Publications by authors named "Yas Sanaiha"

103 Publications

Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States.

PLoS One 2021 23;16(7):e0255122. Epub 2021 Jul 23.

Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America.

Background: Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied.

Objective: The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations.

Methods: Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016-2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up.

Results: Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4-12.5%] vs 6.0% [95% CI 5.8-6.3%] for large bowel resection; 2.3% [95% CI 2.0-2.6%] vs 0.2% [95% CI 0.2-0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1-69.0%] vs 25.9% [95% CI 25.2-26.5%]) and cholecystectomy (33.7% [95% CI 32.7-34.7%] vs 2.9% [95% CI 2.8-3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days.

Conclusions: Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255122PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301636PMC
July 2021

Clinical and Financial Outcomes of Necrotizing Soft-Tissue Infections in Safety-Net Hospitals.

J Surg Res 2021 Jun 16;267:124-131. Epub 2021 Jun 16.

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

Background Prior work has demonstrated inferior outcomes for a multitude of medical and surgical conditions at hospitals with high burdens of underinsured patients (safety-net). The present study aimed to evaluate trends in incidence, clinical outcomes and resource utilization in the surgical management of necrotizing soft-tissue infections (NSTI) at safety-net hospitals. Materials and methods Adults requiring surgical debridement/amputation following NSTI-related hospitalizations were identified in the 2005-2018 National Inpatient Sample. Safety-net status (SNH) was assigned to institutions in the top tertile for annual proportion of underinsured patients. Logistic multivariable regression was utilized to evaluate the association of SNH with mortality, hospitalization duration (LOS), costs and discharge disposition. Results Of an estimated 212,692 patients, 76,719 (36.1%) were managed at SNH. The annual incidence of NSTI admissions increased overall while associated mortality declined. After adjustment, SNH status was associated with greater odds of mortality (adjusted odds ratios: 1.14, 95% CI: 1.03-1.26), LOS (β: +1.8 d, 95% CI: 1.3-2.2) and costs (β: +$4,400, 95% CI: 2,900-5,800). SNH patients had similar rates of amputation but lower likelihood of care facility or home health discharge. Conclusion With a rising incidence and overall reduction in mortality, safety-net hospitals persistently exhibit greater mortality and resource use for surgical NSTI admissions. Variation in access, disease presentation and timeliness of operative intervention may explain the observed findings.
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http://dx.doi.org/10.1016/j.jss.2021.05.012DOI Listing
June 2021

Impact of Frailty on Clinical Outcomes and Hospitalization Costs Following Elective Colectomy.

Am Surg 2021 Jun 14:31348211024233. Epub 2021 Jun 14.

Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Background: Frailty has been increasingly recognized as a risk factor for inferior surgical outcomes and greater resource use. The present study evaluated the impact of a coding-based frailty tool on outcomes of elective colectomy in a national cohort.

Study Design: Adults undergoing elective colectomy were identified in the 2016-17 Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins 10-domain coding-based binary tool. Generalized linear models were used to examine the association of frailty with in-hospital mortality, nonhome discharge, hospitalization duration (LOS), and inflation-adjusted costs. Kaplan-Meier survival analysis and log-rank test was used to compare readmissions up to 1-year.

Results: Of 133 175 patients, 10.6% were considered frail. The most common resections were sigmoid (43.9%) and right (34.7%) while total colectomy was least common (2.8%). After adjustment, frailty was associated with greater odds of mortality (3.2, 95% CI 2.8-3.8) and nonhome discharge (6.0, 95% CI 5.5-6.4) as well as a $13,400-increment (95% CI 12,400-14,400) in costs and 4.4-day (95% CI 4.1-4.6) increase in LOS. Nonelective readmissions at 30 days were greater in frail than non-frail groups (14.7% vs. 10.4%, < .001).

