Publications by authors named "Peyman Benharash"

179 Publications

National Trends in the Cost Burden of Pediatric Gunshot Wounds Across the United States.

J Pediatr 2021 May 12. Epub 2021 May 12.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles. Electronic address:

Objective: To characterize hospitalization costs attributable to gun-related injuries in children across the US.

Study Design: The 2005-2017 National Inpatient Sample (NIS) was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by ICD-procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations.

Results: Over the study period, an estimated 36,283 pediatric patients were admitted for a GSW with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3,246 in 2005 to 3,185 in 2017 (NPtrend<0.001). The median inflation-adjusted cost was $12,408 (IQR $6,253-$24,585). Median costs rose significantly from $10,749 in 2005 to $16,157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18,576 vs $8,942, P<0.001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile.

Conclusions: Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact.
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http://dx.doi.org/10.1016/j.jpeds.2021.05.018DOI Listing
May 2021

Impact of frailty on acute outcomes of endovascular thoracic and abdominal aneurysm repair.

Surgery 2021 Apr 30. Epub 2021 Apr 30.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA. Electronic address:

Background: While coding-based frailty tools may readily identify at-risk patients, they have not been adopted into screening guidelines for endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair at the national level. We aimed to characterize the impact of frailty on clinical outcomes and resource use after endovascular aneurysm repair and thoracic endovascular aortic repair using a nationally representative cohort.

Methods: The 2005 to 2018 National Inpatient Sample was queried to identify all adults undergoing elective endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair. Patients were considered "frail" if they suffered from any frailty-defining diagnoses in the Johns Hopkins Adjusted Clinical Groups. Multivariable regression models were used to identify independent associations with outcomes of interest including in-hospital mortality, nonhome discharge, and hospitalization costs.

Results: Of an estimated 301,869 patients, 273,415 (90.6%) underwent endovascular aneurysm repair and the remainder thoracic endovascular aortic repair. Frailty prevalence was lower in the endovascular aneurysm repair cohort (2.3%) compared with thoracic endovascular aortic repair (4.7%). After adjustment, frailty was associated with higher in-hospital mortality (endovascular aneurysm repair odds ratio 4.0; thoracic endovascular aortic repair odds ratio 2.5), nonhome discharge rates (endovascular aneurysm repair odds ratio 7.2; thoracic endovascular aortic repair odds ratio 4.2), and predicted costs (endovascular aneurysm repair ß coefficient +$10.6K; thoracic endovascular aortic repair ß coefficient +$38.2K) for both cohorts.

Conclusion: Given that frailty portends inferior outcomes for both endovascular aneurysm repair and thoracic endovascular aortic repair, its inclusion in existing risk models may better inform shared decision-making.
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http://dx.doi.org/10.1016/j.surg.2021.03.053DOI Listing
April 2021

The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy.

Surgery 2021 Apr 28. Epub 2021 Apr 28.

Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address:

Background: Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy.

Methods: The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use.

Results: Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients.

Conclusion: Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.
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http://dx.doi.org/10.1016/j.surg.2021.03.034DOI Listing
April 2021

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery.

Ann Thorac Surg 2021 Apr 18. Epub 2021 Apr 18.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California. Electronic address:

Background: Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization.

Methods: Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI.

Results: Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018.

Conclusions: Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.013DOI Listing
April 2021

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study.

Ann Thorac Surg 2021 Apr 18. Epub 2021 Apr 18.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address:

Background: Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

Methods: Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

Results: Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

Conclusions: Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.009DOI Listing
April 2021

Trends and Outcomes of Surgical Re-exploration Following Cardiac Operations in the United States.

Ann Thorac Surg 2021 Apr 17. Epub 2021 Apr 17.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles. Electronic address:

Background: Surgical re-exploration following cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and its impact on clinical outcomes and resource use in a nationally-representative cohort. We sought to determine patient and hospital factors associated with re-exploration and reoperative mortality, defined as failure-to-rescue-surgical (FTR-S).

