Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

Object On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures. Methods The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000–2002) and post-reform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. Results A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre– and post–duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11–1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91–1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17). Conclusions The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

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Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Journal of Neurosurgery Spine ◽

10.3171/2014.5.spine13283 ◽

2014 ◽

Vol 21 (4) ◽

pp. 502-515 ◽

Cited By ~ 27

Author(s):

Ranjith Babu ◽

Steven Thomas ◽

Matthew A. Hazzard ◽

Yuliya V. Lokhnygina ◽

Allan H. Friedman ◽

...

Keyword(s):

Health Care ◽

Mortality Rate ◽

Patient Outcomes ◽

Spine Surgery ◽

Teaching Hospitals ◽

Complication Rates ◽

Reform Era ◽

Increased Risk ◽

Significant Difference ◽

Resident Duty

Object The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery. Methods The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. Results A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55). Conclusions The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

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Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases

Journal of Neurosurgery ◽

10.3171/2016.8.jns161226 ◽

2017 ◽

Vol 127 (5) ◽

pp. 1096-1104 ◽

Cited By ~ 17

Author(s):

Jian Guan ◽

Andrea A. Brock ◽

Michael Karsy ◽

William T. Couldwell ◽

Meic H. Schmidt ◽

...

Keyword(s):

Body Mass Index ◽

Body Mass ◽

Secondary Outcome ◽

Neurosurgical Procedures ◽

Complication Rates ◽

Increased Risk ◽

Neurosurgical Patients ◽

Physical Classification ◽

The Impact ◽

Surgery Duration

OBJECTIVEOverlapping surgery—the performance of parts of 2 or more surgical procedures at the same time by a single lead surgeon—has recently come under intense scrutiny, although data on the effects of overlapping procedures on patient outcomes are lacking. The authors examined the impact of overlapping surgery on complication rates in neurosurgical patients.METHODSThe authors conducted a retrospective review of consecutive nonemergent neurosurgical procedures performed during the period from May 12, 2014, to May 12, 2015, by any of 5 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Overlapping surgery was defined as any case in which 2 patients under the care of a single lead surgeon were under anesthesia at the same time for any duration. Information on patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. Primary outcome was the occurrence of any complication from the beginning of surgery to 30 days after discharge. A secondary outcome was the occurrence of a serious complication—defined as a life-threatening or life-ending event—during this same period.RESULTSOne thousand eighteen patients met the inclusion criteria for the study. Of these patients, 475 (46.7%) underwent overlapping surgery. Two hundred seventy-one patients (26.6%) experienced 1 or more complications, with 134 (13.2%) suffering a serious complication. Fourteen patients in the cohort died, a rate of 1.4%. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%, p = 0.837), nor was the rate of serious complications (14.7% vs 11.8%, p = 0.168). After adjustments for surgery type, surgery duration, body mass index, American Society of Anesthesiologists (ASA) physical classification grade, and intraoperative blood loss, overlapping surgery remained unassociated with overall complications (OR 0.810, 95% CI 0.592–1.109, p = 0.189). Similarly, after adjustments for surgery type, surgery duration, body mass index, ASA grade, and neurological comorbidity, there was no association between overlapping surgery and serious complications (OR 0.979, 95% CI 0.661–1.449, p = 0.915).CONCLUSIONSIn this cohort, patients undergoing overlapping surgery did not have an increased risk for overall complications or serious complications. Although this finding suggests that overlapping surgery can be performed safely within the appropriate framework, further investigation is needed in other specialties and at other institutions.

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Acute Myeloid Leukemia in the Elderly: Trends in Mortality Rates, Hospital Cost, Length of Stay, and Complication Rates in Patients Aged 60 and Older

Blood ◽

10.1182/blood.v128.22.2359.2359 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2359-2359

Author(s):

Ankit Shah ◽

Stuthi Perimbeti ◽

Parshva Patel ◽

Rachel Nathan ◽

Seema Niphadkar ◽

...

