Darryl T. Hiyama

Evaluation of Hospital Readmissions in Surgical Patients: Do Administrative Data Tell the Real Story?

IMPORTANCE The Centers for Medicare & Medicaid Services has developed an all-cause readmission measure that uses administrative data to measure readmission rates and financially penalize hospitals with higher-than-expected readmission rates. OBJECTIVES To examine the accuracy of administrative codes in determining the cause of readmission as determined by medical record review, to evaluate the readmission measures ability to accurately identify a readmission as planned, and to document the frequency of readmissions for reasons clinically unrelated to the original hospital stay. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of all consecutive patients discharged from general surgery services at a tertiary care, university-affiliated teaching hospital during 8 consecutive quarters (quarter 4 [October through December] of 2009 through quarter 3 [July through September] of 2011). Clinical readmission diagnosis determined from direct medical record review was compared with the administrative diagnosis recorded in a claims database. The number of planned hospital readmissions defined by the readmission measure was compared with the number identified using clinical data. Readmissions unrelated to the original hospital stay were identified using clinical data. MAIN OUTCOMES AND MEASURES Discordance rate between administrative and clinical diagnoses for all hospital readmissions, discrepancy between planned readmissions defined by the readmission measure and identified by clinical medical record review, and fraction of hospital readmissions unrelated to the original hospital stay. RESULTS Of the 315 hospital readmissions, the readmission diagnosis listed in the administrative claims data differed from the clinical diagnosis in 97 readmissions (30.8%). The readmission measure identified 15 readmissions (4.8%) as planned, whereas clinical data identified 43 readmissions (13.7%) as planned. Unrelated readmissions comprised 70 of the 258 unplanned readmissions (27.1%). CONCLUSIONS AND RELEVANCE Administrative billing data, as used by the readmission measure, do not reliably describe the reason for readmission. The readmission measure accounts for less than half of the planned readmissions and does not account for the nearly one-third of readmissions unrelated to the original hospital stay. Implementation of this readmission measure may result in unwarranted financial penalties for hospitals.

Inpatient Surgery in California: 1990-2000

BACKGROUND The practice environment for surgery is changing. However, little is known regarding the trends or current status of inpatient surgery at a population level. HYPOTHESIS Inpatient surgical care has changed significantly over the last 10 years. DESIGN Longitudinal analysis of California inpatient discharge data (January 1, 1990, through December 31, 2000). SETTING All 503 nonfederal acute care hospitals in California. PATIENTS All inpatients undergoing general, vascular, and cardiothoracic surgery in California from January 1, 1990, through December 31, 2000, were obtained. MAIN OUTCOME MEASURES Volume, mean age, comorbidity profile, length of hospital stay, and in-hospital mortality were obtained for inpatient general, vascular, and cardiothoracic surgical procedures performed during the period 1990 to 2000. Rates of change and trends were evaluated for the 10-year period. RESULTS Between January 1, 1990, and December 31, 2000, 1.64 million surgical procedures were performed. The number of surgical procedures increased 20.4%, from 135,795 in 1990 to 163,468 in 2000. Overall, patients were older and had more comorbid disease in 2000 compared with 1990. Both crude and adjusted (by type of operation) in-hospital mortality decreased from 3.9% in 1990 to 2.75% (P<.001) and 2.58% (P<.001), respectively, in 2000. Length of hospital stay decreased over the period for all operations analyzed. CONCLUSIONS The total number of inpatient general, vascular, and cardiothoracic surgical procedures has increased over the past decade. Furthermore, our findings indicate that the outcomes of care (eg, in-hospital mortality and length of hospital stay) for patients who undergo general, vascular, and cardiothoracic surgical procedures have improved. However, continued evaluations at the population level are needed.

Scrotal abscess following appendectomy

Abstract. Postoperative infectious complications in children following perforated appendicitis present in diverse ways. We present two unusual complications of appendectomy for perforated appendicitis: an acute scrotum after open and laparoscopic appendectomy. A␣retrospective review of two cases of scrotal abscess following appendectomy at our hospital as well as a MEDLINE search was performed to review the clinical presentation, etiology, type of treatment, and outcome of these patients. Although scrotal inflammation occurring postoperatively in a patient with perforated appendicitis may be due to an incarcerated hernia, it is much more likely to be due to a scrotal abscess. Patients without a patent processus vaginalis or inguinal hernia at initial presentation of peritonitis must be carefully followed in the postoperative period and explored early if testicular or scrotal pain becomes manifest.

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management

Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department (ED) observation with next‐day follow‐up. Outcomes included 1‐month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics‐first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics‐first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/&mgr;L (range 6,200 to 23,100/&mgr;L), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic‐treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics‐first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics‐first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics‐first‐treated participants had less pain and disability. During median 12‐month follow‐up, 2 of 15 antibiotics‐first‐treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

Intraoperative Laparoscopic Near-Infrared Fluorescence Cholangiography to Facilitate Anatomical Identification: When to Give Indocyanine Green and How Much.

