VISHAL DOBARIA | Ucla - Academia.edu (original) (raw)

Papers by VISHAL DOBARIA

Research paper thumbnail of Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis

The American Surgeon, 2020

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify t... more Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as Frail. Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, P < .001) and in-hospital mortality (4% vs. 2%, P < .001). Frailty was...

Research paper thumbnail of National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States

INTRODUCTION Pancreatectomy is a complex operation that has been associated with excess morbidity... more INTRODUCTION Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy. MATERIAL AND METHODS We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality. RESULTS Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy v...

Research paper thumbnail of Impact of frailty on short term outcomes, resource use, and readmissions after transcatheter mitral valve repair: A national analysis

PLOS ONE, 2021

Background Treatment options for mitral regurgitation range from diuretic therapy, to surgical an... more Background Treatment options for mitral regurgitation range from diuretic therapy, to surgical and interventional strategies including TMVR in high-risk surgical candidates. Frailty has been associated with inferior outcomes following hospitalizations for heart failure and in open cardiac surgery. Objective The purpose of the present study was to evaluate the impact of frailty on clinical outcomes and resource use following transcatheter mitral valve repair (TMVR). Methods Adults undergoing TMVR were identified using the 2016–2018 Nationwide Readmissions Database, and divided into Frail and Non-Frail groups. Frailty was defined using a derivative of the Johns Hopkins Adjusted Clinical Groups frailty indicator. Generalized linear models were used to assess the association of frailty with in-hospital mortality, complications, nonhome discharge, hospitalization costs, length of stay, and non-elective readmission at 90 days. Average marginal effects were used to quantify the impact of f...

Research paper thumbnail of National trends and predictors of mastectomy with immediate breast reconstruction

The American Journal of Surgery, 2021

PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors... more PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy. METHODS The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR. RESULTS Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy. CONCLUSION Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.

Research paper thumbnail of Incidence and Outcomes of Laryngeal Complications Following Adult Cardiac Surgery: A National Analysis

Dysphagia, 2021

Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and ... more Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and resource utilization. Using a nationally representative cohort of cardiac surgical patients, we characterized the incidence of LC as well as its associated clinical and financial outcomes. All adults undergoing coronary artery bypass grafting and/or valvular operations were identified using the 2010–2017 Nationwide Readmissions Database. International Classification of Diseases 9th and 10th Revision diagnosis codes were used to identify LC. Trends were analyzed using a rank-based, non-parametric test (nptrend). Multivariable linear and logistic regressions were used to evaluate risk factors for LC, and its impact on mortality, complications, resource use and 30-day non-elective readmissions. Of an estimated 2,319,628 patients, 1.7% were diagnosed with perioperative LC, with rising incidence from 1.5% in 2010 to 1.8% in 2017 (nptrend

Research paper thumbnail of Outcomes and resource use for liver transplantation in the United States: Insights from the 2009‐2017 National Inpatient Sample

Clinical Transplantation, 2021

Liver transplantation (LT) is a life‐saving treatment for end‐stage liver disease patients that r... more Liver transplantation (LT) is a life‐saving treatment for end‐stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use.

Research paper thumbnail of Trends in Mortality and Costs of Pediatric Extracorporeal Life Support

Pediatrics, 2020

BACKGROUND: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustainin... more BACKGROUND: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. METHODS: We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008–2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. RESULTS: Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalization...

Research paper thumbnail of National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US

Journal of the American College of Surgeons, 2020

In Portugal, preventive Archaeology has led to the identification of Palaeolithic sites of except... more In Portugal, preventive Archaeology has led to the identification of Palaeolithic sites of exceptional scientific and cultural value worldwide such as, for instance, the Palaeolithic Art of the Coa Valley. The existence of gaps in the national map of Palaeolithic sites as well as the inherent difficulties of identifying sites of this chronology have led to the creation of a project which seeks to develop and strengthen the relationship between preventive Archaeology and research into the Upper Palaeolithic in Portugal: the PALEORESCUE project, which is briefly presented in this article.