Keyword(s):

Bone Marrow ◽

Length Of Stay ◽

Hospital Mortality ◽

Bone Marrow Transplant ◽

Marrow Transplant ◽

Teaching Hospitals ◽

Complication Rates ◽

Total Cost ◽

Significant Difference ◽

Acute Myeloid

Abstract Background: Acute myeloid leukemia (AML) is associated with a high mortality rate. Advancing age is a risk factor associated with poor prognosis and an increased rate of chemotherapy-related complications in patients with AML. We aimed to evaluate trends in cost of hospitalizations, length of stay, mortality rates, and complication rates in patients aged 60 years and older who were admitted for active AML. We also sought to elucidate differences in these outcomes in teaching and non-teaching institutions. Methods:We queried the Nationwide Inpatient Sample (NIS) between 1999 and 2013 using the ICD-9 codes 205.00, 205.01, 206.00, and 206.01 for acute myeloid and acute monocytic leukemias in the primary diagnosis field. Admission data regarding total cost, length of stay (LOS), and in-hospital mortality was extracted. This data was trended over the 15-year interval and comparisons were made between teaching and nonteaching institutions. Incidence of in-hospital complications including clostridium difficile infection (CDI), bacteremia, sepsis, pneumonia, venous thromboembolism (VTE), neutropenic fever, candidiasis, urinary tract infection (UTI), and acute respiratory failure were determined and compared in subsets of teaching and nonteaching hospitals. Frequency of bone marrow transplant was also determined in both hospital settings. Results: A total of 51,684 (weighted n=247,747) admissions for AML occurred from 1999-2013. Of these 31,004 admissions (weighted n=148,683) were in patients aged 60 and older. Most of these elderly admissions occurred at teaching institutions (n=17,593, weighted n=84,829). In-hospital mortality was higher in patients aged 60 and greater (23.68%) compared to those less than 60 (13.7% (p<.0001)). For patients 60 and older, mortality has decreased by approximately 40% during the 15-year interval (p<.0001). Specifically, in-hospital mortality was 30.21% in 1999 and 18.05% in 2013. In comparing teaching and non-teaching hospitals, mortality rate was not found to have a statistically significant difference (p=.4473). Complication rates due to VTE, bacteremia, febrile neutropenia, pneumonia, and UTI increased during this time period. Rates of CDI and candidiasis did not have a statistically significant difference over time. Rates of acute respiratory failure, neutropenic fever, bacteremia, VTE, sepsis, and CDI were higher at teaching than at non-teaching institutions (p<.0001). Rates of UTI were higher at non-teaching (9.62%) than at teaching institutions (8.43% (p=.004)). Differences in the rate of pneumonia and candidiasis were not statistically significant between the two hospital settings. Rates of bone marrow transplant have roughly doubled from .23% in 1999 to .51% in 2013 (p=.0079) and occurred more frequently in teaching (0.54%) than in non-teaching (0.24%) hospitals (p=.0017). Mean LOS (days) is relatively unchanged over the 15- year interval (p=.2277), however, cost has increased dramatically (p=.0001). Total cost in 1999 was $46,833(±1,508), whereas in 2013 it was $146,965(±4,296). Mean LOS and cost were higher at teaching (17.16, $122,257±1,221) compared with nonteaching (10.57, $65,448±993) institutions (p=.0001). Conclusions: For patients admitted with a primary diagnosis of active AML, in-hospital mortality was markedly higher in patients aged 60 and older compared with those less than 60. In the elderly, in-hospital mortality decreased dramatically between 1999 and 2013. Many factors may contribute to the decrease in mortality in this population including the use of less-aggressive cytotoxic chemotherapy, such as low-dose cytarabine or hypomethylating agents, improved adherence to preventative practices including the use of high-efficiency particulate air filtration, and prophylactic antibiotics. In patients older than 60, LOS and total cost were higher in teaching institutions, although in-hospital mortality was similar. In general, complication rates were higher at teaching hospitals, which may be a consequence of increased medical complexity and more aggressive therapy offered at these hospitals. For instance, bone marrow transplant rates were much higher in teaching than in non-teaching hospitals. Further research is required to determine the exact factors and practice differences contributing to the discrepancies between teaching and non-teaching institutions. Disclosures No relevant conflicts of interest to declare.

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Evaluating resident involvement and the ‘July effect’ in parotidectomy

The Journal of Laryngology & Otology ◽

10.1017/s0022215121000578 ◽

2021 ◽

pp. 1-6

Author(s):

D A Benito ◽

I Mamidi ◽

L J Pasick ◽

A D Sparks ◽

C Badger ◽

...