Conclusion: Frailty is associated with inferior clinical outcomes and increased resource use following elective colectomy. Inclusion of frailty in risk models may facilitate risk stratification and shared decision-making.
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http://dx.doi.org/10.1177/00031348211024233DOI Listing
June 2021

Palliative Care for Extracorporeal Life Support: Insights From the National Inpatient Sample.

Am Surg 2021 Jun 14:31348211024232. Epub 2021 Jun 14.

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

Background: Providing temporary cardiopulmonary support, extracorporeal membrane oxygenation (ECMO) carries a high risk of mortality. Palliative care (PC) may facilitate a patient-centered approach to end-of-life care in order to aid symptom management and provide psychosocial support to families. The present study aimed to identify factors associated with PC consultation and its impact on resource utilization in ECMO.

Study Design: All adults placed on ECMO at a PC capable center were identified in the 2006-2017 National Inpatient Sample. Indications for ECMO were identified using diagnosis codes and classified into postcardiotomy syndrome, respiratory failure, cardiogenic shock, mixed cardiopulmonary failure, and transplant related.

Results: Of 41 122 patients undergoing ECMO, 20 514 (49.9%) died in the same hospitalization. Of those, 3951 (19.3%) received a PC consult. Use of PC consults increased significantly from 5.5% in 2006 to 22.8% in 2017 (nptrend<.001). After multivariable risk adjustment, PC consults did not affect costs (β: -$7341, 95% CI: -22 572 to +7888) or duration of hospitalizations (β: -.37 days, 95% CI: -2.76 to +2.02).

Conclusion: Utilization of PC does not appear to negatively influence resource utilization among non-survivors of ECMO. Increased adaptation of PC in ECMO may improve end-of-life care, a factor that deserves future study.
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http://dx.doi.org/10.1177/00031348211024232DOI Listing
June 2021

Timing of Coronary Artery Bypass Grafting in Acute Coronary Syndrome: A National Analysis.

Ann Thorac Surg 2021 Jun 11. Epub 2021 Jun 11.

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

Background: Timing of surgical revascularization for acute coronary syndrome (ACS) remains debated. We assessed the impact of timing to CABG on mortality and resource utilization in a national cohort.

Methods: Adults admitted for ACS in the 2009-2018 National Inpatient Sample were grouped by time from coronary angiography to CABG (Δt): 0, 1-3, 4-7, and >7 days. Generalized linear models were fit to evaluate associations between Δt and in-hospital mortality and hospitalization costs. Timing and mortality of CABG for ACS was compared between high-performing hospitals (below the median risk adjusted mortality for all CABG and valve operations) and others.

Results: Of 444,065 patients, time to CABG was Δt=0 in 12.3%, Δt=1-3 in 57.3%, Δt=4-7 in 26.3%, and Δt>7 in 4.2%. Risk-adjusted mortality was greatest at Δt=0 (4.5%, 95% confidence interval, CI, 4.1-4.9) and Δt>7 (4.0%, 95% CI 3.4-4.7), but similar for operations performed at Δt=1-3 (1.8%, 95% CI 1.7-1.9) and Δt=4-7 (2.1%, 95% CI 1.9-2.3). Compared to Δt=1-3, hospitalization costs were greater by $6,400 (95% CI 5,900-6,900) for Δt=4-7 and $21,200 (95% CI 19,800-22,600) for Δt>7. High-performing hospitals had similar time to CABG as others (2 vs 2 days, p=0.17), but lower mortality (0.9% vs 3.3%, p<0.001).

Conclusions: Revascularization on day 1-3 and 4-7 led to comparable in-hospital mortality, with greater rates on day 0 and after day 7. Costs were greater for revascularization at day 4-7 compared to day 1-3. These findings support the reduction of time to revascularization to 1-3 days when deemed clinically appropriate and feasible.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.057DOI Listing
June 2021

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

Surgery 2021 Jul 30;170(1):304-310. 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
July 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

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

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 Jul 26;170(1):257-262. Epub 2021 Mar 26.