Methods: Adult hospitalizations entailing cardiac operations (coronary artery bypass and/or valve) were identified using the 2005-2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high-performing. Multivariable regression models examined factors associated with re-exploration as well as clinical outcomes including FTR-S and resource utilization.

Results: Of an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required re-exploration with decreasing incidence over time. Valvular procedures, preoperative intra-aortic balloon pump and liver disease were associated with greater likelihood of re-exploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio (AOR): 3.86, 95%CI: 3.61-4.12), perioperative complications and resource utilization. Increasing time from index operation to re-exploration was associated with higher odds of mortality (AOR:1.10/day, 95%CI: 1.07-1.12). High-performing hospitals were associated with lower odds of re-exploration (AOR: 0.88, 95%CI: 0.82-0.95) and FTR-S (AOR: 0.29, 95%CI: 0.23-0.35).

Conclusions: Surgical re-exploration following cardiac surgery has declined over time. High performing hospitals demonstrated lower rates of re-exploration and subsequent failure-to-rescue. Although unable to identify specific practices, our study highlights the presence of significant variation in takeback rates and further study of underlying factors is warranted.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.011DOI Listing
April 2021

Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery.

J Cardiothorac Vasc Anesth 2021 Mar 8. Epub 2021 Mar 8.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA. Electronic address:

Objectives: Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery.

Design: A retrospective analysis of administrative data.

Setting: The 2010-2017 National Readmissions Database.

Participants: All pediatric patients undergoing congenital cardiac surgery.

Interventions: None.

Measurements And Main Results: Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000).

Conclusions: Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.
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http://dx.doi.org/10.1053/j.jvca.2021.03.008DOI Listing
March 2021

Impact of hospital volume on resource use after elective cardiac surgery: A contemporary analysis.

Surgery 2021 Apr 10. Epub 2021 Apr 10.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA. Electronic address:

Background: Institutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations.

Methods: Adults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models.

Results: Of an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700-$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals.

Conclusion: Despite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms.
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http://dx.doi.org/10.1016/j.surg.2021.03.004DOI Listing
April 2021

Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States.

J Intensive Care Med 2021 Mar 30:8850666211007062. Epub 2021 Mar 30.

Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Purpose: Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort.

Materials And Methods: The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals.

Results: Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (β=+4.5 days) and hospitalization costs (β=+$32,880, all < .01).

Conclusions: We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.
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http://dx.doi.org/10.1177/08850666211007062DOI Listing
March 2021

Failure to rescue after surgical re-exploration in lung resection.

Surgery 2021 Mar 25. Epub 2021 Mar 25.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA. Electronic address:

Background: Surgical re-exploration after lung resection remains poorly characterized, although institutional series have previously reported its association with greater mortality and complications. The present study sought to examine the impact of institutional lung-resection volume on the incidence of and short-term outcomes after surgical re-exploration.

Methods: The 2007 to 2018 National Inpatient Sample was used to identify all adults who underwent lobectomy or pneumonectomy. Hospitals were divided into tertiles based on institutional lung-resection caseload. Multivariable regressions were used to identify associations between independent covariates on clinical outcomes.

Results: Of an estimated 329,273 patients, 3,592 (1.09%) were re-explored with decreasing incidence over time. Open and minimal access pneumonectomy among other factors were associated with greater odds of reoperation. Those re-explored had greater odds of mortality and complications as well as increased duration of stay and adjusted costs. Although risk of re-exploration was similar across hospital tertiles, reoperative mortality was significantly lower at high-volume hospitals.

Conclusion: Re-exploration after lung resection is uncommon; however, when occurring, it is associated with worse clinical outcomes. After re-exploration, high-volume center status was associated with reduced odds of mortality relative to low volume. Failure to rescue at lower-volume centers suggests the need for optimization of perioperative factors to decrease incidence of reoperation.
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http://dx.doi.org/10.1016/j.surg.2021.02.023DOI Listing
March 2021

Impact of hospital safety-net status on clinical outcomes following carotid artery revascularization.

Surgery 2021 Mar 13. Epub 2021 Mar 13.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address:

Background: High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions.

