Matthew A. Pilecki

National Multi-Institutional Comparison of 30-Day Postoperative Complication and Readmission Rates Between Open Retropubic Radical Prostatectomy and Robot-Assisted Laparoscopic Prostatectomy Using NSQIP

BACKGROUND Many American hospitals will soon face readmission penalties deducted from Medicare reimbursements, which will place further scrutiny on techniques that may offer reduced postoperative morbidity. We aimed to perform the first multi-institutional study using the National Surgical Quality Improvement Program (NSQIP) database, to compare predictors of readmission within cohorts of open radical retropubic prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) in a contemporary nationwide series of radical prostatectomy. METHODS All patients who underwent radical prostatectomy in 2011 were identified in the NSQIP database using procedural codes. As no patients in the analysis underwent LRP, patients were grouped as RRP or RALRP for analysis. Perioperative variables were analyzed using chi-squared and Students t-tests as appropriate. Multiple logistic regression was used to identify readmission risk factors. RESULTS Of 5471 patient cases analyzed, 4374 (79.9%) and 1097 (20.1%) underwent RALRP and RRP, respectively. RRP and RALRP cohorts experienced different readmission rates (5.47% vs 3.48%, respectively; p=0.002). In addition, RRP experienced a higher rate of overall complications than RALRP (23.25% vs 5.62%, respectively; p<0.001), but not higher rates of reoperation (1.09% vs 0.96%, respectively; p=0.689). Overall predictors of readmission included operative time, dyspnea, and RRP or RALRP procedure type. Current smoking and patient age were predictive of readmission for RRP only, while dyspnea was predictive of readmission following RALRP only. CONCLUSION This is the first multi-institutional retrospective study that examines readmission rates and procedural intracohort predictors of readmission for RRP in the contemporary United States. We report a significant difference in postoperative complication and readmission rates in RRP compared with RALRP. Further prospective analysis is warranted.

Impact of resident involvement on urological surgery outcomes: An analysis of 40,000 patients from the ACS NSQIP database

PURPOSE In addition to excellent patient care, the focus of academic medicine has traditionally been resident training. The changing landscape of health care has placed increased focus on objective outcomes. As a result, the surgical training process has come under scrutiny for its influence on patient care. We elucidated the effect of resident involvement on patient outcomes. MATERIALS AND METHODS We retrospectively analyzed data from the 2005 to 2011 NSQIP® participant use database. Patients were separated into 2 cohorts by resident participation vs no participation. The cohorts were compared based on preoperative comorbidities, demographic characteristics and intraoperative factors. Confounders were adjusted for by propensity score modification and complications were analyzed using perioperative variables as predictors. RESULTS A total of 40,001 patients met study inclusion criteria. Raw data analysis revealed that cases with resident participation had a higher rate of overall complications. However, after propensity score modification there was no significant difference in overall, medical or surgical complications in cases with resident participation. Resident participation was associated with decreased odds of overall complications (0.85). Operative time was significantly longer in cases with resident participation (159 vs 98 minutes). CONCLUSIONS Urology resident involvement is not associated with increased overall and surgical complications. It may even be protective when adjusted for appropriate factors such as case mix, complexity and operative time.

Predictors of Readmission following Outpatient Urological Surgery

PURPOSE The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties hospital readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, to our knowledge this study provides the first multi-institutional multivariate analysis of patient factors that contribute to readmission. MATERIALS AND METHODS Using the 2011 National Surgical Quality Improvement Program database we identified 7,795 patients. Multiple logistic regression was used to predict 30-day unplanned hospital readmissions controlling for demographics, clinical characteristics and comorbidities. Readmission rates of the 5 most common procedures were calculated along with the rate of postoperative complications associated with readmission. RESULTS Outpatient urological surgery had an overall 3.7% readmission rate. The 5 most common procedures were cystourethroscopy and resection of bladder tumor (readmission rate 4.97%), laser prostatectomy (4.27%), transurethral resection of prostate (4.24%), hydrocele excision (1.92%) and sling surgery for urinary incontinence (0.85%). The most common comorbidities in readmitted patients were hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA(®) level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors of readmission. Readmitted patients also had a higher 30-day complication rate. CONCLUSIONS Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions.