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
July 2021

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

Surgery 2021 06 13;169(6):1544-1550. 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
June 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 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

Frailty Is Independently Associated With Worse Outcomes After Elective Anatomic Lung Resection.

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

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

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

Methods: All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005 to 2014 were identified using the National Inpatient Sample. Patients were categorized as either frail or nonfrail on the basis of 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, nonhome 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 in frail patients. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to nonfrail patients, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%; P < .001) and nonhome discharge (44.7% vs 10.5%; P < .001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% confidence interval, 2.94 to 4.09). Frailty conferred the greatest increase in mortality, complications, and resource use after pneumonectomy relative to lobectomy or segmentectomy, although significant differences were evident for all 3 operations.

Conclusions: Frailty exhibits a strong association with inferior clinical outcomes and increased resource use after 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 disorders.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.004DOI 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
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8281984PMC
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

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

Ann Thorac Surg 2021 07 17;112(1):108-115. 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
July 2021

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

Ann Thorac Surg 2021 05 24;111(5):1537-1544. Epub 2020 Sep 24.

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

Background: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes.

Methods: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes.

Results: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40).

Conclusions: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.027DOI Listing
May 2021

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting.

Am J Cardiol 2020 11 15;134:41-47. Epub 2020 Aug 15.

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

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.011DOI Listing
November 2020

Trends in Mortality and Costs of Pediatric Extracorporeal Life Support.

Pediatrics 2020 09 14;146(3). Epub 2020 Aug 14.

Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and

Background: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations.

Methods: We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs.

Results: Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 ( < .001). Overall mortality decreased from 50.3% to 34.6% ( < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; = .94).

Conclusions: Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement.
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http://dx.doi.org/10.1542/peds.2019-3564DOI Listing
September 2020

National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US.

J Am Coll Surg 2020 10 10;231(4):448-459.e4. Epub 2020 Aug 10.

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

Background: Gun violence remains a major burden on the US healthcare system, with annual cost exceeding $170 billion. Literature on the national trends in cost and survival of gun violence victims requiring operative interventions is lacking.

Study Design: All adults admitted with a diagnosis of gunshot wound requiring operative intervention were identified using the 2005-2016 National Inpatient Sample. The ICD Injury Severity Score, a validated prediction tool, was used to quantify the extent of traumatic injuries. Survey-weighted methodology was used to provide national estimates. Hospitalizations exceeding the 66th percentile of annual cost were considered as high-cost tertile. Multivariable logistic regressions with stepwise forward selection were used to identify factors associated with mortality and high-cost tertile.

Results: During the study period, 262,098 admissions met inclusion criteria with a significant increase in annual frequency and decrease in ICD Injury Severity Scores. A decline in mortality (8.6% to 7.6%; parametric test of trend = 0.03) was accompanied by increasing mean cost ($25,900 to $33,000; nonparametric test of trend < 0.001). After adjusting for patient and hospital characteristics, head and neck (adjusted odds ratio 31.2; 95% CI, 11.0 to 88.4; p < 0.001), vascular operations (adjusted odds ratio 24.5; 95% CI, 19.2 to 31.1; p < 0.001), and gastrointestinal (adjusted odds ratio 27.8; 95% CI, 17.2 to 44.8; p < 0.001) were independently associated with high-cost tertile designation compared with patients who did not undergo these operations.

Conclusions: During the past decade, the increase in gun violence and severity has resulted in higher cost. Operations involving selected surgical treatments incurred higher in-hospital cost. Given the profound economic and social impact of surgically treated gunshot wounds, policy and public health efforts to reduce gun violence are imperative.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.06.022DOI Listing
October 2020

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy.

Surgery 2020 10 3;168(4):625-630. Epub 2020 Aug 3.

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

Background: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy.

Methods: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics.

Results: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001).

Conclusion: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.
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http://dx.doi.org/10.1016/j.surg.2020.06.018DOI Listing
October 2020

Readmissions after ovarian cancer cytoreduction surgery: The first 30 days and beyond.