Methods: The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes.

Results: Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (β +$2,169, P = .016).

Conclusion: HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals.
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http://dx.doi.org/10.1016/j.surg.2021.01.052DOI Listing
March 2021

Factors Associated with High Resource Utilization in Elective Adult Cardiac Surgery from 2005 - 2016.

Ann Thorac Surg 2021 Mar 6. Epub 2021 Mar 6.

Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Lack of consensus remains about factors that may be associated with high resource utilization (HRU) in adult cardiac surgical patients. We aimed to identify patient, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.

Methods: Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft (CABG), valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.

Results: An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34.7K (IQR $26.8K - $47.1K), with HRU (N=175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-white race, and highest income quartile. Hospital factors associated with HRU were low volume hospitals for both CABG and valvular operations. Among postoperative outcomes, mortality, infectious complication, extracorporeal membrane oxygenation use, and hospitalization > 8 days were associated with greater odds of HRU.

Conclusions: In this nationwide study of elective cardiac surgical patients, several important patient and hospital factors, including patient race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.059DOI Listing
March 2021

National trends and predictors of mastectomy with immediate breast reconstruction.

Am J Surg 2021 Feb 17. Epub 2021 Feb 17.

Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States. Electronic address:

Purpose: This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy.

Methods: The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR.

Results: Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy.

Conclusion: Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.014DOI Listing
February 2021

Outcomes and resource use for liver transplantation in the United States: Insights from the 2009-2017 National Inpatient Sample.

Clin Transplant 2021 Feb 22:e14262. Epub 2021 Feb 22.

Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, Los Angeles, CA, USA.

Introduction: Liver transplantation (LT) is a life-saving treatment for end-stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use.

Methods: Using the National Inpatient Sample, we identified all patients undergoing LT from 2009 to 2017 and defined high-resource use (HRU) as having costs ≥ 90th percentile. Hierarchical regression models were used to assess factors associated with length of stay (LOS) and HRU.

Results: Over the study period, approximately 53,000 patients underwent LT, increasing from 5,582 in 2009 to 7,095 in 2017 (nptrend < 0.001). Morbidity and mortality were 42.2% and 3.9%, respectively, with a median post-LT LOS of 10 days. Hospitalization costs increased from $106,866 to $145,868 (nptrend < 0.001). Acute kidney injury (β:4.7 days, P < .001) and end-stage renal disease (ESRD) with dialysis (β:4.3 days, P < .001) were associated with greater LOS while the Northeast region (AOR:5.2, P < .001), ESRD with dialysis (AOR:3.4, P < .001), heart failure (AOR:2.5, P < .001), and fulminant liver disease (AOR:1.8, P = .01) were associated with HRU.

Conclusion: The cost of LT has increased over time. Renal dysfunction, regional practice patterns, and patient acuity were associated with greater resource use. Transplanting patients before health deterioration may help contain costs, mitigate resource use, and improve LT outcomes.
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http://dx.doi.org/10.1111/ctr.14262DOI Listing
February 2021

Outcomes and Resource Use Associated With Acute Respiratory Failure in Safety Net Hospitals Across the United States.

Chest 2021 Feb 19. Epub 2021 Feb 19.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA. Electronic address:

Background: Despite the frequency and cost of hospitalizations for acute respiratory failure (ARF), the literature regarding the impact of hospital safety net burden on outcomes of these hospitalizations is sparse.

Research Question: How does safety net burden impact outcomes of ARF hospitalizations such as mortality, tracheostomy, and resource use?

Study Design And Methods: This was a retrospective cohort study using the National Inpatient Sample 2007-2017. All patients hospitalized with a primary diagnosis of ARF were tabulated using the International Classification of Diseases 9th and 10th Revision codes, and safety net burden was calculated using previously published methodology. High- and low-burden hospitals were generated from proportions of Medicaid and uninsured patients. Trends were analyzed using a nonparametric rank-based test, whereas multivariate logistic and linear regression models were used to establish associations of safety net burden with key clinical outcomes.