Keyword(s):

Length Of Stay ◽

Confidence Interval ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Improvement Program ◽

Resident Participation ◽

Increased Risk ◽

Significant Difference ◽

July Effect ◽

Resident Involvement

Abstract Objective This study aimed to evaluate the effect of resident involvement and the ‘July effect’ on peri-operative complications after parotidectomy. Method The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014. Results There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05–0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11–0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters. Conclusion Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

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COVD-27. THE COVID-19 PANDEMIC AND NEURO-ONCOLOGICAL PATIENTS

Neuro-Oncology ◽

10.1093/neuonc/noaa215.108 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii26-ii26

Author(s):

Sofya Norman ◽

Rupa Juthani

Keyword(s):

New York ◽

Brain Tumor ◽

Patient Outcomes ◽

Care Delivery ◽

Tumor Control ◽

Oncology Patient ◽

Term Survival ◽

Oncological Care ◽

Oncological Patients ◽

Significant Difference

Abstract INTRODUCTION The Coronavirus disease 2019 (COVID-19) pandemic has uprooted healthcare systems worldwide, disrupting care and increasing dependence on alternative forms of health care delivery. It is yet to be determined how the pandemic affected neuro-oncology patient outcomes, given that the majority of even “elective” neurosurgical oncology procedures are time-sensitive. This study quantifies changes in neuro-oncological care during the height of the pandemic in New York City and investigates patient outcomes in 2020 compared to a historical control. METHODS We performed a retrospective review of patients with brain tumor diagnoses (primary or secondary) who were seen at the Weill Cornell Brain and Spine Center between March 13, 2020 and May 1, 2020. A control cohort from the corresponding time period in 2019 was also reviewed. Alterations in care, including shift from in-person to telehealth, delays in evaluation and intervention, and treatment modifications were evaluated. These variables were analyzed with respect to brain tumor control and mortality. RESULTS 114 patients from 2020 and 171 patients from 2019 were included, with no significant difference in baseline demographics between the groups. There was no significant difference in outcomes between the cohorts, despite significantly more treatment delays (p= 0.0154) and use of telehealth (p< 0.0001) in 2020. For patients treated during the pandemic in 2020, patients who experienced delays in care did not suffer from worse outcomes compared to those without delays. Patients who utilized telehealth visits had significantly more stable tumor control (P = 0.0027), consistent with appropriate use of in-person visits for patients with progression. CONCLUSION Our study showed that use of telehealth and selective alterations in neuro-oncological care during the COVID-19 pandemic did not lead to adverse patient outcomes. This suggests that adaptive physician-led changes during the pandemic were successful and effective. Further studies are needed to evaluate impact on long-term survival.

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664 Risk Factors for the Development of Transaminitis in Pediatric Burn Patients Treated with Oxandrolone

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.280 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S177-S177

Author(s):

Kate Pape ◽

Sarah Zavala ◽

Rita Gayed ◽

Melissa Reger ◽

Kendrea Jones ◽

...

Keyword(s):