J Surg Oncol 2020 Nov 22;122(6):1199-1206. Epub 2020 Jul 22.

Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of California, Los Angeles, California.

Background And Objectives: Postoperative readmissions are often used to assess quality of surgical care. This study compared 30-day vs 31- to 90-day readmission following surgery for ovarian, fallopian tube, or primary peritoneal cancer.

Methods: This retrospective study of the 2010-2015 Nationwide Readmissions Database characterized 90-day readmissions following cytoreductive surgery for these cancers. Each patient's first postoperative hospitalization was included. Univariate analysis compared patient demographics and reasons for readmission. Multivariable regression identified independent predictors of readmission.

Results: Of an estimated 76 652 patients, 10 264 (13.4%) were readmitted within 30 days, and 6942 (9.1%) between 31 and 90 days. The 30-day readmissions were more frequently associated with postoperative infection, while 31- to 90-day readmissions were more frequently associated with renal or hematologic diagnoses. Predictors of any 90-day readmission included index hospitalization longer than 7 days (adjusted odds ratio (AOR) 1.61 [1.48-1.75], P < .001), extended surgical procedure (AOR 1.41 [1.30-1.53], P < .001), pulmonary circulation disorder (AOR = 1.34 [1.13-1.60], P = .001), and diabetes mellitus (AOR = 1.12 [1.02-1.24], P = .020).

Conclusions: Readmission rates remain high during the 31- to 90-day postoperative period in ovarian cancer patients, although these readmissions are less frequently related to postoperative complications. Prospective study is merited to optimize surveillance beyond the initial 30 days after ovarian cancer surgery.
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http://dx.doi.org/10.1002/jso.26137DOI Listing
November 2020

Nationwide comparison of the medical complexity of patients by surgical specialty.

J Vasc Surg 2021 Feb 6;73(2):683-688.e2. Epub 2020 Jul 6.

Division of Vascular and Endovascular Surgery, University of California, Los Angeles, Los Angeles, Calif. Electronic address:

Objective: Intuitively, the chronic disease burden of surgical patients varies considerably by surgical specialty, although sparse evidence in the literature supports this notion. We sought to characterize the medical complexity of surgical patients by surgical specialty and to quantify the association between medical complexity and outcomes.

Methods: The National Inpatient Sample, an all-payer inpatient database representative of 97% of all U.S. hospitalizations, was used to identify adults undergoing surgery between 2005 and 2014. The most commonly performed operations that constituted 80% of each surgical specialty's practice were abstracted. The previously validated Elixhauser Comorbidity Index (ECI) was calculated per year by surgical specialty as a measure of medical complexity. Outcomes and resource utilization were assessed by comparing mortality rate, length of stay, and cost.

Results: An estimated 53,232,144 patients underwent operations in one of nine surgical specialty categories. Surgical specialties were ranked by ECI, with cardiac surgery (3.56), vascular surgery (3.49), and thoracic surgery (2.86) having the highest mean ECI (all P values <.0001 compared with vascular surgery). Whereas the high ECI scores in cardiac surgery were driven by arrhythmias and hypertension, vascular patients had a more uniform distribution of comorbidities. The average ECI for all surgical patients increased during the study period from 2.03 in 2005 to 2.65 in 2014 (P < .001), with a similar trend for all specialties considered. Unlike the two specialties with the lowest burden of comorbidities (orthopedic surgery and endocrine surgery), cardiac surgery and vascular surgery exhibited significantly higher inpatient mortality, LOS, and costs.

Conclusions: Although all surgical patients have exhibited an increase in comorbidities during the past decade, candidates for cardiac and vascular operations appear to carry the largest burden of chronic conditions. Despite caring for patients with the highest burden of comorbidities for emergent operations, vascular surgery did not have the highest mortality, inpatient costs, or length of stay compared with some of the other specialties. The intensity of care and assumed risk in treating medically complex vascular patients should be taken into consideration in deciding health policy, reimbursement, and hospital resource allocation.
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http://dx.doi.org/10.1016/j.jvs.2020.05.072DOI Listing
February 2021

Impact of interhospital transfer on clinical outcomes and resource use after cardiac operations: Insights from a national cohort.