Results: Of an estimated 8,941,334 hospitalizations with a primary diagnosis of ARF, 33.9% were categorized as occurring at low-burden hospitals (LBHs) and 31.6% were categorized as occurring at high-burden hospitals (HBHs). In-hospital mortality significantly decreased at HBHs (22.8%-12.6%; nonparametric trend [nptrend] < 0.001) and LBHs (22.0%-10.9%; nptrend < 0.001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <0.001). After adjustment for patient and hospital factors, an HBH was associated with increased odds of mortality (adjusted OR [AOR], 1.11; 95% CI, 1.10-1.12) and tracheostomy use (AOR, 1.33; 95% CI, 1.29-1.37), as well as greater hospitalization costs (β coefficient, +$1,083; 95% CI, $882-$1,294) and longer lengths of stay (β coefficient, +3.3 days; 95% CI, 3.2-3.3 days).

Interpretation: After accounting for differences between patient cohorts, high safety net burden was associated independently with inferior clinical outcomes and increased costs after ARF hospitalizations. These findings emphasize the need for health-care reform to ameliorate disparities within these safety net centers, which treat our most vulnerable populations.
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http://dx.doi.org/10.1016/j.chest.2021.02.018DOI Listing
February 2021

National Utilization and Short-Term Outcomes of Video and Robot-assisted Thoracoscopic Thymectomies.

Ann Thorac Surg 2021 Feb 16. Epub 2021 Feb 16.

Division of Thoracic Surgery, University of California, Los Angeles, CA. Electronic address:

Background: Trans-sternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS) such as video-assisted (VATS) and robot-assisted thoracoscopic (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy.

Methods: Admissions for thymectomies from 2008 - 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies.

Results: An estimated 23,087 patients underwent thymectomy during the study period: Open = 16,025 (69%) and MIS = 7,217 (31%). Of the MIS cohort, 4,119 (18%) underwent VATS and 3,097 (13%) RATS. Performance of RATS and VATS thymectomy has increased while that of open thymectomy has declined. Baseline characteristics between VATS and RATS were similar, except more females underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the three approaches.

Conclusions: Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.003DOI Listing
February 2021

Impact of Frailty on Clinical Outcomes after Carotid Artery Revascularization.

Ann Vasc Surg 2021 Feb 5. Epub 2021 Feb 5.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA. Electronic address:

Background: Frailty has been increasingly recognized as an important risk factor for vascular procedures. To assess the impact of frailty on clinical outcomes and resource utilization in patients undergoing carotid revascularization using a national cohort.

Methods: The 2005-2017 National Inpatient Sample was used to identify patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS). Patients were classified as frail using diagnosis codes defined by the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to evaluate associations between frailty and in-hospital mortality, postoperative stroke, myocardial infarction (MI), hospitalization costs, and length of stay (LOS).

Results: Of 1,426,343 patients undergoing carotid revascularization, 59,158 (4.2%) were identified as frail. Among frail patients, 79.4% underwent CEA and 20.6% underwent CAS. Compared to CEA, a greater proportion of patients undergoing CAS were frail (6.0% vs. 3.8%, P < 0.001). Compared to the nonfrail cohort, frail patients had higher rates of mortality (2.2% vs. 0.5%, P < 0.001), postoperative stroke (2.6% vs. 1.0%, P < 0.001), MI (2.2% vs. 0.8%, P < 0.001), and stroke/death (4.4% vs. 1.4%, P < 0.001). After adjustment, frailty was associated with increased odds of mortality (AOR = 1.59, 95% CI: 1.30-1.80, P < 0.001), stroke (AOR = 1.66, 95% CI: 1.38-1.83 P < 0.001), MI (AOR = 1.51, 95% CI: 1.29-1.72, P < 0.001), and stroke/death (AOR = 1.62, 95% CI: 1.45-1.81, P < 0.001). Furthermore, frailty was associated with increased hospitalization costs (β = +$5,980, 95% CI: $5,490-$6,470, P < 0.001) and LOS (β = +2.6 days, 95% CI: 2.4-2.8, P < 0.001).

