Ralitza P. Parina

Incidence and predictors of 30-day readmission for patients discharged home after craniotomy for malignant supratentorial tumors in California (1995–2010)

OBJECT Hospital readmission within 30 days of discharge is a major contributor to the high cost of health care in the US and is also a major indicator of patient care quality. The purpose of this study was to investigate the incidence, causes, and predictors of 30-day readmission following craniotomy for malignant supratentorial tumor resection. METHODS The longitudinal California Office of Statewide Health Planning & Development inpatient-discharge administrative database is a data set that consists of 100% of all inpatient hospitalizations within the state of California and allows each patient to be followed throughout multiple inpatient hospital stays, across multiple institutions, and over multiple years (from 1995 to 2010). This database was used to identify patients who underwent a craniotomy for resection of primary malignant brain tumors. Causes for unplanned 30-day readmission were identified by principle ICD-9 diagnosis code and multivariate analysis was used to determine the independent effect of various patient factors on 30-day readmissions. RESULTS A total of 18,506 patients received a craniotomy for the treatment of primary malignant brain tumors within the state of California between 1995 and 2010. Four hundred ten patients (2.2%) died during the index surgical admission, 13,586 patients (73.4%) were discharged home, and 4510 patients (24.4%) were transferred to another facility. Among patients discharged home, 1790 patients (13.2%) were readmitted at least once within 30 days of discharge, with 27% of readmissions occurring at a different hospital than the initial surgical institution. The most common reasons for readmission were new onset seizure and convulsive disorder (20.9%), surgical infection of the CNS (14.5%), and new onset of a motor deficit (12.8%). Medi-Cal beneficiaries were at increased odds for readmission relative to privately insured patients (OR 1.52, 95% CI 1.20-1.93). Patients with a history of prior myocardial infarction were at an increased risk of readmission (OR 1.64, 95% CI 1.06-2.54) as were patients who developed hydrocephalus (OR 1.58, 95% CI 1.20-2.07) or venous complications during index surgical admission (OR 3.88, 95% CI 1.84-8.18). CONCLUSIONS Using administrative data, this study demonstrates a baseline glioma surgery 30-day readmission rate of 13.2% in California for patients who are initially discharged home. This paper highlights the medical histories, perioperative complications, and patient demographic groups that are at an increased risk for readmission within 30 days of home discharge. An analysis of conditions present on readmission that were not present at the index surgical admission, such as infection and seizures, suggests that some readmissions may be preventable. Discharge planning strategies aimed at reducing readmission rates in neurosurgical practice should focus on patient groups at high risk for readmission and comprehensive discharge planning protocols should be implemented to specifically target the mitigation of potentially preventable conditions that are highly associated with readmission.

Mortality after ground-level fall in the elderly patient taking oral anticoagulation for atrial fibrillation/flutter: A long-term analysis of risk versus benefit

BACKGROUND Elderly patients with atrial fibrillation or flutter who experience ground-level falls are at risk for lethal head injuries. Patients on oral anticoagulation (OAC) for thromboprophylaxis may be at higher risk for these head injuries. Trauma surgeons treating these patients face a difficult choice: (1) continue OAC to minimize stroke risk while increasing the risk of a lethal head injury or (2) discontinue OAC to avoid intracranial hemorrhage while increasing the risk of stroke. To inform this choice, we conducted a retrospective cohort study to assess long-term outcomes and risk factors for mortality after presentation with a ground-level fall among patients with and without OAC. METHODS Retrospective analysis of the longitudinal version of the California Office of Statewide Planning and Development database was performed for years 1995 to 2009. Elderly anticoagulated patients (age > 65 years) with known atrial fibrillation or flutter who fell were stratified by CHA2DS2-VASc score and compared with a nonanticoagulated control cohort. Multivariable logistic regression including patient demographics, stroke risk, injury severity, and hospital type identified risk factors for mortality. RESULTS A total of 377,873 patient records met the inclusion criteria, 42,913 on OAC and 334,960 controls. The mean age was 82.4 and 80.6 years, respectively. Most were female, with CHA2DS2-VASc scores between 3 and 5. Mortality among OAC patients after a first fall was 6%, compared with 3.1% among non-OAC patients. Patients dying with a head injury constituted 31.6% of deaths within OAC patients compared with 23.8% among controls. Risk of eventual death with head injury exceeded annualized stroke risk for patients with CHA2DS2-VASc scores of 0 to 2. Predictors for mortality with head injury on the first admission included male sex, Asian ethnicity, a history of stroke, and trauma center admission. CONCLUSION Elderly patients on OAC for atrial fibrillation and/or flutter who fall have a greater risk for mortality compared with controls. Patients with low CHA2DS2-VASc scores (0–3) at high risk for falls with identified risk factors should speak to their prescribing physicians regarding the risk/benefits of continued use of OAC. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Long-Term Outcomes of Patients with Nonsurgically Managed Uncomplicated Appendicitis

