Charles T. Tuggle

Clinical and Economic Outcomes of Thyroid and Parathyroid Surgery in Children

CONTEXT Clinical and economic outcomes after thyroidectomy/parathyroidectomy in adults have demonstrated disparities based on patient age and race/ethnicity; there is a paucity of literature on pediatric endocrine outcomes. OBJECTIVE The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy. DESIGN This study is a cross-sectional analysis of Healthcare Cost and Utilization Project-National Inpatient Sample hospital discharge information from 1999-2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes. SUBJECTS Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy. MAIN OUTCOME MEASURES Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs. RESULTS The majority of patients were female (76%), aged 13-17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P < 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P < 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P < 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0-6 yr had higher complication rates (22% vs. 15% for 7-12 yr and 11% for 13-17 yr; P < 0.01), LOS (3.3 d vs. 2.3 for 7-12 yr and 1.8 for 13-17 yr; P < 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P < 0.05), longer LOS (2.7 vs. 1.7 d; P < 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P < 0.01) and thyroidectomy (9.1 vs. 6.3%; P < 0.01). CONCLUSIONS Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.

Pediatric endocrine surgery: Who is operating on our children?

BACKGROUND High surgeon volume is associated with improved outcomes in adult endocrine surgery. This is the first population-based outcomes study for thyroidectomy/parathyroidectomy in children. METHODS Cross-sectional analyses were performed using 1999 to 2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Outcomes included complications, length of stay (LOS), and costs. High-volume surgeons performed >30 cervical endocrine procedures per year in adults and children; pediatric surgeons restricted >90% of their practices to patients </=17 years old. Other surgeons fell into neither category. Bivariate and multivariate regression analyses were performed. RESULTS We included 607 patients, representing 20% of the pediatric endocrine operations done between 1999 and 2005 in the United States. Seventy-six percent of patients were female. Among the procedures performed, 92% were thyroidectomies and 8% were parathyroidectomies. Surgeons were classified as follows: 18% High-volume, 21% Pediatric, and 61% Other. High-volume surgeons had the lowest LOS (1.5 days vs 2.3 Pediatric, 2.0 Other; P = .01), costs (

Complications and morbidity following breast reconstruction – a review of 16,063 cases from the 2005–2010 NSQIP datasets

12,474 vs

Endovascular procedures for aorto-iliac occlusive disease are associated with superior short-term clinical and economic outcomes compared with open surgery in the inpatient population

19,594 Pediatric,

A 30-day risk assessment of mastectomy alone compared to immediate breast reconstruction (IBR)

13,614 Other; P < .01), and complications (6% vs 11% Pediatric, 10% Other; P = NS). In multivariate analyses, case volume of the endocrine surgeons was an independent predictor of LOS and costs. CONCLUSION High-volume surgeons have better outcomes after thyroidectomy/parathyroidectomy in children compared with Pediatric and Other surgeons. Surgeon experience was an independent predictor of LOS and costs. High-volume endocrine and pediatric surgeons could combine expertise to improve outcomes in children.

Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes

Abstract Post-operative complications pose a significant set-back for patients undergoing breast reconstruction. This study aims to characterize factors associated with postoperative complications following breast reconstruction using the National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005–2010. The 2005-2010 ACS-NSQIP databases were reviewed, identifying encounters for CPT codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominus myocutaneous (TRAM), free TRAM, and latissimus dorsi flap with or without implant). Complications were characterized into three categories: major surgical complications, wound complications, and medical complications. During the study period 16,063 breast reconstructions were performed. Autologous reconstructions were performed in 20.7% of patients and implant-based in 79.3%. The incidence of major surgical complications was 8.4%, whereas the incidence of medical and wound complications was 1.6% and 3.5%, respectively. Independent risk factors for major surgical complications included: immediate and autologous reconstructions, obesity, smoking, previous percutaneous cardiac surgery (PCS), recent weight loss, bleeding disorder, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. Risk factors for medical complications included: autologous reconstruction, obesity, tumor involving CNS, bleeding disorders, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. This study characterizes the incidence of surgical and medical complications following breast reconstruction using a large, prospective multicentre dataset. Key identifiable risk factors associated with both surgical and medical morbidity included: autologous breast reconstruction, obesity, ASA ≥ 3, bleeding disorders, and prolonged operative time. Data derived from this cohort can be used to risk-stratify patients and to enhance perioperative decision-making.