Conclusions: Frailty is associated with adverse outcomes and greater resource use for those undergoing carotid revascularization. Risk models should include an assessment of frailty to guide management and improve outcomes for these high-risk patients.
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http://dx.doi.org/10.1016/j.avsg.2020.12.039DOI Listing
February 2021

Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia.

JACC Clin Electrophysiol 2021 Apr 5;7(4):533-535. Epub 2021 Jan 5.

Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA. Electronic address:

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.
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http://dx.doi.org/10.1016/j.jacep.2020.12.001DOI Listing
April 2021

Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia.

Ann Thorac Surg 2021 04 5;111(4):e295-e296. Epub 2021 Jan 5.

Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California. Electronic address:

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.030DOI Listing
April 2021

Impact of the Coronavirus Disease 2019 Pandemic on Utilization of Mechanical Circulatory Support As Bridge to Heart Transplantation.

ASAIO J 2021 04;67(4):382-384

From the Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1097/MAT.0000000000001387DOI Listing
April 2021

Smoothed particle hydrodynamics simulation of biphasic soft tissue and its medical applications.

Med Biol Eng Comput 2021 Jan 8;59(1):227-242. Epub 2021 Jan 8.

Mechanical and Aerospace Engineering Department, University of California, Los Angeles, CA, USA.

Modeling the coupled fluid and elastic mechanics of blood perfused soft tissues is important for medical applications. In particular, the current study aims to capture the effect of tissue swelling and the transport of blood through damaged tissue under bleeding or hemorrhaging conditions. The soft tissue is considered a dynamic poro-hyperelastic material with blood-filled voids. A biphasic formulation-effectively, a generalization of Darcy's law-is utilized, treating the phases as occupying fractions of the same volume. A Stokes-like friction force and a pressure that penalizes deviations from volume fractions summing to unity serve as the interaction force between solid and liquid phases. The resulting equations for both phases are discretized with the method of smoothed particle hydrodynamics (SPH). The solver is validated separately on each phase and demonstrates good agreement with exact solutions in test problems. Simulations of oozing, hysteresis, swelling, drying and shrinkage, and tissue fracturing and hemorrhage are shown in the paper. Graphical Abstract In the paper, a new methodology for the numerical simulation of the full dynamic response of blood-perfused soft tissues was developed.
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http://dx.doi.org/10.1007/s11517-020-02283-wDOI Listing
January 2021

Aortoesophageal fistula involving the central aortic arch salvaged with emergent percutaneous TEVAR, great vessel coverage and in vivo graft fenestration.

Diagn Interv Radiol 2021 Jan;27(1):122-125

Division of Vascular and Interventional Radiology, Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA.

Immediate intervention is needed for aortoesophageal fistulas (AEF), a rare but highly lethal cause of massive gastrointestinal hemorrhage. Emergent thoracic endovascular aortic repair (TEVAR) is considered first-line treatment for massive bleeding from AEFs. We describe an unusual and challenging case of TEVAR coverage of an AEF involving the central aortic arch immediately followed by in vivo endograft fenestration to regain arch vessel perfusion. In vivo fenestration, currently a procedure for emergency or investigational purposes only, was shown to be life saving in our case. The main complications associated with the procedure included stroke and infection, requiring esophagectomy and cervical diversion as well as ongoing antibiotic treatment.
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http://dx.doi.org/10.5152/dir.2020.20033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837712PMC
January 2021

Frailty is Independently Associated with Worse Outcomes Following Elective Anatomic Lung Resection.

Ann Thorac Surg 2020 Nov 27. Epub 2020 Nov 27.

Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles (UCLA), Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, UCLA, Los Angeles, CA. Electronic address:

Background: Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, we aimed to determine the impact of coding-based frailty on clinical outcomes and resource utilization following anatomic lung resection.

Methods: All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005-2014 were identified using the National Inpatient Sample. Patients were categorized as Frail or Non-Frail based on the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, non-home discharge, complications, duration of stay and costs.