Risk Factors ◽

Length Of Stay ◽

Pediatric Patients ◽

Burn Injury ◽

Total Body Surface Area ◽

Future Research ◽

Burn Patients ◽

Thermal Burn ◽

Increased Risk ◽

Significant Difference

Abstract Introduction Oxandrolone is an anabolic steroid that is the standard of care for burn patients experiencing hypermetabolism. Previous studies have demonstrated the benefits of oxandrolone, including increased body mass and improved wound healing. One of the common side effects of oxandrolone is transaminitis, occurring in 5–15% of patients, but little is known about associated risk factors with the development of transaminitis. A recent multicenter study in adults found that younger age and those receiving concurrent intravenous vasopressors or amiodarone were more likely to develop transaminitis while on oxandrolone. The purpose of this study was to determine the incidence and identify risk factors for the development of transaminitis in pediatric burn patients receiving oxandrolone therapy. Methods This was a multicenter, retrospective risk factor analysis that included pediatric patients with thermal burn injury (total body surface area [TBSA] > 10%) who received oxandrolone over a 5-year time period. The primary outcome of the study was the development of transaminitis while on oxandrolone therapy, which was defined as aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >100 mg/dL. Secondary outcomes included mortality, length of stay, and change from baseline ALT/AST. Results A total of 55 pediatric patients from 5 burn centers met inclusion criteria. Of those, 13 (23.6%) developed transaminitis, and the mean time to development of transaminitis was 17 days. Patients who developed transaminitis were older (12 vs 6.4 years, p = 0.01) and had a larger mean %TBSA (45.9 vs 34.1, p = 0.03). The odds of developing transaminitis increased by 23% for each 1 year increase in age (OR 1.23, CI 1.06–1.44). The use of other concurrent medications was not associated with an increased risk of developing transaminitis. Renal function and hepatic function was not associated with the development of transaminitis. There was no significant difference in length of stay and mortality. Conclusions Transaminitis occurred in 23.6% of our study population and was associated with patients who were older and had a larger mean %TBSA burn. Older pediatric patients with larger burns who are receiving oxandrolone should be closely monitored for the development of transaminitis. Applicability of Research to Practice Future research is needed to identify appropriate monitoring and management of transaminitis in oxandrolone-treated pediatric burn patients.

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Predicting Inpatient Length of Stay After Brain Tumor Surgery: Developing Machine Learning Ensembles to Improve Predictive Performance

Neurosurgery ◽

10.1093/neuros/nyy343 ◽

2018 ◽

Vol 85 (3) ◽

pp. 384-393 ◽

Cited By ~ 12

Author(s):

Whitney E Muhlestein ◽

Dallin S Akagi ◽

Jason M Davies ◽

Lola B Chambless

Keyword(s):

Machine Learning ◽

Brain Tumor ◽

Length Of Stay ◽

Patient Outcomes ◽

External Validation ◽

Training Dataset ◽

Ensemble Model ◽

Improvement Program ◽

Improve Patient ◽

Inpatient Length Of Stay

Abstract BACKGROUND Current outcomes prediction tools are largely based on and limited by regression methods. Utilization of machine learning (ML) methods that can handle multiple diverse inputs could strengthen predictive abilities and improve patient outcomes. Inpatient length of stay (LOS) is one such outcome that serves as a surrogate for patient disease severity and resource utilization. OBJECTIVE To develop a novel method to systematically rank, select, and combine ML algorithms to build a model that predicts LOS following craniotomy for brain tumor. METHODS A training dataset of 41 222 patients who underwent craniotomy for brain tumor was created from the National Inpatient Sample. Twenty-nine ML algorithms were trained on 26 preoperative variables to predict LOS. Trained algorithms were ranked by calculating the root mean square logarithmic error (RMSLE) and top performing algorithms combined to form an ensemble. The ensemble was externally validated using a dataset of 4592 patients from the National Surgical Quality Improvement Program. Additional analyses identified variables that most strongly influence the ensemble model predictions. RESULTS The ensemble model predicted LOS with RMSLE of .555 (95% confidence interval, .553-.557) on internal validation and .631 on external validation. Nonelective surgery, preoperative pneumonia, sodium abnormality, or weight loss, and non-White race were the strongest predictors of increased LOS. CONCLUSION An ML ensemble model predicts LOS with good performance on internal and external validation, and yields clinical insights that may potentially improve patient outcomes. This systematic ML method can be applied to a broad range of clinical problems to improve patient care.

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Plasmapheresis for Management of Antiphospholipid Syndrome in the Neurosurgical Patient

Operative Neurosurgery ◽

10.1093/ons/opy135 ◽

2018 ◽

Vol 16 (4) ◽

pp. E124-E129

Author(s):

Eric J Arias ◽

Brent Bruck ◽

Ananth K Vellimana ◽

Charles Eby ◽

Matthew R Reynolds ◽

...