BACKGROUND Emerging literature has supported the safety of nonoperative management of uncomplicated appendicitis. STUDY DESIGN Patients with emergent, uncomplicated appendicitis were identified by appropriate ICD-9 diagnosis codes in the California Office of Statewide Health Planning and Development database from 1997 to 2008. Rates of treatment failure, recurrence, and perforation after nonsurgical management were calculated. Factors associated with treatment failure, recurrence, and perforation were identified using multivariable logistic regression. Mortality, length of stay, and total charges were compared between treatment cohorts using matched propensity score analysis. RESULTS Of 231,678 patients with uncomplicated appendicitis, the majority (98.5%) were managed operatively. Of the 3,236 nonsurgically managed patients who survived to discharge without an interval appendectomy, 5.9% and 4.4% experienced treatment failure or recurrence, respectively, during a median follow-up of more than 7 years. There were no mortalities associated with treatment failure or recurrence. The risk of perforation after discharge was approximately 3%. Using multivariable analysis, race and age were significantly associated with the odds of treatment failure. Sex, age, and hospital teaching status were significantly associated with the odds of recurrence. Age and hospital teaching status were significantly associated with the odds of perforation. Matched propensity score analysis indicated that after risk adjustment, mortality rates (0.1% vs 0.3%; p = 0.65) and total charges (

Long-term Outcomes After Initial Presentation of Diverticulitis.

23,243 vs

Survival After Endovascular vs Open Aortic Aneurysm Repairs.

24,793; p = 0.70) were not statistically different between operative and nonoperative patients; however, length of stay was significantly longer in the nonoperative treatment group (2.1 days vs 3.2 days; p < 0.001). CONCLUSIONS This study suggests that nonoperative management of uncomplicated appendicitis can be safe and prompts additional investigations. Comparative effectiveness research using prospective randomized studies can be particularly useful.

Risk of adverse outcomes when plastic surgery procedures are combined.

Objective: This study aims to determine the long-term outcomes of diverticulitis and to apply the findings to current practice patterns. Background: The long-term morbidity and mortality of diverticulitis are not well defined. Current practice guidelines for diverticulitis are based on limited evidence. Methods: The California Office of Statewide Health Planning and Development database was queried for longitudinal observations across all hospitals from 1995 to 2009. Recurrence up to 15 years, medical versus surgical treatment, and mortality after recurrence were analyzed for patients after emergent admission for diverticulitis. Results: Among the 210,268 patients admitted emergently with diverticulitis, 179,649 (85%) were managed medically at their index admission. Of these medically managed patients, 27,450 (16.3%) suffered a second diverticulitis episode. On multivariable analysis, predictors of mortality with recurrence included the following [hazard ratio (95% confidence interval)]: age more than 50 years [5.19, (3.05–8.29)]; previous tobacco use [1.40 (1.18–1.66)]; and complicated initial presentation with obstruction [1.33 (1.06–1.65)], abscess [2.18 (1.60–2.97)], peritonitis [3.14 (1.99–4.97)], sepsis [1.88 (1.29–2.73)], and fistula [3.50 (2.17–5.66)]. The mortality of delayed elective surgical intervention after the first episode of emergent diverticulitis was 0.3% compared to 4.6% for emergent resection during a second episode. Conclusions: Eighty-five percent of emergent diverticulitis patients do not recur after initial medical treatment. However, in view of significantly worse outcomes associated with diverticulitis recurrence, resection should be strongly considered for diverticulitis patients older than 50 years or those who present with a complicated clinical picture.

Incidence of oral clefts among different ethnicities in the state of California.

IMPORTANCE To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic aneurysms (AAAs) have not been studied on a population level outside a controlled trial setting. OBJECTIVE To determine long-term outcomes of EVAR vs open repair on a population level. DESIGN, SETTING, AND PARTICIPANTS Analysis of the longitudinally linked California Office of Statewide Health Planning and Development inpatient database from 2001 to 2009. Median follow-up was 3.3 years. EXPOSURES Endovascular vs open repairs. MAIN OUTCOMES AND MEASURES Mortality and complications at 30 days, as well as long-term mortality and complications up to 9 years. RESULTS In this observational study, a total of 23 670 patients were studied, with 52% receiving EVAR. Endovascular repair was associated with improved 30-day outcomes (all-cause mortality, readmission, surgical site infection, pneumonia, and sepsis), as well as significantly improved survival until 3 years postoperatively. After 3 years, mortality was higher for patients who underwent an EVAR repair. No significant difference in long-term mortality was observed for the entire cohort on adjusted analysis (hazard ratio, 0.99; 95% CI, 0.94-1.04; P = .64). Endovascular repair was found to be associated with a significantly higher rate of reinterventions and AAA late ruptures. CONCLUSIONS AND RELEVANCE The survival advantage for EVAR repair in a statewide population is maintained for 3 years. After 3 years, EVAR repair was associated with higher mortality; however, these mortality differences did not reach statistical significance over the entire study period. Reintervention and late AAA rupture rates are higher after EVAR repair.