Results: Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were Frail. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to Non-Frail, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%, p<0.001) and non-home discharge (44.7% vs 10.5%, p<0.001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% CI 2.94-4.09). Frailty conferred the greatest increase in mortality, complications and resource use following pneumonectomy relative to lobectomy or segmentectomy, though significant differences were evident for all three.

Conclusions: Frailty exhibits a strong association with inferior clinical outcomes and increased resource utilization following elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary pathologies.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.004DOI Listing
November 2020

Risk factors for penile fracture compared with a surgical control cohort in the United States: the role of substance abuse.

Asian J Androl 2021 May-Jun;23(3):236-239

Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.

Penile fracture (PF) is a surgical emergency. Given its rarity, we queried a national cohort over an 11-year period to study the temporal and demographic variations in presentation, evaluation, and management of patients with PF compared with a cohort of control patients. The National Inpatient Sample was queried between the years 2005 and 2016 for patients with a diagnosis of PF. Appendectomy patients were selected as a control cohort, given the non-discriminatory nature of this disease. Clinical and demographic data of the patients were compared with that of controls. Presenting symptoms, rates of surgical repair, and rates of associated surgical procedures were evaluated in the PF cohort. During the study period, 5802 patients were hospitalized for PF. The annual incidence of PF remained unchanged at 1.0-1.8 cases per 100 000 hospitalizations over the study period. Compared with the control cohort, PF patients were more likely to be younger (38.7 years vs 41.2 years, P ≤ 0.001), have lower rates of comorbidities except erectile dysfunction (1.4% vs 0.1%, P ≤ 0.001), and were more likely of Black race (25.4% vs 6.2%, P ≤ 0.001). Notably, PF patients had significantly higher rates of substance abuse (26.4% vs 18.1%, P ≤ 0.001), despite no difference in the diagnosed psychiatric disorders. PF rarely presented with hematuria (3.5%); however, urethral evaluation was performed in 23.1%, most commonly with cystoscopy (19.2%). PF occurs more commonly in a younger, healthier male population, and among minorities. Importantly, rates of substance abuse appear to be higher in the PF cohort compared with those of controls.
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http://dx.doi.org/10.4103/aja.aja_70_20DOI Listing
November 2020

Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States.

Liver Transpl 2021 02 31;27(2):200-208. Epub 2020 Dec 31.

Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.

Although socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-square tests, respectively. Fine and Gray competing-risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1-year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%-9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%-11.6%) for Medicare, and 10.7% (95% CI, 9.8%-11.6%) for Medicaid. In multivariable competing-risks analysis, Medicare (HR, 1.20; 95% CI, 1.17-1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16-1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.
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http://dx.doi.org/10.1002/lt.25936DOI Listing
February 2021

Management of penetrating aortic arch trauma.

J Trauma Acute Care Surg 2021 02;90(2):e50-e51

From the Division of Cardiac Surgery (J.H., R.M., P.B.), and Division of General Surgery (J.H., C.P.C., A.E.-S., P.S.), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1097/TA.0000000000003015DOI Listing
February 2021

Impact of opioid use disorders on outcomes and readmission following cardiac operations.

Heart 2021 Jun 29;107(11):909-915. Epub 2020 Oct 29.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA

Objective: While opioid use disorder (OUD) has been previously associated with increased morbidity and resource use in cardiac operations, its impact on readmissions is understudied.

Methods: Patients undergoing coronary artery bypass grafting and valve repair or replacement, excluding infective endocarditis, were identified in the 2010-16 Nationwide Readmissions Database. Using International Classification of Diseases 9/10, we tabulated OUD and other characteristics. Multivariable regression was used to adjust for differences.