Keyword(s):

Antiphospholipid Syndrome ◽

Anticoagulation Therapy ◽

Artery Aneurysm ◽

Perioperative Period ◽

Autoimmune Disorder ◽

Left Internal Carotid Artery ◽

Neurosurgical Procedures ◽

Internal Carotid Artery Aneurysm ◽

Increased Risk ◽

Neurosurgical Patients

Abstract BACKGROUND AND IMPORTANCE Antiphospholipid syndrome (APS) is an autoimmune disorder associated with a hypercoagulable state and increased risk of intraoperative and postoperative thrombosis. Few neurosurgical studies have examined the management of these patients, though the standard of care in most other disciplines involves the use of anticoagulation therapy. However, this is associated with risks such as hemorrhage, thrombosis due to warfarin withdrawal, and is not compatible with operative intervention. CLINICAL PRESENTATION We report the cases of 2 antiphospholipid positive patients who were on anticoagulant therapy and underwent surgical bypasses and received perioperative management with plasmapheresis. The first was a 44-yr-old woman who presented with worsening vision, recurring headaches, and a known left internal carotid artery aneurysm that was unsuccessfully treated twice via extracranial to intracranial (ECIC) bypass at another institution. Preoperative tests at our institution revealed elevated beta 2 glycoprotein 1 IgA autoantibodies. The second case was a 24-yr-old woman with previously diagnosed APS, who presented for surgical evaluation of moyamoya disease after sustaining recurrent left hemispheric strokes. Both cases were managed with perioperative plasmapheresis to avoid the need for anticoagulation during the perioperative period, and both underwent successful ECIC bypass procedures without perioperative ischemic or hemorrhagic complications. CONCLUSION Management of neurosurgical patients with APS can be a precarious proposition. We describe the successful use of plasmapheresis and antiplatelet therapy to better manage patients undergoing neurosurgical procedures, specifically ECIC bypass, and feel this approach can be considered in future cases.

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Surgery Delay Increases Length of Stay in Thoracolumbar Trauma

Neurosurgery ◽

10.1093/neuros/nyz310_446 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Lawrence Zeldin ◽

Sean N Neifert ◽

Robert J Rothrock ◽

Ian T McNeill ◽

Jonathan S Gal ◽

...

Keyword(s):

Length Of Stay ◽

Spinal Injury ◽

Specific Effect ◽

Spinal Trauma ◽

Spine Injury ◽

Complication Rates ◽

Improvement Program ◽

Delayed Surgery ◽

Significant Difference ◽

Surgery Timing

Abstract INTRODUCTION The ideal timing from admission of a thoracolumbar spinal trauma patient to the start of surgery at US trauma centers remains a hotly contested area of debate. The effect of surgical latency on patient outcomes in thoracolumbar trauma remains unclear. METHODS All 2013 to 2015 thoracolumbar spinal trauma cases from the American College of Surgeons Trauma Quality Improvement Program (TQIP) were analyzed. Patients with unsurvivable spine injury, polytraumas (serious injuries in more than one bodily region), and those discharged within 24 h were excluded. Patients were classified into 3 groups by surgery timing: less than 8 h (early, N = 1699), between 8 and 24 h (normal, N = 946), and over 24 h (delayed, N = 1601). Mortality, length of stay (LOS), and complication rates were compared between groups. Demographic variables and complication rates were compared. Multivariate logistic regression was utilized to determine the specific effect of surgery timing on outcomes. RESULTS Patients with earlier surgery presented with more severe spinal trauma (P < .0001). Patients in the normal surgical timing cohort were most likely to have altered mental status (4.97% vs 3.24%, P = .05), and less likely to suffer from UTI (4.97% vs 3.24%, P = .03). Patients in the delayed cohort were older (46.2 vs 43.7 yr, P = .0003), more likely to have a longer LOS (11.3 vs 10.6 d, P = .02), return to the ICU (2.94% vs 1.29%, P = .001), experience unplanned intubation (2.06% vs 1%, P = .01) and suffer from cardiac arrest (0.53% vs 1.19%, P = .04). Upon multivariate analysis, delayed surgery was an independent risk factor for prolonged LOS (OR: 1.21, 95% CI: 0.56-1.87, P = .0003). CONCLUSION Patients with earlier surgery possessed more severe spinal injury. When adjusting for demographics and severity, no significant difference is seen in mortality between the different surgery times; however, LOS is prolonged in patients with delayed surgery.

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Trends in Hospital Cost, Length of Stay, Mortality, and Complication Rates in Patients with Acute Myeloid Leukemia in Teaching Versus Non-Teaching Hospitals: Data from the Nationwide Inpatient Sample from 1999-2013

Blood ◽

10.1182/blood.v128.22.2357.2357 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2357-2357

Author(s):

Ankit Shah ◽

Stuthi Perimbeti ◽

Parshva Patel ◽

Rachel Nathan ◽

Daniel Kyung ◽

...