Outcomes of thyroidectomy from a large California state database.

Background: The ability to study population-level outcomes of outpatient cosmetic procedures has been limited by a lack of longitudinal data. This study aimed to describe the rates of adverse events in patients who underwent an isolated cosmetic surgery procedure compared with those who had a combination of two procedures. Methods: Retrospective longitudinal analysis was performed of the 2005 to 2010 California Office of Statewide Health Planning and Development Ambulatory Surgery Database. Patients were included if they had undergone an abdominoplasty or any other procedure that was identified as frequently performed concurrently with abdominoplasty. Patients’ subsequent in-patient admissions and emergency department visits were identified. Outcomes analyzed were the 30-day and 1-year venous thromboembolism rates, 30-day hospital admission rate, 30-day emergency department visit rate, and 30-day mortality rate. Results: A total of 477,741 patients were analyzed, of whom 16,893 had undergone two concurrent procedures. The 12-month venous thromboembolism rate was 0.57 percent for patients undergoing abdominoplasty, 0.20 percent for liposuction, 0.12 percent for breast procedures, 0.32 percent for hernia repair, 0.28 percent for face procedures, and 0.28 percent for thigh lift/brachioplasty. Greater than additive 30-day and 1-year venous thromboembolism rates were observed among patients who underwent an abdominoplasty and liposuction (0.68 percent and 0.81 percent, respectively) and those who underwent an abdominoplasty and hernia repair (0.93 percent). Conclusions: Some combinations of elective outpatient procedures conferred an additive, and sometimes more than additive, venous thromboembolism risk. This is an important consideration when informing patients of potential postoperative complications and for venous thromboembolism prophylaxis.

Quality and safety in obesity surgery-15 years of Roux-en-Y gastric bypass outcomes from a longitudinal database.

IntroductionSeveral population-based epidemiologic studies have been conducted to evaluate the incidence of oral clefts in different ethnicities in the United States and other countries. The largest studies were performed in white (non-Hispanic) subjects. The highest incidence rates have been reported in Asians and Native Americans. Material and MethodsWe performed a retrospective longitudinal analysis of the California Office of Statewide Health Planning and Development patient discharge database from 1995 to 2010. We identified the yearly number of live births and the number of patients diagnosed with cleft palate or cleft lip with or without palate. We also stratified the number of live births and the incidence of clefts based on ethnic backgrounds. We studied the trend in the incidence rates among different ethnicities in the period between 1995 and 2010. We identified and analyzed data from 3 main groups of patients: those with any cleft disease (AC), isolated cleft palate (CP), and cleft lip with or without cleft palate (CLP). ResultsOur database shows a total number of 8,043,393 live births included in the study. The calculated incidence rates for the white (Non-Hispanic) population are 16.2 with AC, 7.6 with CP, and 8.67 with CLP. Rates for the Hispanic population are 12.26 with AC, 4.79 with CP, and 7.5 with CLP. Rates for Asian/Pacific Islanders are 11.57 with AC, 4.9 with CP, and 6.68 with CLP. Rates for the African American population are 8.9 with AC, 4.1 with CP, and 6.7 with CLP. Rates for the Native American population are 8.15 with AC, 2.1 with CP, and 6 with CLP. We also noticed a declining trend in the incidence rates of AC, CP, and CLP over the period of the study between 1995 and 2010. DiscussionOur results suggest different incidence rates among different ethnicities. We found the highest rates for any oral cleft, isolated cleft palate, and cleft lip with and without palate in the white (non-Hispanic) population. The declining incidence rates during the period of the study (15 years) could be attributed to environmental, demographic, or gene pool factors. However, further studies are needed to investigate this finding.

Statewide multicenter analysis of the incidence of secondary surgeries after isolated cleft palate repair.

BACKGROUND Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California. METHODS The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications. RESULTS There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confidence interval, .6 to .97; P = .026). CONCLUSIONS Older age was a significant risk factor for complication after thyroidectomy. High-volume hospitals had lower risk. This information is useful in counseling patients about the risks of thyroid surgery.