Surgery 2020 11 5;168(5):876-881. Epub 2020 Jul 5.

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

Background: Interhospital transfer is a common clinical practice that has been associated with poor patient outcomes in small series. We aimed to evaluate the impact of transfer status on cardiac surgery patients in a national cohort.

Methods: Patients undergoing nonelective coronary artery bypass grafting, valve replacement or repair, or a combination were identified using the 2010 to 2017 Nationwide Readmissions Database. Patients were stratified by transfer status and outcomes were evaluated using adjusted multivariable linear and logistic models.

Results: Of an estimated 1,023,315 patients, 170,319 (16.6%) were transfers. Transfer was independently associated with increased complications, index hospitalization duration of stay, costs, early (30 day), and intermediate (31-90 day) readmission. Among transferred patients, transfer to a high-volume center predicted reduced odds of mortality (adjusted odds ratio: 0.64, P < .001). Additionally, transfers were less likely to be readmitted back to the index hospital (80.7% vs 44.9%, P < .001).

Conclusion: Transfer status is a significant independent predictor of increased complications, length of stay, cost, and readmission among nonelective cardiac surgery patients. Notably, transfer to higher volume facilities appears to increase odds of survival. Our findings are important when considering the risks involved in the management of transferred patients.
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http://dx.doi.org/10.1016/j.surg.2020.05.026DOI Listing
November 2020

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017.

J Surg Res 2020 11 3;255:517-524. Epub 2020 Jul 3.

Department of Surgery, University of California Los Angeles, Los Angeles, California. Electronic address:

Background: Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD).

Materials And Methods: We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality.

Results: Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission.

Conclusions: Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.
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http://dx.doi.org/10.1016/j.jss.2020.05.084DOI Listing
November 2020

National trends in postoperative infections across surgical specialties.

Surgery 2020 10 29;168(4):753-759. Epub 2020 Jun 29.

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

Background: Despite the introduction of several measures to reduce incidence, postoperative infections have been reported to increase. We aimed to assess trends in the incidence and impact of postoperative infections using a recent national cohort.

Methods: Patients undergoing the most commonly performed elective inpatient procedures in 9 surgical specialties were identified from the 2006 to 2014 National Inpatient Sample. Diagnostic coding was utilized to identify patients with postoperative infections. To adjust for patient and operative differences in assessing outcomes, an inverse probability of treatment weighing protocol was used.

Results: Of an estimated 23,696,588 patients, 1,213,182 (5.1%) developed postoperative infections. Skin and soft tissue operations had the highest burden (12.9%) and endocrine the lowest (1.3%). During the study period, we found decreasing incidence, case fatality, and incremental cost of postoperative infections. Infection was associated with increased in-hospital mortality (1.4 vs 0.4%, P < .001), duration of stay (7.6 vs 3.7 days, P < .001), and costs ($27,597 vs $17,985, P < .001). Annually, postoperative infections led to an average incremental cost burden exceeding $700 million in the United States alone.

Conclusion: During the study period there was a substantial decrease in the burden of postoperative infections. Despite encouraging trends, postoperative infections continue to serve as a suitable quality improvement target, particularly in specialties with a high burden of infections.
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http://dx.doi.org/10.1016/j.surg.2020.04.055DOI Listing
October 2020

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States.

J Surg Res 2020 11 24;255:304-310. Epub 2020 Jun 24.

Department of Surgery, University of California Los Angeles, Los Angeles, California. Electronic address:

Introduction: Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy.

Material And Methods: We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality.

Results: Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01).

Conclusions: Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.
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http://dx.doi.org/10.1016/j.jss.2020.04.037DOI Listing
November 2020
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