Research paper thumbnail of National Trends in the Cost Burden of Pediatric Gunshot Wounds Across the United States

The Journal of Pediatrics, 2021

OBJECTIVE To characterize hospitalization costs attributable to gun-related injuries in children ... more OBJECTIVE To characterize hospitalization costs attributable to gun-related injuries in children across the US. STUDY DESIGN The 2005-2017 National Inpatient Sample (NIS) was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by ICD-procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations. RESULTS Over the study period, an estimated 36,283 pediatric patients were admitted for a GSW with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3,246 in 2005 to 3,185 in 2017 (NPtrend<0.001). The median inflation-adjusted cost was 12,408(IQR12,408 (IQR 12,408(IQR6,253-$24,585). Median costs rose significantly from 10,749in2005to10,749 in 2005 to 10,749in2005to16,157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18,576 vs $8,942, P<0.001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile. CONCLUSIONS Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact.

Research paper thumbnail of The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting

The Annals of Thoracic Surgery, 2021

BACKGROUND Although not formalized into current risk assessment models, frailty has been associat... more BACKGROUND Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital mortality, complications and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). METHODS Patients ≥ 18 years who underwent isolated CABG across the United States were identified using the 2005-2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multi-level multivariable regression. RESULTS Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (NP-trend=0.002), while annual mortality rates declined (NP-trend<0.001). Frail patients were older (68.9±10.7 years vs. 65.0±10.6 years, P<0.001), and more commonly female (32.8% vs. 26.2%, P<0.001). After adjustment, frailty was associated with increased odds of in-hospital mortality (adjusted odds ratio, AOR 2.49, 95% confidence interval, 95% CI: 2.30-2.70, P<0.001), major complications (AOR 2.55, 95% CI: 2.39-2.71, P<0.001), increased length of stay (AOR 1.40, 95% CI: 1.09-2.11, P<0.001), and costs (AOR 1.03, 95% CI: 1.02-1.07, P<0.001). CONCLUSIONS Frailty as identified by administrative coding serves as strong independent predictor of death and complications following CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Research paper thumbnail of Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia

The Annals of Thoracic Surgery, 2021

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown ... more Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.

Research paper thumbnail of TCT CONNECT-84 Transcatheter and Surgical Aortic Valve Replacement in Kidney Transplant Recipients: Insights From a National Cohort (2011 to 2017)

Journal of the American College of Cardiology, 2020

Research paper thumbnail of National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

Surgery, 2020

BACKGROUND Laparoscopic cholecystectomy has reached nearly universal adoption in the management o... more BACKGROUND Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001). CONCLUSION Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Research paper thumbnail of National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest

Resuscitation, 2020

INTRODUCTION Extracorporeal life support (ECLS) has shown promise in the management of cardiac ar... more INTRODUCTION Extracorporeal life support (ECLS) has shown promise in the management of cardiac arrest. The purpose of this study was to examine temporal trends and predictors of ECLS utilization and survival to discharge among inpatients with cardiac arrest in the United States. METHODS All patients admitted after out-of-hospital cardiac arrest (OHCA) and those who experienced in-hospital cardiac arrest (IHCA) from 2005 to 2014 were identified in the National Inpatient Sample. Patients carrying a pregnancy as well as those with do-not-resuscitate orders or trauma-related diagnoses were excluded. Multivariable logistic regression was used to identify predictors of ECLS utilization and survival to discharge. RESULTS An estimated 1,624,827 patients were identified. During the study period, use of ECLS increased from 77 to 564 per 100,000 arrests for OHCA, and 60 to 632 per 100,000 arrests for IHCA. Survival among patients on ECLS for OHCA and IHCA increased from 34.2% to 54.2% and from 4.7% to 19.2%, respectively. Age, year of arrest, cardiac rhythm, and the presence of a potentially reversible etiology including myocardial infarction and pulmonary embolism, were predictive of ECLS utilization. Among patients placed on ECLS, age, rhythm at arrest, and location of arrest were predictive of survival to discharge. CONCLUSIONS Mortality after cardiac arrest for those on ECLS has substantially decreased. Younger age, shockable rhythm, and out-of-hospital arrest location were predictive of survival or utilization. As ECLS use increases, it is critical to define selection criteria that maximize the benefits of ECLS.