Recent technological advances have enabled real-time near-infrared fluorescence cholangiography (NIRFC) with indocyanine green (ICG). Whereas several studies have shown its feasibility, dosing and timing for practical use have not been optimized. We undertook a prospective study with systematic variation of dosing and timing from injection of ICG to visualization. Adult patients undergoing laparoscopic biliary and hepatic operations were enrolled. Intravenous ICG (0.02-0.25 mg/kg) was administered at times ranging from 10 to 180 minutes prior to planned visualization. The porta hepatis was examined using a dedicated laparoscopic system equipped to detect NIRFC. Quantitative analysis of intraoperative fluorescence was performed using a scoring system to identify biliary structures. A total of 37 patients were enrolled. Visualization of the extrahepatic biliary tract improved with increasing doses of ICG, with qualitative scores improving from 1.9 ± 1.2 (out of 5) with a 0.02-mg/kg dose to 3.4 ± 1.3 with a 0.25-mg/kg dose (P < .05 for 0.02 vs 0.25 mg/kg). Visualization was also significantly better with increased time after ICG administration (1.1 ± 0.3 for 10 minutes vs 3.4 ± 1.1 for 45 minutes, P < .01). Similarly, quantitative measures also improved with both dose and time. There were no complications from the administration of ICG. These results suggest that a dose of 0.25 mg/kg administered at least 45 minutes prior to visualization facilitates intraoperative anatomical identification. The dosage and timing of administration of ICG prior to intraoperative visualization are within a range where it can be administered in a practical, safe, and effective manner to allow intraoperative identification of extrahepatic biliary anatomy using NIRFC.

PRIMARY MESENTERIC LEIOMYOSARCOMA MASQUERADING AS A PANCREATIC PSEUDOCYST

To the Editor: Primary tumors of the mesentery are rare, and accurate preoperative diagnosis based upon radiologic or clinical findings is uncommon. We report herein a case of a patient with a primary epithelioid leiomyosarcoma of the transverse mesocolon that had been mistakenly diagnosed and surgically treated as a pancreatic pseudocyst for over a year. A review of the world literature on primary tumors of the mesentery was performed to facilitate the clinical, radiologic, and pathologic identification of these rare tumors.

Gastrostomy tube insertion during rectus free flap harvest : Indications, technique, and outcome

INTRODUCTION The redus abdominis free flap has proven to be a useful method of reconstruction for select defects in the head and neck region. As a composite graft of muscle, subcutaneous fat, and skin, it can provide a considerable degree of soft tissue bulk. This soft tissue bulk is advantageous to provide passive obturation of the oral cavity during speech and deglutition in patients who undergo reconstruction after total or near-total glossedomy.1 For skull base reconstruction, the flap provides ample tissues for separation of the intracranial space from aerodigestive secretions, while the long vascular pedicle usually reaches recipient vessels in the neck without requiring vein grafts.2 Patients who undergo signiscant glossectomy or cranial base surgery are frequently in need of a means of longterm nonoral enteral nutrition during the postoperative period. Patients who undergo total or near-total glossectomy with laryngeal preservation are frequently at risk to develop aspiration due to loss of control of the food bolus during deglutition. Temporary or permanent injury to the lower cranial nerves is common after cranial base surgery, resulting in impaired motor control of the tongue, larynx, and pharyngeal constrictors, as well as loss of pharyngeal sensation. These factors combine to result in a high incidence of long-term dysphagia in this patient population. The nasogastric feeding tube is the most commonly employed method of nonoral enteral nutrition in patients after major head and neck surgery. However, th is solution

Biliary disease during pregnancy

BACKGROUND Biliary disease during pregnancy is rare and the need for surgery in these cases is controversial. We evaluated our experience with biliary disease during pregnancy with regard to outcome and cost containment. PATIENTS AND METHODS We reviewed the clinical course of pregnant women with biliary disease at the University of California at Los Angeles and Olive View-UCLA Medical Centers from 1988 to 1993. RESULTS Seventy-two of 46,075 pregnant women presented with biliary disease (incidence 0.16%). Sixteen underwent surgery while pregnant, 5 in the first and 11 in the second trimester. No maternal or fetal deaths occurred secondary to medical or surgical management of biliary disease. Patients who were treated medically at initial presentation had a 69% rate of relapse prior to delivery, compared to no relapses in those treated surgically (P < 0.01). Patients who experienced relapse spent an average of 3.0 additional days in hospital. CONCLUSION Surgical therapy for biliary disease performed in the second trimester of pregnancy does not increase morbidity and may help reduce relapses and additional days in hospital.