Keyword(s):

Respiratory Failure ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Respiratory Failure ◽

Marrow Transplant ◽

Neutropenic Fever ◽

Teaching Hospitals ◽

Complication Rates ◽

Total Charges ◽

Acute Myeloid

Abstract Background: Acute Myeloid Leukemia (AML) is the most common acute leukemia in adults and represents a heterogeneous group of clonal hematopoietic stem cell disorders with varying prognosis based on cytogenetic and host factors. Success in treatment of AML is thought to have only improved modestly in recent decades. We aimed to evaluate trends in hospital cost, length of stay, in-hospital mortality, and complication rates in adult patients admitted with active AML. We also sought to elucidate differences in these outcomes in teaching versus non-teaching institutions. Methods: Using ICD-9 codes for acute myeloid and acute monocytic leukemias, all adult admissions with a primary diagnosis of active AML between 1999-2013 were identified from the Nationwide Inpatient Sample (NIS). Admission information including length of stay (LOS), total charges, and mortality were extracted. Total cost was adjusted for inflation using data from the U.S. Bureau of Labor Statistics. ICD-9 codes were selected to reflect the most common etiologies of in-hospital complications such as clostridium difficile infection (CDI), bacteremia, sepsis, pneumonia, venous thromboembolism (VTE), neutropenic fever, candidiasis, urinary tract infection (UTI), and acute respiratory failure. Rates of these complications were determined over the 15-year interval and compared in subsets of teaching and non-teaching hospitals. Rates of bone marrow transplant were also queried. Results: We identified 51,684 admissions (weighted N = 247,747) with a primary diagnosis of AML from 1999-2013. Most of the admissions were at teaching hospitals (N = 32,982; weighted N = 158,952). Overall in-hospital mortality was determined to be 19.54%. LOS (days) was found to be longer in teaching (21.04 ±0.10) than in non-teaching (12.25 ±0.11) hospitals (p = .0001). Total charges were also greater in teaching ($157,709 ±1,089) versus non-teaching ($79,167 ±965) hospitals (p = .0001). Of note, after correcting for age, multivariate analysis yielded higher mortality in teaching than in non-teaching hospitals (OR = 1.11, CI: 1.04-1.19). Rates of CDI, bacteremia, neutropenic fever, sepsis, acute respiratory failure, and VTE were higher in teaching hospitals (p < .0001). On the other hand, rates of UTI were lower in teaching (7.31%) than in non-teaching (8.31%) hospitals (p=.0026). Rates of pneumonia and candidiasis did not have a statistically significant difference when comparing the two settings. Bone marrow transplant was more frequently performed at teaching (1.36%) than in non-teaching hospitals (0.56%) (p=.0001). Over the 15-year interval, in-hospital mortality has declined by greater than one third for all AML admissions (p <. 0001). Rates of nearly all of the complications, excluding candidiasis, but including CDI, neutropenic fever, bacteremia, UTI, pneumonia, VTE, and acute respiratory failure have increased during this interval, however. Total charges increased during this time period from $66,678 (±1,567) in 1999 to $197,439 (±4,532) in 2013 (p = .0001), which was greater than the expected inflationary increase to $93,235 over the same time period. Conclusions: Most admissions for AML occurred at teaching institutions. This may be due to increased resource requirements to care for this patient population. In-hospital mortality appears to have improved markedly from 1999-2013 for all admissions for AML, which may be a testament to well-established chemotherapy guidelines, use of less toxic chemotherapy regimens in the elderly, and standardized preventative practices such as the use of high-efficiency particulate air filtration and prophylactic antibiotics. On the other hand, rates of nearly all measured complications have increased during this interval. Given the opposite trend in mortality, we believe this may be in part due to improved surveillance and reporting. Rates of mortality as well several complication rates appear to be higher in teaching than in non-teaching institutions, which may be due to increased medical complexity and more aggressive therapy offered at teaching institutions. Further research is required to determine what additional factors and practice differences are contributing to these discrepancies. Total charges were higher at teaching institutions, which may be due to increased LOS, complication rates, medical complexity and resource consumption. Disclosures No relevant conflicts of interest to declare.

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