discharge. Results 132 ACS in-patients (males = 111; mean age = 63.13±13.47) satisfied enrolment criteria. Unconditional linear latent growth modelling identified a 3-class model for the trajectory of depression post-ACS (increasing depression; consistent non-depressed; decreasing non-depressed). For the increasing depression class, resilience at baseline was significant and negative compared to the consistent class, b=−0.06, Wald chi square (1) = 4.42, p=0.036 and the decreasing class, b=−0.09, Wald chi square (1) = 7.20, p=0.007. Conclusions Patients who reported lower levels of resilience during an ACS admission were significantly more likely to experience initially high levels of depressive symptoms (CDS ≥85) that exceeded the clinically relevant cut-off (CDS ≥95) at 6 months post-discharge. This study suggests that screening for resilience and depression will improve risk stratification for persistent and delayed depression post-ACS.

scholarly journals READMISSION FOR HEALTHCARE-ACQUIRED INFECTIONS: DOES PATIENT DISPOSITION MATTER?

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S822-S822
Author(s):  
Geoffrey J Hoffman ◽  
Lillian Min ◽  
Haiyin J Liu ◽  
Lona Mody
Keyword(s):  
Health Care ◽  
Clostridium Difficile ◽  
Home Health Care ◽  
Surgical Site Infections ◽  
Home Health ◽  
Unplanned Readmission ◽  
Nursing Facility ◽  
Patient Disposition ◽  
Healthcare Acquired Infections ◽  
Tract Infections

Abstract Both common and preventable, healthcare-acquired infections (HAI) are nevertheless associated with high risk for hospital readmission. However, whether these infection-related readmissions are more common among older adults discharged from the hospital to a nursing facility as opposed to home is unknown. We used 2013-14 HCUP data and multivariable logistic regression models to retrospectively examine the relationship of patient disposition (home, nursing facility, home health care) with an unplanned readmission for the same HAI observed at the index admission, among older Medicare beneficiaries, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization. Of 8.4 million index admissions, 323,332 (3.9%) involved an index HAI, of which 15,870 (4.9%) resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (p&lt;0.001). Being discharged home or to home health care, compared to a post-acute care setting, was associated with increased odds (OR: 1.63 and 1.62, p&lt;0.001) of HAI readmission, particularly for patients with higher comorbidity scores. For home discharges, HAI readmission risk was doubled for patients with the most compared to fewest comorbidities while nursing facility discharges were equally protective across comorbidity levels. We conclude that Clostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed.

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