The Costs of Complications and Unplanned Readmissions after Pancreatoduodenectomy for Pancreatic and Periampullary Tumors: Results from a Single Academic Center

Background/Objectives: Complications after pancreatoduodenectomy (PD) lead to unplanned readmissions (UR), with a two- to threefold increase in admission costs. In this study, we aimed to create an understanding of the costs of complications and UR in this patient group. Furthermore, we aimed to generate a detailed cost overview that can be used to build a theoretical model to calculate the cost efficacy for prehabilitation. Methods: A retrospective cohort analysis was performed using the Dutch Pancreatic Cancer Audit (DPCA) database of patients who underwent a PD at our institute between 2013 and 2017. The total costs of the index hospital admission and UR related to the PD were collected. Results: Of the 160 patients; 35 patients (22%) had an uncomplicated course; 87 patients (54%) had minor complications, and 38 patients (24%) had severe complications. Median costs for an uncomplicated course were EUR 25.682, and for a complicated course, EUR 32.958 (p = 0.001). The median costs for minor complications were EUR 30.316, and for major complications, EUR 42.664 (p = 0.001). Costs were related to the Comprehensive Complication Index (CCI). The median costs of patients with one or more UR were EUR 41.199. Conclusions: Complications after PD led to a EUR 4.634–EUR 16.982 (18–66%) increase in hospital costs. A UR led to a cost increase of EUR 12.567 (44%). Since hospital costs are directly related to the CCI, reduction in complications will lead to cost-effectiveness.

P-OGC10 Long-term survival is not affected by complications after oesophagectomy

Background Outcomes following oesophagectomy for oesophageal cancer continue to improve, but complications are common and can result in significant morbidity. Post-operative complications are known to impact upon peri-operative and short-term survival but the effect on long-term survival remains unclear. The aim of this study is to investigate the effect of post-operative complications on long-term survival following oesophagectomy. Methods A contemporaneously maintained database from a single centre was reviewed. All patients who underwent oesophagectomy between January 2010 and January 2019 were included. Patients were separated into three groups, those who experienced no or very minor complications (Clavien-Dindo 0 or 1), minor complications (Clavien-Dindo 2), and major complications (Clavien-Dindo 3-4). Those who died during the index hospital admission were excluded to correct for short-term mortality effects. Overall survival was analysed using Kaplan-Meier and log rank testing. Results Seven hundred and twenty-three patients underwent oesophagectomy during this time. Seventeen (2.4%) died during their index hospital stay, and were excluded from the survival analysis. The 30- and 90- day mortality was 1.1% (8/723) and 2.4% (17/723) respectively. There were 43.2% (305/706), 30.2% (213/706) and 26.6% (188/706) in the Clavien-Dindo 0-1, Clavien-Dindo 2, and Clavien-Dindo 3-4 group respectively. Median survival across the three groups was equivalent (50, 57 and 51 months). Across all three groups, overall long-term survival rates were equivalent at 1 (87.5%, 84.9%, 83.5%), 5 (44.2%, 48.9%, 44.7%) and 10 years (36.7%, 36.0%, 36.7%) (p = 0.730). Conclusions Long term survival is not affected by complications, irrespective of severity, following oesophagectomy.

Abstract 11759: Survival Among Medicare Beneficiaries After Out-of-Hospital Cardiac Arrest Undergoing Interhospital Transfer

Intro: Among individuals treated for out-of-hospital cardiac arrest (OHCA), there is hospital-level variability in mortality, but the relationship between interhospital transfer (IHT) OHCA volume and survival remain unclear. We sought to examine the association of OHCA volume and survival for individuals undergoing IHT. Methods: Utilizing age-eligible Medicare fee-for-service claims, we identified an emergency department treated OHCA cohort using ICD-9/10 diagnosis codes. Hospital OHCA volume was defined as the total number of index (first-treated) OHCA claims during the study period and were binned into quartiles. Each claim was assigned the OHCA volume quartile of the index hospital and the index volume of the receiving hospital. Multiple logistic regression was conducted to assess the association between initial and receiving hospital volume categories and survival to 30 days among IHT patients while controlling for patient-level characteristics (age, sex, race), comorbidity index, urbanicity of index hospital and days to transfer. Results: We identified a cohort of 222,018 claims at 4,461 hospitals between 1/2013-12/2015. Median age was 78 years (IQR 71-85); 44% were female; 11% of the cohort was alive at 30 days. IHT occurred in 12,245 cases (5.5%) and 59% of transfers occurred on the day of admission or day 1. Transfers originated from 3411 index hospitals and 1566 receiving hospitals. Median OHCA hospital index volume was 25 [IQR 9, 67]. Adjusted odds of survival at 30 days was significantly lower at index hospitals with lower OHCA volumes compared to the highest volume category (aOR [95%CI] Q2: 0.71 [0.6, 0.83] p<0.001). Additionally, odds of survival at 30 days was significantly lower at low volume receiving hospitals (aOR [95%CI] Q1: 0.73 [0.55, 0.99] p<0.001), and increased for higher OHCA volume receiving hospitals, but these groups did not achieve statistical significance. Conclusion: For Medicare beneficiaries who suffer an OHCA and undergo IHT, lower index and receiving hospital OHCA volume was significantly associated with decreased adjusted odds of 30-day survival. Further exploration of hospital characteristics, timing, and transfer patterns is needed to understand differences in benefit for OHCA patients undergoing IHT.