Results: Of an estimated 1 978 276 patients who had cardiac surgery, 5707 (0.3%) had OUD. During the study period, the prevalence of OUD increased threefold (0.15% in 2010 vs 0.53% in 2016, parametric trend<0.001). Patients with OUD were more likely to be younger (54.0 vs 66.0 years, p<0.001), insured by Medicaid (28.2 vs 6.2%, p<0.001) and of the lowest income quartile (33.6 vs 27.1%, p<0.001). After multivariable adjustment, OUD was associated with decreased mortality (1.5 vs 2.7%, p=0.001). Although these patients had similar rates of overall complications (36.1 vs 35.1%, p=0.363), they had increased thromboembolic (1.3 vs 0.8%, p<0.001) and infectious (4.1 vs 2.8%, p<0.001) events, as well as readmission at 30 days (19.0 vs 13.2%, p<0.001). While patients with OUD had similar hospitalisation costs ($50 766 vs $50 759, p=0.994), they did have longer hospitalisations (11.4 vs 10.3 days, p<0.001).

Conclusion: The prevalence of OUD among cardiac surgical patients has steeply increased over the past decade. Although the presence of OUD was not associated with excess mortality at index hospitalisation, it was predictive of 30-day readmission. Increased attention to predischarge interventions and care coordination may improve outcomes in this population.
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http://dx.doi.org/10.1136/heartjnl-2020-317618DOI Listing
June 2021

Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis.

Am Surg 2020 Oct 25;86(10):1312-1317. Epub 2020 Oct 25.

Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as . Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, < .001) and in-hospital mortality (4% vs. 2%, < .001). Frailty was also associated with increased cumulative costs of care ($39 417 vs. $27 244, < .001). After risk adjustment, frailty remained an independent predictor of readmission (Adjusted odds ratio [AOR] 1.18, CI 1.14-1.23), in-hospital mortality (AOR 1.48, CI 1.34-1.65), and incremental costs (+$7 646, CI $6927-$8365). Frailty is an independent marker of worse outcomes following minor foot amputation, and may be utilized to direct quality improvement efforts.
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http://dx.doi.org/10.1177/0003134820964230DOI Listing
October 2020

National Analysis of 30-Day Readmission Following Inpatient Sinus Surgery for Chronic Rhinosinusitis.

Laryngoscope 2021 05 24;131(5):E1422-E1428. Epub 2020 Oct 24.

Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A.

Objectives: To characterize the incidence, causes, risk factors, and costs of 30-day readmission after inpatient functional endoscopic sinus surgery (FESS) for patients with chronic rhinosinusitis.

Study Design: Retrospective cohort study.

Methods: The Nationwide Readmissions Database was used to characterize readmission after inpatient sinus surgery for chronic rhinosinusitis from 2015 to 2017. International Classification of Disease codes were used to identify the patient population, which included 5,644 patients. Incidence, causes, costs, and predictors of readmission were analyzed and determined.

Results: Among 6,386 patients who underwent inpatient FESS, 742 (11.6%) were readmitted within 30 days of discharge. On univariate analysis, patients who were readmitted were more commonly older than 70 years (23.3% vs. 16.2%); had a higher burden of comorbidities including chronic kidney disease (15.0% vs. 7.8%), diabetes (25.6% vs. 20.4%), and hypertension (13.5% vs. 8.5%); had a greater rate of postoperative complications (20.7% vs. 12.2%); and had a longer length of stay (12.4 vs. 6.9 days) compared to patients who were not readmitted. Readmissions cost an additional $27,141 per patient. On multivariable analysis, age greater than 70 years, Medicaid insurance, several comorbidities, prolonged length of stay, postoperative neurologic complications, and lower hospital volume were independent predictors of 30-day readmission. The most common cause for readmission was infection (36.3%).

Conclusion: Readmission following inpatient FESS is not uncommon. Identification and management of preoperative comorbidities, optimized patient selection for inpatient surgery, and thorough postoperative discharge care may improve patient outcomes and decrease healthcare expenditures.

Level Of Evidence: 3 Laryngoscope, 131:E1422-E1428, 2021.
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http://dx.doi.org/10.1002/lary.29117DOI Listing
May 2021

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting.

Ann Thorac Surg 2020 Oct 17. Epub 2020 Oct 17.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California. Electronic address:

Background: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG).

Methods: Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression.

Results: Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001).

Conclusions: Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.028DOI Listing
October 2020