Nishant K. Shah

The effect of trainee involvement on perioperative outcomes of abdominal aortic aneurysm repair

OBJECTIVE Although the effect of trainee involvement has been evaluated across different specialties, their effects on perioperative outcomes after abdominal aortic aneurysm (AAA) repair have not been examined. Our goal was to examine the association between resident and fellow intraoperative participation with perioperative outcomes of endovascular AAA repair (EVAR), open infrarenal AAA repair (OIAR), and open juxtarenal AAA repair (OJAR). METHODS The American College of Surgeons National Surgical Quality Improvement Program data set (2005-2012) was queried to identify all patients who underwent EVAR, OIAR, or OJAR. Multivariate analysis was performed to assess the association of trainee involvement with perioperative morbidity and mortality. RESULTS We identified 16,977 patients: 12,003 with EVAR, 3655 with OIAR, and 1319 with OJAR. Propensity matching and multivariate analyses revealed that there was no significant difference in perioperative death, cardiac arrest/myocardial infarction, pulmonary, renal, venous thromboembolic, or wound complications, or return to the operating room. However, trainee involvement in AAA repair led to a significant increase in operative time for EVAR (163 ± 77 vs 140 ± 67 minutes; P < .001), OIAR (217 ± 91 vs 185 ± 76 minutes; P < .001), and OJAR (267 ± 115 vs 214 ± 106 minutes; P < .001) and an extended length of stay for EVAR (3.1 ± 5.3 vs 2.8 ± 4.5 days; P < .001) and OIAR (10.6 ± 11.8 vs 9.1 ± 8.9 days; P < .001). CONCLUSIONS Trainee participation in aneurysm repair was not associated with major adverse perioperative outcomes. However, it was associated with an increased operative time and length of stay and therefore may lead to increased resource utilization and cost.

Index complications predict secondary complications after infrainguinal lower extremity bypass for critical limb ischemia

Objective: Patients undergoing lower extremity bypass (LEB) are at high risk of perioperative complications that can lead to a cascade of secondary complications. Our goal was to understand the association of index complications with secondary complications after LEB. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2012 was used to analyze secondary complications after five index complications after LEB: deep/organ space surgical site infection, urinary tract infection (UTI), myocardial infarction (MI), pneumonia, and acute renal failure (ARF). Index cohorts were developed with 5:1 propensity matching for comparison. This score was based on preoperative variables and event‐free days. Results: We evaluated 20,230 LEB patients. Postoperative index surgical site infection increased the risk of secondary ARF (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.1‐15.0), pneumonia (OR, 2.7; 95% CI, 1.0‐7.4), UTI (OR, 3.1; 95% CI, 1.3‐7.5), cardiac arrest (OR, 4.4; 95% CI, 1.6‐12.2), wound disruption (OR, 10.5; 95% CI, 6.7‐16.6), unplanned intubation (OR, 5.1; 95% CI, 2.0‐12.8), prolonged ventilation (OR, 5.9; 95% CI, 2.0‐17.6), sepsis (OR, 16.2; 95% CI, 10.2‐25.6), and mortality (OR, 3.5; 95% CI, 1.7‐7.1). Postoperative index UTI was associated with pneumonia (OR, 5.6; 95% CI, 2.7‐11.6), sepsis (OR, 7.8; 95% CI, 5.1‐11.8), and mortality (OR, 2.7; 95% CI, 1.3‐5.3). Postoperative index MI was associated with secondary ARF (OR, 8.7; 95% CI, 3.8‐20.1), pneumonia (OR, 4.9; 95% CI, 2.7‐8.8), cardiac arrest (OR; 7.4; 95% CI; 4.0‐13.5), deep venous thrombosis (OR, 3.9; 95% CI, 1.7‐9.1), unplanned intubation (OR, 12.2; 95% CI, 7.3‐20.3), prolonged intubation (OR, 12.2; 95% CI, 6.4‐23.2), sepsis (OR, 2.2; 95% CI, 1.2‐3.8), and mortality (OR, 5.6; 95% CI, 3.6‐8.5). Postoperative index pneumonia was associated with secondary ARF (OR, 25.5; 95% CI, 3.0‐219.3), MI (OR, 7.6; 95% CI, 3.2‐18.0), UTI (OR, 4.3; 95% CI, 2.0‐9.0), cardiac arrest (OR, 5.2; 95% CI, 2.0‐13.2), deep venous thrombosis (OR, 7.7; 95% CI, 2.1‐27.4), unplanned intubation (OR, 14.7; 95% CI, 8.3‐26.1), prolonged ventilation (OR, 26.0; 95% CI, 11.8‐56.9), sepsis (OR, 7.2; 95% CI, 4.0‐12.8), and mortality (OR, 6.0; 95% CI, 3.7‐10.0). Last, postoperative index ARF was associated with increased risk of secondary pneumonia (OR, 7.16; 95% CI, 2.6‐20.0), cardiac arrest (OR, 15.5; 95% CI, 1.6‐150.9), unplanned intubation (OR, 6.2; 95% CI, 2.3‐16.8), prolonged ventilation (OR, 8.8; 95% CI, 3.4‐22.4), and mortality (OR, 8.8; 95% CI, 3.4‐22.4). Conclusions: A postoperative index complication after LEB is significantly more likely to lead to serious secondary complications. Prevention and early identification of index complications and subsequent secondary complications could decrease morbidity and mortality.

Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation

Objective: Patients with end‐stage renal disease have multiple comorbidities and are at increased risk for postoperative complications and resource utilization. Our goal was to determine the rate and causes of 30‐day and 90‐day hospital readmissions after the creation of outpatient hemodialysis access. Methods: We retrospectively reviewed all outpatient upper extremity hemodialysis access creations performed at our medical center from 2008 to 2015. Readmission was defined as any inpatient status admission ≤30 and 90 days. Reasons for such admissions were analyzed, and multivariate analyses assessed risk factors. Results: We identified 537 patients (60% male). Average age was 59 years. Access type included radiocephalic (4.5%), brachiocephalic (50.7%), brachiobasilic (22.5%), and prosthetic (20%) arteriovenous fistulas. The 90‐day mortality rate was 0.7%. Postoperative hospital readmission rates were 25.5% at 30 days and 47.7% at 90 days. Reasons for admission were access related in 10.9% and dialysis catheter related in 6.9%. Other reasons for admission included shortness of breath/volume overload (15.8%), gastrointestinal (11.9%), cardiac/chest pain (10.9%), unrelated infectious causes (11.9%), failure to thrive (5%), altered mental status (4%), electrolyte abnormalities (3%), and musculoskeletal (2.5%). Preoperative predictors of all cause 30‐day readmission included dementia (odds ratio [OR], 5.76; 95% confidence interval [CI], 1.34‐24.8; P = .018), hypertension (OR, 3.92; 95% CI, 1.07‐14.4; P = .039), chronic obstructive pulmonary disease (OR, 2.19; 95% CI, 1.01‐4.76; P = .046), and current smoking (OR, 2.14; 95% CI, 1.32‐3.47; P = .002). Predictors of all cause 90‐day readmission were hepatic insufficiency (OR, 6.08; 95% CI, 1.2‐30.8; P = .029), hypertension (OR, 3.43; 95% CI, 1.36‐8.65; P = .009), black race (OR, 2.47; 95% CI, 1.48‐4.14; P = .001), Hispanic ethnicity (OR, 2.04; 95% CI, 1.01‐4.11; P = .046), and obesity (OR, 1.5; 95% CI, 1.02‐2.19; P = .039). Predictors of 90‐day access‐related readmission included chronic obstructive pulmonary disease (OR, 5.27; 95% CI, 1.38‐20.0; P = .015), previous stroke (OR, 3.76; 95% CI, 1.5‐9.4; P = .005), being on dialysis at time of the operation (OR, 2.8; 95% CI, 1.17‐6.84; P = .022), and prosthetic graft placement (OR, 2.86; 95% CI, 1.07‐7.6; P = .036). An additional 9.7% had at least one emergency department presentation ≤90 days but were not admitted. Conclusions: Patients undergoing placement of hemodialysis access are at high risk for readmission mostly from causes unrelated to their operation. This has an effect for global care for these patients as well as care of these patients in accountable care organizations.

Characterization of Planned and Unplanned 30-Day Readmissions Following Vascular Surgical Procedures.

Objective: Thirty-day readmission is increasingly used as a quality of care indicator. Patients undergoing vascular surgery have historically been at high risk for readmission. We analyzed hospital readmission details to identify patients at high risk for readmission in order to better understand these readmissions and improve resource utilization in this patient population. Methods: A retrospective review and analysis of our medical center’s admission and discharge data were conducted from October 2012 to March 2015. All patients who were discharged from the vascular surgery service and subsequently readmitted as an inpatient within 30 days were included. Results: We identified 649 vascular surgery discharges with 135 (21%) readmissions. Common comorbidities were diabetes (56%), coronary artery disease (40%), congestive heart failure (CHF; 24%), and chronic obstructive pulmonary disease (19%). Index vascular operations included open lower extremity procedures (39%), diagnostic angiograms (35%), endovascular lower extremity procedures (16%), dialysis access procedures (7%), carotid/cerebrovascular procedures (7%), amputations (6%), and abdominal aortic procedures (5%). Average index length of stay (LOS) was 7.48 days (±6.73 days). Reasons for readmissions were for medical causes (43%), surgical complications (35.5%), and planned procedures (21.5%). Reasons for medical readmissions most commonly included malaise or failure to thrive (28%), unrelated infection (24%), and hypoxia/CHF complications (21%). Common surgical causes for readmission were surgical site infections (69%), graft failure (19%), and bleeding complications (8%). Of the planned readmissions, procedures were at the same site (79%), a different site (14%), and planned podiatry procedures (7%). Readmission LOS was on average 7.43 days (±7.22 days). Conclusion: Causes for readmission of vascular surgery patients are multifactorial. Infections, both related and unrelated to the surgical site, remain common reasons for readmission and represent an opportunity for improvement strategies. Improved understanding of readmissions following vascular surgery could help adjust policy benchmarks for targeted readmission rates and help reduce resource utilization.