149. Impact of Stewardship on Antibiotic Utilization Rates During the COVID-19 Pandemic: Successes and Challenges in a Regional Hospital

Background Antibiotic stewardship (AS) is at the core of patient safety and prevention of antimicrobial resistance. Healthcare providers prescribe antibiotics for COVID-19 despite low rates of bacterial co-infection. Our regional hospital had antibiotic utilization (AU) rates higher than other health systems even prior to the emergence of SARS-Cov2. We analyzed the effect AS on AU during the pandemic. Total Antibiotic Utilization Rates Before and During COVID-19 Pandemic Methods Total and specific AU rates were benchmarked using BD MedMined’s medication analytics system from 2nd quarter 2019 to 1st quarter 2021. The AS team released yearly antibiogram and individual prescriber’s AU rates and performed weekly, and as needed, review of antibiotic ordering and feedback. To assist in appropriate prescribing decisions, remote educational sessions or mini-lectures and local antibiotic guidelines were developed during the pandemic period. AU rates were monitored quarterly to determine the effects of the AS interventions to prescribing practices. Results Total and specific AU rates were higher (up to 34% and 80%, respectively) in our index hospital compared to other non-teaching hospitals nationally prior to the pandemic. Total antibiotic utilization increased by only 5.5% in the 2nd quarter 2020, peak of AU during the pandemic. Total, vancomycin, piperacillin-tazobactam and quinolone utilization rates decreased by 19%, 41%, 38%, and 52%, respectively, at 1st quarter 2021 compared to 4th quarter 2019. Steeper decreases were noted with implementation of educational activities. Ceftriaxone use remained high and was 50% greater than comparator hospitals at 1st quarter 2021. Conclusion Although problematic during the COVID-19 pandemic, AS can have significant impact on provider prescribing practices and decrease total and specific antibiotic utilization rates. The use of ceftriaxone, an antibiotic commonly used for empiric bacterial coverage for community acquired pneumonia, presents as a continuing challenge. Disclosures All Authors: No reported disclosures

One-year outcomes for lung transplantation recipients with non-alcoholic fatty liver disease

Advanced hepatic fibrosis and cirrhosis are absolute contraindications to lung transplantation. [1] However, whether fatty liver disease with mild-moderate fibrosis contributes to increased adverse outcomes post-lung transplantation remains unknown.We present a retrospective analysis of patients transplanted at Brigham and Women's Hospital between 2015–2017 to identify whether patients with mild-moderate non-alcoholic fatty liver disease (NAFLD) experience increased short-term complications compared to patients with normal liver architecture. Patients with advanced (F3–F4) fibrosis and/or cirrhosis were considered non-suitable transplant candidates, a priori. This study was powered for a difference in index hospital-free days within the first 30 days of 25% (alpha=0.05, beta=0.8). Secondary outcomes included index intensive care unit (ICU) free days within the first 10 days post-transplant, perioperative blood product transfusion, incidence of index hospitalisation arrhythmias and delirium, need for insulin on discharge post-transplant, tacrolimus dose required to maintain a trough of 8–12 ng·mL−1 at index hospital discharge, and 1-year post-transplant incidence of insulin-dependent diabetes, acute kidney injury, acute cellular rejection, unplanned hospital readmissions, and infection.One hundred fifty patients underwent lung transplantation between 2015–2017 and were included in the analysis; of these patients 40 (27%) had evidence of NAFLD. Median index hospital-free days for patients with NAFLD were non-inferior to those without (16 days, IQR 10.5–19.5 versus 12 days, IQR 0–18.0, p= 0.03). Regarding secondary outcomes, both index hospitalisation and 1-year outcomes were non-inferior between patients with NAFLD and those with normal liver architecture.This study demonstrates that mild-moderate severity NAFLD may not be a contraindication to lung transplantation.