Predictors of readmission after outpatient otolaryngologic surgery

Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system‐wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery.

Venous thromboembolism in reconstructive pelvic surgery

OBJECTIVE We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Contemporary National Surgical Outcomes in the Treatment of Ureteropelvic Junction Obstruction

OBJECTIVE To evaluate contemporary national trends and outcomes of open pyeloplasty (OP) vs minimally invasive pyeloplasty (MIP) in the treatment of ureteropelvic junction obstruction using the National Surgical Quality Improvement Program database. METHODS Patients treated by OP or MIP between 2006 and 2011 were identified by The International Classification of Diseases, Ninth Revision, Clinical Modification codes corresponding to pyeloplasty as their primary operative procedure. Perioperative variables were analyzed using the chi-square and the Student t test. Multiple logistic regressions were used to identify morbidities and readmission risk factors. RESULTS Three hundred fifty-five patients were identified. Of them, 20.2% of cases were OP and 79.8% were MIP. There was a significant increase in MIP from 33% in 2006 to 83% in 2011 (P <.001). A total of 11.7% of patients in the MIP group underwent outpatient surgery (P = .002). Patients treated at a teaching hospital were over 3 times more likely to undergo MIP (odds ratio = 3.17; P = .001). There was significantly longer hospitalization in OP vs MIP (3.9 vs. 2.2 days; P = .001). OP was associated with significantly increased risk of reoperation or postoperative morbidity compared with MIP (11.1% vs. 4.2%; P = .02). Multivariate analysis confirmed a higher rate of overall morbidity in the OP cohort (P = .03). Male patients had significantly higher postoperative morbidity or reoperation rates (odds ratio = 4.38; P = .002). There was no significant difference in operative time between groups (P = .2). CONCLUSION Within the American College of Surgeons National Surgical Quality Improvement Program hospitals, MIP is associated with decreased reoperation and postoperative morbidity compared with OP.

The Effect of Operative Time on Perioperative Morbidity After Laparoscopic Hysterectomy

INTRODUCTION: We aimed to determine the effect of operative time on the risk of perioperative morbidity after laparoscopic hysterectomy. METHODS: Deidentified data from the National Surgical Quality Improvement Program Database were reviewed for patients undergoing total or subtotal laparoscopic hysterectomy from 2006 to 2011. Robotic and traditional laparoscopy data were pooled. Primary outcomes were 30-day complication rates in relation to operative time. Demographics, comorbidities, and complications were compared using bivariate and multivariate regression analysis. RESULTS: Nine thousand sixty-four women underwent laparoscopic hysterectomy during the study period. Medical, surgical, and overall complications increased significantly with increasing operative time (Fig. 1). On bivariate analysis, operative times over 240 minutes were associated with significant increases in composite morbidity (13.3% compared with 4.7%, P<.001), surgical complications (4.1% compared with 1.6%, P<.001), medical complications (10.7% compared with 3.3%, P<.001), and reoperation (2.6% compared with 1.2%, P=.013) as well as venous thromboembolis, urinary tract infection, and blood transfusion. These associations remained statistically significant on multivariate analysis. For each additional 10 minutes of operative time, the odds of overall, medical, and surgical complications increased by 5.1%, 6.2%, and 4.1%, respectively, and the odds of reoperation, venous thromboembolism, urinary tract infection, and transfusion increased by 5.1%, 6.2%, 4.1%, and 8.3%, respectively. Fig. 1. Rates of overall, surgical, and medical complications and reoperation stratified by 60-minute intervals of surgical duration. CONCLUSIONS: We demonstrated a direct, independent correlation between increased operative time during laparoscopic hysterectomy and perioperative morbidity. Operating time exceeding 4 hours was associated with a nearly threefold increase in overall complications. Patients considering laparoscopic hysterectomy who are at risk for excessive operating time may benefit from an alternative surgical approach.