Research paper thumbnail of Readmissions after Ileostomy Creation Using a Nationwide Database

The American Surgeon, 2018

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to... more Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0–7, 8–30, 31–90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions w...

Research paper thumbnail of Impact of center volume on outcomes of surgical repair for type A acute aortic dissections

Surgery, 2020

BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative inter... more BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.

Research paper thumbnail of Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States

The Annals of Thoracic Surgery, 2020

BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy rem... more BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual, institutional volume of anatomic lung resections on outcomes following elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Those under 18 years of age, or with a trauma-related diagnoses, mesothelioma, or a non-elective admission were excluded. Hospitals were divided into volume quartiles based on annual, institutional anatomic lung resection caseload. We studied the effect of institutional volume on in-hospital mortality, complications, and failure-to-rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P-trend=0.045). Compared to the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% CI 1.14-2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure-to rescue rates (18.3% vs 12.7%, P=0.024) and adjusted odds of mortality (1.70, 95% CI 1.09-2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure-to-rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

Research paper thumbnail of Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting

The American Journal of Cardiology, 2020

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) ... more The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Research paper thumbnail of Readmission and Resource Use After Robotic-assisted versus Open Pancreaticoduodenectomy: 2010-2017

Journal of Surgical Research, 2020

BACKGROUND Unplanned rehospitalization is considered an adverse quality of care indicator. Minima... more BACKGROUND Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

Research paper thumbnail of Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support

Surgery, 2020

BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been st... more BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.

Research paper thumbnail of Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis

The American Surgeon, 2020

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify t... more Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as Frail. Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, P < .001) and in-hospital mortality (4% vs. 2%, P < .001). Frailty was...

Research paper thumbnail of National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States

INTRODUCTION Pancreatectomy is a complex operation that has been associated with excess morbidity... more INTRODUCTION Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy. MATERIAL AND METHODS We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality. RESULTS Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy v...

Research paper thumbnail of Impact of frailty on short term outcomes, resource use, and readmissions after transcatheter mitral valve repair: A national analysis

PLOS ONE, 2021

Background Treatment options for mitral regurgitation range from diuretic therapy, to surgical an... more Background Treatment options for mitral regurgitation range from diuretic therapy, to surgical and interventional strategies including TMVR in high-risk surgical candidates. Frailty has been associated with inferior outcomes following hospitalizations for heart failure and in open cardiac surgery. Objective The purpose of the present study was to evaluate the impact of frailty on clinical outcomes and resource use following transcatheter mitral valve repair (TMVR). Methods Adults undergoing TMVR were identified using the 2016–2018 Nationwide Readmissions Database, and divided into Frail and Non-Frail groups. Frailty was defined using a derivative of the Johns Hopkins Adjusted Clinical Groups frailty indicator. Generalized linear models were used to assess the association of frailty with in-hospital mortality, complications, nonhome discharge, hospitalization costs, length of stay, and non-elective readmission at 90 days. Average marginal effects were used to quantify the impact of f...

Research paper thumbnail of National trends and predictors of mastectomy with immediate breast reconstruction

The American Journal of Surgery, 2021

PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors... more PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy. METHODS The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR. RESULTS Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy. CONCLUSION Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.