MO1049PROGRESSION OF CHRONIC KIDNEY DISEASE AND LONG-TERM MORTALITY IN PATIENTS HOSPITALIZED WITH TRICUSPID REGURGITATION

Background and Aims Uremic toxins negatively affect the cardiovascular system resulting in significant morbidity and mortality. However, independent risk factors for chronic kidney disease (CKD) and that of worsening CKD have not been studied in patients with tricuspid regurgitation (TR), yet. Accordingly, in this study, we aimed to assess independent risk factors for the development of progressive CKD in patients with TR. Also, the impact of progressive CKD on long-term mortality was evaluated. Method This retrospective, single-center study comprised 444 consecutive patients with TR who were hospitalized between January 2010 and June 2017. We excluded patients with CKD stage 5. Demographic data, comorbidities, type of admission, medication, echocardiographic and laboratory parameters, and survival status were obtained from patient medical record from index hospital admission through discharge. For at least three years, serum creatinine concentrations and survival status were collected from outpatient medical record. We identified independent risk factors for CKD progression. Also, we assessed the impact of CKD progression and other variables on 3-year mortality using multivariable logistic regression analysis. For analysis of 3-year mortality, we grouped patients according to different combinations of their TR grade and presence or absence of CKD progression. Results Stage of CKD at hospital admission (odds ratio 0.34 [95% confidence interval 0.24-0.50], p &lt; 0.001), baseline hemoglobin concentration (OR 0.72 [95% CI 0.57-0.92], p=0.006) and presence of diabetes type 2 (OR 1.81 [95% CI 1.08-3.03], p=0.024) were identified as independent risk factors for CKD progression. Progression of CKD during follow-up (OR 2.16 [95% CI 1.31-3.57], p=0.003), grade of TR and mitral regurgitation during index hospital stay and hemoglobin concentration at baseline were independent risk factors for 3-year mortality. Combination of TR grade and status of CKD progression showed a stepwise pattern for 3-year mortality (Figure 1). Patients with TR 1 and CKD progression had a similar 3-year mortality as patients with TR 2 or 3 but no CKD progression. In patients with TR 1, risk for 3-year mortality doubled if CKD progression occurred (OR 2.49 [95% CI 1.38-4.47], p=0.002). Conclusion Although retrospective studies cannot imply causal relationship, based on study findings, kidney follow-up especially in patients with mild TR may be advisable. If CKD progression can be prevented in patients with TR and if such kidney protection may reduce long-term mortality may be objective of future studies.

A Comparison of Contemporary Clinical Outcomes Following Femoro-Popliteal Plain Balloon Angioplasty and Bypass Surgery for Chronic Limb Threatening Ischemia

Introduction: Despite the BASIL-1 trial concluding that bypass surgery (BS) was superior to plain balloon angioplasty (PBA) in terms of longer-term amputation free (AFS) and overall survival (OS), CLTI patients are increasingly offered an endovascular-first revascularization strategy. This study investigates whether the results of BASIL-1 are still relevant to current practice by comparing femoro-popliteal (FP) BS with PBA in a series of CLTI patients treated in our unit 10 years after BASIL-1 (1999-2004). Methods: We retrospectively analyzed prospectively gathered hospital data pertaining to 279 patients undergoing primary FP BS or PBA for CLTI in the period 2009 to 2014. We report baseline characteristics, 30-day morbidity and mortality, major adverse cardiovascular events (MACE) and long-term AFS, limb salvage (LS), OS, major adverse limb events (MALE), and freedom from re-intervention (FFR). Results: 234 (84%) and 45 (16%) patients underwent PBA and BS respectively. PBA patients were significantly older (77 vs 71 years, P = 0.001) and more likely to be female (45% vs 28%, P = 0.026). Bollinger and GLASS anatomic scores were significantly more severe in the BS group. Technical success was better for BS (100% vs 87%, P = 0.007). Index hospital stay was shorter for PBA (9.1 vs 15.6 days, P = 0.035) but there was no difference in hospital days or admissions over the next 12 months. AFS (HR 1.00), LS (HR 1.44), OS (HR 0.81), MALE (HR 1.25) and FFR (HR = 1.00) were not significantly different between PBA and BS. Conclusion: Important clinical outcomes following FP BS and PBA for CLTI have not changed significantly in our unit in the 10 years following the BASIL-1 trial. BASIL-1 therefore remains relevant to our current practice and should inform our approach to the management of CLTI going forward.