Trit Garg

Does hospital accreditation impact bariatric surgery safety

Objective:To evaluate the impact of hospital accreditation upon bariatric surgery outcomes. Background:Since 2004, the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery have accredited bariatric hospitals. Few studies have evaluated the impact of hospital accreditation on all bariatric surgery outcomes. Methods:Bariatric surgery hospitalizations were identified using International Classification of Diseases, Ninth Revision (ICD9) codes in the 2010 Nationwide Inpatient Sample (NIS). Hospital names and American Hospital Association (AHA) codes were used to identify accredited bariatric centers. Relevant ICD9 codes were used for identifying demographics, length of stay (LOS), total charges, mortality, complications, and failure to rescue (FTR) events. Results:There were 117,478 weighted bariatric patient discharges corresponding to 235 unique hospitals in the 2010 NIS data set. A total of 72,615 (61.8%) weighted discharges, corresponding to 145 (61.7%) named or AHA-identifiable hospitals were included. Among the 145 hospitals, 66 (45.5%) were unaccredited and 79 (54.5%) accredited. Compared with accredited centers, unaccredited centers had a higher mean LOS (2.25 vs 1.99 days, P < 0.0001), as well as total charges (

Adherence to postoperative surveillance guidelines after endovascular aortic aneurysm repair among Medicare beneficiaries.

51,189 vs

Postoperative Surveillance and Long-term Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries

42,212, P < 0.0001). Incidence of any complication was higher at unaccredited centers than at accredited centers (12.3% vs 11.3%, P = 0.001), as was mortality (0.13% vs 0.07%, P = 0.019) and FTR (0.97% vs 0.55%, P = 0.046). Multivariable logistic regression analysis identified unaccredited status as a positive predictor of incidence of complication [odds ratio (OR) = 1.08, P < 0.0001], as well as mortality (OR = 2.13, P = 0.013). Conclusions and Relevance:Hospital accreditation status is associated with safer outcomes, shorter LOS, and lower total charges after bariatric surgery.

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

OBJECTIVE After endovascular aortic aneurysm repair (EVAR), the Society for Vascular Surgery recommends a computed tomography (CT) scan ≤30 days, followed by annual imaging. We sought to describe long-term adherence to surveillance guidelines among United States Medicare beneficiaries and determine patient and hospital factors associated with incomplete surveillance. METHODS We analyzed fee-for-service Medicare claims for patients receiving EVAR from 2002 to 2005 and collected all relevant postoperative imaging through 2011. Additional data included patient comorbidities and demographics, yearly hospital volume of abdominal aortic aneurysm repair, and Medicaid eligibility. Allowing a grace period of 3 months, complete surveillance was defined as at least one CT or ultrasound assessment every 15 months after EVAR. Incomplete surveillance was categorized as gaps for intervals >15 months between consecutive images as or lost to follow-up if >15 months elapsed after the last imaging. RESULTS Our cohort comprised 9695 patients. Median follow-up duration was 6.1 years. A CT scan ≤30 days of EVAR was performed in 3085 (31.8%) patients and ≤60 days in 60.8%. The median time to the postoperative CT was 38 days (interquartile range, 25-98 days). Complete surveillance was observed in 4169 patients (43.0%). For this group, the mean follow-up time was shorter than for those with incomplete surveillance (3.4 ± 2.74 vs 6.5 ± 2.1 years; P < .001). Among those with incomplete surveillance, follow-up became incomplete at 3.3 ± 1.9 years, with 57.6% lost to follow-up, 64.1% with gaps in follow-up (mean gap length, 760 ± 325 days), and 37.6% with both. A multivariable analysis showed incomplete surveillance was independently associated with Medicaid eligibility (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.29-1.55; P < .001), low-volume hospitals (HR, 1.12; 95% CI, 1.05-1.20; P < .001), and ruptured abdominal aortic aneurysm (HR, 1.51; 95% CI, 1.24-1.84; P < .001). CONCLUSIONS Postoperative imaging after EVAR is highly variable, and less than half of patients meet current surveillance guidelines. Additional studies are necessary to determine if variability in postoperative surveillance affects long-term outcomes.