Research paper thumbnail of Incidence and Outcomes of Laryngeal Complications Following Adult Cardiac Surgery: A National Analysis

Dysphagia, 2021

Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and ... more Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and resource utilization. Using a nationally representative cohort of cardiac surgical patients, we characterized the incidence of LC as well as its associated clinical and financial outcomes. All adults undergoing coronary artery bypass grafting and/or valvular operations were identified using the 2010–2017 Nationwide Readmissions Database. International Classification of Diseases 9th and 10th Revision diagnosis codes were used to identify LC. Trends were analyzed using a rank-based, non-parametric test (nptrend). Multivariable linear and logistic regressions were used to evaluate risk factors for LC, and its impact on mortality, complications, resource use and 30-day non-elective readmissions. Of an estimated 2,319,628 patients, 1.7% were diagnosed with perioperative LC, with rising incidence from 1.5% in 2010 to 1.8% in 2017 (nptrend

Research paper thumbnail of Outcomes and resource use for liver transplantation in the United States: Insights from the 2009‐2017 National Inpatient Sample

Clinical Transplantation, 2021

Liver transplantation (LT) is a life‐saving treatment for end‐stage liver disease patients that r... more Liver transplantation (LT) is a life‐saving treatment for end‐stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use.

Research paper thumbnail of Trends in Mortality and Costs of Pediatric Extracorporeal Life Support

Pediatrics, 2020

BACKGROUND: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustainin... more BACKGROUND: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. METHODS: We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008–2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. RESULTS: Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalization...

Research paper thumbnail of National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US

Journal of the American College of Surgeons, 2020

In Portugal, preventive Archaeology has led to the identification of Palaeolithic sites of except... more In Portugal, preventive Archaeology has led to the identification of Palaeolithic sites of exceptional scientific and cultural value worldwide such as, for instance, the Palaeolithic Art of the Coa Valley. The existence of gaps in the national map of Palaeolithic sites as well as the inherent difficulties of identifying sites of this chronology have led to the creation of a project which seeks to develop and strengthen the relationship between preventive Archaeology and research into the Upper Palaeolithic in Portugal: the PALEORESCUE project, which is briefly presented in this article.

Research paper thumbnail of National Trends in the Cost Burden of Pediatric Gunshot Wounds Across the United States

The Journal of Pediatrics, 2021

OBJECTIVE To characterize hospitalization costs attributable to gun-related injuries in children ... more OBJECTIVE To characterize hospitalization costs attributable to gun-related injuries in children across the US. STUDY DESIGN The 2005-2017 National Inpatient Sample (NIS) was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by ICD-procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations. RESULTS Over the study period, an estimated 36,283 pediatric patients were admitted for a GSW with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3,246 in 2005 to 3,185 in 2017 (NPtrend<0.001). The median inflation-adjusted cost was 12,408(IQR12,408 (IQR 12,408(IQR6,253-$24,585). Median costs rose significantly from 10,749in2005to10,749 in 2005 to 10,749in2005to16,157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18,576 vs $8,942, P<0.001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile. CONCLUSIONS Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact.

Research paper thumbnail of The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting

The Annals of Thoracic Surgery, 2021

BACKGROUND Although not formalized into current risk assessment models, frailty has been associat... more BACKGROUND Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital mortality, complications and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). METHODS Patients ≥ 18 years who underwent isolated CABG across the United States were identified using the 2005-2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multi-level multivariable regression. RESULTS Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (NP-trend=0.002), while annual mortality rates declined (NP-trend<0.001). Frail patients were older (68.9±10.7 years vs. 65.0±10.6 years, P<0.001), and more commonly female (32.8% vs. 26.2%, P<0.001). After adjustment, frailty was associated with increased odds of in-hospital mortality (adjusted odds ratio, AOR 2.49, 95% confidence interval, 95% CI: 2.30-2.70, P<0.001), major complications (AOR 2.55, 95% CI: 2.39-2.71, P<0.001), increased length of stay (AOR 1.40, 95% CI: 1.09-2.11, P<0.001), and costs (AOR 1.03, 95% CI: 1.02-1.07, P<0.001). CONCLUSIONS Frailty as identified by administrative coding serves as strong independent predictor of death and complications following CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Research paper thumbnail of Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia

The Annals of Thoracic Surgery, 2021

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown ... more Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.