Concurrent panniculectomy with open ventral hernia repair has added risk versus ventral hernia repair: An analysis of the ACS-NSQIP database

OBJECTIVES There has been a rapid increase in the number of endovascular procedures performed for peripheral artery disease, and especially aorto-iliac occlusive disease (AIOD). Results from single-center reports suggest a benefit for endovascular procedures; however, these benefits may not reflect general practice. We used a population-based analysis to determine predictors of clinical and economic outcomes following open and endovascular procedures for inpatients with AIOD. METHODS All patients with AIOD who underwent open and endovascular procedures in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2004 to 2007, were identified. Independent patient- and provider-related characteristics were analyzed. Clinical outcomes included complications and mortality; economic outcomes included length of stay (LOS) and cost (2007 dollars). Outcomes were compared using χ2, ANOVA, and multivariate regression analysis. RESULTS Four thousand, one hundred nineteen patients with AIOD were identified. Endovascular procedures increased by 18%. Patients who underwent endovascular procedures were more likely to be ≥65 years of age (46% vs 37%), female (54% vs 49%), and in the highest quartile of household income (20% vs 16%), all P<.05. Endovascular patients were more likely to be non-elective (41% vs 20%), in the highest comorbidity index group (8% vs 5%), and with iliac artery disease (67% vs 33%), all P≤.05. In bivariate analysis, endovascular procedures were associated with lower complication rates (16% vs 25%), shorter LOS (2.2 vs 5.8 days), and lower hospital costs (

Venous thromboembolism risk in mastectomy and immediate breast reconstruction: analysis of the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets.

13,661 vs

Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005–2011 NSQIP datasets

17,161), all P<.001. In multivariate analysis, endovascular procedures had significantly lower complication rates and cost, and shorter LOS. CONCLUSIONS Endovascular procedures have superior short-term clinical and economic outcomes compared with open procedures for the treatment of AIOD in the inpatient setting. Further studies are needed to examine long-term outcomes and access-related issues.

Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction

Abstract Immediate breast reconstruction (IBR) is emerging as a favourable reconstruction option for breast cancer patients. Understanding the factors associated with complications following IBR will enhance care delivery, risk counselling and management, and potentially improve patient satisfaction. Women undergoing mastectomy alone and mastectomy with IBR from 2005–2011 were identified in the ACS-NSQIP datasets. Specific complications examined included surgical (flap or prosthesis loss and unplanned reoperation), wound (superficial/deep surgical site infection and wound dehiscence), and medical complications. Bivariate and multivariate analyses were performed to identify predictors of outcomes. A total of 47,443 patients were identified. For patients who underwent IBR compared to mastectomy alone, total complications (11.2% vs 9.2%, p < 0.001) and surgical complications (7.8% vs 4.7%, p < 0.001) were more frequent. In adjusted analysis, a common predictor of complications was class III obesity (BMI ≥ 40 kg/m2) for mastectomy alone (OR = 1.79, p < 0.001) and implant-based IBR (OR = 2.20, p < 0.001), and class II obesity (BMI 35–39.9) for autologous IBR (OR = 1.62, p = 0.003). Wound complications were found to be associated with autologous reconstruction (p < 0.001 kg/m2), smoking (p < 0.001), bilateral procedures (p = 0.005), patient comorbidity (p = 0.006), obesity (p < 0.001), and diabetes (p < 0.001). The strongest predictors of wound complications were class II obesity (OR = 2.12), class III obesity (OR = 3.09), and smoking (OR = 1.70). Risk factors for medical morbidity included: immediate autologous (p < 0.001), recent chemotherapy (p = 0.013), ASA physical status (p < 0.001), bilateral procedure (p = 0.002), patient comorbidity (p < 0.001), and obesity (p < 0.001). The strongest predictors of medical morbidity were immediate autologous reconstruction (OR = 3.54) and comorbidity burden of ≥2 comorbid conditions (OR = 2.28). In conclusion, undergoing IBR is associated with a modality-specific increased risk of morbidity relative to mastectomy alone. However, other modifiable risk factors appear to be strongly correlated with postoperative complications. Level of Evidence: prognostic/risk category, level II.