Aortoiliac Elongation after Endovascular Aortic Aneurysm Repair

IMPORTANCE The Society for Vascular Surgery recommends annual surveillance with computed tomography (CT) or ultrasonography after endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysms. However, such lifelong surveillance may be unnecessary for most patients, thereby contributing to overuse of imaging services. OBJECTIVE To investigate whether nonadherence to Society for Vascular Surgery-recommended surveillance guidelines worsens long-term outcomes after EVAR among Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS We collected data from Medicare claims from January 1, 2002, through December 31, 2011. A total of 9503 patients covered by fee-for-service Medicare who underwent EVAR from January 1, 2002, through December 31, 2005, were categorized as receiving complete or incomplete surveillance. We performed logistic regressions controlling for patient demographic and hospital characteristics. Patients were then matched by propensity score with adjusting for all demographic variables, including age, sex, race, Medicaid eligibility, residential status, hospital volume, ruptured abdominal aortic aneurysms, and all preexisting comorbidities. We then calculated differences in long-term outcomes after EVAR between adjusted groups. Data analysis was performed from January 1, 2002, through December 31, 2011. MAIN OUTCOMES AND MEASURES Post-EVAR imaging modality, aneurysm-related mortality, late rupture, and complications. RESULTS Median follow-up duration was 6.1 years. Incomplete surveillance was observed in 5526 of 9695 patients (57.0%) who survived the initial hospital stay at a mean (SD) of 5.2 (2.9) years after EVAR. After propensity matching, our cohort consisted of 7888 patients, among whom 3944 (50.0%) had incomplete surveillance. For those in the matched cohort, patients with incomplete surveillance had a lower incidence of late ruptures (26 of 3944 [0.7%] vs 57 of 3944 [1.4%]; P = .001) and major or minor reinterventions (46 of 3944 [1.2%] vs 246 of 3944 [6.2%]; P < .001) in unadjusted analysis. Aneurysm-related mortality was not statistically different between groups (13 of 3944 [0.3%] vs 24 of 3944 [0.6%]; P = .07). In adjusted analysis of postoperative outcomes controlling for all patient and hospital factors by the tenth postoperative year, patients in the incomplete surveillance group experienced lower rates of total complications (2.1% vs 14.0%; P < .001), late rupture (1.1% vs 5.3%; P < .001), major or minor reinterventions (1.4% vs 10.0%; P < .001), aneurysm-related mortality (0.4% vs 1.3%; P < .001), and all-cause mortality (30.9% vs 68.8%, P < .001). CONCLUSIONS AND RELEVANCE Nonadherence to the Society for Vascular Surgery guidelines for post-EVAR imaging was not associated with poor outcomes, suggesting that, in many patients, less frequent surveillance is not associated with worse outcomes. Improved criteria for defining optimal surveillance will achieve higher value in aneurysm care.

Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding

BACKGROUND Telemetry monitoring is a widely used, labor-intensive, and often-limited resource. Little is known of the effectiveness of methods to guide appropriate use. OBJECTIVE Our intervention for appropriate use included: (1) a hospitalist-led, daily review of bed utilization, (2) hospitalist-driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives. DESIGN/METHODS Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013-August 2013) on medicine wards. Pre- and post-evaluations measured changes regarding telemetry use. We compared hospital bed-use data between the baseline period (January 2012-December 2012), intervention period, and extension period (September 2014-March 2015). During the intervention period, hospital bed-use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization. SETTING Stanford Hospital, a 444-bed, academic medical center in Stanford, California. RESULTS Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost-saving action (P = 0.002) and the least cost-saving action (P = 0.003) in the pre- and post-evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period. CONCLUSIONS A multipronged, hospitalist-driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost-saving actions among trainees.

Impact of problem-based charting on the utilization and accuracy of the electronic problem list

BACKGROUND Aortoiliac elongation after endovascular aortic aneurysm repair (EVAR) is not well studied. We sought to assess the long-term morphologic changes after EVAR and identify potentially modifiable factors associated with such a change. METHODS An institutional review board-approved retrospective review was conducted for 88 consecutive patients who underwent EVAR at a single academic center from 2003 to 2007 and who also had at least 2 follow-up computed tomography angiograms (CTAs) available for review up to 5 years after surgery. Standardized centerline aortic lengths and diameters were obtained on Aquarius iNtuition 3D workstation (TeraRecon Inc., San Mateo, CA) on postoperative and all-available follow-up CTAs. Relationships to aortic elongation were determined using Wilcoxon rank-sum test or linear regression (Stata version 12.1, College Station, TX). Changes in length over time were determined by mixed-effects analysis (SAS version 9.3, Cary, NC). RESULTS The study cohort was composed of mostly men (88%), with a mean age of (76 ± 8) and a mean follow-up of 3.2 years (range, 0.4-7.5 years). Fifty-seven percent of patients (n = 50) had devices with suprarenal fixation and 43% (n = 38) had no suprarenal fixation. Significant lengthening was observed over the study period in the aortoiliac segments, but not in the iliofemoral segments. Aortoiliac elongation over time was not associated with sex (P = 0.3), hypertension (P = 0.7), coronary artery disease (P = 0.3), diabetes (P = 0.3), or tobacco use (P = 0.4), but was associated with the use of statins (P = 0.03) and the presence of chronic obstructive pulmonary disease (P = 0.02). Significant aortic lengthening was associated with increased type I endoleaks (P = 0.03) and reinterventions (P = 0.03). Over the study period, 4 different devices were used; Zenith (Cook Medical Inc., Bloomington, IN), Talent (Medtronic, Minneapolis, MN), Aneuryx (Medtronic), and Excluder (W. L. Gore and Associates Inc., Flagstaff, AZ). After adjusting for differences in proximal landing zone, significant differences in aortic lengthening over time were observed by device type (P = 0.02). CONCLUSIONS Significant aortoiliac elongation was observed after EVAR. Such morphologic changes may impact long-term durability of EVAR, warranting further investigation into factors associated with these morphologic changes.

Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use

Background: Laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long‐term weight loss can be highly variable beyond 1‐year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding. Methods: A total of 1,331 consecutive patients at a single academic institution were reviewed from a prospectively collected database. Preoperative data collected included demographics, body mass index, and percent excess weight loss. Postoperative BMI and %EWL were collected at 12, 24, and 36 months. Percent excess weight loss was analyzed by the percentiles of excess weight lost, and the distribution of percent excess weight loss was evaluated in 10% increments. Lack of a successful treatment effect was defined as <25% excess weight loss. Results: Of the 1,331 patients, 72.4% (963) underwent laparoscopic Roux‐en‐Y gastric bypass, 18.3% (243) laparoscopic sleeve gastrectomy, and 9.4%(125) laparoscopic adjustable gastric banding. Mean percent excess weight loss was greatest for laparoscopic Roux‐en‐Y gastric bypass, followed by laparoscopic sleeve gastrectomy, and then by laparoscopic adjustable gastric banding at every time point: at 2 years mean percent excess weight loss was 77.9± 24.4 for laparoscopic Roux‐en‐Y gastric bypass, 50.8 ± 25.8 for laparoscopic sleeve gastrectomy, and 40.8± 25.9 for laparoscopic adjustable gastric banding (P < .0001). The rates of a successful treatment effect s for laparoscopic Roux‐en‐Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding were 0.9%, 5.2%, and 24.3% at 1 year; 0.3%, 11.1%, and 26.0% at 2 years; and 1.0%, 25.3%, and 30.2% at 3 years. At 1 year, the odds ratio of lack of a successful treatment effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux‐en‐Y gastric bypass was 6.305 (2.125–19.08; P = .0004), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux‐en‐Y gastric bypass was 36.552 (15.64–95.71; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy was 5.791 (2.519–14.599; P < .0001). At 2 years, the odds ratio for laparoscopic sleeve gastrectomy versus laparoscopic Roux‐en‐Y gastric bypass increased to 70.7 (9.4–531.7; P < .0001), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux‐en‐Y gastric bypass increased to 128.1 (16.8–974.3; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy decreased to 1.8 (0.9–3.6; P = .09). Conclusion: This study emphasizes the existing variability in weight loss across bariatric procedures as well as in the lack of a treatment effect for each procedure. Although laparoscopic adjustable gastric banding has the greatest rate of a lack of a successful treatment effect, the rate remained stable over 3 years postoperatively. Laparoscopic sleeve gastrectomy showed a doubling in the rate of a lack of a successful treatment effect every year reaching 25% at year 3. The rates for lack of a successful treatment effect for laparoscopic Roux‐en‐Y gastric bypass remained stable at about 1% for the first 3 years postoperatively.

A postoperative nutritional consult improves bariatric surgery outcomes

Objective Problem-based charting (PBC) is a method for clinician documentation in commercially available electronic medical record systems that integrates note writing and problem list management. We report the effect of PBC on problem list utilization and accuracy at an academic intensive care unit (ICU). Materials and Methods An interrupted time series design was used to assess the effect of PBC on problem list utilization, which is defined as the number of new problems added to the problem list by clinicians per patient encounter, and of problem list accuracy, which was determined by calculating the recall and precision of the problem list in capturing 5 common ICU diagnoses. Results In total, 3650 and 4344 patient records were identified before and after PBC implementation at Stanford Hospital. An increase of 2.18 problems (>50% increase) in the mean number of new problems added to the problem list per patient encounter can be attributed to the initiation of PBC. There was a significant increase in recall attributed to the initiation of PBC for sepsis (β = 0.45, P < .001) and acute renal failure (β = 0.2, P = .007), but not for acute respiratory failure, pneumonia, or venous thromboembolism. Discussion The problem list is an underutilized component of the electronic medical record that can be a source of clinician-structured data representing the patients clinical condition in real time. PBC is a readily available tool that can integrate problem list management into physician workflow. Conclusion PBC improved problem list utilization and accuracy at an academic ICU.

Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial

Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.