Research paper thumbnail of TCT CONNECT-84 Transcatheter and Surgical Aortic Valve Replacement in Kidney Transplant Recipients: Insights From a National Cohort (2011 to 2017)

Journal of the American College of Cardiology, 2020

Research paper thumbnail of National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy

Surgery, 2020

BACKGROUND Laparoscopic cholecystectomy has reached nearly universal adoption in the management o... more BACKGROUND Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (β: $2,398, P < .001). CONCLUSION Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Research paper thumbnail of National trends in utilization and outcomes of extracorporeal support for in- and out-of-hospital cardiac arrest

Resuscitation, 2020

INTRODUCTION Extracorporeal life support (ECLS) has shown promise in the management of cardiac ar... more INTRODUCTION Extracorporeal life support (ECLS) has shown promise in the management of cardiac arrest. The purpose of this study was to examine temporal trends and predictors of ECLS utilization and survival to discharge among inpatients with cardiac arrest in the United States. METHODS All patients admitted after out-of-hospital cardiac arrest (OHCA) and those who experienced in-hospital cardiac arrest (IHCA) from 2005 to 2014 were identified in the National Inpatient Sample. Patients carrying a pregnancy as well as those with do-not-resuscitate orders or trauma-related diagnoses were excluded. Multivariable logistic regression was used to identify predictors of ECLS utilization and survival to discharge. RESULTS An estimated 1,624,827 patients were identified. During the study period, use of ECLS increased from 77 to 564 per 100,000 arrests for OHCA, and 60 to 632 per 100,000 arrests for IHCA. Survival among patients on ECLS for OHCA and IHCA increased from 34.2% to 54.2% and from 4.7% to 19.2%, respectively. Age, year of arrest, cardiac rhythm, and the presence of a potentially reversible etiology including myocardial infarction and pulmonary embolism, were predictive of ECLS utilization. Among patients placed on ECLS, age, rhythm at arrest, and location of arrest were predictive of survival to discharge. CONCLUSIONS Mortality after cardiac arrest for those on ECLS has substantially decreased. Younger age, shockable rhythm, and out-of-hospital arrest location were predictive of survival or utilization. As ECLS use increases, it is critical to define selection criteria that maximize the benefits of ECLS.

Research paper thumbnail of Readmissions after Ileostomy Creation Using a Nationwide Database

The American Surgeon, 2018

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to... more Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0–7, 8–30, 31–90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions w...

Research paper thumbnail of Impact of center volume on outcomes of surgical repair for type A acute aortic dissections

Surgery, 2020

BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative inter... more BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.

Research paper thumbnail of Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States

The Annals of Thoracic Surgery, 2020

BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy rem... more BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual, institutional volume of anatomic lung resections on outcomes following elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Those under 18 years of age, or with a trauma-related diagnoses, mesothelioma, or a non-elective admission were excluded. Hospitals were divided into volume quartiles based on annual, institutional anatomic lung resection caseload. We studied the effect of institutional volume on in-hospital mortality, complications, and failure-to-rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P-trend=0.045). Compared to the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% CI 1.14-2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure-to rescue rates (18.3% vs 12.7%, P=0.024) and adjusted odds of mortality (1.70, 95% CI 1.09-2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure-to-rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

Research paper thumbnail of Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting

The American Journal of Cardiology, 2020

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) ... more The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.

Research paper thumbnail of Readmission and Resource Use After Robotic-assisted versus Open Pancreaticoduodenectomy: 2010-2017

Journal of Surgical Research, 2020

BACKGROUND Unplanned rehospitalization is considered an adverse quality of care indicator. Minima... more BACKGROUND Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

Research paper thumbnail of Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support

Surgery, 2020

BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been st... more BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.